A nurse on a med surge unit has recieved change of shift report and will care for 4
clients. Which of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with 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
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago
to an AP. Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning
An RN is making assignments for client care to an LPN at the beginning of the shift.
Which of the following assignments should the LPN question?
A. Assisting a client who is 24 hr 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
A nurse is preparing an inservice 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
A nurse manager of a med surge unit is assigning care responsibilities for the oncoming
shift. A client is waiting transfer back to the unit from the PACU following thoracic
surgery. To which staff member should the nurse assign the client?
A. Charge nurse
B. RN
C. LVN
D. AP
,A nurse is caring for a client who decides not to have surgery despite significant
blockages in his coronary arteries. The nurse understands that this clients choice is an
example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse
understands that this aspect of care delivery is an example of which of the following
ethical principles?
A. Fidelity
B. Autonomy
C. Justice
D. Beneficience
A nurse is instructing a group of nursing students about the responsibilities involved with
organ donation and procurement. When the nurse explains that all clients waiting for a
kidney transplant have to meet the same qualifications, the students should understand
that this aspect of care delivery is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence
A nurse questions a med prescription as too extreme and light of the clients advanced
age and unstable status. The nurse understands that this action is an example of which
ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence
Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in
bed she will restrain him
C. A family has conflicting feelings about the initiation of enteral tube feedings of their
father who is terminally ill
D. A client who is terminally ill hesitates to name her spouse on her durable power of
attorney form
The nurse is teaching a 40-year-old man diagnosed with a lower motor
neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
A. use a new sterile catheter each time he performs a catheterization.
, B. perform the Valsalva maneuver(holding breath and bearing down) before doing the
catheterization.
C. perform the catheterization procedure every 8 hours.
D. limit his fluid intake to reduce the number of times a catheterization is needed.
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
A. take the medication five minutes after the pain has started.
B. stop taking the medication if a stinging sensation is absent.
C. take the medication on an empty stomach.
D. avoid abrupt changes in posture.
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if
found by the nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium gluconate for IV administration.
3. Tracheostomy set-up.
4. Suction equipment.
A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client
1. acknowledges willing participation in an incestuous relationship.
2. reestablishes a trusting relationship with his/her other parent.
3. verbalizes that s/he is not responsible for the sexual abuse.
4. in semi-Fowler's position with his head turned to the side.
A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the
following nursing actions should be included in the care plan in order to
BEST prepare the client for the diagnostic test?
1. Start an intravenous line for an oxytocin infusion.
2. Obtain a signed consent prior to the procedure.
3. Instruct client to push a button when she feels fetal movement.
4. Attach a spiral electrode to the fetal head.
Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises.