RN Leadership 2023 A Rational
Study online at https://quizlet.com/_evmbh1
1. There has been a community dis- a client who has multiple sclerosis and reports ataxia
aster and stable clients must be
discharged from a facility to pre- This client is safe to discharge because multiple sclerosis
pare for the influx of new casual- is a chronic disorder and ataxia is an expected finding.
ties. A nurse should identify that
which of the following clients is
safe to discharge?
2. A nurse on a medical-surgical unit A client who has peripheral vascular disease and has an
is caring for four clients. The nurse absent pulse in the right foot
should recognize that which of the
following clients is the priority?
When using the airway, breathing, circulation approach
to client care, the nurse determines that the priority find-
ing is an absent pulse, which indicates no blood flow to
the extremity.
3. A nurse finds that a new IV Tag the pump for maintenance and acquire a new pump
pump has infused 400 mL of so- for the client
lution over 2 hr when the rate
was set at 100 mL/hr. After no- The greatest risk is the potential for injury to a client if a
tifying the provider and verifying nurse uses the pump again before repair; therefore, the
that the pump was properly pro- priority for the nurse is to tag the pump for maintenance
grammed, which of the following and acquire a new pump for the client.
is the nurse's priority?
4. A charge nurse is planning care for ambulating a client who uses a walker, adding thickener
a group of clients. Which of the fol- to thin liquids on a client's food tray
lowing tasks should be delegated
to an assistive personnel (AP)? se- Flushing a client's saline lock is incorrect. This is not
lect all that apply within the AP's scope of practice.
Ambulating a client who uses a walker is correct. This is
within the AP's scope of practice.
, RN Leadership 2023 A Rational
Study online at https://quizlet.com/_evmbh1
Adding thickener to thin liquids on a client's food tray is
correct. This is within the AP's scope of practice.
Teaching a client how to use an incentive spirometer is
incorrect. This is not within the AP's scope of practice.
Evaluating a client's gag reflex before mealtime is incor-
rect. This is not within the AP's scope of practice.
5. A nurse is caring for a client. Which Place an absorbent pad on the client's bed, report the
of the following tasks should the client's blood pressure to the nurse, apply barrier cream
nurse delegate to an assistive per- to the client's buttocks, document the client's vital signs
sonnel (AP)? select all that apply
6. A charge nurse on a maternal new- Newborn 5, Newborn 3, Newborn 1
born unit is receiving change of
shift charge nurse report for a
When prioritizing hypotheses using the urgent vs.
group of newborns. Which of the
non-urgent approach to newborn care, the charge nurse
following 3 newborns should the
should identify newborn 1, newborn 3, and newborn 5
charge nurse identify as requiring
as requiring priority care based on acuity. Newborn 1 has
priority care? Select 3 newborns
manifestations of respiratory distress including tachyp-
the charge nurse should identify
nea, grunting, nasal flaring, and retractions. The charge
as priority.
nurse should further determine if newborn 1 requires
prompt interventions. Newborn 3 presents with manifes-
tations of hypoglycemia including blood glucose below
the expected range, hypothermia, and maternal history
of gestational diabetes insulin dependent. Newborn 5 is
23 hours of age and has not had a successful feeding.
The newborn additionally has not voided or passed their
first meconium stool. Newborns are expected to have at
least one void during the first 24 hours of life, and one
meconium stool with in the first 24 to 48 hours of life.
While newborns are sleepier during the first 48 hours
, RN Leadership 2023 A Rational
Study online at https://quizlet.com/_evmbh1
after birth, the newborn should be awoken for feedings
at least every 3 hours. These finding indicate that further
intervention by the nurse is needed.
7. A nurse manager is assessing in- Client 4, Client 5
cident reports for the unit. Which
of the following client's medical When recognizing cues, the nurse should identify client 4
records indicate professional neg- and client 5 have medical records that indicate instances
ligence? Select 2 clients that the of professional negligence. Professional negligence oc-
nurse manager should recognize curs when an individual with professional training fails
have charts that indicate profes- to practice at the level expected of their profession and
sional negligence. harm is caused to a client. For professional negligence
to occur there must be a correlation between the nurse's
actions and the harm that came to the client. In client 4's
medical record, the nurse failed to administer the client's
prescribed antiseizure medication within the indicated
time frame and the client experienced a seizure. In client
scenario 5's medical record, the nurse administered the
client's medications outside the parameters indicated on
the prescription and the client experienced syncope and
sustained an injury. The nurse should identify these two
client scenarios as instances of professional negligence.
8. A charge nurse is assisting with blood pressure, temperature, heart rate, respiratory rate,
the care of a client. Which of pain level, report by the client
the following findings should the
charge nurse identify that the
When evaluating outcomes, the nurse should identify
client is experiencing an adverse
hypotension, an increase in temperature, heart rate, and
reaction and requires notification
respiratory rate along with reports of abdominal and
of provider and updating the
flank pain as a 6 on a pain scale from 0 to 10 and
client's plan of care? Select 6 find-
client report of short of breath and chills can indicate the
client is experiencing an acute hemolytic reaction to the
Study online at https://quizlet.com/_evmbh1
1. There has been a community dis- a client who has multiple sclerosis and reports ataxia
aster and stable clients must be
discharged from a facility to pre- This client is safe to discharge because multiple sclerosis
pare for the influx of new casual- is a chronic disorder and ataxia is an expected finding.
ties. A nurse should identify that
which of the following clients is
safe to discharge?
2. A nurse on a medical-surgical unit A client who has peripheral vascular disease and has an
is caring for four clients. The nurse absent pulse in the right foot
should recognize that which of the
following clients is the priority?
When using the airway, breathing, circulation approach
to client care, the nurse determines that the priority find-
ing is an absent pulse, which indicates no blood flow to
the extremity.
3. A nurse finds that a new IV Tag the pump for maintenance and acquire a new pump
pump has infused 400 mL of so- for the client
lution over 2 hr when the rate
was set at 100 mL/hr. After no- The greatest risk is the potential for injury to a client if a
tifying the provider and verifying nurse uses the pump again before repair; therefore, the
that the pump was properly pro- priority for the nurse is to tag the pump for maintenance
grammed, which of the following and acquire a new pump for the client.
is the nurse's priority?
4. A charge nurse is planning care for ambulating a client who uses a walker, adding thickener
a group of clients. Which of the fol- to thin liquids on a client's food tray
lowing tasks should be delegated
to an assistive personnel (AP)? se- Flushing a client's saline lock is incorrect. This is not
lect all that apply within the AP's scope of practice.
Ambulating a client who uses a walker is correct. This is
within the AP's scope of practice.
, RN Leadership 2023 A Rational
Study online at https://quizlet.com/_evmbh1
Adding thickener to thin liquids on a client's food tray is
correct. This is within the AP's scope of practice.
Teaching a client how to use an incentive spirometer is
incorrect. This is not within the AP's scope of practice.
Evaluating a client's gag reflex before mealtime is incor-
rect. This is not within the AP's scope of practice.
5. A nurse is caring for a client. Which Place an absorbent pad on the client's bed, report the
of the following tasks should the client's blood pressure to the nurse, apply barrier cream
nurse delegate to an assistive per- to the client's buttocks, document the client's vital signs
sonnel (AP)? select all that apply
6. A charge nurse on a maternal new- Newborn 5, Newborn 3, Newborn 1
born unit is receiving change of
shift charge nurse report for a
When prioritizing hypotheses using the urgent vs.
group of newborns. Which of the
non-urgent approach to newborn care, the charge nurse
following 3 newborns should the
should identify newborn 1, newborn 3, and newborn 5
charge nurse identify as requiring
as requiring priority care based on acuity. Newborn 1 has
priority care? Select 3 newborns
manifestations of respiratory distress including tachyp-
the charge nurse should identify
nea, grunting, nasal flaring, and retractions. The charge
as priority.
nurse should further determine if newborn 1 requires
prompt interventions. Newborn 3 presents with manifes-
tations of hypoglycemia including blood glucose below
the expected range, hypothermia, and maternal history
of gestational diabetes insulin dependent. Newborn 5 is
23 hours of age and has not had a successful feeding.
The newborn additionally has not voided or passed their
first meconium stool. Newborns are expected to have at
least one void during the first 24 hours of life, and one
meconium stool with in the first 24 to 48 hours of life.
While newborns are sleepier during the first 48 hours
, RN Leadership 2023 A Rational
Study online at https://quizlet.com/_evmbh1
after birth, the newborn should be awoken for feedings
at least every 3 hours. These finding indicate that further
intervention by the nurse is needed.
7. A nurse manager is assessing in- Client 4, Client 5
cident reports for the unit. Which
of the following client's medical When recognizing cues, the nurse should identify client 4
records indicate professional neg- and client 5 have medical records that indicate instances
ligence? Select 2 clients that the of professional negligence. Professional negligence oc-
nurse manager should recognize curs when an individual with professional training fails
have charts that indicate profes- to practice at the level expected of their profession and
sional negligence. harm is caused to a client. For professional negligence
to occur there must be a correlation between the nurse's
actions and the harm that came to the client. In client 4's
medical record, the nurse failed to administer the client's
prescribed antiseizure medication within the indicated
time frame and the client experienced a seizure. In client
scenario 5's medical record, the nurse administered the
client's medications outside the parameters indicated on
the prescription and the client experienced syncope and
sustained an injury. The nurse should identify these two
client scenarios as instances of professional negligence.
8. A charge nurse is assisting with blood pressure, temperature, heart rate, respiratory rate,
the care of a client. Which of pain level, report by the client
the following findings should the
charge nurse identify that the
When evaluating outcomes, the nurse should identify
client is experiencing an adverse
hypotension, an increase in temperature, heart rate, and
reaction and requires notification
respiratory rate along with reports of abdominal and
of provider and updating the
flank pain as a 6 on a pain scale from 0 to 10 and
client's plan of care? Select 6 find-
client report of short of breath and chills can indicate the
client is experiencing an acute hemolytic reaction to the
