Saunders NCLEX-PN Ch. 7

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Medical-Surgical: Respiratory

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mnmacharia1985 Preview Start Tr 84 terms Stu The nurse is recording a nurse hands-off (end of shift) report for a client. Which information needs to be included?

• As-needed medications given that shift
• Normal vital signs that have been normal since

admission

• All of the tests and treatments the client has had since

admission

• Total number of scheduled medications that the client

received on that shift As-needed medications given that shift.The nurse if planning the client assignments for the day.Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

• A client who requires wound irrigation
• A client who requires frequent ambulation
• A client who is receiving continous tube feedings
• A client who requires frequent vital signs after a cardiac

catheterization A client who requires frequent ambulation.

The nurse employed in a long-term care facility is planning the assignments for the shift. Which client should the nurse assign to the unlicensed assisitive personnel

(UAP)?

• A client who requires 24-hour urine collection
• A client who requires twice-daily dressing changes
• A client with diabetes mellitus who requires daily insulin

and the reinforcement of dietary measures

• A client who has been placed on a bowel management

program and requires rectal suppositories and a daily enema A client who requires a 24-hour urine collection.The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

• a client in skeletal traction
• A client who is dependent on a ventilator
• A postoperative client preparing for discharge
• A client admitted during the previous shift with a

diagnosis of gastroenteritis A client who is dependent on a ventilator The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emeregency dpartment. The nurse should assign priority to which client?

• A client complaining of muschle ache, headache, and

malaise

• A client who twisted their ankle when they fell in-line

skating

• A client with a minor laceration on the index finger

sustained while cutting an eggplant

• A client with chest pain who states that they just ate

pizza that was made with very spicy sauce A client with chest pain who states that they just ate pizza that was made with a very spicy sauce The nurse is educatin a new nurse about mass casualty events (disasters). Which statement by the nurse indicates a need for further teaching? Select all that apply.

• "An event is termed a mass casualty when it overwhelms

local medical capabilities."

• "Mass casualty events do not require an increase in the

number of staff that are needed."

• "A mass casualty event occurs only within the health

care facility and could endanger staff."

• "Mass casualty events may require the colaboration of

many local agencies to handle the situation."

• "A mass casualty event occurs if a fight between visitors

occurs in the emergency department."

• "Mass casualty events do not require an increase in the number of staff that are

needed

• "A mass casualty event occurs only within the health care facility and could

endanger staff."

• "A mass casualty event occurs if a fight between visitors occurs in the

emergency department."

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?

• A task approach method is used to provide care to

clients.

• Managed care concepts and tools are used when

providing client care.

• Nursing staff are led by the nurse when providing care

to a group of clients.

• A single registered nurse is responsible for providing

nursing care to a group of clients.Nursing staff are led by the nurse when providing care to a group of clients.A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

• Autocratic
• Situational
• Democratic
• Laissez-faire

Autocratic The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

• Document that the task was completed.
• Assign the tasks that were not completed to the next

nursing shift.

• Allow each staff member to make judgements when

performing the tasks.

• Perform follow-up with each staff member regarding

the performance and outcome of the task.Perform follow-up with each staff member regarding the performance and outcome of the task.The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

• A client scheduled for a chest x-ray
• A client requiring daily dressing changes
• A postoperative client preparing for discharge
• A client receiving oxygen who is having difficulty

breathing A client receiving oxygen who is having difficulty breathing