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A nurse is preparing to complete morning assignments on several assigned clients. Which of the following clients should the nurse plan to assess first? a. A client who had a bladder scan that indicat... ed 250 mL of urine in the bladder b. A client who is 3 days postoperative and who's dressing has serosanguinous drainage c. A client who has diabetes and an early morning blood glucose of 220 mg/dL d. A client who has a nasogastric tube to intermittent suction and reports nausea (ANS- d. A client who has a nasogastric tube to intermittent suction and reports nausea A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. Document the client's refusal in the chart. c. Assess the client for urinary retention. d. Obtain a provider's prescription for a blood alcohol level. (ANS- b. Document the client's refusal in the chart. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Pick up the meal trays after lunch. b. Administer a nasogastric tube feeding. c. Plan break times for assistive personnel. d. Determine adequacy of ventilator settings. (ANS- b. Administer a nasogastric tube feeding. A nurse preceptor is evaluating a newly licensed nurse's competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA) a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field b. Opens the sterile pack by first unfolding the top flap away from her body c. Prepares a container of sterile solution on the field after putting on sterile gloves d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e. Holds the sterile solution bottle with the label facing up (ANS- b. Opens the sterile pack by first unfolding the top flap away from her body d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? a. Auscultate the client's lungs. b. Notify the provider. c. Place a faulty equipment tag on the pump. d. Complete an incident report. (ANS- a. Auscultate the client's lungs. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Reinforcing teaching with a client who is learning to self administer insulin b. Ambulating a client who is scheduled for discharge later in the day c. Administering morphine IV bolus to a client who is __ hr postoperative d. Admitting a new client who has chronic back pain to the unit (ANS- a. Reinforcing teaching with a client who is learning to self administer insulin A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? a. The nurse applies goggles. b. The nurse turns her back to the sterile field. c. The nurse holds her hands above her waist. d. The nurse puts on a face mask. (ANS- c. The nurse holds her hands above her waist. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task? a. Review vital sign trends at the end of the shift. b. Recheck vital signs that are outside the expected reference range. c. Ask the AP to write a summary of the delegated tasks during the shift. d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift. (ANS- b. Recheck vital signs that are outside the expected reference range. [Show More]

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