Leadership & Management – Archer Review Part 2
Correct Questions and Answers.
Choice D is correct. This client sustained a nasal fracture caused by facial trauma, which may have
consequently caused brain trauma. Vomiting is an early manifestation of increased intracranial pressure
requiring immediate follow-up. The nurse should notify the physician of the condition change and
prepare the client for an immediate computed tomography (CT) scan of the head to confirm the
findings. Interventions the nurse should take are keeping the client's head of the bed elevated between
30-45 degrees and the client's head neutral. This may help mitigate some of the increasing ICP. Other
findings associated with increased ICP include restlessness, altered level of consciousness, and
headache.
The emergency department nurse cares for a client who sustained multiple rib fractures and a nasal
fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
A. shallow respirations
B. chest pain with repositioning
C. bruising on the chest
D. vomiting
Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a
concern to the nurse. A heart rate of 112 would indicate tachycardia, one of the earliest manifestations
of shock, and the nurse needs to assess the client further.
The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy.
Which of the following findings requires immediate follow-up?
,A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain)
B. Oral temperature of 99.5°F (37.5°C)
C. Heart rate of 112 beats-per-minute (BPM)
D. Hypoactive bowel sounds in all four quadrants
Choice A is correct. It is appropriate for the RN to delegate to the LPN/VN to collect data on the
client's neurovascular status (pulse, skin condition, capillary refill) every two hours while the client is
restrained. Data collection does not require analysis, and the PN can collect data such as auscultating
lung sounds, data collecting on a client's skin integrity, collecting vital signs, and collecting a client's
health history.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is
violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints,
which of the following tasks may the RN delegate to the LPN?
A. Collect data on the client's skin integrity.
B. Educate the client on the need for restraints.
C. Initiate peripheral vascular access.
D. Continually assess the client to determine if restraint use is necessary.
,Choice A is correct. Retractions demonstrate increased respiratory effort, meaning the pediatric client
is in respiratory distress. Since retractions are a medical emergency and this pediatric client is exhibiting
inspiratory retractions, thus indicating respiratory distress, this client should be the first client the nurse
assesses.
A registered nurse arrives for a shift in a pediatric emergency department (ED). There are four pediatric
clients in the ED. Which client would the nurse assess first?
A. A one-month-old infant that is crying with retractions during inspiration
B. A 5-year-old with pneumonia and a 95% pulse oxygen saturation
C. A 10-year-old with diarrhea and vomiting and a potassium level of 3.6 mEq/L
D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL
Choices C and F are correct. The client with angina and ST-segment changes should be assigned to the
RN because of this client's clinical unpredictability. Angina accompanied by ST-segment changes is a
worrisome sign of acute coronary syndrome. A 59-year-old requiring chronic wound care and the
insertion of an indwelling catheter is more appropriate for the LPN to ensure an evenly divided client
assignment. These are skills (wound care and indwelling catheter insertion) within the scope of an LPN.
While an RN may assume this client, to maximize staff resources, this client should be assigned to the
LPN.
The charge nurse reviews staff assignments for one registered nurse (RN) and one licensed
practical/vocational nurse (LPN/VN) on the nursing unit. To maximize staff resources, which client
assignments require modification to be congruent with each nurse's scope of practice? See the image
below.Select all that apply.
, Choice B is correct. A 26-year-old female requiring a one-person assist in ambulating to the restroom
would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in
assisting clients with ambulation and this is within their scope of practice.
The nurse has several tasks that need to be completed. Which of the following client assignments would
be appropriate to delegate to the unlicensed assistive personnel?
A. A 65-year-old male requiring sterile dressing changes.
B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
D. A 16-year-old female who is 4 hours post-cardiac catheterization.
Choice B is correct. The nurse should prepare for the delivery of the newborn because of a presenting
fetal part. The nurse transporting the client to L&D would be highly inappropriate because the client
could deliver the newborn during transport which is not safe. Finally, the nurse should prepare for the
delivery of the newborn because the presenting part requires immediate application of fetal heart
monitoring to determine the stability of the neonate.
The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing
frequent contractions. The nurse observes a presenting part of the fetus during the exam. The nurse
should take which priority action?
A. Assess the client's previous obstetric history
B. Prepare for the delivery of the newborn
C. Transport the client to the labor and delivery unit
D. Time the frequency and duration of contractions
Correct Questions and Answers.
Choice D is correct. This client sustained a nasal fracture caused by facial trauma, which may have
consequently caused brain trauma. Vomiting is an early manifestation of increased intracranial pressure
requiring immediate follow-up. The nurse should notify the physician of the condition change and
prepare the client for an immediate computed tomography (CT) scan of the head to confirm the
findings. Interventions the nurse should take are keeping the client's head of the bed elevated between
30-45 degrees and the client's head neutral. This may help mitigate some of the increasing ICP. Other
findings associated with increased ICP include restlessness, altered level of consciousness, and
headache.
The emergency department nurse cares for a client who sustained multiple rib fractures and a nasal
fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
A. shallow respirations
B. chest pain with repositioning
C. bruising on the chest
D. vomiting
Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a
concern to the nurse. A heart rate of 112 would indicate tachycardia, one of the earliest manifestations
of shock, and the nurse needs to assess the client further.
The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy.
Which of the following findings requires immediate follow-up?
,A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain)
B. Oral temperature of 99.5°F (37.5°C)
C. Heart rate of 112 beats-per-minute (BPM)
D. Hypoactive bowel sounds in all four quadrants
Choice A is correct. It is appropriate for the RN to delegate to the LPN/VN to collect data on the
client's neurovascular status (pulse, skin condition, capillary refill) every two hours while the client is
restrained. Data collection does not require analysis, and the PN can collect data such as auscultating
lung sounds, data collecting on a client's skin integrity, collecting vital signs, and collecting a client's
health history.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is
violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints,
which of the following tasks may the RN delegate to the LPN?
A. Collect data on the client's skin integrity.
B. Educate the client on the need for restraints.
C. Initiate peripheral vascular access.
D. Continually assess the client to determine if restraint use is necessary.
,Choice A is correct. Retractions demonstrate increased respiratory effort, meaning the pediatric client
is in respiratory distress. Since retractions are a medical emergency and this pediatric client is exhibiting
inspiratory retractions, thus indicating respiratory distress, this client should be the first client the nurse
assesses.
A registered nurse arrives for a shift in a pediatric emergency department (ED). There are four pediatric
clients in the ED. Which client would the nurse assess first?
A. A one-month-old infant that is crying with retractions during inspiration
B. A 5-year-old with pneumonia and a 95% pulse oxygen saturation
C. A 10-year-old with diarrhea and vomiting and a potassium level of 3.6 mEq/L
D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL
Choices C and F are correct. The client with angina and ST-segment changes should be assigned to the
RN because of this client's clinical unpredictability. Angina accompanied by ST-segment changes is a
worrisome sign of acute coronary syndrome. A 59-year-old requiring chronic wound care and the
insertion of an indwelling catheter is more appropriate for the LPN to ensure an evenly divided client
assignment. These are skills (wound care and indwelling catheter insertion) within the scope of an LPN.
While an RN may assume this client, to maximize staff resources, this client should be assigned to the
LPN.
The charge nurse reviews staff assignments for one registered nurse (RN) and one licensed
practical/vocational nurse (LPN/VN) on the nursing unit. To maximize staff resources, which client
assignments require modification to be congruent with each nurse's scope of practice? See the image
below.Select all that apply.
, Choice B is correct. A 26-year-old female requiring a one-person assist in ambulating to the restroom
would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in
assisting clients with ambulation and this is within their scope of practice.
The nurse has several tasks that need to be completed. Which of the following client assignments would
be appropriate to delegate to the unlicensed assistive personnel?
A. A 65-year-old male requiring sterile dressing changes.
B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
D. A 16-year-old female who is 4 hours post-cardiac catheterization.
Choice B is correct. The nurse should prepare for the delivery of the newborn because of a presenting
fetal part. The nurse transporting the client to L&D would be highly inappropriate because the client
could deliver the newborn during transport which is not safe. Finally, the nurse should prepare for the
delivery of the newborn because the presenting part requires immediate application of fetal heart
monitoring to determine the stability of the neonate.
The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing
frequent contractions. The nurse observes a presenting part of the fetus during the exam. The nurse
should take which priority action?
A. Assess the client's previous obstetric history
B. Prepare for the delivery of the newborn
C. Transport the client to the labor and delivery unit
D. Time the frequency and duration of contractions
