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While reviewing the hourly rounding logs on an orthopedic trauma unit, the nurse identifies four clients requiring attention. Which client should the nurse evaluate first?

A client who underwent a closed reduction of a fractured femur 24 hours ago and is newly exhibiting agitation and a petechial rash on the upper chest.

A client with an open tibial fracture who has a temperature of 101.8°F (38.8°C) and localized erythema around the external fixator pins.

A client in skeletal traction for a pelvic fracture who is experiencing severe muscle spasms and rating their pain as a 9 on a 0-to-10 scale.

A client recovering from a total hip arthroplasty who has a hemoglobin level of 9.2 g/dL (92 g/L) and reports fatigue when repositioning.

Show answer & explanation

Answer: A client who underwent a closed reduction of a fractured femur 24 hours ago and is newly exhibiting agitation and a petechial rash on the upper chest.

Answer

The client who underwent a closed reduction of a fractured femur 24 hours ago and is newly exhibiting agitation and a petechial rash on the upper chest.

Fat embolism syndrome (FES) is a life-threatening complication that typically occurs 24 to 72 hours after long bone or pelvic fractures. The classic triad of FES includes respiratory distress (often presenting early as restlessness or agitation due to hypoxemia), neurologic changes, and a characteristic petechial rash on the chest, axillae, or conjunctivae. This client is demonstrating early, acute signs of compromised airway, breathing, and circulation, making them the absolute highest priority for immediate intervention and oxygen therapy.

Step-by-Step Solution

Analyze the client with the fractured femur.

Identified signs of Fat Embolism Syndrome (agitation indicating hypoxia, petechial rash).

Fat emboli commonly occur 24 to 72 hours after long bone fractures and cause life-threatening respiratory failure.

Analyze the client with the tibial fracture.

Identified signs of a localized pin site infection (fever, erythema).

Requires antibiotics and wound care, but circulation and airway are intact.

Analyze the client in skeletal traction.

Identified a severe pain issue related to muscle spasms.

Pain is an expected psychosocial and comfort issue that is secondary to physiological survival.

Analyze the client with the hip arthroplasty.

Identified expected postoperative anemia.

A hemoglobin of 9.2 g/dL is a stable, expected finding that does not warrant immediate emergency action.

Apply prioritization frameworks (ABCs and unexpected vs. expected).

The client with signs of Fat Embolism Syndrome is experiencing an acute, unexpected, life-threatening breathing and circulation complication.

ABCs always take precedence over localized infections, pain, and expected laboratory abnormalities.

Key Concept

Prioritization: Recognizing Fat Embolism Syndrome

Question 2262Question →

A registered nurse is coordinating care for an older adult client with vascular dementia who is 24 hours postoperative following a right total hip arthroplasty. The client is restless, repeatedly attempts to exit the bed unassisted, and is prescribed a continuous intravenous infusion of packed red blood cells (PRBCs) for acute blood loss anemia. Which actions by the nurse prioritize accident, error, and injury prevention? (Select all that apply.)

Select all that apply

Verifying the client's two unique identifiers and the blood product details with a second registered nurse actively at the client's bedside.

Elevating all four bed side rails to establish a secure physical barrier while the nurse briefly exits the room to gather transfusion supplies.

Elevating the head of the bed to a full 90-degree angle to prevent aspiration while the client consumes oral medications and meals.

Positioning a bedside commode parallel to the left side of the hospital bed to facilitate safe pivoting on the unaffected extremity.

Delegating the unlicensed assistive personnel (UAP) to remain at the bedside for the first 15 minutes of the transfusion to immediately report any signs of a reaction.

Activating a bed-exit alarm equipped with a weight-sensitive pad that directly integrates with the unit's centralized call light system.

Show answer & explanation

Answer: Verifying the client's two unique identifiers and the blood product details with a second registered nurse actively at the client's bedside.; Positioning a bedside commode parallel to the left side of the hospital bed to facilitate safe pivoting on the unaffected extremity.; Activating a bed-exit alarm equipped with a weight-sensitive pad that directly integrates with the unit's centralized call light system.

Answer

The correct actions for prioritizing safety are verifying the blood product with a second nurse at the bedside, positioning the bedside commode on the unaffected left side for safe transfers, and activating a bed-exit alarm.

Verifying blood products at the bedside with a second RN is a mandatory error-mitigation standard to prevent incompatible transfusions. Positioning the commode on the left (unaffected) side ensures the client can bear weight and pivot on their strong leg, preventing falls and avoiding stress on the newly operated right hip. Activating a bed alarm is a proven restraint alternative that safely alerts staff to unassisted bed exits without confining the client.

Step-by-Step Solution

Analyze the client's specific clinical risks.

The client is at high risk for falls (dementia, restlessness), hip prosthesis dislocation (recent right arthroplasty), and transfusion reactions (PRBC infusion).

Identifying the highest priority risks across multiple physiological and environmental domains dictates the necessary safety interventions.

Evaluate the interventions related to blood administration safety and error mitigation.

Bedside verification by two RNs is a required standard. Delegating the critical initial 15-minute observation to a UAP is an unsafe practice.

Transfusion reactions most commonly occur in the first 15 minutes and require comprehensive clinical nursing assessment, which cannot be delegated.

Evaluate the interventions related to fall and injury prevention.

Using a bed alarm and transferring toward the unaffected left side are safe, evidence-based practices. Conversely, using four side rails is an unauthorized physical restraint, and flexing the hip to 90 degrees creates a severe dislocation hazard.

Safety measures must mitigate existing risks without introducing new hazards, such as physical entrapment or surgical joint complications.

Key Concept

Accident, error, and injury prevention in complex clients requires synthesizing multiple safety protocols simultaneously, including strict blood administration verification, adherence to surgical positioning precautions, safe delegation practices, and utilizing restraint alternatives for confused clients.

Question 2263Question →

A nursing supervisor is auditing isolation protocols for four newly admitted clients on a medical-surgical unit. Match each client's clinical presentation or diagnosis with the primary infection control intervention required by current evidence-based guidelines.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Diphtheria requires droplet precautions (surgical mask). Measles requires airborne precautions (negative-pressure room, N95 respirator). Shigella requires contact precautions (gown, gloves, strict handwashing). Legionella requires only standard precautions.

Each client's clinical presentation points to a specific pathogen with a distinct transmission route. Rubeola (measles) requires airborne isolation; diphtheria requires droplet precautions; Shigella requires contact precautions; and Legionella requires only standard precautions as it is not spread from person to person.

Step-by-Step Solution

Analyze the client with a gray pharyngeal pseudomembrane.

Identified as diphtheria.

Requires droplet precautions to prevent transmission via large respiratory secretions.

Evaluate the clinical presentation of the international traveler with Koplik spots.

Identified as rubeola (measles).

Requires airborne precautions due to transmission via small, aerosolized droplet nuclei.

Assess the client with Shigella dysentery.

Identified as a fecal-oral enteric pathogen.

Requires contact precautions with strict handwashing to prevent cross-contamination via infected stool.

Review the transmission route for Legionella pneumophila.

Identified as an environmental pathogen typically found in water systems.

Does not spread from person to person, making standard precautions sufficient.

Key Concept

Transmission-Based Precautions: Differentiating Airborne, Droplet, Contact, and Standard isolation requirements based on clinical presentation.

Estimated Time:2m 0s

Question 2264Question →

A clinical nurse educator is reviewing basic infection control protocols with a group of newly licensed nurses. Match each category of precautions with its primary requirement for personal protective equipment (PPE) or environmental control.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Airborne Precautions pair with an N95 respirator and negative-pressure room. Droplet Precautions pair with a surgical mask when within 3 feet. Contact Precautions pair with a gown and gloves upon entry. Standard Precautions pair with hand hygiene and gloves when anticipating body fluid contact.

Matching the correct category of isolation to its primary environmental and PPE requirement is fundamental for infection control. Standard precautions are baseline actions for all patient interactions. The three transmission-based precautions (Airborne, Droplet, and Contact) require specific targeted interventions: Airborne needs N95 masks and negative pressure, Droplet needs a surgical mask, and Contact needs gowns and gloves to block physical transfer.

Step-by-Step Solution

Evaluate the transmission route for Airborne Precautions.

Requires specialized ventilation and respiratory protection.

Pathogens like tuberculosis travel on small droplet nuclei that require an N95 mask and negative-pressure environment.

Evaluate the transmission route for Droplet Precautions.

Requires simple respiratory protection for close contact.

Pathogens like influenza travel on large droplets that do not remain suspended in the air, requiring a basic surgical mask.

Evaluate the transmission route for Contact Precautions.

Requires barrier protection for the provider's clothing and hands.

Pathogens like MRSA spread via touch, necessitating a gown and gloves to prevent carrying the bacteria out of the room.

Evaluate the baseline requirements for Standard Precautions.

Requires basic hygiene and targeted barrier use.

Applied to all patients to protect against unknown bloodborne or fluid-borne pathogens.

Key Concept

Basic Transmission-Based Precautions and PPE Selection

Estimated Time:1m 0s

Question 2265Question →

A nurse on a urology and renal medical-surgical unit is reviewing the electronic health records of four newly assigned clients. Which client should the nurse assess first?

A client with acute kidney injury who has a new-onset peaked T-wave on the electrocardiogram.

A client with nephrolithiasis who is reporting sudden, severe flank pain radiating to the groin.

A client with end-stage renal disease who missed their last dialysis session and reports severe pruritus.

A client who is 12 hours post-transurethral resection of the prostate (TURP) and has light pink drainage in the continuous bladder irrigation system.

Show answer & explanation

Answer: A client with acute kidney injury who has a new-onset peaked T-wave on the electrocardiogram.

Answer

The client with acute kidney injury who has a new-onset peaked T-wave on the electrocardiogram.

The client with a peaked T-wave is exhibiting a classic sign of hyperkalemia, a highly dangerous electrolyte imbalance common in acute kidney injury. This can rapidly progress to ventricular fibrillation or asystole. This circulatory threat takes highest priority.

Step-by-Step Solution

Analyze the clinical implications of a peaked T-wave in a client with acute kidney injury.

Identified as a classic, acute sign of severe hyperkalemia.

To recognize immediate life-threatening conditions related to circulation and cardiac function.

Evaluate the severity of the remaining clients' symptoms.

The other clients exhibit expected findings (pink urine post-TURP, pruritus in ESRD) or non-life-threatening conditions (kidney stone pain).

To compare acuity levels using acute versus chronic and expected versus unexpected frameworks.

Apply prioritization frameworks to select the client needing immediate intervention.

The client with the acute cardiac threat (hyperkalemia) is prioritized above those with expected pain or expected post-operative findings.

Cardiac dysrhythmias pose an immediate threat to life (Circulation in the ABCs framework).

Key Concept

Prioritizing acute, life-threatening complications (e.g., hyperkalemia causing cardiac changes) over expected disease manifestations or localized pain.

Question 2266Question →

A parent brings a pediatric client to a busy urgent care clinic. The child presents with a high fever, coryza, and a spreading maculopapular rash, raising high clinical suspicion for rubeola (measles). To mitigate the risk of pathogen transmission, arrange the following nursing actions in the correct chronological sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first achieve source control with a surgical mask, isolate the patient in an AIIR, secure the room's negative pressure by closing the door, don an N95 respirator for provider safety, and finally complete administrative reporting.

According to the principles of transmission-based precautions, airborne pathogens like the measles virus require immediate source control and environmental isolation. Placing a surgical mask on the symptomatic client is the fastest, most effective first action to prevent aerosolization in a public space. Next, the client must be rapidly removed from the waiting room and placed into an airborne infection isolation room (AIIR). The door must be closed to activate negative-pressure containment. Only after the client is safely isolated and the environment secured should the nurse don an N95 respirator to begin the clinical assessment, followed finally by administrative reporting to infection control.

Step-by-Step Solution

Implement immediate source control.

Place a surgical mask on the child.

Blocking the pathogen at the source prevents the spread of infectious aerosols into the waiting room.

Isolate the contagious individual.

Transfer the child to an AIIR.

Removing the client from a shared environment minimizes exposure risk to other susceptible individuals.

Establish environmental containment.

Close the AIIR door and verify negative pressure.

The specialized ventilation system requires a sealed room to safely filter and exhaust contaminated air.

Ensure provider safety.

Don an N95 respirator.

The nurse must protect their own respiratory tract before proceeding with close-contact clinical care.

Initiate administrative protocols.

Notify infection control.

Reporting ensures facility-wide tracking and public health compliance, but follows immediate physical safety measures.

Key Concept

When managing a client with a suspected airborne infection at triage, immediate source control (masking the client) and rapid environmental isolation take clinical priority over provider assessment and administrative reporting.

Question 2267Question →

An adult client with a profound intellectual disability is brought to the emergency department by their legally appointed guardian. During the physical assessment, the registered nurse observes multiple patterned bruises in various stages of healing, which are highly suggestive of physical abuse. The guardian becomes defensive and demands that the nurse immediately show them the current electronic health record (EHR) documentation regarding the assessment findings. Which of the following is the most appropriate action by the nurse?

Deny the guardian's request to view the documentation to protect the client and immediately report the suspected abuse to adult protective services.

Show the guardian the requested documentation, as legally appointed representatives generally have the right to access the client's health information, and separately notify protective services.

Delay entering the objective physical findings into the electronic health record until adult protective services has arrived to prevent the guardian from viewing the information.

Privately ask the client to provide verbal permission to withhold the assessment findings from the guardian to ensure the client's privacy rights are respected.

Show answer & explanation

Answer: Deny the guardian's request to view the documentation to protect the client and immediately report the suspected abuse to adult protective services.

Answer

Deny the guardian's request to view the documentation to protect the client and immediately report the suspected abuse to adult protective services.

Under HIPAA regulations (45 CFR § 164.502(g)(5)), a healthcare provider may refuse to treat a person as a client's personal representative—and thereby deny them access to the client's protected health information—if the provider reasonably believes that the representative is subjecting the client to abuse or neglect, and that granting access could endanger the client. The nurse's priority is to protect the vulnerable client, deny the suspected abuser access to the findings, and fulfill mandatory reporting requirements to adult protective services.

Step-by-Step Solution

Identify the primary legal and ethical conflict in the scenario.

The conflict is between a legally appointed guardian's general right to access the client's medical records and the nurse's duty to protect a vulnerable client from suspected abuse by that same guardian.

Recognizing competing priorities is essential for determining the correct legal framework to apply.

Apply HIPAA Privacy Rule exceptions regarding personal representatives.

HIPAA allows healthcare providers to deny a personal representative (such as a guardian) access to the client's protected health information (PHI) if there is a reasonable belief that the representative is abusing or neglecting the client.

This specific HIPAA exception exists to ensure that privacy laws do not inadvertently endanger vulnerable victims of abuse.

Determine the appropriate nursing intervention.

The nurse must prioritize client safety by refusing the guardian's access to the documentation and fulfilling the legal mandate to report the suspected abuse to adult protective services.

Protecting the client from further harm and adhering to mandatory reporting laws are the highest priorities in this situation.

Key Concept

HIPAA Exceptions for Suspected Abuse and Mandatory Reporting

Question 2268Question →

A nursing care team on a busy postoperative unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). When distributing the workload for the shift, which of the following task assignments is the most appropriate?

Assigning the LPN/VN to administer scheduled oral analgesics and reinforce routine wound care instructions for a client who is two days post-appendectomy.

Delegating the UAP to evaluate the swallowing ability of a client who recently suffered a transient ischemic attack before providing their breakfast tray.

Directing the LPN/VN to conduct the initial admission assessment and develop the plan of care for a client transferring from the emergency department.

Assigning the UAP to feed a client with suspected aspiration pneumonia who has just developed sudden shortness of breath and an oxygen saturation of 88%.

Show answer & explanation

Answer: Assigning the LPN/VN to administer scheduled oral analgesics and reinforce routine wound care instructions for a client who is two days post-appendectomy.

Answer

The most appropriate assignment is having the LPN/VN administer scheduled oral medications and reinforce teaching for a stable postoperative client.

The correct answer involves assigning a stable client to the LPN/VN for routine medication administration and teaching reinforcement. An LPN/VN is licensed to administer oral medications and can reinforce education that was initially provided by the RN. The client is two days post-operative, indicating a stable and predictable recovery trajectory.

Step-by-Step Solution

Analyze each proposed task against the legal scope of practice for RNs, LPN/VNs, and UAPs.

Identified that evaluation, initial assessment, care planning, and managing unstable clients are restricted to the RN.

Delegation must follow the Five Rights of Delegation, ensuring tasks match the caregiver's licensure and competency.

Evaluate the clinical stability of each client presented in the options.

The client with sudden shortness of breath is unstable; the client transferring from the ED requires baseline data; the postoperative appendectomy client is stable.

Only stable clients with predictable outcomes should be assigned to LPN/VNs or UAPs.

Select the option that appropriately matches a routine, predictable task with the correct personnel.

Assigning the stable, two-days post-operative client to the LPN/VN for medication administration and teaching reinforcement is selected as safe and appropriate.

This task falls within the LPN/VN scope of practice and involves a stable client.

Key Concept

The RN retains responsibility for the nursing process (assessment, diagnosis, planning, and evaluation), initial teaching, and the care of unstable clients. Safe delegation involves assigning tasks to LPN/VNs and UAPs that match their educational background and the client's stability.

Question 2269Question →

Upon arriving for the day shift on a progressive care unit, the nurse reviews the electronic health records and shift handoff for a group of assigned clients. Prioritize the order in which the nurse must assess the following clients, from most urgent (first) to least urgent (last).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is: first assess the client with severe asthma and diminished breath sounds, followed by the client postoperative thyroidectomy with circumoral numbness, then the client on a heparin infusion with an aPTT of 145 seconds, and finally the client with chronic heart failure presenting with peripheral edema.

Prioritization is guided by the ABCs (Airway, Breathing, Circulation) and the principle of treating acute problems before chronic ones. The client with asthma is actively losing their airway (silent chest), making them the highest priority. The post-thyroidectomy client is showing signs of hypocalcemia, which threatens the airway via laryngospasm, placing them second. The client on heparin has a critical lab value threatening circulation (bleeding risk) but is asymptomatic, making them third. The client with heart failure has expected, chronic symptoms and is the most stable, placing them last.

Step-by-Step Solution

Identify any clients with immediate, life-threatening airway or breathing compromise.

The client with asthma transitioning to diminished breath sounds and restlessness is experiencing a 'silent chest,' signaling impending respiratory arrest.

According to the ABCs (Airway, Breathing, Circulation) framework, acute loss of airway or breathing takes the absolute highest priority.

Evaluate remaining clients for impending airway threats or acute complications.

The client post-thyroidectomy is exhibiting signs of hypocalcemia, which can rapidly lead to laryngospasm and block the airway.

Conditions that have a high probability of rapidly deteriorating into an airway emergency are prioritized second.

Assess for critical circulatory risks or highly abnormal laboratory values.

The client with an aPTT of 145 seconds has a dangerously prolonged clotting time and requires the heparin drip to be paused.

Circulation and risk for severe injury (hemorrhage) are prioritized after airway and breathing threats, provided there is no active, massive bleeding occurring.

Identify clients with chronic, stable, or expected disease manifestations.

The client with right-sided heart failure has edema and weight gain, which are chronic and expected findings for this condition.

Clients with chronic conditions who are not in immediate physiological distress are the most stable and can safely be assessed last.

Key Concept

Prioritization of client care requires applying the ABCs (Airway, Breathing, Circulation) framework and differentiating between acute, life-threatening conditions and chronic, stable manifestations.

Question 2270Question →

Midway through an evening shift on a neurology step-down unit, a registered nurse (RN) is reviewing pending interventions for a group of assigned clients. The care team includes the RN, a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which of the following tasks is most appropriate to delegate to the LPN/VN?

Performing a baseline neurological assessment on a client just transferred from the emergency department.

Inserting a straight urinary catheter for a clinically stable client with a neurogenic bladder.

Formulating a home safety education plan for a client preparing for discharge after a mild ischemic stroke.

Administering scheduled oral analgesics to a client who suddenly reports an intense, new-onset headache and photophobia.

Show answer & explanation

Answer: Inserting a straight urinary catheter for a clinically stable client with a neurogenic bladder.

Answer

Inserting a straight urinary catheter for a clinically stable client with a neurogenic bladder.

The correct answer describes a standardized, sterile procedure (urinary catheterization) for a client whose condition is stable. This falls perfectly within the defined scope of practice for an LPN/VN, as it does not require initial assessment, care planning, or independent clinical judgment regarding a change in status.

Step-by-Step Solution

Analyze each proposed task against the established scope of practice for an LPN/VN.

Identify tasks involving initial assessment, planning, or unstable clients as inappropriate for delegation.

The National Council of State Boards of Nursing (NCSBN) dictates that the RN retains accountability for assessment, clinical judgment, and evaluation.

Evaluate the clinical stability of the clients associated with each task.

The client requiring an initial assessment, the client needing a discharge plan, and the client with a new-onset severe headache require RN-level intervention.

Delegation to an LPN/VN must involve clients whose conditions are stable and predictable.

Select the task that falls safely within the LPN/VN scope of practice.

Inserting a straight catheter in a stable client is identified as the correct choice.

This is a standardized sterile procedure with a predictable outcome that an experienced LPN/VN is trained to execute.

Key Concept

Delegation of tasks based on scope of practice and client stability.

Question 2271Question →

A clinical nurse on an acute vascular surgical unit is coordinating care for four clients with complex needs. The staffing mix includes the registered nurse and one experienced unlicensed assistive personnel (UAP). Which intervention demonstrates a safe and legally sound delegation decision by the nurse?

Observing and documenting a client's swallowing coordination during their initial trial of clear liquids following a carotid endarterectomy

Reviewing the sequence of post-amputation stump care with a client and their family prior to a scheduled physical therapy session

Obtaining the initial set of vital signs for a client admitted from the emergency department with suspected mesenteric ischemia and worsening abdominal pain

Applying anti-embolism stockings to a client with chronic venous insufficiency who is preparing for discharge

Show answer & explanation

Answer: Applying anti-embolism stockings to a client with chronic venous insufficiency who is preparing for discharge

Answer

Applying anti-embolism stockings to a client with chronic venous insufficiency who is preparing for discharge.

Applying anti-embolism stockings to a stable client preparing for discharge is a standard, routine task with predictable outcomes. It does not require nursing assessment, clinical judgment, or evaluation, making it well within the safe scope of practice for an unlicensed assistive personnel (UAP).

Step-by-Step Solution

Analyze the requested task to determine if it involves assessment, teaching, or evaluation (EAT).

Tasks involving EAT must be performed by the registered nurse.

Unlicensed assistive personnel are not licensed or trained to perform tasks requiring clinical judgment.

Evaluate the clinical stability of each client described in the options.

Clients who are newly admitted, unstable, or experiencing acute changes require direct RN care.

Delegation to a UAP requires the client to be medically stable with predictable health outcomes.

Identify the task that is routine, standard, and assigned to a stable client.

Applying anti-embolism stockings for a discharge-ready client meets all delegation criteria.

This task aligns with the UAP's scope of practice and strictly adheres to the Five Rights of Delegation.

Key Concept

Principles of Safe Delegation to Unlicensed Assistive Personnel

Question 2272Question →

A nursing team on a medical-surgical floor is caring for a diverse group of clients. To optimize workflow while maintaining safety, the registered nurse (RN) must distribute client care activities among the team members. Which task is most appropriate for the RN to delegate to the licensed practical/vocational nurse (LPN/VN)?

Administering a scheduled subcutaneous dose of enoxaparin to a stable client recovering from a total knee arthroplasty.

Evaluating the respiratory status and lung sounds of a client who recently arrived from the emergency department with acute asthma.

Providing comprehensive discharge instructions regarding fluid restrictions to a client newly diagnosed with heart failure.

Developing an individualized plan of care for a client who requires complex wound management for a stage III pressure injury.

Show answer & explanation

Answer: Administering a scheduled subcutaneous dose of enoxaparin to a stable client recovering from a total knee arthroplasty.

Answer

The most appropriate task is administering the scheduled subcutaneous enoxaparin to the stable postoperative client.

The correct answer identifies a task that perfectly aligns with the LPN/VN scope of practice. An LPN/VN is legally authorized to administer standard medications, including subcutaneous injections like enoxaparin, to clients whose conditions are stable and predictable.

Step-by-Step Solution

Review the established scope of practice for the Licensed Practical/Vocational Nurse (LPN/VN) under National Council of State Boards of Nursing (NCSBN) guidelines.

Identified that LPN/VNs can perform routine procedures, administer standard medications, and care for stable clients with predictable outcomes.

Delegation must align with legal scopes of practice to ensure client safety.

Apply the 'EAT' acronym (Evaluate, Assess, Teach) to eliminate tasks that the RN must retain.

Eliminated the options involving evaluating respiratory status, providing initial discharge teaching, and developing a care plan.

Tasks requiring initial assessment, complex clinical judgment, nursing diagnosis, and primary client education cannot be delegated to an LPN/VN or UAP.

Evaluate the remaining option for client stability and task predictability.

Selected the administration of subcutaneous enoxaparin.

The client is stable (recovering post-arthroplasty) and the intervention is a routine, predictable medication administration, making it a safe delegation.

Key Concept

Delegation of tasks based on the scope of practice and the EAT framework (RN retains Evaluation, Assessment, and Teaching).

Estimated Time:1m 0s

Question 2273Question →

The registered nurse is prioritizing care for four assigned clients at the start of the shift. Which client requires the nurse's immediate assessment?

A client with an acute asthma exacerbation who has become lethargic and exhibits significantly diminished breath sounds bilaterally.

A client with a suspected gastrointestinal hemorrhage who has a resting heart rate of 110 beats per minute and a blood pressure of 104/72 mmHg.

An older adult client with advanced dementia who is wandering near the unit exit doors and repeatedly asking to go home.

A client who is 24 hours postoperative following an exploratory laparotomy and reports incisional pain rated as 8 on a 0 to 10 scale.

Show answer & explanation

Answer: A client with an acute asthma exacerbation who has become lethargic and exhibits significantly diminished breath sounds bilaterally.

Answer

The client with an acute asthma exacerbation who has become lethargic and exhibits significantly diminished breath sounds bilaterally.

The correct answer identifies a client in impending respiratory failure. In asthma, a shift from wheezing to diminished breath sounds (a 'silent chest') combined with lethargy indicates severe air trapping, hypercapnia, and exhaustion. According to the ABC (Airway, Breathing, Circulation) prioritization framework, a threat to the airway or breathing is always the highest priority because it leads to rapid physiological collapse.

Step-by-Step Solution

Analyze each client's clinical presentation to determine if the findings are expected or unexpected for their condition.

The postoperative pain and dementia wandering are expected/chronic. The asthma deterioration and GI bleed tachycardia are unexpected/acute.

Prioritization requires identifying acute, unstable conditions over chronic, stable, or expected conditions.

Apply the ABC (Airway, Breathing, Circulation) framework to the remaining acute clients.

The client with asthma is experiencing a breathing/airway crisis (diminished breath sounds and lethargy indicate hypercapnia and respiratory failure). The client with a GI bleed is experiencing a circulation issue (tachycardia indicating early shock).

The ABC framework dictates that airway and breathing emergencies take absolute precedence over circulatory emergencies.

Select the client with the highest priority physiological need.

The client with the asthma exacerbation must be assessed first to secure the airway and support breathing.

Without an airway and breathing, the client will rapidly progress to cardiopulmonary arrest.

Key Concept

Establishing Priorities using the ABC (Airway, Breathing, Circulation) Framework

Question 2274Question →

During a midday staffing reconfiguration on a cardiovascular step-down unit, a registered nurse (RN) must distribute client care activities among the nursing team, which includes a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which of the following task assignments are within the appropriate scope of practice? Select all that apply.

Select all that apply

Delegating the UAP to record the hourly fluid intake and urine output for a clinically stable client.

Assigning the LPN to administer scheduled oral beta-blockers and perform a sterile dressing change.

Instructing the UAP to provide oral feeding assistance to a client exhibiting signs of acute dysphagia.

Directing the LPN to formulate the initial home management teaching plan for a client newly diagnosed with atrial fibrillation.

Delegating the UAP to assist with routine hygiene and ambulation for a client who had an uncomplicated pacemaker insertion three days ago.

Assigning the LPN to assess a client whose telemetry monitor suddenly displays frequent premature ventricular contractions.

Show answer & explanation

Answer: Delegating the UAP to record the hourly fluid intake and urine output for a clinically stable client.; Assigning the LPN to administer scheduled oral beta-blockers and perform a sterile dressing change.; Delegating the UAP to assist with routine hygiene and ambulation for a client who had an uncomplicated pacemaker insertion three days ago.

Answer

The appropriate assignments are delegating the UAP to record fluid intake and output for a stable client, assigning the LPN to administer scheduled oral medications and perform sterile dressing changes, and delegating the UAP to assist a stable client with routine hygiene and ambulation.

Appropriate delegation requires adherence to the rights of delegation and the legal scope of practice. The RN can safely delegate routine, standard, and unchanging tasks to the UAP, such as recording intake and output or assisting with hygiene and ambulation for stable clients. The LPN can perform tasks requiring specialized nursing knowledge but not advanced clinical judgment, such as administering scheduled oral medications and performing sterile procedures.

Step-by-Step Solution

Analyze the clinical stability of each client mentioned in the options.

Clients requiring routine intake/output tracking, scheduled medications, and basic hygiene are clinically stable. Clients with acute dysphagia, newly diagnosed conditions requiring education, and sudden cardiac arrhythmias are unstable or require advanced RN judgment.

Safe delegation requires that the client's condition be predictable and stable when assigning tasks to LPNs or UAPs.

Evaluate the UAP assignments against their scope of practice.

Recording intake/output and assisting with hygiene for stable clients are appropriate. Feeding a client with acute dysphagia is inappropriate due to the high risk of aspiration and need for assessment.

UAPs do not have the training to conduct clinical assessments or intervene during acute complications.

Evaluate the LPN assignments against their scope of practice.

Administering oral medications and performing sterile dressing changes are appropriate. Formulating initial teaching plans and assessing an unstable client with new arrhythmias are inappropriate.

The RN cannot delegate tasks requiring the nursing process (EAT: Evaluation, Assessment, Teaching) or advanced clinical judgment.

Key Concept

Delegation and Scope of Practice for LPNs and UAPs

Question 2275Question →

Upon assuming care for a group of patients on a neurological specialty unit, the nurse reviews the most recent clinical data and patient complaints. Which patient's clinical presentation demands immediate bedside evaluation?

A patient with myasthenia gravis who has developed a weak, muffled voice and jaw fatigue during breakfast

A patient with Guillain-Barré syndrome whose motor paralysis has advanced from the ankles to the knees over the last 12 hours

A patient receiving a continuous intravenous alteplase infusion for an ischemic stroke who has a blood pressure of 168/92 mm Hg

A patient with acute bacterial meningitis who reports extreme photophobia and has an axillary temperature of 102.4°F (39.1°C)

Show answer & explanation

Answer: A patient with myasthenia gravis who has developed a weak, muffled voice and jaw fatigue during breakfast

Answer

The patient with myasthenia gravis exhibiting a weak, muffled voice and jaw fatigue requires immediate evaluation.

The patient with myasthenia gravis is exhibiting bulbar muscle weakness, indicated by a weak, muffled voice and jaw fatigue. These are critical early warning signs of an impending myasthenic crisis and respiratory failure. In nursing prioritization, airway and breathing always take precedence over all other issues. The nurse must assess this patient immediately to ensure airway patency and prepare for potential intubation.

Step-by-Step Solution

Evaluate the patient with myasthenia gravis for ABC (Airway, Breathing, Circulation) threats.

Jaw fatigue and a muffled voice indicate bulbar muscle weakness, which is a direct precursor to respiratory failure and aspiration.

Airway compromise is always the highest priority in emergency triage.

Assess the stability of the patient with Guillain-Barré syndrome.

Ascending paralysis reaching the knees over 12 hours is an expected disease trajectory.

The respiratory muscles (diaphragm) are not yet affected, making this a lower immediate priority.

Analyze the blood pressure of the patient receiving alteplase.

A blood pressure of 168/92 mm Hg is within the strict safe parameters.

Target BP is < 180/105 mm Hg to prevent bleeding; expected therapeutic maintenance does not require immediate acute intervention.

Review the presentation of the patient with bacterial meningitis.

High fever and photophobia are classic, expected signs of meningeal irritation.

While uncomfortable, these expected infection signs do not supersede an airway threat.

Key Concept

In prioritization, unexpected threats to the airway (such as bulbar weakness) take strict precedence over expected disease progressions or stable, monitored therapeutic parameters.

Question 2276Question →

After receiving the shift report on an adult oncology unit, a registered nurse must determine the sequence of client assessments. Arrange the clients in the order they should be assessed, from highest priority (most urgent) to lowest priority (least urgent).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct assessment sequence is: 1) the client with stridor, 2) the client with a potential vesicant extravasation, 3) the client with symptomatic hypercalcemia, and 4) the client with anxiety.

The correct sequence follows the ABC framework and Maslow's hierarchy of needs. Airway compromise (stridor) is the highest priority, followed by an acute, actively occurring tissue injury (extravasation). Systemic metabolic issues (hypercalcemia) follow acute emergencies, and psychosocial needs (anxiety) are addressed after all physiological needs are stabilized.

Step-by-Step Solution

Identify the client with the most critical, immediately life-threatening condition using the ABC framework.

The client with the cervical malignancy has inspiratory stridor, indicating impending airway obstruction.

Airway issues take absolute precedence over all other physiological emergencies.

Determine the second priority among the remaining clients with acute needs.

The client receiving the vesicant chemotherapy agent has signs of extravasation (burning, swelling).

Extravasation is an actively occurring injury that will result in severe, irreversible tissue necrosis if the infusion is not stopped instantly, placing it immediately after airway management.

Evaluate the remaining clients based on physiological versus psychosocial stability.

The client with multiple myeloma has symptomatic hypercalcemia (lethargy, elevated calcium).

Systemic metabolic imbalances represent a physiological threat that must be addressed before psychological needs.

Assign the lowest priority to the most physiologically stable client.

The client crying about an upcoming mastectomy is assigned the last assessment priority.

According to Maslow's hierarchy of needs, emotional and psychosocial support are provided after acute physiological needs are stabilized.

Key Concept

Prioritization of Care using the ABCs and Maslow's Hierarchy of Needs

Estimated Time:1m 30s

Question 2277Question →

An experienced registered nurse (RN) is coordinating client assignments on a respiratory care unit. The care team includes the RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which delegation decision by the RN ensures safe client care?

Allowing the LPN to suction the established tracheostomy of a stable client requiring routine airway clearance.

Having the UAP explain the rationale for strict contact precautions to the family members of a newly admitted client.

Requesting the UAP to investigate the underlying reason for a sudden decrease in a client's oxygen saturation.

Asking the UAP to gauge the effectiveness of an intravenous diuretic by analyzing the client's hourly urine output trends.

Show answer & explanation

Answer: Allowing the LPN to suction the established tracheostomy of a stable client requiring routine airway clearance.

Answer

The correct delegation is allowing the LPN to suction the established tracheostomy of a stable client.

The RN demonstrates safe delegation by assigning the LPN to perform tracheostomy suctioning on a stable client. LPNs possess the clinical training to perform procedural tasks, including sterile procedures and maintaining established airways, in predictable and stable situations.

Step-by-Step Solution

Evaluate the scope of practice for the Unlicensed Assistive Personnel (UAP).

UAPs cannot perform tasks requiring nursing judgment, such as teaching families, assessing sudden clinical changes, or evaluating medication effectiveness.

According to the principles of delegation, the RN cannot delegate the core components of the nursing process (assessment, planning, teaching, and evaluation) to unlicensed staff.

Evaluate the scope of practice for the Licensed Practical Nurse (LPN).

The LPN is qualified to perform procedural tasks, such as suctioning an established tracheostomy, for a medically stable client.

LPNs have the required education and licensure to care for stable clients with predictable outcomes and can perform sterile or invasive procedures under RN supervision.

Identify the safest and most appropriate assignment among the options.

The only safe delegation is assigning the tracheostomy suctioning to the LPN.

All other options involve delegating non-delegable RN responsibilities (teaching, assessment, and evaluation) to a UAP.

Key Concept

Assignment, Delegation and Supervision

Question 2278Question →

Upon completing initial safety rounds on an acute care unit, a charge nurse must determine the assessment sequence for four newly admitted or transferring clients. Arrange the clients in the priority order they must be evaluated, from first (highest priority) to last (lowest priority).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The nurse should first assess the client with the tracheostomy and hypoxia (Airway/Breathing), followed by the client with the GI bleed and signs of shock (Circulation). The third assessment should be the client experiencing severe postoperative pain (Comfort), and the final assessment should be the stable client waiting for discharge instructions.

Prioritization in nursing follows the ABCs (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs. The client with a tracheostomy and an oxygen saturation of 87% has an immediate airway/breathing threat and is the highest priority. The client with a GI bleed and signs of hypovolemic shock (hypotension, tachycardia) has a critical circulatory issue and is the second priority. The client with severe postoperative pain requires urgent comfort measures and is the third priority. The client awaiting discharge instructions is physiologically stable and is the lowest priority.

Step-by-Step Solution

Evaluate the first priority based on the ABCs (Airway, Breathing, Circulation) framework.

Identify the client with the tracheostomy and oxygen saturation of 87% as having an acute airway and breathing compromise.

Airway and breathing are the most critical physiological needs. Hypoxia can lead to rapid deterioration and must be treated immediately.

Determine the second priority among the remaining clients by continuing with the ABCs.

Identify the client with the GI bleed, hypotension, and tachycardia as having a severe circulatory deficit.

Once airway and breathing are secure, circulatory failure (shock) is the next most immediate threat to life.

Prioritize the remaining two clients based on urgency and physiological needs.

Select the client with severe surgical site pain.

Acute pain is an urgent physiological need that requires prompt intervention, taking precedence over routine tasks.

Assign the lowest priority to the most stable client.

Select the client awaiting discharge instructions.

This client is physiologically stable and requires routine teaching, which can be safely delayed until all unstable or symptomatic clients have been managed.

Key Concept

Prioritization of Care using ABCs and Maslow's Hierarchy

Question 2279Question →

A registered nurse on a medical-surgical unit is evaluating the current clinical status of assigned clients. Which client requires the most immediate intervention?

A client admitted with acute pyelonephritis who is newly restless and has a blood pressure of 88/54 mmHg.

A client with an exacerbation of ulcerative colitis who reports having six bloody, diarrheal stools over the past 12 hours.

A client with end-stage liver cirrhosis who exhibits palmar erythema and a moderately distended abdomen.

A client who is 2 days post-laparoscopic cholecystectomy and is requesting an immediate dose of PRN analgesic for surgical site pain.

Show answer & explanation

Answer: A client admitted with acute pyelonephritis who is newly restless and has a blood pressure of 88/54 mmHg.

Answer

The client with acute pyelonephritis exhibiting restlessness and hypotension requires the most immediate intervention.

The correct answer identifies a client experiencing an acute, life-threatening complication. In a client with a known localized infection (pyelonephritis), the sudden onset of restlessness (indicating decreased cerebral perfusion) and marked hypotension are classic indicators of systemic inflammatory response and septic shock. This represents a severe circulatory emergency, making this client the highest priority.

Step-by-Step Solution

Analyze each client's clinical presentation to determine whether the findings are expected or unexpected for their current diagnosis.

The client with pyelonephritis has unexpected acute findings; the other clients exhibit expected, chronic, or non-emergent findings.

Prioritization requires a nurse to first identify unexpected, acute deviations from a client's baseline.

Apply the Airway, Breathing, Circulation (ABC) framework to the client with unexpected findings to determine the severity of the threat.

The pyelonephritis client's hypotension and restlessness indicate a severe circulatory compromise.

Circulatory emergencies, such as septic shock, are immediately life-threatening and take absolute precedence over chronic conditions and pain management.

Key Concept

Prioritization using the ABC framework and distinguishing acute, life-threatening complications from chronic or expected findings.

Question 2280Question →

A pediatric nurse is prioritizing initial rounds for four assigned clients. Which client requires the nurse's immediate assessment?

An 18-month-old with acute bronchiolitis whose respiratory rate decreased from 55 to 16 breaths per minute over the last hour

A 7-year-old with sickle cell anemia who is crying with leg pain rated 8 on a 0-10 scale

A 4-year-old with cystic fibrosis who is experiencing frequent productive coughing and expectorating thick mucus

A 10-year-old with new-onset type 1 diabetes mellitus who has a pre-meal blood glucose level of 235 mg/dL (13.0 mmol/L)

Show answer & explanation

Answer: An 18-month-old with acute bronchiolitis whose respiratory rate decreased from 55 to 16 breaths per minute over the last hour

Answer

The 18-month-old with acute bronchiolitis whose respiratory rate decreased significantly.

The correct answer identifies the toddler with bronchiolitis. An 18-month-old should have a normal respiratory rate of 20 to 30 breaths per minute. A sudden decrease from tachypnea (55 breaths/min) to bradypnea (16 breaths/min) in the context of a severe lower respiratory tract infection strongly suggests respiratory muscle exhaustion, loss of compensatory mechanisms, and impending respiratory arrest. According to the ABCs (Airway, Breathing, Circulation) framework, this constitutes a life-threatening emergency requiring immediate intervention.

Step-by-Step Solution

Evaluate all client presentations using the Airway, Breathing, Circulation (ABC) prioritization framework.

The toddler with bronchiolitis has a breathing/airway issue, while the others have pain, chronic airway clearance needs, and a metabolic issue.

Airway and breathing abnormalities are the most immediate threats to a client's life.

Analyze the clinical significance of a respiratory rate dropping from 55 to 16 in an 18-month-old.

Normal respiratory rate for a toddler is 20-30 breaths per minute. A rate of 16 is bradypnea.

Recognizing age-appropriate vital signs is necessary to determine if a change indicates improvement or deterioration.

Distinguish between expected chronic findings and unexpected acute deteriorations.

The cystic fibrosis mucus is expected; the sickle cell pain and diabetic hyperglycemia are acute but stable. The bronchiolitis respiratory drop is an unexpected, life-threatening deterioration.

Prioritization requires seeing through stable chronic symptoms to identify clients at risk of immediate harm.

Key Concept

Prioritizing unexpected physiological deteriorations in Airway and Breathing (ABC framework).

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