After receiving change-of-shift report, A client who has heart failure and reports severe dyspnea
which of the following clients should the
nurse collect data from first?
A charge nurse in a long-term care unit is Measuring urine output every 2 hr for a client recently diagnosed with a urinary
planning care for a group of clients. Which infection
of the following care tasks should the nurse
plan to delegate to an assistive personnel?
A client's daughter calls the nurse "You will need to contact your mother directly about her condition."
requesting information about her mother's
condition. The client's chart does not
specify that information can be released to
the daughter. Which of the following is an
appropriate response by the nurse?
A client who has inoperable cancer tells the "You have the right to refuse the recommended treatment plan."
nurse that she does not want to pursue the
recommended treatment. She asks if the
provider can force her to have the
treatment. Which of the following is an
appropriate response by the nurse?
,A client who is participating in an anger Rationalization
management session explains that his
recent behaviors are related to his job loss.
Which of the following defense mechanisms
is the client using?
A client who is prescribed metoprolol for "Let's talk with your doctor about other options."
hypertension tells the nurse, "I don't want to
take this medication because makes me
tired all the time." Which of the following is
the appropriate response?
A home health nurse is reinforcing teaching Sweep the extinguisher from side to side to put out the fire.
with a client about kitchen safety. Which of
the following instructions should the nurse
reinforce about using a fire extinguisher?
A nurse and an assistive personnel (AP) are Document the client's respiratory rate in 1 hr.
caring for a client who requests a PRN pain
medication. After the nurse administers the
medication, which of the following tasks
should the nurse assign to the AP?
,A nurse collecting data from a client who is The client was not harmed as a result of the incident.
receiving a continuous IV infusion of 0.9%
sodium chloride. The nurse discovers the IV
infusion pump was set incorrectly and the
client received 200 mL more than
prescribed. Data collection reveals that the
client is stable. The nurse recognizes that
this incident is not considered malpractice
for which of the following reasons?
A nurse delegates a task to an assistive Perform the task.
personnel (AP) and the AP refuses the
assigned task. Which of the following
actions should the nurse take first?
A nurse discovers a fire in a trash can in a Walk the client to the waiting room.
client's room. Which of the following actions
should the nurse take first?
A nurse from a medical-surgical unit is A client who had a cesarean delivery 24 hr ago
floating to a postpartum unit. Which of the
appropriate assignment for the nurse to
accept?
, A nurse in a clinic is reinforcing teaching Apply the patch to the lower abdomen,"
with a client who has a new prescription for
a combination contraceptive transdermal
patch. Which of the following should the
nurse include in the teaching?
A nurse in a long-term care facility is Holding his hands up and elbows down while washing his hands
observing an assistive personnel (AP) who
is performing hand hygiene. Which of the
following actions by the AP requires
intervention?
A nurse in a mental health facility is Sodium level of 130 mEg/L for a client who has bipolar disorder and takes lithium
reviewing the laboratory reports for four
clients. Which of the following results
should the nurse report to the provider
immediately?
A nurse in a mental health unit asks a client "How are you?"
who has schizophrenia, "How are you?"
Which of the following responses should
the nurse identify as the speech alteration
of echolalia?
which of the following clients should the
nurse collect data from first?
A charge nurse in a long-term care unit is Measuring urine output every 2 hr for a client recently diagnosed with a urinary
planning care for a group of clients. Which infection
of the following care tasks should the nurse
plan to delegate to an assistive personnel?
A client's daughter calls the nurse "You will need to contact your mother directly about her condition."
requesting information about her mother's
condition. The client's chart does not
specify that information can be released to
the daughter. Which of the following is an
appropriate response by the nurse?
A client who has inoperable cancer tells the "You have the right to refuse the recommended treatment plan."
nurse that she does not want to pursue the
recommended treatment. She asks if the
provider can force her to have the
treatment. Which of the following is an
appropriate response by the nurse?
,A client who is participating in an anger Rationalization
management session explains that his
recent behaviors are related to his job loss.
Which of the following defense mechanisms
is the client using?
A client who is prescribed metoprolol for "Let's talk with your doctor about other options."
hypertension tells the nurse, "I don't want to
take this medication because makes me
tired all the time." Which of the following is
the appropriate response?
A home health nurse is reinforcing teaching Sweep the extinguisher from side to side to put out the fire.
with a client about kitchen safety. Which of
the following instructions should the nurse
reinforce about using a fire extinguisher?
A nurse and an assistive personnel (AP) are Document the client's respiratory rate in 1 hr.
caring for a client who requests a PRN pain
medication. After the nurse administers the
medication, which of the following tasks
should the nurse assign to the AP?
,A nurse collecting data from a client who is The client was not harmed as a result of the incident.
receiving a continuous IV infusion of 0.9%
sodium chloride. The nurse discovers the IV
infusion pump was set incorrectly and the
client received 200 mL more than
prescribed. Data collection reveals that the
client is stable. The nurse recognizes that
this incident is not considered malpractice
for which of the following reasons?
A nurse delegates a task to an assistive Perform the task.
personnel (AP) and the AP refuses the
assigned task. Which of the following
actions should the nurse take first?
A nurse discovers a fire in a trash can in a Walk the client to the waiting room.
client's room. Which of the following actions
should the nurse take first?
A nurse from a medical-surgical unit is A client who had a cesarean delivery 24 hr ago
floating to a postpartum unit. Which of the
appropriate assignment for the nurse to
accept?
, A nurse in a clinic is reinforcing teaching Apply the patch to the lower abdomen,"
with a client who has a new prescription for
a combination contraceptive transdermal
patch. Which of the following should the
nurse include in the teaching?
A nurse in a long-term care facility is Holding his hands up and elbows down while washing his hands
observing an assistive personnel (AP) who
is performing hand hygiene. Which of the
following actions by the AP requires
intervention?
A nurse in a mental health facility is Sodium level of 130 mEg/L for a client who has bipolar disorder and takes lithium
reviewing the laboratory reports for four
clients. Which of the following results
should the nurse report to the provider
immediately?
A nurse in a mental health unit asks a client "How are you?"
who has schizophrenia, "How are you?"
Which of the following responses should
the nurse identify as the speech alteration
of echolalia?
