Prioritization and Delegation Exam Questions with Answers, Exams of Nursing

Download Prioritization and Delegation Exam Questions with Answers and more Exams Nursing in PDF only on Docsity! NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The pediatric nurse provides care to a group of children. Which pediatric client requires priority action by the nurse? A child experiencing rebound tenderness in the right lower quadrant (RLQ) of the abdomen. An infant who experiences bulging fontanelles as a result of crying. A former premature neonate who is now 3 months of age who is diagnosed with respiratory syncytial virus (RSV) who is restless and requires suctioning prior to a scheduled oral feeding. An infant who is 4 months of age who is diagnosed with hydrocephalus who requires an abdominal assessment due to a lack of a bowel movement for one day The nurse receives hand-off shift communication for assigned clients. Which client requires priority assessment by the nurse based on the current data? An adult client. 24 hours postoperative for a newly placed ileostomy, who received a prescribed dose of hydromorphone 15 minutes ago. A client, 48 hours postoperative for an open Roux-en-Y gastric bypass procedure, who is gagging and reports feeling sick to the stomach. A client scheduled for discharge, who is three days postoperative for a hip replacement A client with a forearm infection from injecting illicit drugs who demands to be discharged because my pain is not be addi essed by anyone who works here" The nurse is assigned a group of hospitalized clients. Which client requires priority action by the nurse? A client who is 12-hours post-abdominal aortic aneurysm (AAA) repair who has weak pedal pulses A client, diagnosed with peripheral venous insufficiency, who successfully amulets to the bathroom twice A client diagnosed with multiple sclerosis (MS), who reports numbness and tingling in the feet and weakness when ambulating A client, with a history of diabetes mellitus (DM) reports operative site foot pain rated 8 of 10 two days after a right foot amputation due to gangrene The nurse provides care for a group of children. Which client requires priority action by the nurse? A 4-year-old client who has burning on urination and a temperature of 99.5 F (37.5 C). NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A 8-year-old client with a laceration to the arm who is very anxious, with respirations of 22 breaths per min. A 10-year-old client crying with abdominal pain who has a white blood cell (WBC) count of 12.000mm3 (12 x109) A 16-year-old client with altered mental status and a fever of 104.2 F (40.1 C) who had a collision on the soccer field The nurse receives hand-off communication from the previous shift for assigned clients. Which client requires priority action by the nurse? A client with a ureteral stent placement after lithotripsy who reports hematuria and pain when urinating. A client two days postoperative for transurethral resection of the prostate (TURP), who describes feeling spasms when urinating A client admitted with pyelonephritis, scheduled for a computed tomography (CT) scan who reports frequent painful urination. A dient, diagnosed with thoracic spinal cord trauma, who requires intermittent urinary catheterization reports sudden onset of severe pain in the head and blurred vision The nurse is assigned to a group of hospitalized clients. Which client data indicates the need for priority action by the nurse? A client, postoperative for splenectomy, who has a temperature of 102.5 F with reports of body aches. A client, diagnosed with hemolytic anemia, who reports "feeling chilled." A client, with a hemoglobin of 11g/dL, who reports dyspnea on exertion. A client. diagnosed with myeloproliferative neoplasm, who tests positive for the JAK2 gene. The nurse provides care for a clients immediately following surgery in the postanesthesia care unit (PACU). Which client should be considered the highest priority by the PACU nurse? A client, who had a lumbar plasty, who requests assistance with repositioning. A client who had a partial colectomy procedure and is reporting severe nausea. A client who had a prostatectomy and reports bladder spasms. A client post vaginal hysterectomy, with mild bleeding noted on the peri-pad. The nurse provides care for a clients immediately following surgery in the postanesthesia care unit (PACU). Which client should be considered the highest priority by the PACU nurse? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ It is important to reinforce instructions not to play with matches or lighters. Keep the poison control number available in case of accidental poisoning. Teach the child not to accept a ride or gifts from a stranger. The nurse is caring for a client admitted with end-stage renal disease (ESRD). Which lab valu priority to report to the health care provider (HCP)? Blood Urea Nitrogen (BUN) 54 mg/dL Creatinine (Cr) 6.8 mg/dL Potassium 5.8 mmol/L Phosphorus 4.4 mg/dL The nurse conducts shift assessments for each assigned client. Which finding requires priority intervention by the nurse? An adult client presently detoxing from alcohol who is prescribed diazepam every two hours for acute anxiety and elevated blood pressure (BP). A middle-age adult client with chest pain that is relieved by nitroglycerin who reports lightheadedness while ambulating. An older adult client with end-stage kidney failure with a blood pressure (BP) of 170/86 mm Hg and bilateral lower extremity edema who reports itching and muscle cramps. A 90-year-old adult client with a sacral pressure injury with new onset altered mentation, a temperature of 96.5 F (35.8 C), hypotension and tachycardia The nurse is discharging a 10 year-old client with a new diagnosis of epilepsy. Which instruction priority for the nurse to provide to the child's parents? Do not allow the child to ride a bike or skateboard. Make sure the child does not swim until 6 months seizure free. Ensure that the child wears medical identification indicating he has epilepsy. Your child will not be able to get his driver's license if he continues to have seizures. The nurse reviews and evaluates recent diagnostic results for newly assigned clients. Which client requires immediate intervention by the nurse? A client awaiting surgery for acute cholecystitis who has a temperature of 102.2 F (39.0 C) and a red blood cell (RBC) count of 4.2 million/mm3. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A client diagnosed with colon cancer who received chemotherapy and now has a temperature of 100.5 F (38.0 C) and white blood cell count (WBC) of 500/mm3 (1.0 * 109L) A client diagnosed with myelodysplastic syndrome with a current platelet count of 140.000/mm3 who is prescribed acetaminophen to treat a fever of 100.9 F (38.3C). A client diagnosed with vancomycin resistant enterococcus (VRE) who is prescribed Intravenous (IV) ampicillin therapy with a temperature of 101.5F(38.6C) and positive blood cultures. The charge nurse is making room assignments. Which client is the priority to place in a room close to the nurse's station? 72 year-old female on droplet precautions with influenza 82 year-old male with dementia and a history of falls 42 year-old quadriplegic female who requires frequent assistance 74 year-old post-surgical female who is getting 2 units of blood The nurse receives hand-off shift communication for newly assigned clients. Which client should the nurse see first? A client with an exacerbation of chronic obstructive pulmonary disease (COPD) who after nebulizer treatment reports mild dyspnea. A client with a history of congestive heart failure (CHF) who reports dyspnea and is coughing up pink frothy sputum. A client diagnosed with lung cancer who has a left pleural effusion and diminished breath sounds. A client, diagnosed with type 2 diabetes mellitus (DM) and venous insufficiency with new onset stasis dermatitis and pruritus. The nurse is caring for several clients and has multiple medications to give. Which medicine is the priority for the nurse to give first? Losartan to a client with hypertension, blood pressure is currently 146/90 mm Hg Hydrocodone to a client complaining of pain 7 out of 10 on a 1-10 scale Fluticasone to a client with chronic obstructive pulmonary disease (COPD), oxygen saturation is 92% NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Dextrose 50% (D50) to an unconscious client whose blood glucose is 52 mg/dL NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ room. Which client should the nurse see first? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A client who is 48 hours post total abdominal hysterectomy A client admitted after a suicide attempt during the night A client with a pulse oximeter reading of 93% on room air. A client with type 1 diabetes with a blood glucose of 180 mmol/L after breakfast. The nurse provides care for several clients on a medical-surgical unit. Which client requires priority action by the nurse? A client, two hours post-op for a below the knee amputation (BKA), whose surgical wrap is soaked with sanguineous drainage. A client, scheduled for a dressing change at the bedside by the wound care nurse within the next 15 minutes, whose current heel ulcer dressing has come loose. A client with a newly placed central venous access device who has tenderness and mild erythema at the site. A client with a three-way indwelling urinary catheter after a transurethral resection of the prostate (TURP) who reports pain The nurse is caring for a client who is 2 hours post partial gastrectomy. Which intervention has the highest priority? Instruct the client to advance to a clear liquid diet slowly until tolerated Prepare the client to perform wound care at home upon discharge for convenience Teach the client to turn, cough and deep breathe while also splinting the abdomen Educate the client and family about the need for supplements upon discharge A type 1 diabetic client is brought to the emergency department by family with confusion, abdominal pain, nausea and vomiting. What is the nurse's first action? Check blood glucose level Record family history Record client's home meds Administer regular insulin via IV infusion. The nurse prepares to administer prescribed medications to assigned clients. Which client requires NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ priority action by the nurse? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Administer sliding scale insulin to a client with a blood glucose of 350 mmol/L Report a hemoglobin level of 12.5 g/dL to the health care provider. Admit a client who is scheduled for an elective hip replacement surgery. The nurse provides care for a group of adult clients on a medical-surgical unit. Which client requires priority action by the nurse? A 25-year-old client newly diagnosed with anemia who reports discomfort. A 30-year-old client admitted for treatment of an upper respiratory tract infection who reports sharp pain upon inspiration. A 55-year-old client admitted with a fractured hip who receives a prescribed intravenous (IV) dose of hydromorphone for acute pain who develops periods of apnea while sleeping. A 60-year-old client who is one day post-op for an ileostomy who reports incisional pain, 4 of 10 after an oral dose of prescribed analgesics. The nurse working in an addiction recovery unit is caring for a client with a history of addiction to hallucinogens. Which action is the priority in the client's plan of care? Provide low environmental stimuli to minimize anxiety. Monitor for signs of agitation and attempt to deescalate as needed. Administer medications as needed to treat anxiety and agitation. Monitor for flashbacks and ensure the environment is safe. Which hand-off communication report received by the oncoming emergency department (ED) nurse indicates a need for priority client assessment? An adult client who reports extreme back spasm immediately after lifting heavy weights at the gym. A client who reports stabbing leg pain on ambulation that is alleviated with inactivity. A client who reports sharp sudden tearing pain in the upper to lower back and above the umbilicus. A client who reports of swelling left leg with new pitting edema following extended bed rest While in the room with a client who has a sealed radiation implant, the nurse discovers that the implant has become dislodged. Which action is the priority for the nurse to take? Contact the oncologist immediately. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Assure the client that most of the radioactive source will be eliminated from the body in excrement within 48 hours. Place a lead shield on the client. Use long-handled forceps to deposit the radioactive source in a lead container. The nurse is caring for a client with a newly initiated total parenteral nutrition (TPN) infusion. Which assessment is the nurse's priority? Blood glucose Blood pressure Bowel sounds Temperature The nurse is assigned 4 clients. Which client is a priority? A client post transfusion who is requesting a lunch tray immediately A client receiving chemotherapy with a fever of 101.5°F (38.6°C) A client that refuses morning care from the Unlicensed Assistive Personnel (UAP) A client who states pain is 3/10 on the pain scale ten minutes after medication. The nurse is assigned a group of clients on a medical-surgical unit. Which client requires priority action by the nurse? A client, diagnosed with a blood clotting disorder, who did not receive a prescribed dose of rivaroxaban. A client with a colostomy that is half full of dark brown stool. A client, diagnosed with emphysema, who reports dyspnea on exertion with a pulse oximetry reading of 89% on room air. An older adult client with new onset hematuria and bloody stools who is receiving intravenous (IV) antibiotic therapy for a urinary tract infection (UTI) A 17 year-old female comes into the Health Department requesting the Morning-after pill (levonorgestrel). Which priority action does the nurse include in the plan of care? Ensure that parental consent is obtained for the Morning-after pill. Tell the client to call the clinic immediately if she experiences nausea/vomiting after taking the pill. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Tell the client to avoid driving for at least 24 hours after taking the pill. Assess the client's sexual habits and provide education on safe sexual practice. The nurse provides care for several clients who receive medical care in the emergency department (ED). Which client is the highest priority for evaluation by the nurse? A client, prescribed naproxen sodium for the treatment of osteoarthritis (OA), who reports abdominal pain and dark tarry stools. A client with acute gastroenteritis receiving an intravenous (IV) fluid bolus of D5 normal saline (NS) who reports diarrhea. A client with an acute change in mentation who begins to vomit. A client with chronic kidney disease (CKD) receiving hemodialysis with temperature of 101.5 F (38.6 C) who reports chills and nausea. Which client should the nurse see first? A client with asthma who is on nebulizer treatments with respiratory at the bedside A client who was admitted two days ago with a productive cough A client who developed a fever of 99°F (37.2°C) during the night shift A client who is dehydrated whose IV bag has 25 mL of fluid left. The nurse is caring for several clients. After assessing each client, the nurse notes several problems. Which finding is a priority for the nurse to report to the health care provider (HCP)? Client receiving levofloxacin reports having one episode of diarrhea Client receiving digoxin is complaining of nausea, vomiting, and blurry vision Client receiving rifampin has orange urine Client receiving ferrous sulfate reports black, tarry stools After receiving handoff shift report, which client should the nurse assess first? A client post lobectomy with a Jackson-Pratt drain who reports the bandage coming loose. A client with latent tuberculosis (TB) who is prescribed rifabutin and reports reddish-orange urine. A client with asthma who reports increased difficulty breathing after inhaler use. A client with chronic bronchitis whose pulse oximetry reading is 89% on room air. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Ensure nobody smokes in the room where oxygen is in use. Keep the oxygen at least six feet away from any source of fire, such as a stove Be careful to prevent children from getting tangled up in the oxygen tubing. The nurse removed the Foley catheter from a female client who is eight hours postoperative following a cholecystectomy. The client reports feeling the urge to void but has not been successful. Which action is the priority action for the nurse? Contact the provider to request reinsertion of the Foley catheter. Perform an in-and-out catheterization Allow the client to hear running water while attempting to void. Administer an oral dose of oxybutynin Four clients receiving radiation are given instructions by the nurse. Which client is the priority for clarification of instructions? The client who states. "I will use the lotion that the health care provider prescribed" The client who states. "It is okay if work often in my garden this summer." The client who states, "I will protect my skin from heat and cold The client who states. "I need to avoid an excessive amount of sun." The nurse is instructing an older adult client who is taking several medications and is scheduled for a clinic visit the next day. What is the nurse's priority response? "You cannot take any over-the-counter medications with your medications." "Be sure a family member is with you who knows about your medication." "Bring all of your medications and supplements with you when you visit the health care provider." "You need a home health nurse that can visit your home daily to make sure you are taking the right medications." Which response by the nurse is most appropriate when addressing an unlicensed assistive personn (UAP) who refuses to help answer call lights for clients on the unit? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ "The unit needs your help to give good care to all clients." NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ "I will personally answer the call lights as soon as possible." "Could you please be a team player and do your job?" "Your behavior is unprofessional and am reporting this incident to the unit manager." The nurse provides care for a client who is diagnosed with acute kidney injury (AKI). The laboratory informs the nurse that the morning laboratory data indicate blood cultures are positive for bacteria. Which is the priority action by the nurse? Ask the unit secretary to call the nursing supervisor. Call the healthcare provider (HCP) immediately to report the results. Notify the healthcare provider (HCP) during rounds at 0800. Place the results in the client's medical record and document the information in the nurses notes. The nurse is conducting an in-service to unlicensed assistive personnel (UAP) in a long-term care acility regarding care of clients and skin breakdown. Which is important regarding skin breakdown? Select all that apply Keep the client clean and dry Assess the skin for any changes or breakdown Avoid hot water for bathing Proper nutrition is not a concern Use an alcohol based skin product on the skin The nurse enters a room and finds a surgeon asking a client's bilingual child to translate information regarding an upcoming surgical procedure to obtain informed consent. Which action by the nurse is appropriate based on the current data? Witnessing the client's signature for the surgical informed consent. Encouraging the surgeon to utilize another nurse to assist with translation. Reporting the incident to the charge nurse or nursing manager of the unit. Speaking to the surgeon privately to provide a reminder about the importance of using certified medical interpreters. Which client situation requires the nurse to complete an incident report? Select all that apply. The client who develops sepsis after not receiving prescribed intravenous (IV) antibiotics. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Right prone position Sim's position The nurse wants to implement a change in policy based on research that has the potential to enhance client care. Which is the initial step by the nurse? Determine the source of financial support for the research study. Identify if the research study group matches the clients who receive care on the nursing unit. Analyze if there is consent and endorsement from an official review board. Examine if the study researcher's credentials and background are appropriate. The charge nurse is precepting a graduate nurse who is teaching a client about safety while using crutches. Which statement by the graduate nurse is a cause for concern? "You will need to prepare your home environment for safety." "You will place your body weight on your hands when using the crutches." "Going up the stairs, you will start with your injured leg first" "Your elbows should be slightly bent when using the crutches." Which semi-private room should the nurse assign to a client returning from surgery following a tota hip replacement? A client one day post-op from a fasciotomy due to compartment syndrome. A client post open reduction external fixation of femur fracture with reddened pin sites. A client with a leg cast following a closed reduction of a fractured tibia. A client with osteomyelitis secondary to a blunt trauma injury of the tibia. The graduate nurse has a client who reports pain at the IV site after infusion of vancomycin. The preceptor teaches the graduate nurse to take which action next? Assess the peripheral IV site Check for blood return Document the incidence Call the health care provider NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The charge nurse anticipates several client admissions over the next few hours. Which client pair are most appropriate to sharing a semi-private room on the unit? A 4-year-old female client who is postoperative for tonsillectomy and a 3-year-old female client in a Bryant traction device. A 6-year-old female client newly diagnosed with tuberculosis (TB) and a 7-year-old female client newly diagnosed with varicella. A 10-month-old female client who is diagnosed with a salmonella infection and a 9-month-old male client who is diagnosed with a rotavirus infection. A 13-year-old female client who is diagnosed with hand cellulitis and a 14-year-old male client who is hospitalized with sickle cell disease (SCD). Which interdisciplinary team member or department should the nurse consult to assess a client's living situation and potentially arrange for a new living quarters? Child protective services (CPS). Healthcare provider (HCP). Occupational therapy (OT) department. Social work department. During a staff meeting, the nurse manager announces a new benefit available to employees namely, no deductible, preventative healthcare coverage for employees and covered family members. Which services will be covered for these employees and covered family members? Select all that apply. Breast augmentation Prostate screening Mammogram Colonoscopy Testosterone treatment Immunizations Which critical information has been excluded by the nurse from the SBAR report to a health care provider (HCP)? SBAR report: "Client in room 104 had an open appendectomy yesterday. The client's pulse is rising at 145 beats per minute, temperature of 101.2 F, and systolic blood pressure decreased 76 mm Hg. I am anxious that the client is slipping into septic shock." A complete set of vital signs. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The time of initial onset of symptoms. The client's past medical history. A request for action. The nurse is planning discharge teaching for an adolescent who is newly diagnosed with Type 1 diabetes. Which is most important for the nurse to demonstrate for the client? Monitor blood glucose levels and administer insulin subcutaneously Administer intravenous insulin every 4 hours as needed Instruct how to check urine ketones to manage complications of diabetes Teach how to choose foods low in saturated fats to decrease cholesterol A client who has taken insulin for type 1 diabetes mellitus over 50 years is in the primary care clinic for yearly screenings. The nurse understands which laboratory tests will be included in the screening to monitor and promote optimal health? Select all that apply. Creatinine Troponin I Hemoglobin A1C Fasting blood glucose Brain natriuretic peptide Total cholesterol Which client statement indicates a need for the nurse to provide additional education regarding the various adjunctive services being used for rehabilitation after a cerebrovascular accident? "The role of occupational therapy is to help me learn how to use a walker and a cane safely." "The role of social services is to find places that will help me pay for my prescribed medications." "The role of speech therapy is to help me learn how to eat without choking." "The wound care nurse will help me to take care of the open wounds I have on my hips and legs." The nurse manager is teaching a graduate nurse how to approach an aging hearing-impaired client. Which statement is most appropriate? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Sexual Elder The charge nurse observes an unlicensed assistive personnel (UAP) performing deep leg massages on a one-hour post adrenalectomy client to "prevent blood clots". Which response by the charge nurse is most appropriate when in front of the client? "Don't do a deep leg massage please. If there is a blood clot, it will cause it to move and become a pulmonary embolism, which could kill the client." "We give enoxaparin twice a day to the client to prevent blood clots." "I see you are really working hard to help this client. Can I speak with you in the hallway for a minute please?" "That must feel so good to the client. Thank you for taking the time to help the client." The community health nurse is a member of a mobile crisis team who responds to a mass casualty incident in a local neighborhood. Which initial strategy is best by the nurse to provide mental health care to those who may need it as a result of the incident? Going door-to-door letting victims know the availability of services. Notifying other community agencies of their presence. Placing paper flyers around in the community. Reporting to the command center for the community. The preceptor for a graduate nurse notices the new graduate is struggling with time management, which causes the nurse to not complete a thorough admission assessment. Which response by the nurse preceptor best addresses this issue with the new graduate nurse? "I see your assessments are missing some pertinent details. How can help you?" "How were you taught to do an admission assessment?"" "Do you know how to complete an admission assessment?" "You need better time management skills so you can complete a thorough assessment." The nurse manager is informed about a conflict between family members of an unresponsive client regarding decisions surrounding use of life support. What is the manager's priority response? Ask the family if they would like a private room to gather and talk Contact the hospital's ethics committee regarding the matter NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Contact the donor services representative to reach out to the family Refer the family to the hospital's spiritual care team for direction Nursing that focuses on the use of tasks and activities and not on the holistic care of clients is recognized as what type of nursing model? Functional nursing Team nursing Primary care nursing Total patient care Which action is most appropriate when a nurse faces lateral workplace violence? Ignore acts of lateral violence, including remarks, comments, and threats. Keep a record of all episodes and interactions made by the offender. Report any lateral violent episodes to hospital administration. Stand up to the bully and return similar remarks and gestures. After receiving report in the intensive care unit (ICU), which client assessment should the nurse complete first? The client with a traumatic brain injury (TBI) with a score of 13 using the Glasgow Coma Scale (GCS) who exhibits memory loss and muscle aches. A client with a cervical spine injury who is experiencing neurogenic shock with a pulse of 58 and blood pressure of 110/68 mm Hg. A client with a subdural hematoma sustained from blunt force trauma with a pulse of 52, blood pressure of 198/92, irregular respirations, and slow pupillary response. A client recovering from a recent head injury with excessive urine output of 500 mL/hr and serum sodium level of 150 mEq/L. A client with Parkinson's Disease is admitted to the long-term care facility with a BMI of 19 and is having difficulty swallowing. Which referral is appropriate for the nurse to seek? Speech therapy because the client needs a swallowing study Nutritional services because the client needs thinner fluids NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Legal authorities because the client has been neglected Social services because the client and family need to find a support group A client in recovery for prescription pain medication abuse reminds the nurse that after the adrenalectomy, they do not need or want pain medication. Which response is most appropriate? "I understand your concern. We will only ask the surgeon for demerol if you insist and have a 10/10 pain." "I understand your concern. I do want you to know there are other non-narcotic options we can use to keep you as comfortable as possible." "I understand your concern. As you request, then, we will not treat your pain regardless of your request for it after surgery." "I understand your concern. Nevertheless, it is your right to have pain medication if you change your mind and decide you need it. Which of the following delegation of tasks by the graduate nurse should the charge nurse question? Asking unlicensed assistive personnel (UAP) to record the afternoon intake and output totals on clients Asking an unlicensed assistive personnel (UAP) to reassess a client's pain following oral pain medication Asking a licensed practical nurse (LPN) to collect data on a client during an admission assessment Asking a licensed practical nurse (LPN) to apply a dressing to a stage 1 pressure injury The nurse is teaching a graduate nurse about initiating total parenteral nutrition (TPN). Which teaching should be included in the plan of care? Select all that apply Change the dressing using strict aseptic technique Monitor the blood glucose when initiating TPN Check hemoglobin and hematocrit daily Obtain vital signs q 2 hours during infusion Never discontinue TPN abruptly Which client requires priority intervention by the nurse in the provision of care? The client receiving a transfusion of packed red blood cells (RBCs) reporting back pain and a blood pressure reading of 92/60 mm Hg. A client who is prescribed valsartan with a current heart rate of 58 beats per minute before the administration of the medication. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A client who has a new prescription for warfarin who is discharged to the outpatient coumadin clinic. A client status post chemotherapy with a temperature of 102.5 F (39.1 C) with a prescription to be discharged home. Which client can be delegated to the graduate nurse to assess? An older adult client with dementia A client with schizophrenia who has been shouting all night An adult client with acute mania who is pacing the room A client who is admitted on suicide watch The day shift nurse assesses a client who states, "I did not receive good care from the nurse last night." Which is the most appropriate response by the nurse to the client? Give reassurance of the care that the client will receive this shift. Give valid reasons for the nurse's behavior to the client. Ask the client to provide more details about the care provided by the nurse the previous night. Let the nursing manager know what the client reported regarding the care received by the night shift nurse. The charge nurse prepares for the admission of a client from the postanesthesia care unit (PACU). Which semi-private room assignment is most appropriate for this client? A client with cellulitis of the arm secondary to an insect bite with an elevated white blood cell count. A client with end-stage renal failure on hemodialysis and elevated blood glucose. A client who is diagnosed with AIDS who reports feeling under the weather for a few days now. A client with severe epistaxis after a traumatic fall who has a platelet count of 72,000/mm3. As the nurse attempts to insert a narrow-bore feeding tube, the client begins to cough forcefully an becomes flushed and dyspneic. Which is the priority action by the nurse? Continue advancing the tube until the client stops coughing and check placement Place several ice chips in the client's mouth and allow time for them to melt. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Stop advancing, pull back on the tube, and allow the client time to recover. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Take the feeding tube completely out and attempt re-insertion in the opposite naris. The nurse reviews the results of a client's urine dipstick test and notes a trace amount of protein in the urine. Which is the priority nursing intervention for this client? Immediately notify the client's nephrologist. Determine if the client has had any recent illnesses. Check the client's blood pressure (BP) for elevation. Have the client drink water and obtain a second test. The nurse visits the home of a client requiring breathing treatments to treat chronic bronchi Which information indicates to the nurse that the client is having issues accepting this life ch Stopped smoking 3 weeks ago Wears a mask when in a crowded area Sleeps in an elevated position at night Performs breathing treatments when dyspneic The nurse is providing care for a client that is a victim of sexual assault. Which priority intervention will the nurse implement while performing the rape kit exam? Provide the client an explanation as each step of the exam is completed Explain why collecting the specimens is important for the client before beginning Be sensitive to the client's response and be respectful of the client's feelings Be careful to maintain all specimen collections as directed by protocol The occupational health nurse is notified that a construction worker is experiencing an anaphylactic reaction. The worker is found outside and has several layers of protective clothing on. Which action by the nurse is best? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ notes that there is pink-tinged urine in the drainage bag and the client is observed pulling at the catheter and moaning in pain. Which is the priority action by the nurse? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Clean around the insertion site with clean towel. Remove the saline from the urinary catheter balloon. Assess for kinks or dependent loops in the catheter tubing. Insert the catheter about 2 inches further into the urethra. The nurse auscultates a client's apical pulse. Which location should the nurse place the stethoscope to hear the point of maximal impulse (PMI)? The second intercostal space (ICS) to the right of the sternal border. The third ICS to the left sternal border. The fifth ICS to the lower left sternal border. The fifth ICS at the midclavicular line. During administration of a saline solution enema, a client reports severe abdominal discomfort an cramping. Which action should the nurse implement next? Tell the client that this is an expected side effect for this type of enema. Stop the procedure temporarily then begin again at a decreased rate. Contact the health care provider (HCP) for a prescription for a fleet enema. Increase the rate of infusion of the enema to limit the client's discomfort. The partner of a client who is caring for a newborn wants to be involved in the newborn's care during feedings. Which recommendation should the nurse make to the partner? Realize that the breast-feeding time is a mother/baby time Bring the infant to the mother for the feeding times Recognize that there is little that can be done during the feeding time NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Strive to maintain a quiet environment during the feeding time NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ insertion. Advance the catheter an additional 2 inches. Let go of the catheter and ask the client to relax. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ When providing education to the client prescribed insulin to treat type 2 diabetes, which instruction will the nurse provide the client for needle disposal? "As long as you recap the needle, it is fine to discard the syringe in the trash." "It is best to use pliers to break the needle off, then discard the syringe in the trash." "Put all the used needles in a cardboard box and bring them back to the clinic for discarding "Use a hard plastic needle box to discard the needles and then tape the lid shut before discarding the box in the trash." Which is the most appropriate order of movement when providing care for a client who is ascending stairs while using crutches? All answer options must be used. 1. While in the tripod position, place full body weight on the crutches. 2. Raise the leg that is affected and crutches up onto the step. 3. Transition body weight on the unaffected leg and lift body to the next stair. 4. Put the leg that is unaffected on the stairs first. Answer Example: 4231 1432 The nurse assesses a client with a nasogastric (NT) tube in place that is being used for continuous feedings when the tube marking the original location is noted as being considerably lower than during the previous assessment. Which is the nurse's first action? Immediately stop the feeding and listen to the client's breath sounds. Advance the tube to the original marking and place bilateral wrist restraints on the client. Aspirate the tube for gastric contents and notify the health care provider. Pull the tube out and obtain a prescription to reinsert the NG tube. Which statement by the novice nurse indicates a need for further instruction about the procedure for obtaining a client's wound culture? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ "I should always label the specimen with the date, time, and my initials." "I will swab the wound starting in the center and work my way outward." "I will don sterile gloves to remove the dressing covering the wound." "I will make sure my swab doesn't brush up against the skin at the wound edge." The nurse provides for a client who is diagnosed with advanced congestive heart failure (CHF) who requires strict measuring of intake and output (I&O). Calculate the total input and output for the shift based on the supplied record. Ensure answer is rounded to the appropriate whole number. 120 Ml The nurse provides care for a client who is prescribed intravenous (IV) norepinephrine. Which nursing action is appropriate when the IV administration of the prescribed medication causes the client to report shooting pain and the skin is noted to be pale along the vein pathway? Select all that apply. Flush the line with normal saline and give PRN IV meperidine. Discontinue the infusion promptly and disconnect IV tubing. Document findings as normal. Slow the infusion of norepinephrine and reassess in 15 minutes. Remove the IV line while aspirating the drug from the vein The novice nurse provides care to neonates on the maternal-newborn unit with the assistance of a nurse preceptor. Which statement made by the novice nurse while preparing to give an intramuscular (IM) injection to a neonate requires the nurse preceptor to intervene? "I will clean the deltoid muscle in a circular motion and let it dry before injecting the medication," "I will use aseptic technique when preparing the site for administration of the injection." "I will draw up the medication using a small, tuberculin syringe" "The appropriate needle gauge for this IM injection is 22" NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ weeks." NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The nurse provides care for a group of clients in a nursing home and is assisted by an unlicensed assistive personnel (UAP). Which action by the UAP regarding client positioning would warrant intervention from the nurse? Positioning a client with significant ascites in the high-Fowler position. Positioning a client on the left side immediately after a liver biopsy procedure. Positioning the client supine prior to assisting with the discontinuation a subclavian central line. Positioning a client with arms resting on a bedside table for a thoracentesis. Which statement made by an 18-year-old client alerts the nurse that further teaching is needed regarding the proper use of an epinephrine injection pen (EpiPen)? Select all that apply. "If I absolutely have to, I can inject myself through my clothes." "I should keep my EpiPen with me at all times, even when I go out with friends." "The Injection should be given in my mid to outer thigh area." "I won't go to the emergency department if my pen helps my symptoms." "So if I ever have trouble breathing this EpiPen will help with that right? The nurse provides care for a client who is prescribed a 24-hour urine specimen collection. Which statement does the nurse include when providing education to this client about the prescribed diagnostic test? "Empty your bladder in the morning and that is your first specimen and start time." "Empty your bladder in the morning, discard it, and record that time as the start time." "You will require the insertion of a urinary catheter into the bladder for the 24-hour urine collection." "Keep the urine container near the commode so you won't forget to place all urine there" The nurse provides an inservice for new clinical staff who provide client care to both mothers and babies on the maternal-newborn unit. Which statement made a participant indicates an accurate understanding of the proper methods for performing heel sticks on a neonate? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ "Using automatic lancets may cause too deep of a puncture and should be avoided." "I will use the center of the heel to perform the procedure." "Prior to the puncture. It is best to make sure the neonate's heel is warm." "Venipuncture is quite painful and should only be used if unable to get an adequate sample by heel stick The nurse provides care for a client who is prescribed vancomycin 1.5 in 100 mL of normal saline by intravenous (IV) infusion over 45 minutes. The IV tubing has a drop factor of 20 gtt/mL. How many drops per min (gtt/min) is required to administer this client's medication as prescribed? Record answer using a whole number. Answer: gtt/min 9 gtt/min The nurse assesses a client who is prescribed a blood transfusion by the healthcare provider (HCP). Which assessment finding should delay the implementation of the prescribed transfusion? The client has a triple-lumen, subclavian central venous catheter. The client has a current hemoglobin (Hgb) level of 7.2 mg/dL. The client has a 22-gauge peripheral intravenous (IV) catheter in the left hand. The client has been placed in restraints for acute confusion. When conducting an educational in-service regarding the care of clients who have had mastectomies with lymph node involvement, which teaching point should the nurse include? Select all that apply. "Review the medical record to be sure it reflects a history of mastectomy." "Do not insert an intravenous catheter into the arm of the affected side." "Teach the client to notify all staff that they have had a mastectomy upon admission to the facility." "Always assess the client's blood pressure on the unaffected arm or leg." "Place a Do Not Use armband on the client's affected side" Which statement will the nurse make when caring for a client who verbalizes extreme fear about the insertion of a lifeport? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Bilateral posterior tibial pulses palpated left-night Bilateral posterior tibial pulses palpated, night 2 left PT 2 Bitateral posterior till pulses palpatest right re left a The nurse provides care for a infant who is prescribed ceftriaxone, 0.1 mg/kg intramuscular (IM) stat for the treatment of an upper respiratory infection (URI). The infant's current weight is 3700 grams How many mL of medication does the nurse draw into the syringe when the ceftriaxone is available at a concentration of 0.4 mg/mL? Record your answer using one decimal place. Answer: 2500Mg/ml The nurse preceptor discusses the proper order for performing an abdominal assessment with a novice nurse. Which statement made by the novice nurse requires additional teaching from the nurse preceptor? 1 will place the client in a supine position for the assessment I will inspect the client's abdomen before listening for bowel sounds Twill perform light palpation before auscultating bowel sounds I will perform deep palpation as the last step of my abdominal assessment The novice nurse provides care to a client with a intrajugular triple-lumen central venous catheter (CVC). Which statement made by a novice nurse indicates understanding of how to properly care the client's CVC? Select all that apply. "I will always use the distal port if I have a prescription to obtain central venous pressure readings on my client" I should use a 10 ml syringe when giving medications or flushing the line "We can infuse total parenteral nutrition (TPN) using the medial port for clients who cannot tolerate tube feedings "When not in use all ports of the central line should be flushed with 10 mL normal saline at least once per shift. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ should scrub the hub for at least 15 seconds prior to using the port for medication administration The novice nurse who just finished the required 12 week hospital orientation provides care for a client who is prescribed a liver biopsy. Which action by the novice nurse prompts the charge nurse to intervene? Ensures that inform consent is signed and placed on the client's medical record Verifies that the client's blood type and crossmatch results are located in the medical record Neglects to verify that the results of the client's prescribed coagulation studies are in the medical record. Monitors vital signs every 15 minutes post-procedure Place the teaching steps in order for a nurse providing education to a client on the use of an incentive spirometer. All options must be used. 1. Have the client breathe out then place the mouthpiece in the mouth. 2. Slowly breathe out. 3. For at least 2-3 seconds, hold breath. 4. Breathe in deeply until the desired tidal volume is achieved. 5. Place lips firmly around the mouthpiece. Answer Example: 42315 32145 The nurse provides care for a pediatric client who is prescribed PO ceftriaxone, 10 mg/kg/day divided into two equal doses. The child currently weighs 80 pounds. The medication is available with a concentration of 125 mg/7.5 ml. How many mL of ceftriaxone should the nurse administer to this client? Record answer using one decimal place. Answer: 50mg/ml The health care provider prescribes 4 mg of inhaled ipratropium via a nebulizer treatment. This medication is available in 2 mg/3 mL. How many mL should the nurse use to administer the prescribed nebulizer treatment to this client? Record your answer as a whole number. Answer: ML 6Ml NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ While obtaining a health history from a client scheduled for eye surgery, which statement alerts the nurse for a potential risk of eye infection due to the client's technique for eye drop instillation? "I have been putting in the eye drops each night as the healthcare provider ordered." "To save money. I used the eye drops that my spouse was given for eye surgery" I have pressed on the tear duct area after putting the drops in to keep them in the eyes It has not been easy, but I have worked hard to not touch the eyedropper to my eyes" The nurse encounters an older adult who begins coughing while eating a meal in the hospital cafeteria. Which action does the nurse implement first? Ask the individual "Are you choking?" Initiate cardiopulmonary resuscitation Stand behind the individual and initiate 5 back blows Ask a fondline server to call 911 for emergency assistance The nurse provides care to a pediatric client who is diagnosed with diabetic ketoacidosis (DKA). The healthcare practitioner prescribes insulin at 0.3 units/kg/hour. How many units/hour should the nurse administer to a child who weighs 50 lbs? Record your answer to the nearest tenth. Answer: Units/hr 25 Units/hr The nurse preceptor assists the novice nurse in the provision of care for a client with a left peripherally inserted venous catheter that is used for the administration of the prescribed total parenteral nutrition (TPN). Which action by the novice nurse warrants intervention by the nurse preceptor when changing the site dressing and IV tubing? Maintain sterile technique when changing the dressing Have the client take a deep breath in when changing out the habing Positions the client supine before and during the procedure. Washes hands before and after the procedure NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A sitting position on the side of the bed with arms resting on the bedside table. The Trendelenburg. lateral side-lying position with the affected side up. A client with an indwelling urinary catheter reports leakage around the insertion site. Which intervention should the nurse perform next? Ask the charge nurse to assess the client's catheter Inspect the catheter tubing for kinks or obstructions Discontinue the catheter and replace it with a larger se inect the catheter balloon with addional sterile sale Place the steps in order that the nurse implements when suctioning a client who is intubated, and currently on a ventilator. All options must be used. 1. Steadily move suction catheter forward into the trachea. 2. Assess the client's response. 3. Carefully turn suction catheter while applying suction. 4. Pre-oxygenate with 100% oxygen. 5. Perform oral care and provide suction. 6. Wash hands and apply clean gloves. Answer Example: 523146 2451436 The nurse provides care for a client who has a subclavian central venous catheter (CVC). Which syringe does the nurse use when flushing the client's subclavian CVC? Select all that apply. A 1 mL syringe. A 3 mL syringe. A 5 mL syringe. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ A 10 mL syringe. 00 A 12 mL syringe. The nurse provides care for a client on the telemetry unit. The unlicensed assistive personnel (UAP) reports the most recent client blood pressure of 184/102 mm Hg. The client is scheduled for percutaneous renal biopsy in 2 hours. Which is the nurse's priority action? Immediately alert the healthcare provider (HCP Assess the client's current creatinine level Ensure that informed consent has been signed Re-check the blood pressure manually in 30 minutes The nurse administers a tuberculin skin test (TST) to a client. Which instruction should the nurse provide to the client regarding when to return to have the area of injection assessed? Select all that apply. In 12 hours in 24 hours in 36 hours in 48 hours in 72 hours in 96 hours The nurse is providing instructions to a female client about self-catheterization in the home setting. Which action will the nurse emphasize to maintain safety and infection control during the procedure? Select all that apply. Avoid inserting the catheter in the vaginal area- insert in the urethra Lubricate the urinary catheter tip with vaseline to prevent tissue trauma when inserting tip Wash hands with warm water/soap before beginning procedure NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Wash the urinary catheter in the dishwasher to remove any germs before procedure NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Tattoos on the hands. White blood cell (WBC) count of 15,000/mm3. The nurse provides care for a client who is prescribed stomach decompression via a nasogastric (NG) tube. Which action by the nurse is appropriate for measuring the NG tube for insertion? Mark the NG tube at the halfway point. Measure the NG tube from the earlobe to the nose to the xiphoid process. Measure the NG tube from the tip of the nose to ear to the bottom of the last rib. Measure the NG tube from the tip of the nose to earlobe to the xiphoid process. Which nursing is the priority immediately following the placement of a nasogastric tube (NGT) for a hospitalized client? Document how the client tolerated the procedure. Connect the NGT to wall suction prior to starting feedings, Instill 20 mL of tap water while auscultating the abdomen. Obtain a prescription for a chest radiography. Which is the appropriate nursing action when administering an intradermal injection to a Once the needle is inserted, inject the medication at a steady, rapid pace. Place the tip of the needle into the skin at a 90 degree angle. Use a tuberculin syringe with a 27-gauge needle for the injection. Don sterile gloves and prepare the area with chlorhexidine solution before injection. The nurse provides care for a client who is diagnosed with anemia and prescribed a blood transfusion. Which nursing action is the priority when preparing to administer the prescribe transfusion? Obtain baseline vital signs and reassess every hour. Prime the infusion tubing with normal saline and infuse with the blood. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Ensure that the infusion is complete within a 4 hour timeframe. Stay in the client's room for the first 15 minutes of the transfusion The nurse performs a central line tubing change for a client. During the procedure, the client suddenly experiences shortness of breath and begins moving on the bed. Which is the priority nursing action based on the current data? Immediately administer oxygen. Lower the head of the bed until the client is supine. Alert the healthcare provider (HCP) Have respiratory therapy administer a breathing treatment The nurse provides care for a client who is prescribed an indwelling urinary catheter. Which priority nursing action when the indwelling catheter is placed and no urine output is noted Request a urology consultation from the attending health care provider (HCP). Insert an additional indwelling urinary catheter higher into the perineal area. Attempt to irrigate the catheter with sterile water and ask the client to bear down as if attempting a bowel movement. Discontinue the current catheter and attempt re-insertion with an intermittent in and out catheter. A client who is diagnosed with diabetes mellitus (DM) has a prescription for 10 units of r and 10 units of insulin NPH to be administered now for hyperglycemia. Which nursing a appropriate? Administer the regular insulin now but hold the insulin NPH. Give the client a snack of 15 G carbohydrates before giving the insulin. Draw up the regular insulin first then the insulin NPH and administer to the client. Administer the insulin NPH now but hold the regular insulin for one hour NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The nurse prepares to administer medication via a client's nasogastric (NG) tube when 10 mL of gastric residual is aspirated. Which action by the nurse is best? Administer the medications. Notify the health care provider. Replace the 10 mL of aspirate. Postpone medication administration. The nurse conducts education to a client who is newly prescribed bilateral hearing aids. Which action indicates a need for further teaching about the use and care of new hearing aids? Selec that apply. Increases the television volume to drown out background noise. Maintains clean hearing aids by rinsing them with water weekly. Ensures the battery area is completely closed after placement. Increases the volume on the aid before placing it in the ear Avoids wearing hearing aids when blow drying hair The nurse prepares to change a central line dressing for a client who is unable to follow si instructions. Which is the priority nursing action to decrease the client's risk for infection? Asking all visitors to leave the room until the procedure is complete. Explaining the procedure to the client prior to changing the dressing. Maintaining therapeutic communication during the procedure. Maintaining a sterile field throughout the procedure. During the implementation of cardiopulmonary resuscitation (CPR) for a client, the unlicensed assistive personnel (UAP) notifies the nurse that a client in another room is requesting nausea medication. Which response by the nurse is appropriate? Instruct the UAP to have the nauseated client rate the current level of pain and report back. Have the UAP draw up and administer the prescribed nausea medicine to the client. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The critical care nurse is assessing a client. The following changes are noted in the client's 1000 assessment. GCS Decreased from 15 to 13 since 0800 New onset disorientation to time The client is now very easily distracted Which intervention should the nurse implement first? Administer 5 mg haloperidol IM now. Apply soft wrist restraints bi- laterally. Assess the client using the confusion assessment tool. Evaluate the client's pain using a 0-10 scale. The nurse provides care for a client who survives a near drowning experience. Which data collected by the nurse requires priority action? Crackles in lung bases. Decorticate posturing Decerebrate posturing Radial pulses 1+ bilateral. Which action should the nurse implement when bubbling is observed in the suction control chamber for a client with a mediastinal chest tube? Continue to monitor the client and document chest tube drainage. Disconnect the chest tube from suction for one hour and restart suction. Notify the healthcare provider (HCP) of the presence of an air leak. Palpate around the chest tube dressing to assess for crepitus. The nurse provides care for a client who is hypothermic. The client is covered with warm blankets and warm intravenous (IV) fluids are infusing. Which is the next priority nursing action? Check the client's capillary glucose level. Place the client on cardiac monitoring. Put a warm towel over the client's head. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Start a second 18-gauge IV for rapid IV fluid infusion. A daycare worker asks for a hepatitis vaccine because there has been an "outbreak" where she works. Which of the following vaccines would be the highest priority for her to receive at this time? NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Hepatitis A Hepatitis B Hepatitis C Hepatitis D Which acid/base imbalance is correctly identified by a nurse caring for a post-surgical client who is crying uncontrollably in pain with the following arterial blood gases (ABGS) and vital sign Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis When planning care for a client newly diagnosed with Guillain-Barre syndrome (GBS), the nurse should include which intervention in the plan of care? Select all that apply. Close monitoring of the rate and depth of respirations. Document non-reactive pupils and continue to monitor. Encourage slow position changes during transfers. Immediately report absent knee reflexes to the health care provider (HCP). Keep an incentive spirometer at bedside at all times. The nurse is caring for a client with a potassium level of 7.1 mEq/L. Application of electrodes and defibrillator pads in anticipation of potential complications is an example of which process? Clinical judgment and clinical reasoning skills Collaboration with clients, familles, and team members Advocacy and moral agency in solving ethical issues Facilitation of learning for clients, families, and team members The nurse manager supervises the implementation of cardiopulmonary resuscitation (CPR) for a client NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ medication. Assess for sources of anxiety. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Complete a head to toe assessment. Assess the client's pain level. The nurse teaches a class on basic cardiopulmonary resuscitation (CPR). Which instruction should the nurse provide regarding high quality chest compressions? Select all that apply. Compressions should be administered at a depth of at least 2 inches on adult clients. Compressions are provided at a rate of at least 80 to 100 per minute. Compressions are never paused for more than 10 seconds to check for a pulse. Compressions should always allow for complete chest recoil. Compressions are only administered if the client is breathing adequately. Which is the best explanation of the rationale for performing an Allen test prior to drawing arterial blood gases (ABG) on a client? It is performed to test for adequate peripheral perfusion via the radial artery. It is performed to ensure adequate peripheral perfusion via the ulnar artery. It is performed to determine that capillary refill time is not prolonged. It is performed to ensure that the client does not have peripheral arterial disease. The nurse provides care for a client who is diagnosed with cardiogenic shock. Which intervention should the nurse anticipate to be included in this client's plan of care? Select all that apply. Maintenance of the high-Fowler position. Placement of a pulse oximeter monitor on the client's forehead. Prescription for a loop diuretic to address a central venous pressure (CVP) of 20 mm Hg. Prescription to titrate intravenous (IV) dopamine to maintain a systolic blood pressure of 90 mm Hg. Prescription for atropine to treat bradycardia The nurse leads the cardiopulmonary resuscitation (CPR) for a client whose current rhythm is asystole. Which action by a member of the code team would require intervention by the nurse? Assesses carotid pulse for 10 seconds. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Gives epinephrine 1:10000 intravenous push (IVP). Performs chest compressions. Prepares for defibrillation. Which intervention should the nurse implement when providing care for a client who requires gastric decompression due to ingestion of a toxic substance? Select all that apply. Gather suction supplies and place at bedside. Initiate gastric decompression within 3 hours of admission. Place intubation supplies at bedside. Position the client supine in the Trendelenburg position. Request a large bore nasogastric (NG) tube from central supply. A nurse has been having difficulty sleeping and mood swings since the recent, unexpected death of a client. The nurse and family had many conversations regarding Do Not Resuscitate orders prior to the client's death. The nurse's symptoms are likely signs of which issue? Change fatigue Moral distress Medical futility Ethical dilemma The novice nurse provides care for a client who is diagnosed with septic shock. The most recent vital signs are as follows: temperature of 98.6 F (37 C); blood pressure (BP) is 102/54 mm Hg; heart rate (HR) is 88 beats per minute; respiratory rate (RR) is 20 breaths per minute; and the oxygen saturation is 98% on 40% aerosol face mask. Based on the most recent client vital signs, which action by the novice nurse necessitates priority intervention by the nurse preceptor? Does not notify pharmacy in a timely manner when the client's intravenous (IV) dopamine bag is nearly empty. Places nasal cannula on the client per a standing protocol to maintain the client's oxygen saturation at 95%. Requests clarification for a new prescription to change the client's maintenance intravenous (IV) fluids from normal saline to 0.45% normal saline. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Obstructive Septic The nurse provides teaching to the spouse of a client receiving mechanical ventilation via endotracheal tube (ETT). Which statement by the spouse alerts the nurse that further teaching is necessary? "My partner will be suctioned after the nurse performs mouth care each hour." "The nurse will listen to my partner's neck to check for leaks in the endotracheal tube." "I should expect the nurse to suction my partner, and complete oral care, every two hours per hospital protocol." "The nurse will change my partner's position at least every two hours." The critical care nurse will perform which action first when assessing the needs of the client's family? Explain medications and procedures in easy to understand language. Evaluate who the essential family members are and their roles. Consider the developmental stages of each family member. Appoint one family member as the primary contact person for the patient. The nurse provides care for a client who has a right brachial arterial access device. Which finding alerts the nurse to a potential complication of this invasive device? Pressure bag filled with sterile normal saline. Right and left radial pulses are 1+. Right hand cool to touch compared to the left hand. Systolic blood pressure reading of 92 mm Hg. The nurse prepares the room for a near drowning victim that is on the way to the unit. Which action should the nurse implement when preparing for the care this client will require? Select all that apply. Place several blankets in the warmer Gather intubation and mechanical ventilation supplies. Ensure that intravenous (IV) fluids are warmed before administration. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Prepare warmed packed red blood cells (RBCs) Prepare to place the client on continuous telemetry. The nurse prepares to defibrillate an 18-month-old client but the only available pads are adult sized. Which action by the nurse is appropriate? Perform cardiopulmonary resuscitation (CPR) without defibrillation. Place one pad on the upper right chest and one pad on the upper left chest. Place one pad on the chest and one pad on the client's back. Use only one of the pads to defibrillate the pediatric client, if needed. The nurse is teaching a client with type 2 diabetes about a new prescription for long-acting insulin. It is most important for the nurse to follow up on which client statement? "I am glad that will learn how to give myself insulin shots before I go home." "It is important to test my blood sugar at the same time every day." "I may feel irritable or anxious if my blood sugar starts to drop too low." "Having to take insulin for my sugar means that I have failed to control my diabetes." The nurse supervises the implementation of cardiopulmonary resuscitation (CPR) for a client on the telemetry unit. The rhythm presently observed is a polymorphic ventricular tachycardia with a prolonged QT interval. Which medication should the nurse prepare to administer to this client? Adenosine Index Atropine Diltiazem Magnesium sulfate The nurse provides care for a client who requires continuous arterial blood pressure (BP) monitoring. Which location should the nurse place that transducer to achieve accurate measurements? Left of the sternal border at the 2nd intercostal space. Right of the sternal border in the pulmonic NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ area. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Fluid volume deficit Impaired urinary elimination increased cardiac output Knowledge deficit The nurse provides care for a client who is intubated and mechanically ventilated in the intensive care unit (ICU). Which action should the nurse implement to decreases this client's risk for developing ventilator associated pneumonia? Select all that apply. Endotracheal suctioning every two hours and PRN Implement a ventilator weaning protocol Keep head of bed elevated at least 15 degrees at all times 0000 Performing mouth care with approved antiseptic solution Wear clean gloves when providing client care When a critically ill client exhibits signs of anxiety, which is the nurse's priority action? Administer pain medication as prescribed. Identify and treat the underlying cause. Administer sedation medication as prescribed. Assess the client hourly to determine the severity of anxiety. A client with an automated implantable cardiac-defibrillator (ICD) is shocked twice by the device but remains in ventricular fibrillation. Which response by the nurse is appropriate? Begin chest compressions at 100 per minute. Continue to monitor the client closely. Give epinephrine 1:1000 intravenous push (IVP) now. Start a second large bore intravenous (IV) catheter. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ The nurse provides care for a client who is admitted to the emergency department (ED) with a traumatic brain injury (TBI). Which nursing intervention is best to assist with visualization of the client's airway for intubation? Head-tilt, chin lift while lying flat Head tilt, chin lift with head elevated Jaw-thrust while lying flat Jaw thrust with head elevated Which statement by the client receiving fibrinolytics warrants further assessment by the critical care nurse? "I have the worst headache have ever had." "There is blood on my toothbrush." "Look at these bruises on my arm." "I have some oozing from my IV site" The nurse is developing protocols to optimize evidenced based nutrition therapy to critically ill clients. Which of the following should be included? Select all that apply. Verify proper tube feeding placement daily via chest x-ray. Initiate tube feedings within 7 days of admission if unable to tolerate oral feedings. Avoid stopping feedings inappropriately. Flush with water before and after medication administration. Avoid early enteral feedings in obese clients. The nurse assesses a post-cardiac surgery client when the low pressure alert indicator alarms for the brachial arterial line. Which is the priority action by the nurse? Assess the tubing for loose connections or evidence of bleeding Ensure the transducer is at the level of the phlebiostatic avis Performa fast flushy of the fine and men re-zero the system Request a prescription for an ifravenous vi fluid bone for hypotensions NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Which client would benefit most from placement of a percutaneous endoscopic gastrostomy (PEG) tube? A client just diagnosed with acute pancreatitis A client with burns who cannot meet nutritional needs orally CA client with a decreased level of consciousness due to overmedication with a sedative A client with dysphagia resulting from a cerebral vascular accident The nurse provides care for a newly extubated client. Which is the first nursing intervention when providing care for this client? Auscultate breath sounds in all fields. Provide oral care every two hours. Administer oxygen. 2 liters per minute by nasal cannula (NC). Teach the client to use the incentive spiromete The nurse assesses a client who returns to the unit following abdominal surgery to repair damage from a stab wound. Which clinical finding should be reported to the health care provider (HCP) immediately? Heart rate of 112, regular rhythm per telemetry. Skin that is mottled and cold to touch. Small amount of serosanguineous drainage on abdominal dressing. Total urinary output of 100 mL over the past 2 hours. The nurse prepares to administer total parenteral nutrition (TPN) to a client with a newly placed double lumen central venous catheter. Which is the priority action for the nurse to perform before infusing the prescribed TPN? Assess the placement of the central venous catheter via chest x-ray. Check patency of the central venous catheter by aspirating for blood return. Obtain a bedside capillary blood glucose level NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ notes compares the client's most recent assessment findings with a previous assessment 2 hours prior. Based on the findings, which prescription requires the nurse to clarify with the HCP? Aspirin 81 mg PO NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Enoxaparin 40 mg SQ Furosemide 40 mg IVP Metoprolol 100 mg PO A client who is diagnosed with emphysema is prescribed non-invasive positive pressure ventilation (NIV). The following medications are due at 0900: Salmeterol inhaler 4 puff, Vancomycin 1 gm IVPB; Prednisone 10 mg PO; and Enoxaparin 80 mg SQ. Which is the most important assessment to perform for this client? Capillary blood glucose, Level of consciousness. Peripheral pulse quality White blood cell (WBC) count A client has a temporary permcath inserted into the subclavian area for emergent hemodialysis. Which of the following is an important part of routine nursing care for this client? Maintain sterile technique when changing the catheter dressing. Keep the affected extremity immobilized for the first 24 hours. Flush the catheter with heparin every 8 hours and after medication administration. Auscultate for a bruit and palpate for a thrill every 12 hours. The nurse provides care for a client in the post anesthesia care unit (PACU). Which client assessment finding requires immediate action by the nurse? Lethargy Muscle rigidity Pupils 1+ Temperature 99 F (37.2 C) The nurse provides care for a toddler-age client. Which clinical finding noted by the nurse warrants notification of the rapid response team (RRT)? HR 118 BPM NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Temperature 100.5 F (38) NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Monitor the complete blood count for any decreases in the white blood cell count (WBC) The nurse is caring for a client who has been hospitalized in the intensive care unit for one week. The nurse should monitor the client for which manifestations of ICU psychosis? Signs of increasing agitation and confusion to place and time. Reports of phantom limb pain following amputation. Reports of sleeping no more than 3 hours per night Decreased alertness noted during the morning assessment. The nurse is administering 50 mL of 50% dextrose with 10 units Regular insulin IV to a client with acute kidney injury (AKI). When asked by the client what the rationale is for this medication, which is the nurse's best response? "The provider ordered it and I will ask for clarification This medication will help keep your glucose within normal limits" These medications will help correct your low sodium This will help correct your elevated potassium The nurse assesses a client who presents to the emergency department (ED) with a potential diagnosis of frostbite. Assessment data reveals mottled extremities and the client reports numbness and tingling. Which is the priority action by the nurse? Cover affected areas with semi-occlusive dressings. Elevate the affected extremities once they are warm. Perform a complete pain assessment on the client Vigorously rub affected areas to stimulate circulation Which factor should the nurse recognize as a potential contributor to the high pressure alarm on a client who is mechanical ventilated? Select all that apply. An air leak in the endotracheal (ET) tube. Obstruction in endotracheal (ET) tube. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Client biting down on the endotracheal (ET) tube. NR422 |prioritization and delegation EXAM QUESTIONS WITH ANSWERS 2023 A+ Client coughing vigorously. Ventilator tubing is kinked Which factor should the nurse recognize as a potential contributor to the high pressure alarm on a client who is mechanical ventilated? Select all that apply. An air leak in the endotracheal (ET) tube. Obstruction in endotracheal (ET) tube. Client biting down on the endotracheal (ET) tube. Client coughing vigorously. Ventilator tubing is kinked The nurse is a witness to a motor vehicle crash. The client is awake and alert but currently reporting neck pain. Which action is appropriate for the nurse to implement when providing care to this client? Select all that apply. Count the client's respirations. Implement cervical spine precautions. Obtain a Glasgow Coma Scale score. Perform a head to toe physical assessment Place the client on a backboard prior to transport The nurse caring for a client with HIV is monitoring the progression of the disease. This morning's lab work reveals an absolute neutrophil count of 400 cells/microliter. Which is the priority intervention to protect this client from infection? Administer prophylactic antibiotics as prescribed Wash hands after every contact with the client. Assess the client's current body temperature.