WITH CORRECT ANSWERS 100% GRADE A!!
VERSION 1
1. The skin barrier covering a client's intestinal fistula keeps falling off when she stands up
to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only
when the client is supine in bed. The nurse telephoned the physical therapist about the
difficulties containing the drainage from the fistula, so the therapist didn't ambulate the
client today. The client sat in a chair during lunch w/an absorbent pad over the fistula.
The client ate all the food on her tray. The wound care nurse confirmed that she will see
the client later today. The client states she feels frustrated at not having physical
therapy, but the nurse thinks the client welcomed having a day to rest. Which of the
following information should the nurse include in the change-of-shift report? Select all
that apply.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a "day off" from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray
A, B, D
2. A nurse is receiving a provider's prescription by telephone for morphine for a client who
is reporting moderate to severe pain. Which of the following nursing actions are
appropriate? Select all that apply.
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone
A, B, C
, 3. A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days.
He states that it is difficult to prepare adequate nutritious meals at home for just 1
person. To which of the following members of the health care team should the nurse
refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker
D. social worker
Rational: A social worker can make arrangements for a meal delivery service to provide
nutritious meals daily, or recommend a congregate meal site near the client's home
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4. A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the inter-professional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist E. Registered dietitian
D. Occupational therapist
Rational: An occupational therapist can assist clients who have physical challenges to use
adaptive devices & strategies to help w/self-care activities
5. Can an RN delegate to the LPN to provide tracheostomy care to a client with
pneumonia? Yes.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which
of the following client's needs may the nurse assign to a assistive personnel (AP)?
A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
, D. Applying a sterile dressing to a pressure ulcer
C. Reapplying a condom catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that the
nurse may delegate to the AP
6. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to
an AP. Which of the following information should the nurse share with the AP? Select
All.
A. The roommate is up independently.
B. The client ambulates w/his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
B, C, D
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7. An RN is making assignments for client care to a LPN at the beginning of the shift. Which
of the following assignments should the LPN question?
A. Assisting a client who is 24hr postop to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump
D. Replacing the cartridge and tubing on a PCA pump
Rationale: The RN is responsible for the PCA pump
A nurse is preparing an in-service program about delegation. Which of the following elements
should she identify when presenting the 5 rights of delegation? Select all.
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances
, B, C, E
Rational: A and D are rights of medication administration
8. A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming
shift. A client is awaiting transfer back to the unit from the PACU following thoracic
surgery. To which staff member should the nurse assign to this client?
A. Charge nurse
B. RN
C. LPN
D. AP
B. RN
Rational: A client returning from surgery requires assessment and establishment of a plan of
care. RNs are responsible for this, especially if the client is potentially unstable.
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9. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP
tells him she will put a diaper on him if he does not use the urinal more carefully next
time. Which of the following torts is the AP committing?
A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy
A. Assault
Rational: By threatening the client, the AP is committing assault.
10. An adult client who is competent tells the nurse that he is thinking about leaving the
hospital against medical advice. The nurse believes that this is not in the client's best
interest, so she administers a PRN sedative med that the client has not requested along
w/his usual meds. Which of the following tort has the nurse committed?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality