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41. A large number of family members are gathered at the 47. The nurse should be aware that a client is susceptible to
bedside of a terminally ill Hispanic client in a semi spontaneous bleeding if taking which of the following herbs
private room. Recognizing the family’s cultural response with an anticoagulant?
to death and dying, the nurse should: a. black cohosh
a. restrict visitors 2 at a time in the client’s room b. gingko biloba
b. move the client to a private room to allow family c. chamomile tea
to be with the client d. valerian root
c. have security limit the members of the family
who can visit at one time
d. ask the family members to show greater
emotional control around the client
48. The physician prescribes Fluoxetine (Prozac). Before C. dehydration
starting this medication, it is most important for the nurse D. fluid overload
to ask the client if he takes which of the following herb? E. uterine tetany
a. St. John’s wort F. bradycardia
b. Valerian root
c. Black cohosh 59. An end-stage AIDS client requires suctioning. When
d. Chamomile tea performing this task, the nurse is correct to wear
a. mask and eye protection
The following patients are in your charge. Delegate the b. sterile gloves and eye protection
following patient’s general care to a registered nurse (RN), c. mask and sterile gloves
licensed practical nurse (LPN), and unlicensed personnel d. mask, eye protection, and sterile gloves
(ULP).
60. When counseling a parent about the side effects of varicella
49. A 60 year old patient with congestive heart failure (CHF) vaccine (Varivax), the nurse is correct to include which of the
second day after admission to the hospital. following in the teaching plan?
50. A 40 year old patient with MI new admission to the a. The child may cry inconsolably for 24 hours after the
hospital vaccination.
51. A 70 year old patient with chronic renal failure new b. A lump may appear at the site of injection and persist
admission for weeks to months (local pain and tenderness may
52. A 30 year old patient with secondary polycythemia second occur)
day after admission c. Vaccine-induced paralysis may occur
d. A mild maculopapular rash may appear
A 50-year-old patient has been admitted to the hospital with
severe renal failure. Delegate the following tasks to an RN, A 52-year-old male patient has been admitted to the hospital
LPN, and ULP. diagnosed with CHF. Delegate the following tasks to an RN,
LPN, and ULP.
53. Assessment of the patient at the time of admission
61. Irrigate central line
54. Administration of medications
62. Change abdominal dressing
55. Urinary Foley care and measuring output
63. IV push 20 mg of Lasix
56. Working with a patient to develop short term goals
64. Report slow decubitus ulcer healing to RN
57-58: Select all that applies. Incomplete or excess tagging
will not be considered correct.(1 point each number) The following patients are in your charge. Delegate their
general care to an RN, LPN and ULP. A patient with
57. The nurse is planning care for a client with human
immunodeficiency virus (HIV). She’s being assisted by 65. Asthma on the day of admission to the hospital
licensed practical nurse (LPN). Which statements by the
LPN indicate her understanding of HIV transmission? 66. Viral hepatitis on the second day after admission
A. “I’ll wear a gown, mask and gloves for all client 67. Liver abscess on the second day of admission
contact.”
B. “I don’t need to wear any personal protective 68. Chronic glomerulonephritis on the third day after admission
equipment because nurses have a low risk of
occupational exposure.” You are caring for a 90 year old female on the second day in the
C. “I’ll wear a mask if the client has a cough caused by hospital after a colon resection surgery. Delegate the following
an upper respiratory infection.” interventions to an RN, LPN, and ULP.
D. “I’ll wear a mask, gown and gloves when splashing
of body fluids is likely.” 69. Administer potassium 20 mg IV push
E. “I will wash my hands after client care.”
70. Aspirin PO
58. The nurse is monitoring a client who is receiving oxytocin
(Pitocin) to induce labor. The nurse should be prepared 71. Use restraints as prescribed
for which of the following maternal adverse reactions.
A. hypertension 72. Insertion of a nasogastric tube
B. jaundice
A 28-year-old female has been admitted to the hospital with 91. diabetes insipidus and specific gravity of 1.010.
a diagnosis of appendicitis. Which of the following skills
would you delegate to an RN, LPN, and ULP? 92. Downs syndrome, 20 years of age, with a WBC count of
10,000 ml
73. Vital signs and I and O on the day of admission
93. The nurse is teaching a group of unlicensed personnel new to
74. Evaluating the patient’s vital signs psychiatry about balance in a therapeutic milieu. Which of the
following statements by a member of the group indicates the
75. Assessing abdominal pain need for further teaching?
a. “Balance includes safe and effective treatment for all
76. Administering intravenous fluids clients.”
b. “Controlling clients helps them feel more
You are caring for a 90 year old female the second day in the comfortable.”
hospital after hip replacement. Which of the following tasks c. “We don’t fix clients but help them solve their
would you delegate to an RN, LPN, and ULP? problems.”
d. “We need to think of “patients’ rights” when working
77. Bathing and turning client with clients.”
78. Listening and answering family and patient’s basic 94. Two nursing assistants are arguing about which person is
concerns. responsible for taking the dirty linen bags into the utility room.
One nursing assistant approaches the charge nurse and
79. Removing Buck’s traction per physician’s orders complains about the other. Which of the following actions
would the nurse employ?
80. Administering blood a. Advise the nursing assistant to be more tolerant of his
coworker.
A 52 year old male is admitted to the hospital with severe b. Tell the nursing assistant to take care of the linen
herpes zoster and you have on your team a female RN, 28 bags himself.
years of age; a female LPN, 52 years of age; and a 30 year c. Urge the nursing assistant to discuss the problem with
old male ULP. Delegate the following skills to them. his coworker.
d. Take care of the linen bags to avoid further conflict.
81. Bathing the client
95. Which of the following interventions can be delegated to an
82. Administering medications unlicensed assistive personnel?
a. assessment of the blood pressure of a patient with
83. Apply calamine lotion as prescribed pre-eclampsia
b. providing discharge teaching to a diabetic patient
84. Observe the patient for hearing loss c. observing a patient in the demonstration of crutch
walking
Patients with the following diagnosis have been assigned to d. obtaining a specimen form an indwelling urinary
you. Delegate their general care to an RN, LPN and ULP. A catheter
client with
96. Which attitude would most likely be seen in a Mexican
85. scarlet fever American client with pain
a. “Enduring pain is a part of God’s will.”
86. meningitis b. “This pain is killing me.”
c. “I’ve got to see a doctor right away.”
87. encephalitis d. “I can’t go on in pain like this any longer.”
100. A nurse is making a home health visit and finds the client
experiencing right lower quadrant abdominal pain, which
has decreased in intensity over the last day. The client
also has a rigid abdomen and a temperature of 103. 6 F.
The nurse should intervene by
a. administering Tylenol for the elevated
temperature
b. advising the client to increase oral fluids
c. asking the client when she last had a bowel
d. notifying the physician