prioritize what must be done.”
110 C LIENT M ANAGEMENT AND L EADERSHIP S UCCESS
PRACTICE QUESTIONS ANSWERS AND RATIONALES
Setting Priorities When Caring
for Clients
1. 1. This client is exhibiting signs of auto- nomic dysreflexia, which requires immediate intervention. A distended bladder may be causing the signs/ symptoms.
2. This is a psychosocial need and should be addressed, but it is not priority over a phys- iologic need.
3. This temperature is elevated and the client should be seen, but this is not priority over a client who is experiencing autonomic dys- reflexia, which is a medical emergency. 4. The client should be medicated prior to
being taken to whirlpool, but this is not pri- ority over a client experiencing autonomic dysreflexia, which is a medical
emergency.
MAKING NURSING DECISIONS:When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the expected options, the test taker should determine which situation is more life threatening.
2. 1. The client having pain when ambulating after an ORIF of the hip is expected; this client would not need to be assessed first. 2. The client should be ambulating and mov-
ing the left leg while in bed and would not need to be in the continuous passive motion (CPM) machine 10 days postoperatively.
3. Numbness and tingling of the legs are signs of possible neurovascular compro- mise. This client should be assessed first.
4. The client being transferred should be assessed but would be considered stable; therefore, this client would not be assessed before a client experiencing possible neu- rovascular compromise.
3. 1. An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease. If the client can move the toes and denies tingling or numbness, then no further action should be taken.
2. To identify the location of the pulse, the nurse should use a Doppler device to amplify the sound, but this is not the first
intervention if the client is able to move the toes and denies numbness and tingling. 3. Placing the client’s leg in a dependent posi-
tion will increase blood flow and may help the nurse palpate the pulse, but it is not the nurse’s first intervention.
4. Warming will dilate the arteries and may help the nurse to find the pedal pulse, but this is not the first intervention. (Cooling, in contrast, causes vasoconstriction and decreases the ability to palpate the pulse.)
4. 1. If the client’s international normalized ratio (INR) is elevated, the antidote for the oral anticoagulant warfarin (Coumadin) is vitamin K, but this is not the nurse’s first intervention.
2. The client should be using a soft bristle toothbrush, but this is not the nurse’s first intervention.
3. The nurse can always check the client’s vital signs, but it is not the first intervention when addressing the client’s complaint of gums bleeding.
4. The nurse should first check the client’s INR to determine whether the bleeding is secondary to an elevated INR level— above 3.
5. 1. The NSAID is a routine medication and is not a priority medication.
2. The client complaining of heartburn should receive the antacid first because the client is in pain. A client in pain should be the nurse’s first priority.
3. The client who is constipated needs the stool softener, but this is not priority over the client who is in pain.
4. The antiplatelet is not priority over a client who is in pain.
6. 1. The nurse should demonstrate the proce- dure on a model, but the first intervention should be to assess, to determine whether the client has any questions.
2. The nurse should provide the client with written instructions, but the first interven- tion should be to assess, to determine whether the client has any questions.
3. The client cannot learn if he has any questions or concerns. Therefore, the first intervention is to ask the client whether he has any questions. The
nurse must allay any concerns or fears of the client before beginning to teach the client.
4. The nurse should show the client all the equipment, but the first intervention should be to assess, to determine whether the client has any questions.
7. 1. Identifying the first area that began seizing will provide information and clues as to the location of the seizure origin in the brain, but it is not the nurse’s first intervention.
2. The nurse should first look at his or her watch and time the seizure. Assessment is the first intervention because there is no action the nurse can implement to stop or intervene with the seizure.
3. The client’s bed rails should be padded, but this is not the first intervention when walk- ing into a room where the client is begin- ning to have a seizure. The nurse should first assess the seizure and then pad the side rails if there is time. The seizure may be over by the time the nurse can pad the side rails.
4. The client should be protected from onlookers, but the nurse should always assess and care for the client first.
8. 1. The nurse should obtain the needed equip- ment, but that is not the first intervention. 2. The nurse should remove the old dressing
with nonsterile gloves, but not before determining whether the client has been premedicated.
3. The nurse should explain the procedure prior to performing the dressing change, but that is not the first intervention.
4. Dressing changes for a stage III pres- sure ulcer will be painful for the client, and the nurse should make sure the client has received pain medication at least 30 minutes prior to the procedure. This is showing client advocacy.
9. 1. The H&H are low, which requires the nurse to assess this client first. The nurse must take the client’s vital signs, check the surgical dressing, and deter- mine whether the client is symptomatic for hypovolemia.
2. The client with rheumatoid arthritis should have a positive rheumatoid factor (RF). The positive RF factor confirms the diag- nosis of this disease process.
3. A client with a stage IV pressure ulcer would frequently have an infection; there- fore, the nurse would expect an elevated white blood cell (WBC) count.
4. The therapeutic level for digoxin is 0.8 to 2; therefore, this client would not need to be assessed first.
MAKING NURSING DECISIONS: The test taker must know normal laboratory data. See Appendix A for normal laboratory data.
10. 1. The nurse should complete a report docu- menting the client’s fall, but this is not the first intervention.
2. The nurse should notify the clinical manager, but this is not the nurse’s first intervention.
3. The nurse must first determine whether the client has any injuries before taking any other action. This is the first intervention the nurse must implement prior to moving the client.
4. The nurse should determine why the client was ambulating alone, but it is not the priority nursing intervention. Deter- mining whether the client has any injuries is the most important intervention.
Delegating and Assigning
Nursing Tasks
11. 1. The triple-lumen lines should be flushed with 100 units/mL heparin solution, and this task should not be delegated to a UAP. 2. This is teaching, and the nurse should not
delegate teaching to the client.
3. The UAP can assist the client to the bathroom as part of the bowel train- ing; the nurse is responsible for the training, but the nurse can delegate this task.
4. This client is unstable and at risk for choking; therefore, the nurse should not delegate this task.
MAKING NURSING DECISIONS: The nurse cannot delegate assessment, evaluation, teaching, administering medications, or an unstable client to a UAP.
12. 1. Because the UAP is informing the nurse of pertinent information, the nurse should assess the client to deter- mine which action to take.
2. The client may be hemorrhaging; there- fore, the nurse cannot delegate assessing vital signs on an unstable client. 3. The nurse should not remove the dress-
ing. The nurse should reinforce the dress- ing and notify the HCP if bleeding does not stop or if the client is showing signs of hypovolemia. Reinforcing the dressing
would help decrease bleeding, but the nurse must assess first.
4. The client is potentially unstable; there- fore, the nurse should not delegate any care to the UAP.
MAKING NURSING DECISIONS:Anytime the nurse receives information from another staff member about a client who may be experiencing a complication, the nurse must assess the client. The nurse should not make decisions about client’s needs based on another staff member’s information.
13. 1. Tying a client to a chair is a form of restraint, and the client cannot be restrained without an HCP order; therefore, the nurse should immedi- ately free the client. This is a legal issue.
2. The UAP is not hired to smoke with the client and the nurse should talk to the UAP, but this does not warrant an imme- diate response. The client’s being illegally restrained warrants immediate
intervention.
3. The UAP’s bringing a beverage to the client would not warrant immediate intervention.
4. The UAP can assist the client to ambulate.
14. 1. The client is diabetic, and the charge nurse should not delegate cutting the client’s toenails to the UAP.
2. The LPN should not cut the client’s toe- nails because the client is diabetic.
3. A podiatrist can cut the client’s toe- nails, the nurse should make this referral.
4. The client is diabetic. This puts the client at risk for delayed healing if a cut on the foot occurs; therefore, this client is unsta- ble and the nurse should not cut the toenails.
MAKING NURSING DECISIONS:When the test taker is deciding which option is the most appropriate task to delegate/assign, the test taker should choose the task that allows each member of the staff to function within his or her full scope of practice. Do not assign a task to a staff member that requires a higher level of expertise than the staff member has; similarly, do not assign a task to a staff member when it could be dele- gated/assigned to a staff member with a lower level of expertise.
15. 1. The UAP can assist a client to eat a regu- lar meal; this would not warrant immedi- ate action.
2. The UAP’s request for assistance is appro- priate because it is ensuring client safety. This action would not warrant immediate behavior.
3. The UAP is attempting to move a client who weighs 400 pounds to the bedside commode. The UAP should request assistance to ensure client safety as well as to protect the UAP’s back. This is a dangerous situation and requires intervention by the nurse.
4. This action ensures client safety and does not require immediate intervention by the nurse.
16. 1. The client with a lower extremity amputa- tion should be placed in the prone posi- tion to prevent contractures.
2. The nurse should praise the UAP for taking the initiative and placing the client in the prone position. The prone position will help prevent contractures of the residual limb, which helps when applying a prosthetic device.
3. This action is appropriate and should not be reported to the charge nurse. The nurse should first praise the UAP and then report this behavior to the charge nurse if wanting to reward the UAP for appropriate behavior.
4. The client with a lower extremity amputa- tion presents one of the few times a client should be placed on the stomach, the prone position.
17. 1. Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest. Applying the stockings when the client is sitting in a chair indi- cates that the UAP does not understand the correct procedure for applying the elastic compression stockings.
2. The top of stocking should not be too tight. The UAP should be able to insert two to three fingers under the proximal end of the stocking. Not allowing this much space indicates the UAP does not understand the correct procedure for applying compression stockings.
3. Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest. Having the client elevate the legs before placing
the stockings on the legs indicates that the UAP understands the procedure for applying the elastic compression stockings.
4. The toe opening should be positioned on the bottom of the foot; therefore, this indicates the client does not understand the correct procedure for applying the elastic compression stockings.
18. 1. Someone must talk to this client, but the RN does not need to be assigned this client.
2. The multidisciplinary team has been preparing the client for discharge since admission to the rehabilitation unit; there- fore, the charge nurse does not need to assign the RN this client.
3. The client with AIDS dementia would be confused and disoriented as a result of this diagnosis; therefore, the charge nurse would not need to assign the RN this client.
4. New deficits in the visual fields in a client diagnosed with a CVA could indicate an expanding or a new prob- lem. The RN should be assigned to this client.
MAKE NURSING DECISIONS:When the nurse is deciding which client should be assigned to the RN, the most critical client or the client requiring more expert care should be assigned to the RN.
19. 1. The LPN should not be sent to the emer- gency department because the LPN’s expertise is needed to care for the clients on the busy rehabilitation unit.
2. The RN has 8 years experience on the rehabilitation unit, and the charge nurse does not want to send a nurse who is a vital part of the rehabilitation team. 3. The UAP who is completing orientation
should stay on the unit, and a UAP would not be able to do as much in the emergency department as a licensed nurse.
4. The RN with medical unit experience would be the most appropriate nurse to send to the emergency department because this nurse has experience that would be helpful in the ED. The nurse is also an RN, who would be more helpful in the ED than a UAP or an LPN.
20. 1. The UAP cannot teach the client; there- fore, this task cannot be delegated.
2. The client is confused and should be assessed prior to being placed in an inclu- sion bed, which is used when a client wan- ders. The client should be assessed, and assessment cannot be delegated.
3. The UAP cannot administer medications; therefore, this task cannot be delegated.
4. The UAP is a vital part of the health- care team and should be encouraged to attend the multidisciplinary team meeting and provide input into the client’s care.
Managing Clients
and Nursing Staff
21. 1. This action will not address the client’s pounding headache. The nurse should either assess the client or intervene prior to calling the HCP.
2. Elevating the head of the bed may help decrease the client’s blood pressure by causing orthostatic hypotension, but the nurse must first determine whether the client’s BP is elevated.
3. If the client’s BP is elevated, this is proba- bly autonomic dysreflexia, an acute emergency that occurs as a result of exag- gerated autonomic responses to stimuli that are harmless in normal people and only occur after spinal shock has
resolved in clients with an SCI above T-6. The most common cause of autonomic dysreflexia is a full bladder.
4. The nurse must determine whether the client’s blood pressure is elevated. If it is, then the client is probably experiencing autonomic dysreflexia, and the nurse should assess for bladder distention, the most common cause of autonomic dysreflexia.
MAKING NURSING DECISIONS: If the test taker wants to select “notify the HCP” as the correct answer, the test taker must examine the other three options. If infor- mation in any of the other options is data the HCP would need to know in order to make a decision, then the test taker should eliminate the “notify the HCP” option.
22. 1. According to the National Council of State Boards of Nursing (NCSBN), management of care includes being knowledgeable about referrals. This client would benefit from a home health-care nurse to evaluate the
client’s home and the wife’s ability to care for the client.
2. The nurse should help the client care for her husband in the home. Placing him in a nursing home may be a possibility if she is unable to care for him, but the most appropriate response would be trying to help the wife care for her husband in the home.
3. The HCP can talk to the wife but will not be able to address her concerns of taking care of her husband when he is discharged home.
4. This is false reassurance and does not address the wife’s concern about being able to care for her husband.
23. 1. This is a formal step in filing a grievance, but the nurse’s next action should be to follow the chain of command and place an informal complaint with the clinical manager.
2. The female nurse has already told the male nurse this makes her feel uncomfortable; therefore, this action is not appropriate.
3. If a direct request to the perpetrator does not stop the comments, then an informal complaint may be effective, especially if both parties realize a problem exists. The female nurse should utilize the chain of command and notify the clinical manager.
4. The female nurse should follow the chain of command and notify the clinical man- ager as the next action.
MAKING NURSING DECISIONS:The nurse is responsible for knowing and complying with local, state, and federal standards of care.
24. 1. Assisting the client to become indepen- dent in self-care is the role of the occupa- tional therapist.
2. The client must be able to be in therapy at least 3 hours a day, but the 3-hour period includes all types of therapy, not just phys- ical therapy. This is a true statement, but it does not answer the client’s question. 3. A multidisciplinary team decides which
therapy the client should be receiving, but this does not answer the client’s question.
4. The physical therapist will assist in improving the circulation, strengthen- ing muscles, and ambulating and trans- ferring the client from a bed to a chair. This is the nurse’s best response in explaining why the client goes to phys- ical therapy daily.
25. 1. The speech therapist addresses swal- lowing problems as well as speech impediments. This is the most appro- priate team member to address the problem.
2. The registered dietitian addresses the client’s nutritional status but does not help with swallowing difficulties.
3. The occupational therapist addresses the upper extremity activities of daily living, not choking difficulties.
4. The HCP can prescribe tests to determine why the client is having choking prob- lems, but the speech therapist is the team member who can help the client with