A TI RN LEADERSHIP 2019 GRADED A+. 1.A client is brought to the emergency department following a motor-vehicle crash. Drug use
issuspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuse
s toprovide thespecimen.Whichof the following istheappropriateactionbythenurse?
a.Telltheclientthatacatheterwillbeinserted.
b.Documenttheclient'srefusalinthechart.
c.Assesstheclientforurinaryretention.
d.Obtain a provider's prescription for a blood alcohol levelAnswer: b-Document theclient'srefusal inthechart .
If the client is repeatedly refusing to provide specimen for drug test then nurse can justdocumentedhisrefusal.Thatdocumentcanbeusedagainsttheclientregardingthemotorvehicle accident.
2.A nurse is making shift assignments in a hospital. Which of the following tasks is appropriateto assignto alicensed practicalnurse?
a.Pickupthemeal traysafter lunch.
b.Administeranasogastrictubefeeding.
c.Planbreaktimesforassistivepersonnel.
d.Determine adequacy of ventilator settingsAnswer:b.Administeranasogastrictube feeding
3.A nurse preceptor is evaluating a newly licensed nurse's competency in assisting with a sterileprocedure. Which of the following actions indicates the newly licensed nurse is maintainingsteriletechnique?(SATA)
a.Placessterileitemswithin a1.25cm(0.5in)borderaroundtheedgesofthe sterilefield
b.Opensthesterile packbyfirstunfoldingthe topflap awayfromherbody
c.Preparesacontainerofsterilesolutiononthefieldafterputtingonsterilegloves
d.Removestheoutsidepackagingofasterileinstrument beforedroppingitontothesterilefield
e.Holds the sterile solution bottle with the label facing upb. Opens the sterile pack by firstunfolding thetop flap awayfromher body
Answer: d. Removes the outside packaging of a sterile instrument before dropping it onto thesterilefield 1
4.A nurse enters a client's room and identifies that the client is receiving too much IV fluidbecausetheIVpumpisnotworkingproperly.Whichofthefollowingactionsshouldthenursetak
efirst?
a.Auscultatetheclient'slungs.
b.Notifytheprovider.
c.Placeafaulty equipmenttag onthepump.
d.Completeanincidentreport.
Answer:a.Auscultatetheclient'slungs.
5.A nurse is planning care for a group of clients and can delegate care to a licensed practicalnurse(LPN)andanassistive personnel.Whichofthe followingtasksshouldthenurseassigntothe LPN?
a.Reinforcingteachingwithaclientwhoislearningtoself-administerinsulin
b.Ambulatingaclientwhoisscheduledfordischargelaterintheday
c.AdministeringmorphineIVbolustoaclient whois hrpostoperative
d.Admittinganewclientwhohaschronicback painto theunit
Answer:a.Reinforcingteachingwithaclientwhoislearningtoself-administerinsulin
6.A nurse is supervising a newly licensed nurse who is performing surgical asepsis. Afterdonning a sterile gown and gloves, which of the following actions by the newly licensed nursedemonstratescorrectaseptictechnique?
a.Thenurseappliesgoggles.
b.Thenurse turnsherbackto thesterilefield.
c.Thenurseholdsherhandsabove herwaist.
d.Thenurse putsonaface mask.
Answer:c.Thenurseholdsherhandsaboveherwaist
7.A nurse who is caring for a group of clients delegates collection of vital signs to an
assistivepersonnel(AP).Which ofthefollowingactionsshouldthe nursetaketo
evaluatethedelegatedtask?