HURST REVIEW Customize Quiz - Leadership 2023
Questions and Answers with complete solution
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving acetaminophen with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's nasogastric (NG) tube.
5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy
(PEG).
1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can
provide hygiene needs to a client such as perineal care and cleaning of the nares. Also,
making a surgical bed for the client returning from surgery is a basic procedure.
2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of
pain medication. That is what you are asking the UAP to do here. The client has
received a narcotic and you have asked the UAP to evaluate the effectiveness of the
medication.
5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice
for the UAP. This is a procedure which requires a licensed personnel. Catheter
placement must be confirmed, client identity checked, tube site flushed with water or
sterile water and flow rate determined.
What action should the nurse take after mistakenly administering the wrong medication?
Select all that apply
1. Notify the nursing supervisor.
2. Inform the primary healthcare provider.
3. Complete an incident (variance) report.
4. Document client assessment and response to medication.
5. Document medication error and incident (variance) report in nurse's notes.
1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns
or problems to the supervising nurse, the primary healthcare provider and/or the
performance improvement or risk management department. A written report of the
incident is completed by the nurse and turned into the appropriate person (generally the
performance improvement department). Documentation of what occurred, and the
client's assessment is required in the nurse's notes.
5. Incorrect: Do not document that an error was made or that an incident (variance)
report was completed. Document what medication was given, the client's assessment,
the notification of the nursing supervisor, and primary healthcare provider, and any
prescriptions received.
The nurse is caring for four clients. Which client should the nurse see first?
1. The client hospitalized with dehydration related to diarrhea.
,2. The seizure client who is currently in the postictal phase.
3. The post-op client who received Morphine 4 mg IV 15 minutes ago.
4. The client who is due pre-op medication now.
3. Correct: This client is at risk for respiratory depression caused by morphine and
should be assessed. Remember airway, breathing and circulation (ABCs). Decreased
or suppressed respiration are priority.
1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation
and if it develops quickly or is severe, coma and seizure may occur. Decreased
respiratory rate would be priority.
2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic,
and possibly asleep. Make sure the client is safe and in the recovery position. Client
would need to be seen soon, but again, decreased respirations takes priority.
4. Incorrect: Decreased or suppressed respirations would be priority over the client
needing pre-op medications.
Following a large hurricane, multiple clients arrive at the emergency room for treatment.
The charge nurse must triage and assign clients to appropriate staff. Which clients
could be assigned to an LPN?
Select all that apply
1. Child with superficial burns on both upper arms.
2. Adolescent with bruising to left upper quadrant.
3. Crying toddler missing both upper front teeth.
4. Adult reporting headache and blurred vision.
5. Elderly adult reporting nausea and heartburn.
1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even
though the client is a child, superficial burns require only dry sterile dressings and
possibly oral pain medication, both tasks which are within the scope of practice for an
LPN. The crying toddler has missing front teeth, but there is no indication this was the
result of the hurricane. However, providing care for missing teeth would also be within
the LPN scope of practice.
2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen
and internal bleeding. This adolescent will require further tests, such as CT scan, and
possibly emergency surgery. Because of the complexity of the situation, an RN should
be assigned this client.
4. Incorrect: Since these clients were injured during the hurricane, the charge nurse
must assume the worst. This client is reporting headache and diplopia; therefore, a safe
nurse would consider the possibility of head trauma with brain swelling accounting for
the blurred vision. Such potential makes this client serious to critical, and as such,
should be assigned to an RN for on-going neurologic assessment.
5. Incorrect: While the trauma of a hurricane could adversely affect the digestive
system, the charge nurse would assume the worst and suspect the likelihood the client
, is having a myocardial infarction. Only an RN can complete the appropriate
assessment, testing, and other needs expected with an M.I. client.
An LPN/VN has been floated to the emergency room following a chemical plant
explosion. What task would be best to assign to the LPN/LVN?
1. Identify and assess each incoming client.
2. Triage and assign color-coded tags to each client.
3. Gather and apply dressings to open wounds.
4. Initiate oxygen and IV lines as needed.
3. Correct: An LPN/LVN's scope of practice includes tasks such as wound care.
Covering open wounds will help to decrease bacterial exposure until the registered
nurse or primary healthcare provider can assess and treat each wound. If the LPN
notes any serious bleeding situations, it would need reported immediately to the RN.
1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/LVN's
scope of practice does not include assessment. That task would require an RN or
primary healthcare provider.
2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare
provider to quickly determine which clients are critical versus those stable enough to
wait. Because this involves assessment, an LPN/LVN would not be assigned this task.
4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN.
Additionally, the decision to apply oxygen involves assessment of the respiratory
system, which also is not within the LPN/LVN's scope of practice.
The charge nurse identifies that three admissions were received during the night shift,
one nurse has called in sick, and the clients on the unit have high acuity levels. What
action should the nurse implement first to ensure client safety?
1. Take report on the most critical clients first.
2. Encourage the staff to help each other.
3. Assign one additional client to each nurse.
4. Call the nursing supervisor to request additional staff immediately.
4. Correct: The hospital nurse to client staffing ratio should reflect the complexity of
nursing care for high acuity clients. The nurse should call for immediate help so that a
safe care environment is maintained for all clients. The charge nurse should notify the
nursing supervisor who will seek additional staff. The nursing supervisor may be able to
assist with client care until another nurse can come in to work.
1. Incorrect: The critical clients are important, but all clients must be considered. The
charge nurse must evaluate each client's status and needs to assign the appropriate
staff to care for them. The safety of each client must be reviewed.
2. Incorrect: The charge nurse may encourage the staff to work together. This is a
positive action but the priority for the charge nurse is to ask for additional staff to
maintain safe nursing care.
3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing
Questions and Answers with complete solution
Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
Select all that apply
1. Prepare a client's room for return from surgery.
2. Observe for pain relief in a client after receiving acetaminophen with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's nasogastric (NG) tube.
5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy
(PEG).
1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can
provide hygiene needs to a client such as perineal care and cleaning of the nares. Also,
making a surgical bed for the client returning from surgery is a basic procedure.
2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of
pain medication. That is what you are asking the UAP to do here. The client has
received a narcotic and you have asked the UAP to evaluate the effectiveness of the
medication.
5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice
for the UAP. This is a procedure which requires a licensed personnel. Catheter
placement must be confirmed, client identity checked, tube site flushed with water or
sterile water and flow rate determined.
What action should the nurse take after mistakenly administering the wrong medication?
Select all that apply
1. Notify the nursing supervisor.
2. Inform the primary healthcare provider.
3. Complete an incident (variance) report.
4. Document client assessment and response to medication.
5. Document medication error and incident (variance) report in nurse's notes.
1., 2., 3., & 4. Correct: Nurses must immediately report all client care issues, concerns
or problems to the supervising nurse, the primary healthcare provider and/or the
performance improvement or risk management department. A written report of the
incident is completed by the nurse and turned into the appropriate person (generally the
performance improvement department). Documentation of what occurred, and the
client's assessment is required in the nurse's notes.
5. Incorrect: Do not document that an error was made or that an incident (variance)
report was completed. Document what medication was given, the client's assessment,
the notification of the nursing supervisor, and primary healthcare provider, and any
prescriptions received.
The nurse is caring for four clients. Which client should the nurse see first?
1. The client hospitalized with dehydration related to diarrhea.
,2. The seizure client who is currently in the postictal phase.
3. The post-op client who received Morphine 4 mg IV 15 minutes ago.
4. The client who is due pre-op medication now.
3. Correct: This client is at risk for respiratory depression caused by morphine and
should be assessed. Remember airway, breathing and circulation (ABCs). Decreased
or suppressed respiration are priority.
1. Incorrect: Dehydration can produce postural hypotension, fever, confusion, agitation
and if it develops quickly or is severe, coma and seizure may occur. Decreased
respiratory rate would be priority.
2. Incorrect: Postictal is the phase after the seizure where they are drowsy, lethargic,
and possibly asleep. Make sure the client is safe and in the recovery position. Client
would need to be seen soon, but again, decreased respirations takes priority.
4. Incorrect: Decreased or suppressed respirations would be priority over the client
needing pre-op medications.
Following a large hurricane, multiple clients arrive at the emergency room for treatment.
The charge nurse must triage and assign clients to appropriate staff. Which clients
could be assigned to an LPN?
Select all that apply
1. Child with superficial burns on both upper arms.
2. Adolescent with bruising to left upper quadrant.
3. Crying toddler missing both upper front teeth.
4. Adult reporting headache and blurred vision.
5. Elderly adult reporting nausea and heartburn.
1. & 3. Correct: An LPN should be assigned clients with predictable outcomes. Even
though the client is a child, superficial burns require only dry sterile dressings and
possibly oral pain medication, both tasks which are within the scope of practice for an
LPN. The crying toddler has missing front teeth, but there is no indication this was the
result of the hurricane. However, providing care for missing teeth would also be within
the LPN scope of practice.
2. Incorrect: Bruising of the left upper quadrant is often indicative of a ruptured spleen
and internal bleeding. This adolescent will require further tests, such as CT scan, and
possibly emergency surgery. Because of the complexity of the situation, an RN should
be assigned this client.
4. Incorrect: Since these clients were injured during the hurricane, the charge nurse
must assume the worst. This client is reporting headache and diplopia; therefore, a safe
nurse would consider the possibility of head trauma with brain swelling accounting for
the blurred vision. Such potential makes this client serious to critical, and as such,
should be assigned to an RN for on-going neurologic assessment.
5. Incorrect: While the trauma of a hurricane could adversely affect the digestive
system, the charge nurse would assume the worst and suspect the likelihood the client
, is having a myocardial infarction. Only an RN can complete the appropriate
assessment, testing, and other needs expected with an M.I. client.
An LPN/VN has been floated to the emergency room following a chemical plant
explosion. What task would be best to assign to the LPN/LVN?
1. Identify and assess each incoming client.
2. Triage and assign color-coded tags to each client.
3. Gather and apply dressings to open wounds.
4. Initiate oxygen and IV lines as needed.
3. Correct: An LPN/LVN's scope of practice includes tasks such as wound care.
Covering open wounds will help to decrease bacterial exposure until the registered
nurse or primary healthcare provider can assess and treat each wound. If the LPN
notes any serious bleeding situations, it would need reported immediately to the RN.
1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/LVN's
scope of practice does not include assessment. That task would require an RN or
primary healthcare provider.
2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare
provider to quickly determine which clients are critical versus those stable enough to
wait. Because this involves assessment, an LPN/LVN would not be assigned this task.
4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/LVN.
Additionally, the decision to apply oxygen involves assessment of the respiratory
system, which also is not within the LPN/LVN's scope of practice.
The charge nurse identifies that three admissions were received during the night shift,
one nurse has called in sick, and the clients on the unit have high acuity levels. What
action should the nurse implement first to ensure client safety?
1. Take report on the most critical clients first.
2. Encourage the staff to help each other.
3. Assign one additional client to each nurse.
4. Call the nursing supervisor to request additional staff immediately.
4. Correct: The hospital nurse to client staffing ratio should reflect the complexity of
nursing care for high acuity clients. The nurse should call for immediate help so that a
safe care environment is maintained for all clients. The charge nurse should notify the
nursing supervisor who will seek additional staff. The nursing supervisor may be able to
assist with client care until another nurse can come in to work.
1. Incorrect: The critical clients are important, but all clients must be considered. The
charge nurse must evaluate each client's status and needs to assign the appropriate
staff to care for them. The safety of each client must be reviewed.
2. Incorrect: The charge nurse may encourage the staff to work together. This is a
positive action but the priority for the charge nurse is to ask for additional staff to
maintain safe nursing care.
3. Incorrect: Each nurse may have to increase his/her client load until adequate staffing
