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The nurse is caring for assigned clients. The nurse should initially
- A. evaluate a client’s Mantoux test for tuberculosis tuberculin skin (TB) test for reactivity 48 hours after it has been administered.
- B. assess a client with atrial fibrillation who has an irregular pulse (P) of 90 beats/minute.
- C. apply the catheter prescribed medication to the lumbar back region of a client with chronic pain.
- D. administer the prescribed antibiotic scheduled for a client with peritonitis.
Correct Answer: D
Rationale: Administering antibiotics for peritonitis (C) is the priority to treat life-threatening intra-abdominal infection. TB test evaluation (D), AF pulse assessment (B), and lidocaine patch application (A) are less urgent, as they address stable or chronic conditions.
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The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Irrigates an indwelling catheter with warm tap water.
- B. Administers glargine insulin for a client with nothing by mouth (NPO) status.
- C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia.
- D. Clamps a chest tube while the client ambulates.
- E. Repositions a client who requires log rolling by using a gait belt.
Correct Answer: A, B, D, E
Rationale: Irrigating with tap water (A) risks infection, insulin for NPO client (B) risks hypoglycemia without RN assessment, clamping a chest tube (D) risks pneumothorax, and using a gait belt for log rolling (E) is incorrect technique. ECG (C) is within LPN scope.
The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client
- A. immediately post-operative following a thyroidectomy.
- B. with a paralytic ileus requiring the management of a nasogastric tube.
- C. receiving intravenous magnesium sulfate for status asthmaticus.
- D. with a hypertensive crisis requiring initiation of intravenous nicardipine.
Correct Answer: B
Rationale: Managing a nasogastric tube for paralytic ileus (B) is within the LPN’s scope for stable clients. Post-thyroidectomy (A), magnesium sulfate (C), and hypertensive crisis (D) require RN monitoring due to critical risks.
The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.
The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit?
- A. The nurse documents care under another nurse's username and password
- B. The nurse takes pictures of a client's medical record and distributes them online
- C. The nurse does not notify the physician of a client's critical laboratory result
- D. The nurse treats their spouse in the acute care facility with prescribed medications
Correct Answer: A, B, C, D
Rationale: All options (A, B, C, D) are sources of negligent lawsuits: documenting under another’s credentials (A) is fraudulent, sharing medical records online (B) violates HIPAA, failing to report critical results (C) delays care, and treating a spouse with medications (D) breaches professional boundaries and scope of practice. Since the question implies multiple selections, all are correct.