A charge nurse on a med surg unit is assigning client care to an RN and an LPN. Which of the
following tasks should the nurse assign to the RN? Select all that apply.
A. Performing colostomy care
B. Administering blood to a client
C. Developing a plan of care for a client
D. Calculating a TPN flow rate
E. Checking nasogastric tube patency - ANS - B, C, D
\A client is brought back to the unit after a total hip arthroplasty. The client is confused, is
moving his leg into positions that could dislocate the new hip joint, & repeatedly attempts to get
out of bed. Which of the following actions should the nurse take? Select all that apply.
A. Apply arm & leg restraints immediately
B. Get an order from the provider
C. Have a family member sign the consent for restraints
D. Use a square knot to secure the restraints to the bed frame
E. Ensure that on - ANS - A, B, C
\A client is prescribed morphine sulfate IM. Which of the following should the nurse recognize as
a requirement for governing controlled substances?
A. Delegate med admin to a RN
B. Ask another nurse to observe disposal of unused med
C. Request another nurse to validate admin of the med
D. Observe the LPN admin the med - ANS - B
\A home health nurse is assessing the safety of a client's home. Which of the following factors
may increase the client's risk for falls? Select all that apply.
A. History of a previous fall
B. Reduced vision
C. Impaired memory
D. Takes rosuvastatin (Crestor)
E. Wears house slippers
F. Kyphosis - ANS - A, B, C, E, F
\A new charge nurse on a busy surgical unit notes a high degree of tension among the nursing
staff. Which of the following should be the initial method used for resolving this issue?
A. Work w/the nurses to identify stressors
B. Hire additional staff to decrease the work load
, C. Make relaxation tapes available to staff to help decrease stress
D. Reassess the situation after the nurses have become accustomed to the new charge nurse -
ANS - A
\A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required
naloxone (narcan) for depressed respirations. Is this an appropriate task for the AP? - ANS - no
\A nurse discovers that a client was administered an antihypertensive med in error. Number the
following actions in the appropriate sequence that the nurse should follow.
___A. Call the client's provider
___B. Monitor the client's vitals
___C. Notify the risk manager
___D. Complete an incident report
___E. Instruct the client to remain in bed until further notice - ANS - 1. B
2. E
3. A
4. D
5. C
\A nurse has prepared an IM injection for a client who is preoperative, when another client
suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is
waiting to take the client to surgery. Which of the following is an appropriate action by the LPN?
A. Prepare a new syringe for the client who is preop
B. Give the prepared med to the client who is preop
C. Help the client requesting assistance so the nurse can give the prepared injection
D. Report this request to - ANS - C
\A nurse is assessing a client's negligible progress in following a weight loss program. Which of
the following is a likely reason the client was unable to achieve a short-term goal established
during the planning phase of the nursing process?
A. The goals were realistic & formulated w/client input.
B. The underlying problem behind past weight gain was misidentified.
C. The implementation of the plan used flexibility in following the nursing actions
D. The nurse obtained objective & subjectiv - ANS - B
\A nurse is caring for a client who has recently been prescribed lithium carbonate (Eskalith).
Which of the following is the priority assessment finding for this client?
A. Fine hand tremors
B. Weight gain of 2.7 kg (6 lb)
C. Report of nausea
D. Poor motor coordination - ANS - D
\A nurse is caring for a client who is being prepared for surgery. The client hands the nurse info
about advance directives & states, "Here, I don't need this. I am too young to worry about
life-sustaining measures & what I want done for me." Which of the following actions should the
nurse take?
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