RN Leadership 2024 A Rational
There has been a community disaster and stable clients must be discharged from
a facility to prepare for the influx of new casualties. A nurse should identify that
which of the following clients is safe to discharge? - ANSWER a
client who has multiple sclerosis and reports ataxia
This client is safe to discharge because multiple sclerosis is a chronic disorder and
ataxia is an expected finding.
A nurse on a medical-surgical unit is caring for four clients. The nurse should
recognize that which of the following clients is the priority? - ANSWER
A client who has peripheral vascular disease and has an absent pulse in the right
foot
When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority finding is an absent pulse, which indicates no blood
flow to the extremity.
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when
the rate was set at 100 mL/hr. After notifying the provider and verifying that the
pump was properly programmed, which of the following is the nurse's priority? -
,ANSWER Tag the pump for maintenance and acquire a new pump
for the client
The greatest risk is the potential for injury to a client if a nurse uses the pump
again before repair; therefore, the priority for the nurse is to tag the pump for
maintenance and acquire a new pump for the client.
A charge nurse is planning care for a group of clients. Which of the following tasks
should be delegated to an assistive personnel (AP)? select all that apply -
ANSWER ambulating a client who uses a walker, adding thickener
to thin liquids on a client's food tray
Flushing a client's saline lock is incorrect. This is not within the AP's scope of
practice.
Ambulating a client who uses a walker is correct. This is within the AP's scope of
practice.
Adding thickener to thin liquids on a client's food tray is correct. This is within the
AP's scope of practice.
Teaching a client how to use an incentive spirometer is incorrect. This is not within
the AP's scope of practice.
Evaluating a client's gag reflex before mealtime is incorrect. This is not within the
AP's scope of practice.
, A nurse is caring for a client. Which of the following tasks should the nurse
delegate to an assistive personnel (AP)? select all that apply - ANSWER
Place an absorbent pad on the client's bed, report the client's blood pressure to
the nurse, apply barrier cream to the client's buttocks, document the client's vital
signs
A charge nurse on a maternal newborn unit is receiving change of shift charge
nurse report for a group of newborns. Which of the following 3 newborns should
the charge nurse identify as requiring priority care? Select 3 newborns the charge
nurse should identify as priority. - ANSWER Newborn 5,
Newborn 3, Newborn 1
When prioritizing hypotheses using the urgent vs. non-urgent approach to
newborn care, the charge nurse should identify newborn 1, newborn 3, and
newborn 5 as requiring priority care based on acuity. Newborn 1 has
manifestations of respiratory distress including tachypnea, grunting, nasal flaring,
and retractions. The charge nurse should further determine if newborn 1 requires
prompt interventions. Newborn 3 presents with manifestations of hypoglycemia
including blood glucose below the expected range, hypothermia, and maternal
history of gestational diabetes insulin dependent. Newborn 5 is 23 hours of age
and has not had a successful feeding. The newborn additionally has not voided or
passed their first meconium stool. Newborns are expected to have at least one
void during the first 24 hours of life, and one meconium stool with in the first 24
to 48 hours of life. While newborns are sleepier during the first 48 hours after
birth, the newborn should be awoken for feedings at least every 3 hours. These
finding indicate that further intervention by the nurse is needed.
There has been a community disaster and stable clients must be discharged from
a facility to prepare for the influx of new casualties. A nurse should identify that
which of the following clients is safe to discharge? - ANSWER a
client who has multiple sclerosis and reports ataxia
This client is safe to discharge because multiple sclerosis is a chronic disorder and
ataxia is an expected finding.
A nurse on a medical-surgical unit is caring for four clients. The nurse should
recognize that which of the following clients is the priority? - ANSWER
A client who has peripheral vascular disease and has an absent pulse in the right
foot
When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority finding is an absent pulse, which indicates no blood
flow to the extremity.
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when
the rate was set at 100 mL/hr. After notifying the provider and verifying that the
pump was properly programmed, which of the following is the nurse's priority? -
,ANSWER Tag the pump for maintenance and acquire a new pump
for the client
The greatest risk is the potential for injury to a client if a nurse uses the pump
again before repair; therefore, the priority for the nurse is to tag the pump for
maintenance and acquire a new pump for the client.
A charge nurse is planning care for a group of clients. Which of the following tasks
should be delegated to an assistive personnel (AP)? select all that apply -
ANSWER ambulating a client who uses a walker, adding thickener
to thin liquids on a client's food tray
Flushing a client's saline lock is incorrect. This is not within the AP's scope of
practice.
Ambulating a client who uses a walker is correct. This is within the AP's scope of
practice.
Adding thickener to thin liquids on a client's food tray is correct. This is within the
AP's scope of practice.
Teaching a client how to use an incentive spirometer is incorrect. This is not within
the AP's scope of practice.
Evaluating a client's gag reflex before mealtime is incorrect. This is not within the
AP's scope of practice.
, A nurse is caring for a client. Which of the following tasks should the nurse
delegate to an assistive personnel (AP)? select all that apply - ANSWER
Place an absorbent pad on the client's bed, report the client's blood pressure to
the nurse, apply barrier cream to the client's buttocks, document the client's vital
signs
A charge nurse on a maternal newborn unit is receiving change of shift charge
nurse report for a group of newborns. Which of the following 3 newborns should
the charge nurse identify as requiring priority care? Select 3 newborns the charge
nurse should identify as priority. - ANSWER Newborn 5,
Newborn 3, Newborn 1
When prioritizing hypotheses using the urgent vs. non-urgent approach to
newborn care, the charge nurse should identify newborn 1, newborn 3, and
newborn 5 as requiring priority care based on acuity. Newborn 1 has
manifestations of respiratory distress including tachypnea, grunting, nasal flaring,
and retractions. The charge nurse should further determine if newborn 1 requires
prompt interventions. Newborn 3 presents with manifestations of hypoglycemia
including blood glucose below the expected range, hypothermia, and maternal
history of gestational diabetes insulin dependent. Newborn 5 is 23 hours of age
and has not had a successful feeding. The newborn additionally has not voided or
passed their first meconium stool. Newborns are expected to have at least one
void during the first 24 hours of life, and one meconium stool with in the first 24
to 48 hours of life. While newborns are sleepier during the first 48 hours after
birth, the newborn should be awoken for feedings at least every 3 hours. These
finding indicate that further intervention by the nurse is needed.
