assist the client back to bed complete an incident report notify the health care provider assess the client for any injuries document in the medical record that the client fell
The nurse is caring for a client with documented severe allergies to latex. Which item on the client’s meal tray should the nurse remove?
a banana a bowl of beef broth a vanilla pudding cup a cup of strawberries
The charge nurse is making assignments for the day shift. One of the nurses is 5 months pregnant. Which of the following clients is the most appropriate assignment for this expectant nurse?
a client with shingles a client with measles a client with pneumonia a client with Clostridium difficile
The nurse is working in a cardiac care unit with an LPN. A new client has just arrived. Which task is not appropriate for the nurse to delegate to the LPN?
manage existing IV fluid administration administer IM pain medication insert an indwelling catheter assess response to pain medication
The nurse is precepting a student nurse on an orthopedic floor. The student nurse needs to insert an indwelling catheter into a male client. Which of the following statements by the student nurse are correct regarding insertion of the catheter? Select all that apply.
“I need to establish an aseptic field.” “I will place the client in the supine position.” “I will lubricate the tip of the catheter with sterile lubricant included in the tray.” “I will inflate the catheter balloon with 5 cc of sterile water.”
The nurse in a long-term care setting wants to delegate the task of ambulating an elderly client with a walker to an unlicensed assistive personnel (UAP). Before delegating a task to the UAP, the nurse should first ensure which of the following is accomplished?
The client is comfortable with the UAP assisting them. The UAP is comfortable with performing the task. The UAP has performed the task previously. The UAP is approved to perform this task based on a credentialing process approved by the facility.
The nurse is caring for a 27-year-old female who presents to the ED with a fractured arm along with multiple bruises in various stages of healing around her left eye and chest. The client implies an intimate domestic partner inflicted her injuries. Which statement by the nurse is most appropriate?
“Why do you stay with a person like that? “Are you in need of an immediate place for safety?” “Why did he hit you?” “You need to report your partner to the police.”
The nurse has received report on the day’s assigned clients. Which of the following clients should the nurse see first ?
a client who is post-op day 2 from a spinal fusion at L3-4 with a pain level of 4 on a scale of 1 – 10 a client with a peripheral IV on a 6-hour infusion with 42 cc remaining a client who is 6 hours post–atrial fibrillation ablation, is agitated, has a HR of…
An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls outside the scope of practice of an LPN?
administer oral medications to a client insert a nasogastric tube care for a patient with a tracheostomy develop a nursing care plan
The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?
check the blood pressure elevate the client’s head to 30 degrees administer oxygen increase the IV rate