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The nurse is demonstrating effective prioritization for assigned clients. Place the actions in the order in which they need to be performed, starting with the highest priority.
- A. Complete an incident report about a client fall that occurred three hours ago.
- B. Perform a sterile dressing change on a client with a sacral wound.
- C. Suction a client's endotracheal tube who is receiving mechanical ventilation.
- D. Administer prescribed antihypertensive medications to a client with hypertension.
- E. Administer a prescribed long-acting bronchodilator via nebulizer for a client with pneumonia.
Correct Answer: C, D, B, E, A
Rationale: 1. Suctioning an endotracheal tube (C) ensures airway patency, a life-saving priority. 2. Administering antihypertensives (D) prevents cardiovascular complications. 3. Sterile dressing change (B) prevents infection but is less urgent. 4. Bronchodilator (E) improves breathing but is long-acting, less time-sensitive. 5. Incident report (A) is administrative and not urgent.
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The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN? Select all that apply. A client
- A. receiving oral antibiotics for lower extremity cellulitis.
- B. newly admitted with an exacerbation of myasthenia gravis.
- C. with a chest tube and receiving mechanical ventilation.
- D. requiring a referral to an outpatient support group.
- E. needing to receive intramuscular RhoGAM.
- F. needing scheduled tube feedings and colostomy irrigations.
Correct Answer: A, E, F
Rationale: Oral antibiotics for cellulitis (A), intramuscular RhoGAM (E), and tube feedings/colostomy irrigations (F) are stable tasks within the LPN’s scope. Myasthenia gravis exacerbation (B), chest tube/ventilation (C), and support group referral (D) require RN assessment or coordination due to instability or complexity.
The nurse serves as a witness to a client giving informed consent to the primary healthcare provider (PHCP). The nurse understands that by a client giving consent this respects the client's
- A. beneficence.
- B. autonomy.
- C. nonmaleficence.
- D. confidentiality.
Correct Answer: B
Rationale: Informed consent respects client autonomy (B), allowing self-determination in medical decisions, per ethical principles. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and confidentiality (D) protects information, but autonomy is central to consent.
The nurse manager reviews the results of a staff satisfaction survey. The feedback requests better engagement from the manager and staff involvement in unit-based decisions. Based on this feedback, the nurse manager plans to adjust their management style to
- A. democratic.
- B. transactional.
- C. laissez-faire.
- D. autocratic.
Correct Answer: A
Rationale: A democratic management style (A) involves staff in decision-making, addressing the feedback for better engagement and involvement. Transactional (B), laissez-faire (C), and autocratic (D) styles do not promote collaborative decision-making.
The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who
- A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation.
- B. has profuse bleeding from a chest laceration and is experiencing apnea.
- C. has a crushed leg reporting no sensation and has no distal pulse.
- D. is experiencing severe anxiety and has abrasions on both arms.
Correct Answer: B
Rationale: Profuse chest bleeding and apnea (B) indicate immediate life-threatening airway and circulation compromise, requiring trauma center transport. Forearm swelling (A), crushed leg (C), and anxiety (D) are serious but less acute, as they have intact vital signs or are stable.
Client One, prednisone 10 mg PO Daily for asthma exacerbation
Client Two, acetaminophen 500 mg PO x 1 dose for fever
Client Three, magnesium oxide 250 mg PO Daily For chronic dode 150 mg PO Daily
Client Four, glargine insulin 15 units SubQ Daily for diabetes mellitus
The nurse is performing medication administration for four clients. Which client and medication should be administered first?
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
Correct Answer: B
Rationale: Acetaminophen for fever (B) is the priority to address an acute symptom that may indicate infection or discomfort, requiring timely intervention. Prednisone (A), magnesium oxide (C), and glargine insulin (D) are daily medications with less immediate urgency.