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A charge nurse on a medical-surgical unit is coordinating care assignments for the upcoming shift. The staffing mix includes the charge nurse, a registered nurse (RN) floated from the inpatient psychiatric unit, an experienced licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which of the following task assignments are appropriate? Select all that apply.
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A registered nurse in a respiratory step-down unit is caring for a client scheduled for a bronchoscopy with biopsy. The healthcare provider has already obtained the client's signature on the informed consent document. As the nurse brings the prescribed preoperative midazolam to the bedside, the client states, 'I have decided I do not want anyone putting a tube into my lungs. Cancel the test.' Arrange the following nursing actions in the correct priority order from first to last.
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A nurse is initiating an urgent telephone consultation with the on-call hospitalist regarding a client who suddenly developed respiratory distress two days after a right total knee arthroplasty. Arrange the nurse's statements in the correct chronological sequence according to the ISBAR (Identify, Situation, Background, Assessment, Recommendation) interdisciplinary communication framework. All options must be used.
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A nurse is utilizing the SBAR (Situation, Background, Assessment, Recommendation) framework during an interdepartmental handoff report for a 65-year-old client transferring to acute rehabilitation following a radical neck dissection. The client has a tracheostomy, receives continuous enteral feedings, and exhibits spinal accessory nerve damage causing profound ipsilateral shoulder weakness. During the 'Assessment' phase, the nurse highlights the client's severe frustration over the inability to manipulate the feeding pump controls or perform independent oral care. Additionally, the spouse tearfully states, 'I cannot manage all this medical equipment at home.' Which collaborative action should the nurse prioritize in the 'Recommendation' phase of the SBAR?
The nurse is assessing a client with a history of chronic heart failure who has just arrived at the emergency department reporting severe shortness of breath. Which of the following clinical cues require immediate intervention by the nurse? Select all that apply.
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A client with rapidly progressing lower extremity weakness is scheduled for an emergent magnetic resonance imaging (MRI) scan of the spine. During the pre-procedure safety screening, the nurse obtains the following information. Which finding represents the highest priority for the nurse to communicate immediately to the healthcare provider and the radiology team?
A charge nurse on an acute gastroenterology unit is reviewing shift allocations for a team consisting of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which specific delegation decision by the RN demonstrates safe and legally sound practice?
A registered nurse is implementing safety measures for a group of clients on a medical-surgical unit. Which nursing action best promotes client safety and injury prevention?
A client who sustained an ischemic stroke 48 hours ago is clinically stable but experiences right-sided hemiparesis. The registered nurse (RN) is coordinating care with an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the UAP?
A home health nurse is reviewing overnight messages and scheduling the daily visitation itinerary. Based on the reported data, which client's situation warrants the first home visit of the day?
An 82-year-old client is being prepared for an elective cataract extraction. The ophthalmologist has discussed the procedure and left the unit. When the registered nurse hands the client the consent form to sign, the client states, "I cannot remember if they are fixing my right or left eye today. But I guess memory problems are just part of getting old. I will go ahead and sign it." Which action should the nurse take first?
A 35-year-old client presents to an urgent care clinic reporting sudden chills, severe myalgia, and a dry cough. A point-of-care rapid diagnostic test confirms an influenza type A infection. Which of the following infection control interventions should the nurse implement? (Select all that apply.)
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A nurse is participating in interdisciplinary care rounds for a client who sustained a complex pelvic fracture and bilateral wrist fractures in a motor vehicle collision. The client is immobilized in bed, exhibits acute agitation, and is entirely dependent on staff for meals due to the upper extremity injuries. Which nursing action demonstrates appropriate care management and interprofessional collaboration?
A clinical educator is reviewing infection control protocols with a group of newly hired nurses. Match each specific infection control action to its corresponding precaution category.
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Following the morning shift change on a high-acuity surgical step-down unit, the nurse is reviewing the clinical data of four newly assigned clients. Which client presentation mandates the most immediate assessment?
Match each complex clinical scenario described on the left with the core ethical nursing principle it most directly demonstrates on the right.
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Care is being organized for four clients admitted to a progressive care unit. The personnel available includes one registered nurse (RN) and one licensed practical/vocational nurse (LPN/VN). Which client is most appropriate to assign to the LPN/VN?
During morning rounds on a neurology unit, a nurse observes a client with an acute exacerbation of multiple sclerosis consuming breakfast. The client coughs repeatedly and clears their throat forcefully after taking sips of water. When asked how they are feeling, the client states, 'My throat feels unusually weak today when I try to drink.' Which action by the nurse demonstrates the most appropriate interprofessional collaboration?
A nurse in the intensive care unit is coordinating care for a client who has sustained a severe traumatic brain injury. The client's family members are experiencing significant distress and are expressing conflicting expectations to various staff members regarding the client's long-term prognosis. In what chronological sequence should the nurse perform the following collaborative actions to effectively manage this situation?
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A registered nurse (RN) assumes care for four clients on a medical-surgical telemetry unit after receiving the shift report. In which order should the RN assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).
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