document the event in the client’s medical record only document the event in the client’s medical record and file an incident report document the event in the client’s medical record and have the nursing assistant file an incident report have the nursing assistant file an incident report
The nurse is working on a postsurgical floor with an LPN. A new client has just arrived. Which task is appropriate for the nurse to delegate to the LPN?
taking the client’s vital signs flushing the client’s PICC line with heparin administering morphine 2 mg IV push for pain starting total parenteral nutrition (TPN) to the client’s PICC line
The nurse has received report on the day’s assigned clients. Which of the following clients should the nurse see first ?
a client complaining of nausea and vomiting after eating breakfast a client complaining of itching and burning at the IV site while receiving normal saline a client who is post-op day 1 from a hernia repair with a pain level of 6 on a scale of 1 – 10 a client who has been given…
The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?
a client with multiple pressure ulcers requiring daily dressing changes a client with a permanent tracheostomy requiring daily tracheostomy care a client recovering from pneumonia with orders to ambulate in the hall BID a client who just received pain medication and needs to have her pain level assessed in 30 minutes
The nurse is caring for a client who lives below the poverty level. While providing discharge teaching, the nurse notes that the client has received a prescription for warfarin (Coumadin) and will need to return to the clinic for regular lab work. Which of the following is most appropriate for the nurse to ask the client?
“Which pharmacy do you use for your medications?” “Do you know when your next appointment is for lab work?” “Do you have a car or someone to take you to get your lab work done?” “Can you tell me the side effects that you should report to your physician?”
The nurse is caring for a client who is 12 weeks pregnant and presented with the following symptoms: mild uterine cramping with spotting of blood. The cervical os is closed upon examination. How should the nurse chart the findings?
missed miscarriage complete miscarriage inevitable miscarriage threatened miscarriage
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
Vital signs, including temperature, are monitored every 4 hours. The student nurse inspects the client’s mouth at least every 8 hours. The student nurse delivers a potted plant to the room sent by the client’s family. The student nurse washes her hands before performing client care or touching client belongings.
The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?
if the tube must be capped, place the cap before deflating the cuff inflate the cuff and remove the inner cannula before capping the tube inflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration deflate the cuff (if the tube is not capped) for meals and…
The nurse reviews the chart of a client diagnosed with nephrotic syndrome and expects to note which finding associated with this diagnosis?
lipiduria hypolipidemia hyperalbuminemia decreased coagulation
The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?
“Altered level of consciousness is a late sign of increased ICP.” “Elevated temperature is the earliest indication of increased ICP.” “Late signs of increased ICP include narrowed pulse pressure and a lowered heart rate.” “Late signs of increased ICP include increased systolic blood pressure and a widened pulse pressure.”