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A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients.
Which of the following client's needs may the nurse assign to an assistive personnel
(AP)?
A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
B. Reinforcing teaching w/a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer - ANSWERS-C. Reapplying a condom
catheter for a client who has urinary incontinence
Rationale: The application of a condom catheter is a noninvasive, routine procedure that
the nurse may delegate to the AP
A nurse has noticed several occasions in the past week when another nurse on the unit
seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse
asleep in a chair in the break room when she was not on break. Which of the following
actions should the nurse take?
,A. Remind the nurse that safe client care is a priority on the unit
B. Ask others on the team whether they have observed the same behavior
C. Report observations to the nurse manager on the unit
D. Conclude that her coworker's fatigue is not her problem to solve - ANSWERS-C.
Any nurse who notices behavior that could possibly jeopardize client care or indicate a
substance abuse problem has a duty to report the situation immediately to the nurse
manager
A nurse is preparing info for a change-of-shift report. Which of the following info should
the nurse include in the report?
A. The client's input & output for the shift
B. The client's BP from the previous day
C. A bone scan that is scheduled for today
D. The med routine from the med administration record - ANSWERS-C. A bone scan
that is scheduled for today
This is important because the nurse might have to modify the client's care to
accommodate them leaving the unit
A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the
shower, but I got myself back up & into my chair." How should the nurse document this
in the client's chart?
A. The client fell in the shower.
B. The client states he fell in the shower & was able to get himself back into his chair
C. The nurse should not document this info because she did not witness the fall
D. The client fell in the shower & is now resting comfortably - ANSWERS-B.
By writing what the client states, the info is subjective data
,A nursing instructor is reviewing documentation w/a group of nursing students. Which of
the following legal guidelines should they follow when documenting a client's record?
Select all.
A. Cover errors w/correction fluid, & write in the correct info
B. Put the date & time on all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document - ANSWERS-B, C
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up
to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only
when the client is supine in bed. The nurse telephoned the physical therapist about the
difficulties containing the drainage from the fistula, so the therapist didn't ambulate the
client today. The client sat in a chair during lunch w/an absorbent pad over the fistula.
The client ate all the food on her tray. The wound care nurse confirmed that she will see
the client later today. The client states she feels frustrated at not having physical
therapy, but the nurse thinks the client welcomed having a day to rest. Which of the
following information should the nurse include in the change-of-shift report? Select all.
A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the - ANSWERS-A, B, D
A nurse is receiving a provider's prescription by telephone for morphine for a client who
is reporting moderate to severe pain. Which of the following nursing actions are
appropriate? Select all.
A. Repeat the details of the prescription back to the provider
B. Have another nurse listen to the telephone prescription
C. Obtain the prescriber's signature on the prescription within 24hrs
D. Decline the verbal prescription because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone -
ANSWERS-A, B, C
, A nurse is caring for an older adult client who lives alone & is to be discharged in 3
days. He states that it is difficult to prepare adequate nutritious meals at home for just 1
person. To which of the following members of the health care team should the nurse
refer him?
A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker - ANSWERS-D. social worker
A social worker can make arrangements for a meal delivery service to provide nutritious
meals daily, or recommend a congregate meal site near the client's home
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use
adaptive devices. The nurse caring for the client should initiate a referral w/which of the
following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist - ANSWERS-D.
An occupational therapist can assist clients who have physical challenges to use
adaptive devices & strategies to help w/self-care activities
A client who is postop following a knee arthroplasty is concerned about the adverse
effects of the medication he is receiving for pain management. Which of the following
members of the interprofessional care team may assist the client in understanding the
medication's effects? Select all.
A. Provider
B. CNA