You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene? A. Suctioning the tracheostomy tube before performing tracheostomy care B. Removing old dressings and cleaning off excess secretions C. Removing the inner cannula and cleaning using universal precautions … Read More »
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? Select all that apply. A. Assess for indicators of fluid imbalance. B. Review fingerstick glucose results every hour. C. Measure vital signs every 15 minutes. D. Document intake and output every hour.… Read More »
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A. Evaluating the patient’s complaint of chest pain. B. Monitoring laboratory values for changes in oxygenation. C. Assessing for symptoms of respiratory failure. D. Auscultating the lungs for crackles. … Read More »
During the shift of a triage nurse in the Emergency Department (ED), the following clients arrive. Which client needs the most rapid response to protect other clients in the ED from infection? A. A 72-year-old who must undergo tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight. B. A 58-year-old… Read More »
The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities Correct Answer: A. Respiratory status Assessing respiratory status is the… Read More »
You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly prove to the RN? Select all that apply. A. Position the patient supine and turned on his side. … Read More »
The nurse is assigned to a client who has a draining sacral wound infected by MRSA. Which personal protective equipment (PPE) will the nurse plan to use in preparing to change the linens of the client? Select all that apply. A. Gloves B. Goggles C. Gown D. N95 respirator E. Surgical… Read More »
A client is admitted to the unit with the diagnosis of Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be charged to a nursing assistant? A. Administer intravenous (IV) fluids as prescribed by the physician. B. Develop a plan for added fluid intake over 24 hours.… Read More »
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid: A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates Correct Answer: B. Broccoli Broccoli is known to be… Read More »
You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? A. Assessing for… Read More »