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1.Charge nurse takes over for nurse on break, which client checked first
3. Assess first
-Need to discuss new clinical documentation that helps save lifes and require one more document
-pneumothorax with 80 o2
-duragesic
Assess first
-constipation
-weakness
-hep A
-elderly
-child
-female
-male
16. Female resident who is mentally alert and lives in a long-term care facility reports that a staff
member slapped her
-Pain scale of 9
18. PN reports to RN, patient pulled out CVC, UAP is with him in room. Stat dose of oral antianxiety med.
RN assign care
19. 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
20.Order women with history of HTN transferred from long-term to ICU b/c of HF, has DNR (SATA)
-BP, MAP 92
-monitor urine
21. RN assigned to care for four surgical clients. Which client should nurse see first.
-3 postop, 1 preop
22. The nurse is caring for a group of clients on a surgical unit. What action should the nurse implement
first
-prepared for OR
23.0200 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
24. Watches UAP bring soap, washcloths, and towels and a basin into room with male client who has
suprapubic catheter inserted earlier today.
25. Telephone triage at clinic office. Which client is most acute and should be scheduled for the first
available appointment.
26. Nurse should assess the client with which problem first
-arterial occlusion
27. RN gathering supplies to assist HCP with bedside thoracentesis when ED calls to report on a client
with unstable angina
28. UAP give bath and change bed linen on Kaposi sarcoma (associated with HIV)
30. Postop RR decrease from 14 to 6 after opioid. 30 minutes later decreases to 4. Narcan given
32. Nurse planning care for 4 postop clients, different drainage systems
33. 5 y/o boy with mumps is transferred to the peds unit. Nursing intervention most important to
implement?
34. 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
35. 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?
36. 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.
37. 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?
38. Making assignments for the day, which info provided during change of shift report is most important
for the charge nurse to consider?
39. Patient being transferred from PACU, what would finish the report… cardiac patient
40. Patient being transferred from PACU, what would finish report
41. 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?
43. 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
44. 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 patient’s bed. What action
should the CN take?
45. Charge nurse is making assignments in an inpatient psych unit. Which task should be given to the
LPN
47. Which can the LPN do? (THESE ARE NOT THE ANWERS)