After receiving report from the previous shift nurse, which client should the nurse assess first?

Leadership

Form B

1. A nurse is assessing a client who had a recent stroke. Which of the following findings should

indicate to the nurse the need for referral to an occupational therapist?

a.Facial drooping

b.Receptive aphasia

c.Unilateral neglect

d.Memory loss

2. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP).

Which of the following is an appropriate task for the AP?

a.Show a new mother how to change the newborn’s diaper

b.Inspect the skin of a newborn who is receiving phototherapy

c.Obtain the weight of a newborn who is receiving formula

d.Answer the parents’ questions about newborn circumcision

3. A charge nurse is planning the care of four newborns. An assistive personnel and licensed

practical nurse are available for staffing. Which of the following tasks should the nurse assign to

a licensed practical nurse?

a.Conduct the newborn hearing screening

b.Perform a New Ballard screening

c.Administer a hepatitis B vaccine

d.Obtain vital signs

4. A nurse is completing discharge teaching with a client who is being treated for tuberculosis

(TB). Which of the following statements by the client indicates an understanding of the

teaching?

a.I need to have a TB skin test done once per year

b.I need to take my prescribed medication for 3 months

c.I should have a sputum culture done every 2 to 4 weeks

d.I should wear a mask while around my family

5. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have

sufficient experience to safely care for his assigned clients. Which of the following actions

should the nurse take?

a.Accept the assignment with help from assistive personnel on the unit

b.Document the concern in the nurse’s notes

1. The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse

   4. the client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL

2. The nurse is administering medicatins for clients on a neurological unit. Which medication should the nurse administer first?

   3. An anticholinesterase medication to a client dx with myasthenia gravis

3. The nurse has just received the shift report. Which client should the nurse assess first?

   2. The client with Guillain-Barre syndrome who has ascending paralysis to the knees

4. THe nurse and unlicensed assistive personnel are caring for a client with right-sided paralysis. Which action by the uap requires the nurse to intervene?

   3. The UAp places her hand under the client's right axilla to help the client move up in bed

5. The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?

   1. THe elderly client who is experiencing a stroke in evolution

6. The client diagnosed with a cerebrovascular accident has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time?

   1. Inpatient rehabilitation unit

7. THe nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN?

   2. Administer the client's anticoagulant subq

8. The nurse is caring for a client diagnosed with Alzheimer's disease. Which nurseing tasks should not be delegated to the unlicensed assistive personnel? Select all that apply

   1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication.

9. THe nurse on the surgical unit is working with an unlicensed assistive personnel. Which task is most appropriate for the nurse to delegate to the uap?

   4. Escort a client who has been discharged to the client's vehicle

10. Which client should the charge nurse assess first after receiving the change-of-shift report?

    1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute

11. The client with a C-6 spinal cord injury coes to the emergency department complaining of a throbbing headache and has a b/p of 200/120. Which intervention should the nurse implement first?

    3. Insert an indwelling urinary catheter

12. The ICU nurse and UAP are caring for a client with right sided paralysis secondary to a cerebrovascular accident. Which action by the UAP requires the nurse to intervene?

    2. THe UAP places the client on the abdomen with the head to the side

13. The critical care charge nurse is making clienta ssignments for the shift. WHich cilent should the charge nurse assign to the graduate nurse who just completed the orientation?

    1. THe client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside

14. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse?

    2. THe client extends the upper and lower extremities in response to painful stimuli

15. The charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. Which action should the charge nurse implement?

    3. Instruct the UAP to change the sharps container

16. The wife of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse?

    1. "I will call the chaplain to come and talk to you."

17. Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barre syndrme who is admitted to the critical care unit?

    4. Ineffective breathing pattern

18. To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis?

    4. Speech therapist

19. The nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. THe nurse flushes the skin with water and tries to get the area to bled. WHich action should the nurse implement next?

    2. Notify the charge nurse and complete the incident report

20. The nurse is caring for clients in a long-term care facility. WHich client should the nurse assess first after receiving th emorning report?

    1. The client dx with Parkinson's disease who began to hallucinate during the night.

21. THe nurse is a long-term care facility is administering medications to a group of clients. WHich medication should the nurse administer first?

    2. Neostigmine (Prostigmin) to a client dx with myasthenia gravis

22. THe nurse is a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer's disease. WHich client problem is priority for this client?

    2. Increased risk for injury

23. THe clinic nurse is providing discharge instructions to an elderly client diagnosed with cataracts. WHich intervention is most important for the nurse to implement?

    1. Teach the client to increase the light in the home

24. A wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where he is, and is not acting like his usual self. WHich intervention should the nurse implement first?

    1. Perform a neurological assessment

25. THe charge nurse observes the client's nurse telling the UAP to feed an elderly client diagnosed with a cerbrovascular accident. WHich question should the charge nurse ask the client's nurse?

    1. "How does the client swallow the medications?"

26. THe client diagnosed iwth a CVA is confined to a wheelchair for most of the waking hours. WHich intervention is priority for the nurse to implement?

    3. Get a pressure-relieving cushion to place in the wheelchair

27. THe nurse enters the room, and the client is beginning to have a tonic-clonic seizure. WHich action should the nurse implement first?

    2. Note the time the client's seizure began

28. THe rehabilitation nurse tells the UAP to assist the client recovering from Gillain-Barre syndrome with a.m. care. WHich aciton by the UAP warrants immediate intervention?

    4. The UAP puts the side rails up when bathing the client

29. THe client diagnosed with a right-sided CVA, or brain attack, is admitted to the rehab unit. WHich interventions should be included in the nursing care plan? Select all that apply.

    • 1. Position the client to prevent shoulder adduction
    • 2. Refer the client to occupational therapy daily
    • 3. Encourage the client to move the affected side
    • 4. Perform quadriceps exercises five times a day

30. THe nurse is the first person on the scene of a motor vehicle accident. THe driver is in the driver's seat unconsious. WHich action should the nurse implement first?

    Ensure the driver has a patent airway

31. THe clinic nurse is making assignments for th elarge family practice clinic. WHich task should be assigned to the staff nurse who is 4 months pregnant?

    1. Have the staff nurse answer the telephone calls from clients

32. WHich task is most appropriate for the clinic nurse to delegate to the UAP?

    2. Ask the UAP to escort the client in a wheelchair to the car

33. The employee health nurse is caring for an employee who feel off a ladder and is complaining of low back pain radiating down both legs. WHich intervention should the nurse implement first?

    1. Refer the client to an HCP for further eval

34. THe employee health nurse is caring for a male employee who reports tripping and is complaining of right knee pain. There is no visible injury, and the client has a normal neurovascular assessment. Which intervention should the nurse implement?

    2. Obtain a urine specific specimen for a drug screen

35. THe community health nurse is triaging victims at the site of a disaster. WHich client should the nurse categorize as balck, priority 4?

    4. TH client who has full thickness burns over 60% of the body

36. The home health nurse enters the home of an 80 y.o. female client who had a CVA, or brain attack 2 months ago. The client is complaining of a severe headache. WHich intervention should the nurse implement first?

    4. Tell the client to sit down, and take her blood pressure

37. A client has been diagnosed with rule out bacterial meningitis, and a nurse is assisting the healthcare provider with a lumbar puncture. WHich intervention should the nurse implement first?

    2. Tell the client to empty the bladder

38. THe home health nurse is scheduling visits for the day. WHich client should th enurse visit first?

    4. THe client with a C-5 SCI who reports redness and drainage at the Halo vest sites

39. THe clinic nurse is triaging client's telephone calls. WHich client should the nurse call first?

    4. THe client whose friend has botulism who has vomiting and abdominal craping pain

40. THe home health nurse is caring for a 22 year old female client who sustained an L-5 spinal cord injry 2 months ago. THe client says, " I will nevr be happy agian. I can't walk, I can't drive, and I had to quit college." WHich intervention should th enurse implement first?

    1. Allow the client to ventilate her feelings of powerlessness

41. THe client being admitted with transient ischemic attack is complaining of a headache. THe client is allergic to morphine, iodine, and codeine. Which healthtcare provider order whould the nurse question?

    1. Schedule for CT scan with contrast in a.m.

42. THe home health nurse is admitting a female client diagnosed with myasthenia gravis. THe client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement?

    2. Contact the HH occupational therapist to discuss the client's concern

43. THe nurse is caring for clients in the emergency department. WHich client should the nurse assess first?

    1. The client with an epidural hematoma

44. THe nurse in the neurological clinic is traiging phone calls. WHich client should the nurse contact first?

    1. THe client with tension headache who is reporting nausea and vomiting

45. A client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. WHich statement indicates the wife understands the most important action to take if her husband has a seizure?

    2. "I will move all the furniture out of his way."

46. THe multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a Stage 2 pressure ulcer over the sacral area that is not healing. WHich priority intervention should the client's hom ehealth nurse recommmend?

    4. Recommend a referral to the home healthcare agency wound care nurse

47. The homehealth aid tels the nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. WHich intervention should the nurse implement?

    4. Contact the agency physical therapist about the situation

48. The urse is teaching the client with tension-type headaches. WHich statment indicates the client needs more teaching?

    3. "Cold packs to the back of my neck will help my headache"

49. The client in a multiple car crash dies in the ER. Which priority intervention should the ER nurse implement when addressing the needs of the client's family?

    3. Escort the family to a private room to grieve.

50. THe neurologist has explained to the fmaily of a 22 y.o. client with a traumatic brain injury placed on a ventilator after a motor vehicle accident that the client does not have any brain function. Which referral is appropriate at this time?

    4. A tissue and organ bank

51. The nurse is caring for clients in an ophthalmology clinic. WHich client warrants interveniton by the nurse?

    4. The client with primary open angle glaucoma who reports excruciating eye pain

52. The nurse is at a park and bserves a client fall and a stick become impaled into the right eye. WHich intervention should the nurse implement first?

    2. Stablizise the stick in the client's eye

53. THe nurse and UAP are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. WHich action is priority when moving the client in the bed?

    1. Obtain a lifting device made for lifeting heavy clients

54. THe terminally ill client diagnosed with ALS has a DNR order in place and is curreently complaining of "pain all over." THe nurse notes the client has shallow breathing and P 67, R 8, B/P 104/62. WHich intervention should the nurse implement?

    1. Administer the narcotic pain medication IVP

55. The nurse in rehabilation facility is evaluating the progress of a female client who sustained a C-6-C-7 spinal cord injury. WHich outcome indicates the client is improving?

    1. THe client can maneuver the automatic wheelchair in the hallway

56. The nurse is triaging pohne calls in a neurosensory clinic. WHich client should the nurse contact first?

    3. The client with external otitis who has serosanguineous drainage and otalgia

57. THe nurse is planning care for the client diagnosed with Parkinson's disease. WHich client problem is priority?

    2. Altered mobility

58. A client comes to the ER after having bleach splash in the eyes. WHich intervention should the nurse implement first?

    3. Irrigate the eyes with sterile solution

59. THe 24 y.o. diagnosed with a traumatic brain injury is being transferred to a rehab unit. WHich healthcare provider order should the nurse question?

    4. Methylpredisonole, a seroid, IVP q6hr

60. The rehabilitation nurse is planning the discharge of a 68 y.o. client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. WHich referral should the nurse initiate at this time?

    4. Referral to a home health agency

61. THe client is postoperative a right eye enucleation. WHich statement indicates the client needs more discharge teaching?

    1. "It will be approximately 2 weeks before I can get a prosthetic eye"

62. THe nurse is caring for a client newly diagnosed with multiple clerosis. WHich referral is appropriate at this time?

    3. To a psychological counselor for therapy

63. THe nurse and LPN has been assigned to care for clients on a neurology unit. WHich nursing task is most appropriate to assign to the LPN?

    1. Administer the adrenocorticopic hormone to the client with multiple sclerosis

64. THe nurse is administering medications on a neurological unit. WHich medication should the nurse administer first?

    1. THe osmotic diuretic to the client with a closed head injury

65. THe charge nurse observes the new grad nurse delegating tasks to the UAP and the UAP appears to be ignoring the grad nurse. WHich action should the charge nurse implement first?

    1. Wait and observe how the graduate nurse handles the situation

66. THe client on the rehab unit post-motor vehicle accident has been prescribed 50 mg of Baclofen per dose orally for muscle spasms. Baclofen comes in 10 mg, 20 mg, and 75 mg tablets. How many tablets should the nurse administer and in which quanity?

    two 20 mg and 1 10 mg

67. The 19 y.o. client is in the rehab unit following a traumatic brain injury. WHich intervention should the nurse delegate to the UAP? Select all that apply?

    • 1. Make safety rounds hourly
    • 3. Assist the client with meals
    • 4. Clamp and unclamp the indwelling catheter every 2 hours

68. Elizabeth, who is the day staff nurse, and the UAP are caring for a client with a right-sided CVA with hemi-paralysis. WHich action by the UAP requires Elizabeth to intervene?

    1. The UAP places the call light on the client's left side

69. THe client dx with a right-sided CVA is complaining of a severe headache. WHIch intervention should ELizabeth implement first?

    4. Assess the clients neurological status

70. Courtney is caring for the following clients on the Neurological ICU. WHich client should Courtney assess first?

    3. The client with traumatic brain injury who has a Glasgow Coma Scale score of 6

71. The ICU is very busy and Mr. Lea is transcribing the healthcare providers admission orders for a client with a closed head injury. Which medication orer should Mr. Leo question?

    1. a subcutaneous anticoagulant

72. Jessie is caring for a client who had a c-6 SCI 2 years ago and is admitted forStage IV pressure ulcers in the coccyx area. THe client is complaining of a severe headache and the B/P is 190/110. Which intervention should Jessie implement first?

    4. palpate the clients bladdr

73. Mr. Leo is making rounds and as he enters the room the client is having tonic-clonic seizure. Which priority intervenition whould Mr. Leo implement?

    1. Place the client on the side

74. THe UAP is attempting to put an oral airway in the mouth of a client having tonic clonic seizures. Which intervention should Mr. Leo take first?

    2. instruct the UAP to stop inserting the oral airway

75. Mr. Leo is telling one of his graduate nurses the correct procedure for assisting the healthcare provider iwth a lumbar puncture to R/O meningitis. WHich interventions should Mr. Leo discuss with the graduate nurse? Select all that apply

    • 1. Obtain an informed consent from the client or significant other
    • 3. Place the client in the supine position witht he foot of the bed elevated
    • 4. Instruct the client to relax and brethe normally
    • 5. Explain to the client what to expect during the procedure

76. Mr. Leo is making shift assignments. Which client should be assigned to the most experienced nurse?

    4. The client ALS who is having respiratory distress

77. THe nurse is caring for clients on a Neurological Intensive Care unit. Which client should be assessed first?

    2. The client dx with a c-6 SCI who has bradycardia, hypotension, and hyperflexia

Which client should the nurse assess first?

Which client does the nurse assess first after receiving Morning Report?

What information needs to be immediately reported to a nurse?

Which client should the charge nurse assign to the room closest to the nurses station?