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The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply.
- A. As needed (PRN) medications that were administered
- B. Normal assessment findings for the shift
- C. Normal laboratory results
- D. Scheduled medications that were administered
- E. Abnormal vital signs
Correct Answer: A, D, E
Rationale: PRN medications (A), scheduled medications (D), and abnormal vital signs (E) are critical for care continuity, per ISBAR standards. Normal findings (B) and normal lab results (C) are less essential unless they impact care.
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The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following activities would be appropriate to delegate? Select all that apply.
- A. Performing initial client assessments
- B. Making client beds
- C. Giving clients bed baths
- D. Administering client medications
- E. Ambulating clients
- F. Assisting clients with meals
Correct Answer: B, C, E, F
Rationale: UAPs can make beds (B), give bed baths (C), ambulate clients (E), and assist with meals (F), as these are non-clinical tasks. Initial assessments (A) and medication administration (D) require nursing judgment, reserved for RNs or LPNs.
The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.
The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
The nurse is caring for assigned clients. The nurse should initially follow up on the client who
- A. is being treated for uterine fibroids and reports painful menstrual bleeding.
- B. has type II diabetes mellitus (type two) and has a capillary blood glucose of 124 mg/dL (6.882 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. has emphysema and refused prescribed medications.
- D. is six hours postoperative following an abdominal aortic aneurysm repair and has no urine output.
Correct Answer: D
Rationale: No urine output six hours post-abdominal aortic aneurysm repair (D) suggests serious complications like renal artery occlusion or hypoperfusion, requiring immediate assessment. Painful bleeding (A), slightly elevated glucose (B), and medication refusal (C) are less urgent.
The nurse is admitting a client who is blind and deaf. The nurse should prioritize which action?
- A. Review the plan of care with the client
- B. Communicate with the nursing supervisor with any safety concerns
- C. C. Update the client on the social activities
- D. D. Provide a safe environment for the client
Correct Answer: D
Rationale: Providing a safe environment (D) is the priority for a blind and deaf client to prevent injury, using tactile communication and clear pathways. Reviewing care plans (A), addressing concerns (B), or social updates (C) are secondary to immediate safety.