1. Medications./should./be./given./through./what?:./Central./line
2. The. / nurse. / working. / on. / a. / medical. / surgical. / unit. / is. / delegating. / tasks. / to. / un-
licensed. / personnel.. / Which. / of. / the. / following. / delegated. / task. / would. / REQUIRE./
FOLLOW./UP./by./the./charge./nurse?:./A../Assisting./a./client./who./had./a./paracentesis./2./hours./ago./to./g
et./out./of./bed./for./the./first./time.
Rationale./-./anytime./a./client./is./doing./something./for./the./first./time./the./RN./needs./to./do./it
3. The./nurse./is./prioritizing./patient./care./after./a./change./of./shift./report../The./nurse./sh
ould./first./plan./to./see./the./patient./who::. / B../Had./an./endoscopic./retrograde./cholangiopancreatog-
raphy./30./minutes./ago./and./is./reporting./diflculty./swallowing./Rationale./-./Diflculty./swallowing./-./ABC's!
4. The. / nurse. / working. / on. / the. / mom/baby. / unit. / has. / become. / aware. / of. / the. / follo
w-
ing./client./situations../Which./of./the./following./clients./should./the./nurse./INITIALLY./ass
ess?:./C../a./neonate./who./is./4./hours./old,./whose./resting./HR./is./95./BPM.
Rationale./-./Normal./HR./for./a./newborn./is./120-140./BPM./-./95./is./a./LOW./BPM
5. A./nurse./working./on./a./medical./surgical./unit./has./just./received./a./handoff./report./o
n./the./following./clients../The./nurse./should./FIRST./plan./to./assess./the./client./who./has::.
/D../Acute./pancreatitis./and./is./reporting./the./development./of./pain./on./deep./inspiration
Rationale./-./"acute"./if./not./caught./early,./will./possible./burst./and./patient./will./become./septic
6. The. / nurse. / working. / on. / a. / pediatric. / unit. / is. / caring. / for. / the. / following. / children./
who. / have. / been. / admitted. / in. / the. / past. / 12. / hours.. / It. / would. / be. / a. / priority. / goal.
/ for./the./nurse./to./initiate./an./interdisciplinary./conference./for./the./child./who::./A../5./yr.
/old./with./diagnosed./cystic./fibrosis./at./birth./and./has./been./hospitalized./4./times./in./the./past./2./months
Rationale./-
./This./is./conferencing./everyone!!!./PT,./dietary,./spiritual./guidance,./everyone./should./be./conferenced./for./this./patient..
/This./question./is./asking./-./WHO.//./WHICH./child./is./requiring./the./MOST./help./and./resources???
7. The. / nurse. / working. / in. / the. / ED. / has. / received. / the. / following. / prescriptions. / for
a. / newly. / admitted. / client.. / Which. / prescriptions. / should. / the. / nurse. / implement. / FI
RST?:./D../Initiate./IV./sodium./and./potassium./for./a./client./admitted./with./diarrhea./and./dehydration./who./has./a./seru
m./potassium./level./of./2.9.
Rationale./-./serum./potassium./of./2.9./is./CRITICAL./-this./is./a./critical./lab./value./and./should./be./addressed./first!
8. A. / nurse. / is. / working. / in. / a. / community. / health. / clinic. / is. / assessing. / clients. / who. /
are./waiting. / to. / be. / seen.. / Which. / client. / should. / the. / nurse. / have. / the. / primary. / he
./ .
/
, alth. / care./provider./see./FIRST?:./A../a./57./year./old./with./graves./disease./with./a./temperature./of./100.5
Rationale./-./Thyroid./issue
./ .
/
2. The. / nurse. / working. / on. / a. / medical. / surgical. / unit. / is. / delegating. / tasks. / to. / un-
licensed. / personnel.. / Which. / of. / the. / following. / delegated. / task. / would. / REQUIRE./
FOLLOW./UP./by./the./charge./nurse?:./A../Assisting./a./client./who./had./a./paracentesis./2./hours./ago./to./g
et./out./of./bed./for./the./first./time.
Rationale./-./anytime./a./client./is./doing./something./for./the./first./time./the./RN./needs./to./do./it
3. The./nurse./is./prioritizing./patient./care./after./a./change./of./shift./report../The./nurse./sh
ould./first./plan./to./see./the./patient./who::. / B../Had./an./endoscopic./retrograde./cholangiopancreatog-
raphy./30./minutes./ago./and./is./reporting./diflculty./swallowing./Rationale./-./Diflculty./swallowing./-./ABC's!
4. The. / nurse. / working. / on. / the. / mom/baby. / unit. / has. / become. / aware. / of. / the. / follo
w-
ing./client./situations../Which./of./the./following./clients./should./the./nurse./INITIALLY./ass
ess?:./C../a./neonate./who./is./4./hours./old,./whose./resting./HR./is./95./BPM.
Rationale./-./Normal./HR./for./a./newborn./is./120-140./BPM./-./95./is./a./LOW./BPM
5. A./nurse./working./on./a./medical./surgical./unit./has./just./received./a./handoff./report./o
n./the./following./clients../The./nurse./should./FIRST./plan./to./assess./the./client./who./has::.
/D../Acute./pancreatitis./and./is./reporting./the./development./of./pain./on./deep./inspiration
Rationale./-./"acute"./if./not./caught./early,./will./possible./burst./and./patient./will./become./septic
6. The. / nurse. / working. / on. / a. / pediatric. / unit. / is. / caring. / for. / the. / following. / children./
who. / have. / been. / admitted. / in. / the. / past. / 12. / hours.. / It. / would. / be. / a. / priority. / goal.
/ for./the./nurse./to./initiate./an./interdisciplinary./conference./for./the./child./who::./A../5./yr.
/old./with./diagnosed./cystic./fibrosis./at./birth./and./has./been./hospitalized./4./times./in./the./past./2./months
Rationale./-
./This./is./conferencing./everyone!!!./PT,./dietary,./spiritual./guidance,./everyone./should./be./conferenced./for./this./patient..
/This./question./is./asking./-./WHO.//./WHICH./child./is./requiring./the./MOST./help./and./resources???
7. The. / nurse. / working. / in. / the. / ED. / has. / received. / the. / following. / prescriptions. / for
a. / newly. / admitted. / client.. / Which. / prescriptions. / should. / the. / nurse. / implement. / FI
RST?:./D../Initiate./IV./sodium./and./potassium./for./a./client./admitted./with./diarrhea./and./dehydration./who./has./a./seru
m./potassium./level./of./2.9.
Rationale./-./serum./potassium./of./2.9./is./CRITICAL./-this./is./a./critical./lab./value./and./should./be./addressed./first!
8. A. / nurse. / is. / working. / in. / a. / community. / health. / clinic. / is. / assessing. / clients. / who. /
are./waiting. / to. / be. / seen.. / Which. / client. / should. / the. / nurse. / have. / the. / primary. / he
./ .
/
, alth. / care./provider./see./FIRST?:./A../a./57./year./old./with./graves./disease./with./a./temperature./of./100.5
Rationale./-./Thyroid./issue
./ .
/
