A registered nurse is planning care for a team of clients. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?
Measuring and recording vital signs for a stable client on the second day after surgery UAP can do routine, predictable tasks for stable clients, like taking vital signs. Assessment, teaching and evaluation need nursing judgment, so the RN keeps them. The RN still reviews the vital signs the UAP records.
After shift report, which client should the nurse see first?
A client 2 days after hip replacement surgery who suddenly feels short of breath and has chest pain Sudden shortness of breath and chest pain after hip surgery can mean a pulmonary embolism, which can kill quickly. That’s a breathing and circulation problem, so it comes first. The other clients are stable and can wait a few minutes.
A client is about to sign a consent form for surgery and says, “I don’t really understand what the surgeon is going to do.” What should the nurse do?
Hold off on the signature and let the surgeon know the client needs more information Consent is only valid if the client understands the procedure. Explaining the surgery, its risks and options is the surgeon’s job. The nurse’s role is to make sure the client understands before signing, so the nurse stops and contacts the surgeon.
Before giving a medication, which is the best way for the nurse to identify the client?
Compare the client’s full name and date of birth with the medication record Safe practice uses two client-specific identifiers, such as full name and date of birth, checked against the record. Room and bed numbers aren’t identifiers because clients move. A yes-or-no question can get a wrong “yes” from a confused or hard-of-hearing client.
A client has diarrhea caused by Clostridioides difficile (C. diff). After leaving the client’s room, how should the nurse clean their hands?
Wash with soap and water C. diff forms spores, and alcohol doesn’t kill them. Washing with soap and water rubs the spores off and rinses them away. That’s why hand washing, not hand rub, is used with C. diff.
A client is admitted with suspected active pulmonary tuberculosis. Which precautions should the nurse put in place?
Airborne precautions in a negative-pressure room, with an N95 respirator for staff Tuberculosis spreads through tiny airborne particles that stay in the air and travel. Airborne precautions use a negative-pressure isolation room with the door closed, and staff wear a fitted N95 respirator. A surgical mask isn’t enough for staff.
The parents of a healthy 6-month-old ask how their baby should ride in the car. What should the nurse tell them?
In a rear-facing car seat in the back seat Infants ride rear-facing in a car seat in the back seat. Rear-facing seats support the baby’s head, neck and spine in a crash. A rear-facing seat must never go in front of an active airbag.
A client asks which exercise will help most to prevent osteoporosis. Which activity should the nurse recommend?
Brisk walking Weight-bearing exercise, where your bones carry your body’s weight, helps keep bones strong. Walking is weight-bearing. Swimming and cycling are good for the heart but take weight off the bones.
A client in rehabilitation says, “I don’t think I’ll ever get better.” Which response by the nurse is most therapeutic?
“It sounds like you’re feeling discouraged. Tell me more about that.” Naming the feeling you hear and inviting the client to say more shows you’re listening. It keeps the conversation open and lets the client explain what worries them. The other replies shut the client down.
A client being treated for major depression has suddenly become calm and has started giving away personal belongings. What should the nurse do first?
Ask the client directly whether they are thinking about suicide A sudden calm and giving away belongings can be warning signs that a person has made a suicide plan. The nurse asks directly about suicidal thoughts and plans so the client can be kept safe. Asking about suicide doesn’t put the idea in someone’s head.
A client who is confined to bed is at high risk for pressure injuries. Which action should the nurse include in the plan of care?
Reposition the client at least every 2 hours Turning the client at least every 2 hours relieves pressure before the skin and tissue are damaged. Massaging red areas can harm tissue that’s already stressed. A high head of bed increases sliding and shear, and donut cushions cut off blood flow around the edge.
A client who had a stroke has trouble swallowing. Which action helps the client eat safely?
Have the client sit upright and tuck the chin down when swallowing Sitting upright and tucking the chin helps close off the airway and guide food toward the esophagus. That lowers the risk of choking and aspiration. Thin liquids, straws, lying flat and rushing all raise that risk.
An adult client is due for a scheduled dose of digoxin. The nurse counts an apical pulse of 52 beats per minute. What should the nurse do?
Hold the dose and notify the health care provider Digoxin slows the heart rate. Before each dose the nurse counts the apical pulse for a full minute. In adults, the usual rule is to hold the dose and notify the provider if the pulse is below 60.
A client takes warfarin every day. Which lab result should the nurse check to see whether the dose is working safely?
International normalized ratio (INR) Warfarin is monitored with the PT and INR. The INR shows how long blood takes to clot compared with normal, so the provider can adjust the dose. The aPTT is used to monitor IV heparin.
A client is prescribed insulin lispro, a rapid-acting insulin, before breakfast. What is most important for the nurse to do?
Make sure the meal is ready so the client eats within about 15 minutes Rapid-acting insulin starts working in about 15 minutes. If the client doesn’t eat soon after, blood glucose can drop too low. So the nurse gives it when the food is there and the client is ready to eat.
A client returned from abdominal surgery 6 hours ago. Which finding should the nurse report to the surgeon right away?
Urine output of 20 mL per hour for the past 2 hours Urine output below 30 mL an hour in an adult can be an early sign of low blood volume, bleeding or kidney problems. Two hours in a row needs to be reported. The other findings are expected after surgery.
The nurse reviews a client’s morning lab results. Which result is the priority to report to the health care provider?
Serum potassium 6.0 mEq/L The normal potassium range is about 3.5 to 5.0 mEq/L, so 6.0 is high. High potassium can cause dangerous heart rhythms, so it needs to be reported quickly. The other results are in the normal range.
A client with diabetes is shaky and sweaty. The blood glucose is 58 mg/dL. The client is awake and can swallow. What should the nurse do first?
Give 15 grams of a fast-acting carbohydrate, such as 4 ounces of juice, and recheck in 15 minutes This is hypoglycemia. If the client is awake and can swallow, the first step is 15 grams of fast-acting carbohydrate by mouth, then a recheck in 15 minutes. Glucagon is for clients who can’t safely swallow.
During an IV antibiotic infusion, a client develops hives, wheezing and a tight feeling in the throat. What should the nurse do first?
Stop the infusion These are signs of anaphylaxis. The first step is to stop the drug that’s causing it, so the client stops receiving more. Then the nurse calls for help and gives emergency treatment, such as epinephrine, as prescribed.
The nurse is caring for a client with a head injury. Which finding is the earliest sign of increased intracranial pressure?
A change in level of consciousness, such as new restlessness or confusion A change in level of consciousness is the earliest and most sensitive sign of rising pressure in the skull. Fixed pupils, Cushing’s triad and abnormal posturing are late signs that mean the brain is already badly affected.
United States · Licensing exam