A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is appropriate for the nurse to make currently?
1. Physical Therapist
2. Speech Pathologist
3. Registered Dietitian
4. Occupational Therapist
2. Speech Pathologi...
a client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia which of the following referrals is appropriate for the nurse
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A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the
following referrals is appropriate for the nurse to make currently?
A client who has chronic progressive dementia exhibits symptoms of malnutrition. Which action is
needed at this time?
1. Notify social services about concern for abuse.
2. Initiate a consult for physical therapy to visit daily.
3. Ask home care services to provide written instructions.
4. Arrange a meeting with the interprofessional team to coordinate care? - ANSWER4. Arrange a meeting
with the interprofessional team to coordinate care?
A nurse should recognize which of the following clients are likely to need rehabilitation services after
hepatization? (SATA)
1. School-age child who is recovering from an appendectomy.
2. Client who had a cesarean delivery for a breech presentation.
3. An adult client who has left hemiplegia after a stroke.
4. An adult client who is recovering from Guillain-Barre syndrome.
5. An older adult client who had a left hip replacement.
6. An adolescent client who required hospitalization due to asthma. - ANSWER3. An adult client who has
left hemiplegia after a stroke.
4. An adult client who is recovering from Guillain-Barre syndrome.
,5. An older adult client who had a left hip replacement.
A nurse is assigned to a group of clients. Which of the following has an increased risk of aspiration while
eating? (SATA)
1. A client who has a new diagnosis of gastroesophageal reflux disease.
2. A client who has admitted with a diagnosis of cerebrovascular accident.
3. A client who is 4 hr. post-op and received general anesthesia.
4. A client who is 8 hr. following traumatic laryngeal nerve damage.
5. A client who continually experiences prolonged coughing episodes. - ANSWER2. A client who has
admitted with a diagnosis of cerebrovascular accident.
3. A client who is 4 hr. post op and received general anesthesia.
4. A client who is 8 hr. following traumatic laryngeal nerve damage.
5. A client who continually experiences prolonged coughing episodes.
A client is receiving packed RBCs and becomes tachypneic. The client's temperature changes from
36.8*C (98.4*F) to 38.4*C (101.2*F). Which of the nursing interventions should the nurse perform first.
1. Give 750 mg acetaminophen orally.
2. Collect blood and urine specimens for analysis.
3. Administer and IV infusion of 0.9% sodium chloride.
4. Stop the infusion and return the blood to the lab. - ANSWER4. Stop the infusion and return the blood
to the lab.
A nurse receives a request from four clients at the same time. Which of the following clients should the
nurse address first? A client who
1. Needs to void 1 hr. after removal of an indwelling urinary catheter.
2. Reports restlessness and shortness of breath following surgery for a fractured femur.
3. Asks for a stool softener 2 days following surgery.
4. Demands to take prescribed insulin early the spouse is bringing dinner. - ANSWER2. Reports
restlessness and shortness of breath following surgery for a fractured femur.
,After receiving the report, a nurse should plan to access the clients in which priority order?
1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter.
3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. - ANSWER1st) 2. A 6-
year-old who is receiving continuous chemotherapy via a central venous catheter.
2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally.
3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter.
4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy.
A nurse received the report and should plan to see which of the following client first?
1. A client at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds.
2. A client who is pregnant and has a blood glucose level of 150mg/dl.
3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV.
4. A client 1 day postpartum who has changed perineal pads twice in the last 7 hr. - ANSWER3. A client
at 33 weeks of gestation who is receiving magnesium sulfate IV.
After receiving the report, which of the following clients should the nurse see first?
1. A client who was admitted with kidney stones and is crying with back pain.
2. A client who had chest discomfort prior to admission and is now requesting coffee.
3. A client who is scheduled for surgery and needs the linen changed.
4. A client who is to receive one unit of packed RBCs today and needs an IV restarted. - ANSWER1. A
client who was admitted with kidney stones and is crying with back pain.
The nurse should triage which of the following clients first?
1. Vomiting, photosensitivity, and stiff neck.
2. Elevated temperature, sore throat, and fatigue.
, 3. A guarded gait and a bruised, edematous ankle.
4. Cloudy urine with painful urination. - ANSWER1. Vomiting, photosensitivity, and stiff neck.
5 Rights of Delegation - ANSWERRight Person
Right Task
Right Circumstance
Right Direction/Communication
Right Supervision/Evaluation
Scope of Practice
RN -
LPN -
UAP - - ANSWERRN - Unstable clients, Assessments, Initiate Care Plans, Initial Teaching, Blood
Productions, IV Fluids and IV Push Medications.
LPN - Stable clients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood
Transfusions, Administer Piggybacks.
UAP - Stable clients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed making, Feeding,
Positioning, Ambulation.
A nurse is organizing care for four clients, which of the following tasks should the nurse instruct the UAP
to perform?
1. Measure the urine output from a client who was recently admitted with dehydration.
2. Bathe and shampoo hair for a client who was just admitted after a motor vehicle crash.
3. Help a client who is requesting a bedpan after a lumbar puncture.
4. Decrease the oxygen on a nasal cannula for a client who is being discharged with COPD. - ANSWER1.
Measure the urine output from a client who was recently admitted with dehydration.
Which of the following tasks should a nurse assign to the experienced unlicensed assistive personnel
(UAP)? (SATA)
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