On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to: A. Give the client orientation materials and review the unit rules and regulations. B. Introduce him/her and accompany the client to the client’s room. C. Take the client to the day room… Read More »
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A. Angina at rest B. Thrombus formation C. Dizziness D. Falling blood pressure Correct Answer: B. Thrombus formation A thrombus formation may prevent blood from flowing normally through the… Read More »
You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI? A. Assess the patient’s respiratory status every 4 hours. B. Take the patient’s vital signs and record them every 4 hours. C. Monitor nutritional… Read More »
During the endorsement, which of the following clients should the on-duty nurse assess first? A. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute. B. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm… Read More »
Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to… Read More »
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant? A. Document the seizure B. Perform neurologic checks C. Take the patient’s vital signs D. Restrain the patient for protection Correct Answer: C. Take the patient’s vital… Read More »
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment B. Set up oxygen and suction equipment C. Place a padded tongue blade at the bedside D. Pad the side rails before the patient arrives … Read More »
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with acute myocardial infarction. Which of the following actions would breach the client’s confidentiality? A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit. B. The… Read More »
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the… Read More »
After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching. B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59-year-old with Parkinson’s… Read More »