WITH ANSWERS
A nurse is preparing a client for a lumbar puncture. The client has signed the consent
form but tells the nurse that she does not remember what the doctor will do during the
procedure. Which of the following actions should the nurse take?
Remind the client that the doctor will insert a needle to get a sample of fluid from her
spine.
A nurse manager is implementing a team nursing approach on his unit, hiring licensed
practical nurses (LPNs) and assistive personnel (AP) as additional staff. Which of the
following actions should the nurse manager take to facilitate acceptance of this change?
Introduce the new approach and facilitate the development of a task force to plan
implementation.
A group of providers is participating in a resuscitation effort for a client who is in cardiac
arrest. Which of the following types of leadership is required for this group to function
most efficiently?
Autocratic
A nurse is having difficulty completing care and documentation without staying past the
end of the shift. The nurse manager suggests focusing on time-management skills. Which
of the following strategies should the nurse plan to use?
Identify tasks in order of their priority.
A charge nurse on a pediatric unit is delegating tasks to an assistive personnel (AP) who
is pregnant and reports that she is unsure of her immune status. Which of the following
clients should the charge nurse assign to the AP?
A 2-year-old child who has impetigo contagiosa (impetigo).
A nurse is assisting a provider with an amniotomy on a client who is in labor. Which of
the following is the priority nursing assessment following the procedure?
Fetal heart rate.
A nurse is preparing to transfer an older adult client to a long-term care facility. To
promote continuity of care, which of the following actions should the nurse plan to
take?
Give a written summary of the client's nursing plan of care to the long-term care facility.
,A nurse in the emergency department is preparing to obtain informed consent for surgery
from a client who received a meperidine hydrochloride IV during transport from a rural
hospital. Which of the following actions should the nurse take to obtain consent for
surgery?
Obtain consent from a relative of the client.
A nurse working at a rehabilitation facility is attending an interdisciplinary team
meeting for a client who had a left hemispheric stroke. Which of the following
members of the interdisciplinary team should the nurse recommend to assist this
client? (Select all that apply.)
Nurse Speech therapist
Occupational therapist Physical therapist
A nurse on a medical-surgical unit is caring for a group of clients. For which of the
following situations should the nurse complete a variance report?
The discovery that a preoperative client has received and eaten breakfast.
A nurse is selecting clients for discharge following an environmental disaster. Which of
the following clients should the nurse select?
A client who is 1 day postoperative following an inguinal hernia repair.
An RN and a licensed practical nurse (LPN) are caring for a client who has a small bowel
obstruction and is NPO with a nasogastric (NG) tube set to continuous suction. Which of
the following tasks should the RN perform?
Assess for bowel sounds every 2 hours.
A nurse is caring for a child who has sustained extensive head injuries. The provider has
diagnosed brain death. Which of the following statements should the nurse use to begin a
conversation about the option of organ and tissue donation with the child's parents?
"I want to give you some information about an option that you have regarding donating
your child's organs to others who are in need."
A charge nurse is conducting an in-service training session on ethics to a group of newly
licensed nurses. Which of the following situations should the charge nurse include as an
example of the ethical principle of veracity?
A nurse truthfully answers the client's questions about upcoming chemotherapy.
A nurse is completing an incident report after administering an incorrect dose of
medication to a client, even though the client experienced no ill effects from the error.
What is the purpose of completing the incident report?
Identifying situations that contribute to the occurrence of medication errors.
, A charge nurse in an emergency department is making assignments for an assistive
personnel (AP) during a shift with unexpected staff absences. Which of the following
assignments should the charge give to a float AP from the medical-surgical unit?
Escorting clients from the emergency department to other areas of the facility for tests.
A nurse is receiving report on a client who has Clostridium difficile and is being
transferred from another unit. Which of the following precautions should the nurse take?
Perform hand hygiene with nonantimicrobial soap and water after client care.
A nurse receives the morning change-of-shift report and delegates several tasks to an
assistive personnel (AP) on the team. Which of the following tasks should the nurse
instruct the AP to perform first?
Obtain the morning capillary blood glucose tests.
A nurse discovers that the wrong medication was given to a confused client who
answered to the name the nurse stated when entering the room. The provider is notified
and reports that the medication the client received will not cause any harm. Which of the
following actions should the nurse take?
Complete an incident report documenting the occurrence.
A nurse is teaching a group of unit nurses about the Health Insurance Portability and
Accountability Act (HIPAA). Which of the following pieces of information should the
nurse include in the teaching?
The Security Rule provides a uniform level of security to protect client records.
A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client
states, "I don't think I can go through with the surgery after all." Which of the following
responses should the nurse provide?
"I will let the surgeon know about your decision."
A nurse is assisting with the informed consent process for a client who is scheduled for
a below-the-knee amputation. The client asks the nurse, "Why are they making me have
this surgery today? I don't understand why they are doing this." Which of the following
actions should the nurse take?
Notify the provider of the client's comments.
A nurse is planning care for a group of clients. Which of the following actions should the
nurse plan to take?
Delegate the administration of an intermittent tube feeding to a licensed practical nurse
(LPN).