leadership

Charge nurse takes over for nurse on break, which client checked first
-40ml dark colored urine
UAP stuck in palm by needle with Hep B
-wash hands with soap and water
Assess first
-coronary syndrome with increasing SOB
New clinical documentation
-Need to discuss new clinical documentation that helps save lifes and require one
more document
PCA to PO. BP increases 120/72 to 150/90. Additional questions/comments to HCP
-can PCA be reinitiated
Most immed, intervention by nurse
-pneumothorax with 80 o2
Intervention best to delegate to LPN
-duragesic
Morning lab, follow-up first
-BNP assay, MI with SOB 1000
UAP to assemble nephrostomy tube
-change bag to leg bag
Women health fair, PN helping RN
-assist with bone density prep
Warrants immediate attention
-female with RLQ pain in abd, febrile and vomiting
Delegated to UAP
-apply abd binder
Multidisplinary team

-elderly man with BGL 400

Assess first
-constipation
-weakness
-pressure ulcer with skin flap
-hep A
Triaging ER client assess first
-elderly
-child
-female
-male
67 y/o female client recently widowed, increased confusion/disorientation.
-medical eval, managed healthcare plan
Female resident who is mentally alert and lives in a long-term care facility reports
that a staff member slapped her
-does she know the name of the person
Most important to assign which client to a RN rather than PN
-Pain scale of 9
PN reports to RN, patient pulled out CVC, UAP is with him in room. Stat dose of oral
antianxiety med. RN assign care
-RN with CVC, PN stat med, UAP VS on new admission
Charge nurse is making assignments for a 15 bed skilled nursing unit with staff of
one RN, 2 LPNs, and 2 UAPs which assigned to RN
Order women with history of HTN transferred from long-term to ICU b/c of HF, has
DNR (SATA)
-BP, MAP 92
-body weight daily
-prepare family for end of life

-monitor urine
RN assigned to care for four surgical clients. Which client should nurse see first.
-3 postop, 1 preop
The nurse is caring for a group of clients on a surgical unit. What action should the
nurse implement first
-prepared for OR
0200 nurse phones HCP to request med for client who is unable to sleep four times
the the dose. Nurse questions, HCP sleepy says yea, ok action first
-call HCP about dosage
Watches UAP bring soap, washcloths, and towels and a basin into room with male
client who has suprapubic catheter inserted earlier today.
Telephone triage at clinic office. Which client is most acute and should be
scheduled for the first available appointment.
-21 y/o with kidney transplant, fever of 102, flu-like symptoms
Nurse should assess the client with which problem first
-arterial occlusion
RN gathering supplies to assist HCP with bedside thoracentesis when ED calls to
report on a client with unstable angina
-PN assist with thoracentesis, RN gets report, UAP prepares room
UAP give bath and change bed linen on Kaposi sarcoma (associated with HIV)
-tell UAP to wear gloves and gown when handling linen
Safely assess last drainage
-Jackson-Pratt, no postop drainage after 8 hours
Postop RR decrease from 14 to 6 after opioid. 30 minutes later decreases to 4.
Narcan given
-why wait so long to call HCP
Nurse determines that an IV vesicant chemo infusion is infiltrated
-apply cold compress
Nurse planning care for 4 postop clients, different drainage systems

5 y/o boy with mumps is transferred to the peds unit. Nursing intervention most
important to implement?
-PPE cart placed in front of the clients door
Evening shift on med unit is busy, only nurse on the unit is busy with an unstable
patient. HTC is on the phone with the unit secretary for an order for OTC laxative
PRN. What is the best response?
-the nurse will call you back as soon as possible to obtain the order
Elderly male who is ketoacidotic becomes agitated when the nurse attempts to
orient the client to time and place. What room is the best for this client?
-the room next to nurses station
Pt diagnosed with unstable angina is scheduled for cardiac cath. Select all.
-assess chest pain or armpit pain, check pulses on both feet, assess groin access
site, monitory VS per post op protocol.
Nationally known management consultant is expensive and is here to give a
presentation at a local hospital. What is the best way to make sure that the
information is received and passed onto other staff members?
-send 2 nurses to get information
Making assignments for the day, which info provided during change of shift report is
most important for the charge nurse to consider?
-elderly female client who refuses to be cared for by a male nurse
Patient being transferred from PACU, what would finish the report cardiac patient
-when was the last narcotic given
Patient being transferred from PACU, what would finish report
-absent bowel sounds..
PN observes that LPN performed a dressing change. But when the PN goes the
check the patient she notices that the dressing is 2 days old. What should the PN
do first?
-consult the LPN about the discrepancy
Which client is assessed first at the beginning of the shift
-acute abdominal pain

Iv on male client admitted with sepsis. UAP told to get VS. UAP reports that skin is
flushed and dry with temp of 102 HR 120, RR 24. What should the nurse delegate to
the UAP
-ask client if in pain
UAP has restrained a female client to a wheel chair and the client is asking to be
untied. The UAP explains to the nurse that this is the only way she can put new
sheets on the patients bed. What action should the CN take?
-advise the UAP to remove the restraints immediately
Charge nurse is making assignments in an inpatient psych unit. Which task should
be given to the LPN
-admin of routine meds
Upon morning shift, which patient do you assess first
-40 y/o with triple A and low back pain
Which can the LPN do? (THESE ARE NOT THE ANWERS)