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A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following
client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
A nurse is caring for an adolescent client who requires a blood transfusion. The client's parents will not
consent to the transfusion due to religious beliefs. Which of the following actions should the nurse take?
Inform the charge nurse and recommend that social services be contacted
A nurse in a long term care facility is caring for a client who had a stroke 1 week ago. the client is
experiencing left-sided weakness, difficulty swallowing, drooping of the mouth, inarticulate speech, and
memory loss. Which of the following referrals is the priority for the nurse to make?
Speech Therapy
A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of
the following manifestations should the nurse include?
Headaches
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of
the following events should the nurse document as a variance?
The client has a circular area of nonblanchable redness on her left heel
, A nurse is assisting with discharge planning for a client. Which of the following actions should the plan to
take?
Include community resource phone numbers with the clients discharge instructions
A nurse enters the room of a client who is sleeping and observes sparks coming from a frayed bed plug
in the clients electrical outlet. Which of the following actions should the nurse take first?
Evacuate the client
A nurse is assisting with the evacuation of clients who have been triaged following a mass casualty event.
Which of the following clients should the nurse recommend for first transport to the health care facility?
A client who has paradoxical respirations and has been assigned a red tag
A nurse observes an assistive personnel (AP) taking a picture of a client who has not given consent. The
nurses should identify the AP has committed which of the following torts?
Invasion of privacy
A nurse is contributing to the plan of care for a client who has a new diagnosis of type 2 diabetes
mellitus. Which of the following members of the interprofessional health care team should the nurse
consult to assist the client with glucose management?
Registered dietician
A nurse is discussing the condition of several clients with an assistive personnel prior to routine vital
sign measurement. The nurse should plan to measure vital signs for which of the following clients rather
than delegation this task to the AP?
A client who has new onset atrial fibrillation and reports lightheadedness