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A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
- A. A client with a chest tube requiring frequent oral suctioning.
- B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
- C. A client 24 hours post-abdominal surgery requiring daily wound care.
- D. A client with new-onset seizures awaiting diagnostic tests.
Correct Answer: C
Rationale: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.
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The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
The nurse is caring for the following assigned clients. The nurse should prioritize following up with the client
- A. who had a myocardial infarction two days ago, and has an elevated troponin level.
- B. with infective endocarditis who wants to leave against medical advice (AMA).
- C. who has arterial insufficiency and is reporting leg pain after walking in the hall.
- D. recovering from cardiac catheterization, who has developed atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation post-cardiac catheterization (D) is a new, potentially unstable arrhythmia requiring immediate follow-up. Elevated troponin (A) is expected post-MI, AMA (B) needs discussion, and leg pain (C) is less urgent.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
- A. Battery is an intentional touching of another's body without the other's consent.'
- B. Assault is when the nurse makes a verbal or physical threat.'
- C. Unintentional torts include negligence and malpractice.'
- D. Defamation is presenting false credentials for employment.'
- E. Occurrence reports reduce the liability for a negligent tort.'
Correct Answer: A, B, C
Rationale: Battery (A) is non-consensual touching, assault (B) is a threat, and negligence/malpractice (C) are unintentional torts, all correct. Defamation (D) involves false statements harming reputation, not credentials, and occurrence reports (E) document but don’t reduce liability.
The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.