1. Medications should be given through a central line
2. The nurse working on a medical surgical unit is delegating
tasks to unlicensed personnel which of the following delegated
task would REQUIRE FOLLOW UP by the charge nurse?
A - Assisting a client who had a paracentesis 2 hours ago to get out of
bed for the first time
Rationale – anytime a client is doing something for the first time the RN
needs to do it
3. The nurse is prioritizing patient care after a change of shift
report the nurse should first plan to see the patient who:
B – Had an endoscopic retrograde cholangiopancreatography 30
minutes ago and is reporting difficulty swallowing
Rationale – Difficulty swallowing – ABC’s!
4. The nurse working on the mom/baby unit has become aware of
the following client situations, which of the following clients
should the nurse INITIALLY assess?
C – a neonate who is 4 hours old, whose resting HR is 95 BPM.
Rationale – Normal HR for a newborn is 120-140 BPM – 95 is a LOW BPM
5. A nurse working on a medical surgical unit has just received a
hand-off report on the following clients, the nurse should
FIRST plan to assess the client who has:
D –Acute pancreatitis and is reporting the development of pain on
deep inspiration
Rationale – “acute” if not caught early, will possible burst and patient will
become septic
, 6. The nurse working on a pediatric unit is caring for the
following children who have been admitted in the past 12 hours
- it would be a priority goal for the nurse to initiate an
interdisciplinary conference for the child who:
A – 5 yr old with diagnosed cystic fibrosis at birth and has been
hospitalized 4 times in the past 2 months
Rationale – This is conferencing everyone!!! PT, dietary, spiritual guidance,
everyone should be conferenced for this patient. This question is asking –
WHO / WHICH child is requiring the MOST help and resources???
7. The nurse working in the ED has received the following
prescriptions for a newly admitted client, which prescriptions
should the nurse implement FIRST?
D – Initiate IV sodium and potassium for a client admitted with
diarrhea and dehydration who has a serum potassium level of 2.9.
Rationale – serum potassium of 2.9 is CRITICAL - this is a critical lab value
and should be addressed first!
8. A nurse is working in a community health clinic is assessing
clients who are waiting to be seen, which client should the
nurse have the primary health care provider see FIRST?
A – a 57-year-old with graves disease with a temperature of 100.5
Rationale – Thyroid issue
9. A nurse is working on a pediatric cardiac unit is reviewing the
telemetry monitors for assigned clients, which client should the
nurse INITIALLY plan to assess?
A – 2-year-old toddler who is walking in the hallway and has a HR of
160 BPM
Rationale – Abnormal HR – all the other choices were normal for the child
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