1.A nurse in the emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- Insert an indwelling urinary catheter.
- Inspect the mouth for signs of inhalation injuries.
- Administer intravenous pain medication.
- Draw blood for a complete blood cell (CBC) count.
Explanation: In a client with burns, especially to the face, the priority is to assess the airway because burns to the face can indicate potential inhalation injuries, which can lead to airway compromise—a life-threatening condition. The ABCs (Airway, Breathing, Circulation) are the priority in emergency care, and inspecting the mouth for signs of inhalation injuries (like soot, singed nasal hairs, or swelling) addresses the airway first. The other actions, while important, are not the immediate priority in this scenario.
2.A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?
- The most experienced nurse receives the more complex clients.
- Personal comfort level in making the assignments.
- Social relationships between nurses working the oncoming shift.
- The physiologic status of the clients on the unit.
Explanation: When making assignments, the charge nurse’s primary consideration should be the clients’ needs, specifically their physiologic status (e.g., acuity, stability, and complexity of care). This ensures that clients receive appropriate care based on their condition and that nurses are assigned tasks matching their skills and the clients’ needs. While experience is a factor, it’s secondary to client needs. Personal comfort and social relationships are not appropriate criteria for making clinical assignments.
3.A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
- Administering an anticonvulsant.
- Padding side rails to prevent injury.
- Preparing for artificial ventilation.
- Applying a cooling blanket.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin, often due to medication interactions. Severe manifestations include hyperthermia (elevated body temperature), muscle rigidity, and seizures. The priority is to address hyperthermia, which can lead to organ damage or death if untreated. Applying a cooling blanket helps lower the body temperature, making it the priority intervention. While the other options may be part of the overall care plan, managing hyperthermia takes precedence.
4.A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- The client runs 4 miles outdoors every afternoon.
- The client drinks 2 liters of liquids daily.
- The client eats 2 to 3 gm of sodium-containing foods daily.
- The client eats foods high in tyramine.
Explanation: Lithium toxicity can occur due to dehydration, which can be exacerbated by excessive sweating from activities like running 4 miles outdoors, especially if fluid intake isn’t adequate. Lithium is excreted by the kidneys, and dehydration can lead to increased lithium levels in the blood, causing toxicity. Drinking 2 liters of fluid daily is generally adequate, and 2–3 grams of sodium is within a normal range (though low sodium can also increase lithium levels, this amount isn’t a concern). Tyramine is more relevant to MAOI medications, not lithium.
5.A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
- Instruct the client to sit down and stop pacing.
- Allow the client to pace alone until physically tired.
- Have a staff member escort the client to her room.
- Walk with the client at a gradually slower pace.
Explanation: For a client with generalized anxiety disorder who is pacing due to an upsetting event, the nurse should use a therapeutic approach to help de-escalate the anxiety. Walking with the client at a gradually slower pace provides a calming presence, helps reduce the client’s anxiety, and allows the nurse to engage with the client therapeutically. Instructing the client to stop pacing may increase anxiety, allowing them to pace alone doesn’t provide support, and escorting them to their room may feel isolating or punitive.
6.A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
- Inform the staff member of her appraisal time for that day prior to change-of-shift report.
- Schedule the appraisal interview as early in the shift as possible.
- Provide a chair directly across the desk for the staff member to sit in.
- Provide the staff member with a copy of the appraisal form in advance.
Explanation: Providing the staff member with a copy of the appraisal form in advance promotes transparency and allows the staff member to prepare for the appraisal, fostering a constructive dialogue. Scheduling the appraisal early in the shift or informing the staff member right before a shift report may not give them adequate time to prepare mentally. The physical setup (like chair placement) is less critical than ensuring the process is fair and collaborative.
7.A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- Wound drainage for culture.
- Urine from an indwelling catheter.
- Blood for PaCO2.
- Random stool specimen.
Explanation: Assistive personnel (AP) can perform tasks that don’t require clinical judgment or sterile technique, such as collecting urine from an indwelling catheter, which is a straightforward procedure. Collecting wound drainage for culture or blood for PaCO2 requires sterile technique or specific training (e.g., arterial blood gas sampling), which is typically outside an AP’s scope. While APs can collect a random stool specimen, the question focuses on delegation, and urine collection from a catheter is the most appropriate task here.
8.A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4°C (97.6°F). Which of the following is the priority nursing action?
- Insert an indwelling urinary catheter.
- Initiate IV access.
- Witness the signature for informed consent for surgery.
- Prepare the abdominal and perineal areas.
Explanation: The client is showing signs of placenta previa (painless, bright red vaginal bleeding at 38 weeks), and her vital signs indicate hypovolemic shock (low blood pressure, elevated heart rate, and respiratory rate). The priority is to stabilize the client by initiating IV access to administer fluids or blood products to address the shock and prepare for potential emergency delivery (likely a cesarean section). While the other actions may be part of the care plan, restoring circulation through IV access is the most immediate need.
9.When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?
- The AP’s ability to prioritize.
- The AP has the knowledge and skill to perform the task.
- The AP’s rapport with clients.
- The AP’s ability to complete the task without assistance.
Explanation: The five rights of delegation are: right task, right circumstance, right person, right direction/communication, and right supervision. The “right person” involves ensuring the AP has the knowledge and skill to perform the task safely and effectively. While the other options may be considerations in a broader context, the core of delegation is ensuring the AP is competent for the task, aligning with the “right person” principle.
11.A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
- A client who is scheduled for an abdominal x-ray and is awaiting transport.
- A client who has a prescription for discharge.
- A client who received oral pain medication 30 min ago.
- A client who told an assistive personnel he is short of breath.
Explanation: Using the ABCs (Airway, Breathing, Circulation) for prioritization, the client reporting shortness of breath is the priority because it indicates a potential respiratory issue that could be life-threatening. The nurse must assess this client first to determine the severity and intervene if necessary. The other clients’ needs (x-ray, discharge, pain management) are important but not as urgent as a potential airway or breathing problem.
12.A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?
- Provide an inservice on medication administration to all the nurses.
- Require staff nurses to demonstrate competency by passing a medication administration examination.
- Review the events leading up to each medication administration error.
- Develop a quality improvement program for nurses involved in medication administration errors.
Explanation: In a continuous quality improvement (CQI) process, the first step after a sentinel event (a serious, unexpected event causing harm) is to conduct a root cause analysis. This involves reviewing the events leading up to each medication administration error to identify the underlying causes and contributing factors. Understanding why errors occurred is essential before implementing interventions like inservices, competency exams, or quality improvement programs, as it ensures that the solutions address the actual problems.
13.A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?
- Take an arterial blood gas (ABG) specimen to the laboratory.
- Transport a client to the radiology department for an x-ray.
- Pass fresh water to clients on the unit.
- Obtain a routine urine sample from a newly admitted client.
Explanation: When delegating tasks to assistive personnel (AP), the nurse must consider the urgency of the tasks and the AP’s scope of practice. Passing fresh water to clients is a basic, non-urgent task that an AP can safely perform and is often a priority to ensure client comfort and hydration across the unit. Taking an ABG specimen to the lab involves handling a critical specimen, which may require more training, and transporting a client for an x-ray or obtaining a urine sample may depend on timing or client readiness. Hydration needs are a fundamental priority in this context.
14.A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
- Insert a tongue blade in the client’s mouth.
- Place the client on his side.
- Hold the client’s arms and legs from moving.
- Place the client back in bed.
Explanation: During a seizure, the priority is to ensure the client’s safety and maintain an open airway. Placing the client on their side (if possible) helps prevent aspiration by allowing saliva or vomit to drain from the mouth, aligning with the ABCs (Airway, Breathing, Circulation). Inserting a tongue blade is an outdated and unsafe practice that can cause injury. Holding the client’s limbs can lead to injury, and attempting to move the client back to bed during a seizure is unsafe until the seizure stops.
15.A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client’s vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2°C (100.8°F). Which of the following neurologic disorders should the nurse suspect?
- Transient ischemic attack (TIA)
- Hemorrhagic stroke
- Thrombotic stroke
- Embolic stroke
Explanation: The client’s symptoms—sudden, severe headache, vomiting, seizure, unresponsiveness, and significantly elevated blood pressure (198/110 mm Hg)—are classic signs of a hemorrhagic stroke, which occurs when a blood vessel in the brain ruptures, often due to hypertension. The fever may indicate brain irritation from the bleed. A TIA typically resolves quickly without lasting effects, and thrombotic or embolic strokes (ischemic strokes) are more likely to present with focal neurologic deficits like weakness or speech issues, not a sudden severe headache and seizure.
16.A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
- “Hold the cane with your left hand.”
- “When walking, move your left foot forward first.”
- “Move the cane forward 18 inches with each step.”
- “Keep your elbow straight when you hold the cane.”
Explanation: Proper cane use for a client with left-sided weakness involves holding the cane in the stronger (right) hand and moving it forward with the weaker (left) leg to provide support. The elbow should be kept straight (or slightly flexed, depending on comfort) to ensure proper posture and balance while using the cane. Holding the cane with the left hand would be incorrect since the stronger side should hold it. Moving the left foot first is not the correct sequence (the cane and weaker leg move together), and 18 inches is an arbitrary distance not specific to cane use.
19.A nurse is caring for a client 1 hr following a subtotal thyroidectomy. In which of the following positions should the nurse place the client?
- Semi-Fowler’s
- Dorsal recumbent
- Supine
- Sims
Explanation: After a subtotal thyroidectomy, the client should be placed in the Semi-Fowler’s position (head of the bed elevated 30–45 degrees) to promote venous drainage from the neck, reduce swelling, and facilitate breathing. This position also helps prevent pressure on the surgical site. Dorsal recumbent (flat on the back) and supine positions may increase swelling and compromise the airway, while Sims (a side-lying position) is not appropriate for this postoperative scenario.
20.A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client’s dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take?
- Change the client’s dressing.
- Reassign the task to another nurse.
- Verify the LPN knows how to do a dressing change.
- Report the issue to the unit manager.
Explanation: The charge nurse’s first step should be to verify that the LPN understands how to perform the dressing change, as this addresses the root cause of the issue—potential lack of knowledge or clarity. This aligns with the principles of effective delegation (ensuring the right person and right direction). Changing the dressing or reassigning the task bypasses the opportunity to address the LPN’s performance, and reporting to the unit manager is premature without first investigating the reason for the delay.
21.A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?
- Availability of resources, such as fire extinguishers
- Nursing staff ratios
- Quality of nursing care provided
- Length of facility stay for a cohort of clients
Explanation: A process audit evaluates the methods and procedures used to deliver care, focusing on the quality of care provided by nurses (e.g., adherence to protocols, documentation, and interventions). Availability of resources and nursing staff ratios are structural measures, while length of stay is an outcome measure, not directly related to the process of care delivery.
22.A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5°C (103.4°F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following haloperidol complications should the nurse suspect?
- Agranulocytosis
- Neuroleptic malignant syndrome
- Akathisia
- Tardive dyskinesia
Explanation: Neuroleptic malignant syndrome (NMS) is a life-threatening complication of antipsychotic medications like haloperidol, characterized by hyperthermia (39.5°C), muscle rigidity, and autonomic instability (e.g., elevated blood pressure). NMS typically occurs within weeks to months of starting the medication. Agranulocytosis involves a low white blood cell count, akathisia is restlessness, and tardive dyskinesia involves involuntary movements—none of which match the client’s symptoms.
23.A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?
- Measure blood glucose levels every 4 hr.
- Administer a diuretic.
- Initiate fluid restrictions.
- Check urine specific gravity.
Explanation: Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a lack of antidiuretic hormone (ADH) or kidney response to it, leading to dilute urine. Checking urine specific gravity helps monitor the client’s fluid balance and the effectiveness of treatment (e.g., desmopressin for central DI). Measuring blood glucose is relevant for diabetes mellitus, not DI. Diuretics and fluid restrictions are contraindicated in DI, as the client is already at risk of dehydration due to excessive fluid loss.
23.A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?
- Measure blood glucose levels every 4 hr.
- Administer a diuretic.
- Initiate fluid restrictions.
- Check urine specific gravity.
Explanation: Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH) or the kidneys' inability to respond to it, resulting in dilute urine. Checking urine specific gravity is a key intervention to monitor the client’s fluid balance and the effectiveness of treatment (e.g., desmopressin for central DI). Urine specific gravity in DI is typically low (e.g., 1.005 or less) due to the inability to concentrate urine. Measuring blood glucose is relevant for diabetes mellitus, not DI. Administering a diuretic or initiating fluid restrictions would worsen dehydration in DI, as the client is already losing excessive fluid.
24.A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?
- Ask what she will be assigned to do.
- Determine if she has the skills to complete the assignment.
- Identify her options.
- Notify the nurse manager about her concerns for client safety.
Explanation: When a nurse is reassigned to an unfamiliar unit, the first step is to assess her own competency to ensure she can safely perform the assigned tasks. This aligns with the principles of safe delegation and the nursing process (assessment comes first). Determining her skills ensures she can provide safe care and identifies any need for support or training. Asking about the assignment or identifying options comes after confirming her ability to perform the tasks, and notifying the nurse manager is a later step if concerns persist after assessment.
25.A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A private room in a quiet location on the unit.
- A semi-private room with a roommate who has a similar diagnosis.
- A private room close to the nursing station.
- A seclusion room until the client’s activity level becomes more subdued.
Explanation: A client in the manic phase of bipolar disorder often experiences heightened energy, agitation, and distractibility. Placing them in a private room in a quiet location minimizes external stimuli, which can help reduce overstimulation and promote a calmer environment for recovery. A semi-private room with a roommate may increase agitation, a room near the nursing station may be too noisy, and a seclusion room is not appropriate unless the client poses an immediate safety risk, which is not indicated here.
26.A nurse is teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicates an understanding of the teaching?
- “Disaster drills should be held on a regular basis.”
- “An actual disaster cannot take the place of a disaster drill.”
- “A staff nurse can function as the incident commander.”
- “A physician must triage victims of a disaster in the emergency department.’’
Explanation: Disaster preparedness requires regular drills to ensure staff are trained and ready to respond effectively during an actual disaster. This statement reflects an understanding of the importance of ongoing training and practice, a key component of disaster planning. An actual disaster can sometimes replace a drill for evaluation purposes, a staff nurse typically does not act as the incident commander (a role usually held by a trained leader), and triage in the emergency department can be performed by nurses, not only physicians.
27.A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?
- Discharge the client.
- Obtain a prescription for the appropriate anti-venom.
- Remove both of the elastic bandages from the leg.
- Obtain a prescription for pain medication.
Explanation: Elastic bandages placed snugly above and below a snake bite can act as a tourniquet, potentially trapping venom in the area and increasing local tissue damage or systemic absorption once removed. Current guidelines for snake bites recommend against tourniquets or tight bandages; instead, the limb should be immobilized, and the client should be kept calm while awaiting anti-venom. The client should not be discharged, as a poisonous snake bite requires monitoring and treatment. Anti-venom is necessary but is not the first action (it requires a prescription and preparation). Pain medication may be needed later but is not the priority over addressing the bandages.
28.A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? (Select all that apply.)
- Demonstrate the technique to instill eye drops.
- Ambulate a client who has a cane.
- Irrigate a wound.
- Transfer a client to a stretcher.
- Record urinary output.
Explanation: Assistive personnel (AP) can perform tasks that do not require nursing judgment or advanced skills. Ambulating a client with a cane and transferring a client to a stretcher are within the AP’s scope, as they involve assisting with mobility under the nurse’s supervision. Recording urinary output (e.g., measuring and documenting) is also appropriate for an AP, as it involves observation and reporting rather than assessment. Demonstrating eye drop instillation involves teaching, which requires nursing knowledge, and irrigating a wound involves a sterile procedure and assessment, both of which are outside the AP’s scope.
29.A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?
- Hyperthermia
- Hypotension
- Ototoxicity
- Muscle pain
Explanation: Verapamil is a calcium channel blocker used to treat cardiac dysrhythmias, such as supraventricular tachycardia. A common adverse effect is hypotension due to its vasodilatory effects and reduction in cardiac contractility. The nurse should monitor the client’s blood pressure closely during and after administration. Hyperthermia, ototoxicity, and muscle pain are not typically associated with verapamil; these are more common with other medications (e.g., ototoxicity with aminoglycosides).
30.A nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. Which of the following laboratory values should the nurse report to the provider before initiating the medication?
- Sodium 140 mEq/L
- Potassium 4.5 mEq/L
- BUN 55 mg/dL
- Glucose 120 mg/dL
Explanation: Amphotericin B is an antifungal medication known for its nephrotoxicity (kidney toxicity). A BUN (blood urea nitrogen) level of 55 mg/dL is elevated (normal range is typically 7–20 mg/dL), indicating potential renal impairment. The nurse should report this to the provider before administering amphotericin B, as it may exacerbate kidney damage. The other values—sodium 140 mEq/L (normal: 135–145), potassium 4.5 mEq/L (normal: 3.5–5.0), and glucose 120 mg/dL (normal: 70–110, but not critical here)—are within or near normal limits and do not pose an immediate concern for amphotericin B administration.
31.A nurse is reviewing data for four children. Which of the following children should the nurse assess first?
- A 10-year-old child who has sickle cell anemia and reports severe chest pain.
- A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016.
- A 1-year-old toddler who has roseola and a temperature of 39°C (102.2°F).
- A 4-year-old child who has asthma and a PCO2 of 37 mm Hg.
Explanation: The 10-year-old with sickle cell anemia reporting severe chest pain is the priority, as this could indicate acute chest syndrome, a life-threatening complication involving vaso-occlusion in the lungs, which can lead to hypoxia and requires immediate assessment. The 7-year-old with diabetes insipidus and a urine specific gravity of 1.016 (normal is 1.005–1.030) is not in immediate danger, as this value is not critically abnormal. The 1-year-old with roseola and a fever of 39°C is concerning but not immediately life-threatening, as fever is expected with roseola. The 4-year-old with asthma and a PCO2 of 37 mm Hg (normal: 35–45) is stable, as this value does not indicate respiratory distress.
33.A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor?
- Headache
- Dependent edema
- Polyuria
- Photosensitivity
Explanation: Ondansetron is a 5-HT3 receptor antagonist commonly used to manage nausea and vomiting associated with chemotherapy. A well-known adverse effect of ondansetron is headache, which occurs in a significant percentage of patients. Dependent edema (swelling in lower extremities) is not typically associated with ondansetron; it’s more related to conditions like heart failure or fluid overload. Polyuria (excessive urination) and photosensitivity are also not common side effects of this medication. Monitoring for headache is essential as it may require additional management.
42.A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- "The infusion rate has stopped but the tubing is not kinked."
- "The area surrounding the insertion site feels warm to the touch."
- "There is fluid leaking around the insertion site."
- "There is no blood return when the tubing is aspirated."
Explanation: Phlebitis is inflammation of the vein, often associated with IV therapy. Common signs include warmth, redness, swelling, and tenderness at the insertion site. Warmth is a key indicator of inflammation, making this the correct choice. The other options may indicate different issues: a stopped infusion could suggest a mechanical issue, fluid leakage might indicate infiltration, and lack of blood return could suggest a clot or occlusion, but these are not specific to phlebitis.
33.A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor?
- Headache
- Dependent edema
- Polyuria
- Photosensitivity
Explanation: Ondansetron is a 5-HT3 receptor antagonist commonly used to manage nausea and vomiting associated with chemotherapy. A well-known adverse effect of ondansetron is headache, which occurs in a significant percentage of patients. Dependent edema (swelling in lower extremities) is not typically associated with ondansetron; it’s more related to conditions like heart failure or fluid overload. Polyuria (excessive urination) and photosensitivity are also not common side effects of this medication. Monitoring for headache is essential as it may require additional management.
43.A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?
- Assigning two assistive personnel (AP) to ambulate ALL clients.
- Assigning a new graduate nurse to perform a wet-to-dry dressing change.
- Assigning the most efficient AP to perform glucometer monitoring for each client.
- Assigning the most competent RN to perform a central line dressing change.
Explanation: Overdelegation occurs when a task is assigned beyond the capability or scope of practice of the personnel, or when the workload is excessive. Assigning two APs to ambulate all clients on a 10-bed unit is likely excessive, as it may not be feasible for two individuals to safely and effectively manage all clients, especially if some have complex mobility needs. The other options are within the scope of practice: a new graduate nurse can perform a wet-to-dry dressing change with supervision, glucometer monitoring is appropriate for an AP, and a competent RN is suitable for a central line dressing change.
44.A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
- A client who needs assistance with a bath.
- A client requesting a referral for home health services.
- A client asking about his PCA pump that contains morphine.
- A client who has questions about his new prescription.
Explanation: Prioritization in nursing follows the ABCs (Airway, Breathing, Circulation) and focuses on addressing the most urgent needs first. A client asking about their PCA (patient-controlled analgesia) pump with morphine may be experiencing pain or a malfunction, which could indicate a need for immediate assessment to ensure proper pain management and safety (e.g., avoiding overdose or underdose). The other clients’ needs—assistance with a bath, a referral, or questions about a prescription—are less urgent and can be addressed after ensuring the PCA pump issue is resolved.
45.A nurse in the emergency department is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (Select all that apply.)
- Hypotension
- Polyuria
- Hyperthermia
- Absence of bowel sounds
- Weakened gag reflex
Answer: Hypotension, Hyperthermia, Weakened gag reflex.
Explanation: A suspected cervical cord injury requires immediate interventions to stabilize the client and prevent further damage. Hypotension is a concern due to potential neurogenic shock from loss of sympathetic tone, which can lead to vasodilation and decreased blood pressure—requiring immediate intervention like fluid resuscitation or vasopressors. Hyperthermia can occur if the injury disrupts the body’s temperature regulation, and it needs to be addressed to prevent further complications. A weakened gag reflex indicates a risk of aspiration, requiring airway protection measures. Polyuria and absence of bowel sounds, while concerning, are not immediate priorities in this context, as they are less likely to cause acute harm compared to the other options.
46.A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)?
- Developing the plan of care for a client who has an amputation.
- Evaluating the outcomes of a new postoperative client.
- Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus.
- Assisting a client with crutch walking following knee replacement surgery.
Explanation: LPNs have a scope of practice that includes performing tasks like assisting with activities of daily living, monitoring stable clients, and providing basic care under the supervision of an RN. Assisting a client with crutch walking is within the LPN’s scope, as it involves supporting mobility and ensuring safety. The other tasks—developing a plan of care, evaluating outcomes, and analyzing data—require higher-level critical thinking and decision-making, which are typically the responsibility of an RN.
47.An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
- "There is a higher risk of infection for our clients associated with artificial nails."
- "You should feel that artificial nails have a very unprofessional appearance."
- "I want you to review the facility’s policy on personal attire before you begin the shift."
- "Why would you wear artificial nails to work when you know it’s against the rules?"
Explanation: Artificial nails can harbor bacteria and increase the risk of infection, which is a significant concern in a healthcare setting. The nurse should address this issue professionally by focusing on patient safety, making the first statement the most appropriate. The second option is subjective and unprofessional, the third deflects the issue without addressing the immediate concern, and the fourth is confrontational and accusatory, which is not conducive to a constructive conversation.
48.A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A client who is experiencing fetal death at 32 weeks of gestation.
- A client who is experiencing preterm labor at 26 weeks of gestation.
- A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.
- A client who has a post-term pregnancy at 42 weeks of gestation.
Explanation: Tocolytic therapy is used to suppress preterm labor and delay delivery, typically to allow time for fetal lung maturation (e.g., with corticosteroids) or transfer to a higher level of care. A client in preterm labor at 26 weeks is an appropriate candidate for tocolytics, as delaying delivery can improve neonatal outcomes. Tocolytics are not indicated for fetal death (as there is no benefit to delaying delivery), Braxton-Hicks contractions (which are normal and not true labor), or post-term pregnancy (where the goal is often to induce labor, not delay it).
49.A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?
- Close the fire doors on the unit.
- Activate the fire alarm.
- Move any clients in the immediate vicinity.
- Use a fire extinguisher to put out the fire.
Explanation: The priority in this situation is to address the immediate danger—the smoldering fire—before it escalates. Using a fire extinguisher to put out the fire is the most direct action to eliminate the threat. While the other actions (closing fire doors, activating the alarm, and moving clients) are part of a comprehensive fire response, they are secondary to extinguishing the small fire, especially since it is still in the smoldering stage and can be managed quickly. This follows the RACE protocol (Rescue, Alarm, Confine, Extinguish), but in this case, extinguishing the fire is the most urgent step since it’s a small, manageable fire.
50.A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
- Identify the client’s nutritional status.
- Request a mental health consult.
- Plan a therapeutic diet for the client.
- Provide a structured environment for the client.
Explanation: The client’s significant weight loss (11 kg in 3 months) and low body weight (40 kg) suggest a critical nutritional deficit, potentially indicative of an eating disorder like anorexia nervosa, especially given her distorted body image (“believes she is fat”). The first priority is to assess her nutritional status to determine the extent of malnutrition and any immediate risks (e.g., electrolyte imbalances, cardiac issues), which can be life-threatening. While a mental health consult, therapeutic diet, and structured environment are important, they come after ensuring the client’s physical stability through a nutritional assessment.
61.A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A client who has a splintered open fracture of left medial malleolus
- A client who has a massive head injury and is experiencing seizures
- A client who has severe respiratory stridor and a deviated trachea
- A client who has a small circular partial-thickness burn of the left calf
Explanation: In a mass casualty event, triage prioritizes clients based on the ABCs (Airway, Breathing, Circulation). The client with severe respiratory stridor and a deviated trachea indicates a critical airway emergency, likely due to a tension pneumothorax or upper airway obstruction, which can lead to rapid deterioration and death if not addressed immediately. The client with a massive head injury and seizures is also critical but has a less immediate threat to life if the airway is patent. The splintered open fracture and partial-thickness burn, while serious, are not immediately life-threatening compared to the airway issue.
62.A nurse receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- “The client’s family members have been present most of the day.”
- “The client’s blood pressure and pulse have been fluctuating throughout the day.”
- “The client discussed having prior thoughts of suicide.”
- “The client works in the hospital radiology department.”
Explanation: A client with a history of suicidal thoughts requires close monitoring and a comprehensive mental health assessment, which are within the scope of a registered nurse’s responsibilities. This situation indicates the need for the nurse to assume total care rather than delegating tasks to assistive personnel (AP), who are not trained to handle complex psychological assessments or interventions. The other options—family presence, fluctuating vital signs, and the client’s occupation—do not necessarily preclude delegation of appropriate tasks to an AP, such as taking vital signs or assisting with daily activities, under the nurse’s supervision.
63.A nurse manager is reviewing information about critical pathways with the unit nurses. Which of the following information should the nurse manager include?
- “Critical pathways should include evidence-based interventions.”
- “Critical pathways replace nursing care plans.”
- “Critical pathways are used for clients who have rare medical diagnoses.”
- “Critical pathways reduce the amount of paperwork involved in client care.”
Explanation: Critical pathways are standardized, evidence-based care plans designed to guide the management of specific conditions, ensuring consistency and quality of care. They are based on best practices and research to optimize patient outcomes, making the inclusion of evidence-based interventions a key component. Critical pathways do not replace nursing care plans but complement them by providing a structured approach. They are typically used for common diagnoses (not rare ones) to streamline care, and while they may improve efficiency, their primary goal is not to reduce paperwork but to enhance care coordination and outcomes.
64.A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- Cover the cord with a sterile, moist saline dressing
- Prepare the client for an immediate birth
- Place the client in knee-chest position
- Insert a gloved hand in the vagina to relieve pressure on the cord
Explanation: Umbilical cord prolapse is an obstetric emergency where the cord slips into the vagina ahead of the fetus, risking compression and compromised fetal oxygenation. The first action is to relieve pressure on the cord to restore blood flow, which can be done by inserting a gloved hand into the vagina and gently lifting the presenting part (e.g., the baby’s head) off the cord. This is a priority to prevent fetal hypoxia. Covering the cord with a sterile, moist saline dressing is a subsequent step to prevent drying, while the knee-chest position can help but is not the first action. Preparing for immediate birth is not the initial step, as relieving pressure takes precedence.
65.A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?
- Insomnia
- Constipation
- Drowsiness
- Hypoactive deep-tendon reflexes
Explanation: Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. An overdose can lead to symptoms of hyperthyroidism, as it increases the body’s metabolic rate. Insomnia is a classic sign of hyperthyroidism due to increased metabolism and nervous system stimulation. Constipation, drowsiness, and hypoactive deep-tendon reflexes are more indicative of hypothyroidism (underactive thyroid), which would occur if the dose were insufficient, not excessive.
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