but how can I provide for this right thing always to be done.
—Florence Nightingale
1. The nurse is caring for clients on a medical unit. Which task should the nurse implement first?
1. Change the abdominal surgical dressing for a client who has ambulated in the hall.
2. Discuss the correct method of placing Montgomery straps on the client with the UAP.
3. Assess the male client who called the desk to say he is nauseated and just vomited.
4. Place a call to the extended care facility to give the report on a discharged client.
2. The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client?
1. Obtain informed consent from the client for the diagnostic procedure.
2. Discuss the need to increase oral fluid intake after the procedure.
3. Explain to the client that he or she will have to drink a white, chalky substance.
4. Tell the client not to eat or drink anything prior to the procedure.
3. Which client warrants immediate intervention from the nurse on the medical unit?
1. The client diagnosed with dyspepsia who has eructation and bloating.
2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia.
3. The client with diverticulitis who has left lower quadrant pain and fever.
4. The client with Crohn’s disease who has right lower abdominal pain and diarrhea.
4. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia.
2. Request the UAP change the linens for the 89-year-old client with fecal incontinence.
3. Tell the UAP to assist the 54-year-old client with a bowel management program.
4. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis.
5. Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
1. The UAP is refusing to feed the client diagnosed with acute diverticulitis.
2. The UAP would not place the client on the bedside commode who was on bed rest.
3. The UAP placed the client with a continuous feeding tube in the supine position.
4. The UAP placed sequential compression devices on the client who is on strict bed rest.
QUESTIONS
6. The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised.
Which action is most appropriate for the nurse to implement first?
1. Discuss the blood administration flow sheet with the chief nursing officer.
2. Contact an individual to help design a new blood transfusion flow sheet.
3. Learn to adapt to the present form and do not take any further action.
4. Volunteer to be on an ad hoc committee to research alternate flow sheets.
7. The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure?
1. The cardiac catheterization department.
2. The dietary department.
3. The nuclear medicine department.
4. The hospital laboratory department.
8. The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse?
1. The client who has received three units of packed red blood cells (RBCs).
2. The client scheduled for an esophagogastroduodenoscopy in the morning.
3. The client with short bowel syndrome who has diarrhea and a K
+
level of 3.3 mEq/L.4. The client who has just returned from surgery for a sigmoid colostomy.
9. At 0830, the day shift nurse is preparing to administer medications to the client NPO for an endoscopy. Which medication should the nurse question administering? Select all that apply.
110 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
Client’s Name: Account Number: 123456 Allergies: Penicillin Date:
Signature/Initials Medication Lanoxin (digoxin) 0.125 mg PO every day
Lasix (furosemide) 40 mg PO bid Zantac (ranitidine) 150 mg in 250 mL NS IV continuous infusion every 24 hours Vancomycin 850 mg IVPB every 24 hours Mylanta 30 mL PO PRN heart burn.
0701–1500 0900
0900
0900
Night Nurse RN NN 2301–0700
0300 NN@11 mL/hr
Day Nurse RN DN
1501–2300
1600
2100
1. Lanoxin (digoxin) 0.125 mg PO every day.
2. Lasix (furosemide) 40 mg PO bid.
3. Zantac (ranitidine) 150 mg in 250 mL NS IV continuous infusion every 24 hours.
4. Vancomycin 850 mg IVPB every 24 hours.
5. Mylanta 30 mL PO PRN heartburn.
10. Which client should the nurse assess first after receiving the p.m. shift assessment?
1. The client with Barrett’s esophagus who has dysphagia and pyrosis.
2. The client with proctitis who has tenesmus and passage of mucus through the rectum.
3. The client with liver failure who is jaundiced and has ascites.
4. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.
11. The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority?
1. Altered nutrition.
2. Self-care deficit.
3. Impaired body image.
4. Fluid and electrolyte imbalance.
12. The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first?
1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn’s disease.
2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia.
3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease.
4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery.
13. The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first?
1. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants.
2. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset.
3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen.
4. The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10.
14. The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone?
1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm.
2. The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36.
3. The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL.
4. The client who is 8 hours postoperative for exploratory laparotomy who has a serum potassium level of 4.5 mEq/L.
15. The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications?
1. The client scheduled for removal of an abdominal mass who is overweight.
2. The client scheduled for a gastrectomy who has arterial hypertension.
3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day.
4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis.
QUESTIONS
16. The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority.
1. Cleanse the stomal site with mild soap and water.
2. Assess the stoma for a pink, moist appearance.
3. Monitor the drainage in the ostomy drainage bag.
4. Apply stoma adhesive paste to the skin around the stoma.
5. Attach the ostomy drainage bag to the abdomen.
17. The nurse is transcribing the HCP’s orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first?
1. Obtain the client’s informed consent.
2. Administer 2 mg of IV morphine, every 4 hours, PRN.
3. Shave the lower right abdominal quadrant.
4. Administer the on-call IVPB antibiotic.
18. The client 1 day postoperative abdominal surgery has an evisceration of the wound.
Which intervention should the nurse implement first?
1. Place sterile normal saline gauze on the eviscerated area.
2. Reinforce the abdominal dressing with an ABD pad.
3. Assess the client’s abdominal bowel sounds.
4. Place the client in the left lateral position.
19. The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first?
1. The client who has a paralytic ileus and has absent bowel sounds.
2. The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen.
3. The client who is 6 hours postoperative and has an abdominal wound dehiscence.
4. The client who had a liver transplant and is being transferred to the rehabilitation unit.
20. The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement?
1. Take no action because this is appropriate delegation.
2. Tell the UAP to obtain a bedside commode for the client.
3. Discuss the inappropriate delegation of the nursing task.
4. Document the situation in an adverse occurrence report.
21. The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
1. The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO244, HCO330.
2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10.
3. The client who is 12 hours postoperative abdominal surgery and has dark green bile draining in the nasogastric tube.
4. The client who is 2 days postoperative for hiatal hernia repair and is complaining of feeling constipated.
22. The unlicensed assistive personnel (UAP) tells the nurse angrily, “You are the worst nurse I have ever worked with and I really hate working with you.” Which action should the nurse implement first?
1. Don’t respond to the comment and appraise the situation.
2. Tell the UAP to leave the unit immediately.
3. Report this comment and behavior to the charge nurse.
4. Explain to the UAP that he or she cannot talk to the primary nurse like this.
112 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
23. The client is admitted to the critical care unit after a motor vehicle accident. The client asks the nurse, “Do you know if the person in the other car is all right?” The nurse knows the person died. Which statement supports the ethical principle of veracity?
1. “I am not sure how the other person is doing.”
2. “I will try to find out how the other person is doing.”
3. “You should rest now and try not worry about it.”
4. “I am sorry to have to tell you, but the person died.”
24. The client admitted to the critical care unit tells the nurse, “I have an advance directive (AD) and I do not want to have cardiopulmonary resuscitation (CPR).”
Which intervention should the nurse implement first?
1. Ask the client for a copy of the AD so that it can be placed in the chart.
2. Inform the healthcare provider of the client’s request as soon as possible.
3. Determine whether the client has a durable power of attorney for healthcare.
4. Request the hospital chaplain to come and talk to the client about this request.
25. The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse?
1. The client’s hemoglobin/hematocrit is 11.4/32.
2. The client’s abdomen is soft to touch and non-tender.
3. The client’s vital signs are T 99, AP 114, RR 18, B/P 88/60.
4. The client’s nasogastric tube has coffee ground drainage.
26. Which task should the nurse in the long-term care facility delegate to the unlicensed assistive personnel (UAP)?
1. Assist the resident up in a wheelchair for meals.
2. Assess the incontinent client’s perianal area.
3. Discuss requirements with the client for going out on a pass.
4. Explain how to care for the client’s colostomy to the family.
27. The nurse and the unlicensed assistive personnel (UAP) are caring for a client on a medical unit who has difficulty swallowing and is incontinent of urine and feces.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Check the client’s PEG feeding tube for patency.
2. Place DuoDERM wound care patches on the client’s coccyx.
3. Apply non-medicated ointment to the client’s perineum.
4. Suction the client during feeding to prevent aspiration.
28. Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the long-term care nurse?
1. The UAP is giving the client with a gastrostomy tube a glass of water.
2. The UAP is ambulating the client outside using a safety belt.
3. The UAP is assisting the client with putting a jigsaw puzzle together.
4. The UAP is giving a back rub to the client who is on bed rest.
29. The nurse is preparing to teach the male client how to irrigate his sigmoid colostomy.
Which intervention should the nurse implement first?
1. Demonstrate the procedure on a model.
2. Provide the client with written instructions.
3. Ask the client whether he has any questions.
4. Show the client all of the equipment needed.
30. The LPN tells the nurse the client diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first?
1. Assess the client’s neurological status.
2. Notify the client’s healthcare provider.
3. Request a STAT ammonia serum level.
4. Tell the LPN to obtain the client’s vital signs.
QUESTIONS
31. The nurse is changing the client’s colostomy bag. Which interventions should the nurse implement? Rank in the order of priority.
1. Remove the client’s colostomy bag.
2. Apply the client’s new colostomy bag.
3. Don non-sterile gloves.
4. Assess the client’s stoma site.
5. Cleanse the area around the client’s stoma.
32. Which task is most appropriate for the home healthcare nurse to delegate to the unlicensed assistive personnel (UAP)?
1. Instruct the UAP to give the herb ginkgo biloba to the client with Alzheimer’s.
2. Ask the UAP to perform the tube feedings for a client with a gastrostomy tube.
3. Request the UAP to perform the daily colostomy irrigation for the client.
4. Tell the UAP to wash and dry the client’s hair.
33. Which behavior by the UAP warrants intervention by the home health (HH) nurse?
The client tells the HH nurse the UAP:
1. Would not accept a birthday gift from the client.
2. Gave the client a vase of flowers from the UAP’s garden.
3. Picked up the client’s prescriptions from the pharmacy.
4. Cleaned the client’s bathroom, including scrubbing the commode.
34. The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, “I am having really bad pain in my left lower stomach and I think I have a fever.” Which action should the nurse take?
1. Recommend the client take an antacid and lie flat in the bed.
2. Instruct one of the nurses to visit the client immediately.
3. Tell the client to have someone drive them to the emergency room.
4. Ask the client what she has had to eat in the last 8 hours.
35. The client with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. Which intervention is most appropriate for the home health nurse (HH) to implement?
1. Refer the client to the wound care nurse.
2. Notify the client’s healthcare provider.
3. Continue to monitor the stoma site.
4. Place Karaya paste over the excoriated area.
36. The client, who is terminally ill, tells the nurse, “I just want to live to see my grandson graduate in 2 months.” Which stage of grief is the client experiencing?
1. Anger.
2. Bargaining.
3. Depression.
4. Acceptance.
37. The nurse is discussing end-of-life care (EOL) with the client diagnosed with pancre-atic cancer. Which statements are the goals for end-of-life care? Select all that apply.
1. To provide comfort and supportive care during the dying process.
2. To plan and arrange the funeral for the client.
3. To improve the client’s quality of life for the remaining time.
4. To help ensure a dignified death for the client and family.
5. To assist with the financial cost of the dying process.
38. The male Mexican American client, who is terminally ill, refuses hospice services because he says it is “giving up” and he is not going to die. Which is the most appropriate action by the nurse?
1. Discuss the philosophy and services of palliative care with the client.
2. Take no other action and support the client’s decision.
3. Contact the client’s healthcare provider to discuss the prognosis.
4. Talk to the client’s family members about his choice to refuse hospice.
114 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
39. The nurse is discussing end-of-life issues with a client. The nurse is explaining about a document used for listing the person the client will allow to make healthcare decisions should he or she become unable to make informed decisions for him- or herself. Which document is the nurse discussing with the client?
1. Advance directive.
2. Directive to physicians.
3. Living will.
4. Durable power of attorney for healthcare.
40. The significant other of a client diagnosed with liver cancer and who is dying asks the nurse, “What is bereavement counseling?” Which statement is the nurse’s best response?
1. “Bereavement counseling helps the client accept the terminal illness.”
2. “It provides support to you and your family in the transition to a life without your loved one.”
3. “We provide counseling to you and your loved one during the dying process.”
4. “It is group counseling for family members whose loved ones have died.”
41. The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice (EBP)?
1. Turn on the tap water to help a client urinate.
2. Use two identifiers to identify a client before a procedure.
3. Educate a client based on current published information.
4. Read nursing journals about the latest procedures.
42. The charge nurse notices a nurse recapping a needle in a client’s room. Which action should the charge nurse take first?
1. Tell the nurse not to recap the needle.
2. Quietly ask the nurse to step into the hall.
3. Reprimand the nurse for not following procedure.
4. Notify the house supervisor of the nurse’s behavior.
43. The administrative supervisor is staffing the hospital’s medical-surgical units during an ice storm and has received many calls from staff members who are unable to get to the hospital. Which action should the supervisor implement first?
1. Inform the chief nursing officer.
2. Notify the on-duty staff to stay.
3. Call staff members who live close to the facility.
4. Implement the emergency disaster protocol.
44. The nurse is working in a community health clinic. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Instruct the UAP to take the client’s history.
2. Request the UAP to document the client’s complaints.
3. Ask the UAP to obtain the client’s weight and height.
4. Tell the UAP to complete the client’s follow-up care.
45. The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. Which action should be taken by the nurse?
1. Ask the supervisor to come to the unit.
2. Determine what is bothering the nurse.
3. Suggest the nurse go home.
4. Smell the nurse’s breath for alcohol.
QUESTIONS
46. The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse?
46. The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse?