BALANCE CONSOLIDADO EN EL AÑO 2015 DEL MERCADO NACIONAL DE CERVEZA
TASAS DE VARIACIÓN (%) EN EL IMPUESTO SOBRE EL ALCOHOL Y BEBIDAS DERIVADAS
11. The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? 1. The UAP empties the indwelling catheter bag for the client with transurethral
resection of the prostate (TURP).
2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall.
3. The UAP provides apple juice to a client who has just been advanced to a clear liquid diet.
4. The UAP applies moisture barrier cream to the elderly client who has an excori- ated perianal area.
30 CLIENTMANAGEMENT ANDLEADERSHIPSUCCESS
9. The rehabilitation nurse is caring for a client who is 1 week postoperative for left carotid endarterectomy. The client’s 11:30 A.M. bedside glucometer reading is 408 mg/dL. Based on the medication administration record (MAR), which intervention should the nurse implement first?
Client’s Name: Account Number: 123456 Allergies: NKDA Height: 69 inches Weight: 165 pounds
Date Medication 2301–0700 0701–1500 1501–2300 Regular Insulin by bedside glucose subcu ac & hs <60 notify HCP 150 0 units 151–200 2 units 201–250 4 units 251–300 6 units 301–350 8 units 351–400 10 units ⬎400 notify HCP 0730 DN BG 142 0 units
12. The charge nurse is making shift assignments to the surgical staff, which consists of two registered nurses (RNs), two licensed practical nurses (LPNs), and two UAPs. Which assignment would be most appropriate by the charge nurse?
1. Instruct the RN to administer all prn medications. 2. Instruct the UAP to clean the recently vacated room. 3. Assign the LPN to administer routine medications.
4. Request the LPN to complete the admission for a new client.
13. The nurse on the surgical unit is working with a UAP. Which task would be most appropriate for the nurse to delegate to the UAP?
1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client’s IV insertion site on the right arm.
3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client’s vehicle.
14. The charge nurse is making assignments for the surgical unit. Which client should be assigned to the new graduate nurse?
1. The 84-year-old client who has a chest tube that is draining bright red blood.
2. The 38-year-old client who is 1 day postoperative with a temperature of 101.2ºF.
3. The 42-year-old client who has just returned to the unit after a breast biopsy. 4. The 55-year-old client who is complaining of unrelenting abdominal pain.
15. The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the UAP to assist the client to the bathroom. Which action should the charge nurse implement?
1. Take no action because this is appropriate delegation. 2. Tell the UAP to obtain a bedside commode for the client. 3. Discuss the inappropriate delegation of the nursing task. 4. Document the situation in an adverse occurrence report.
16. The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement?
1. Tell the UAP to ambulate the client with the walker. 2. Request a referral to the physical therapy department. 3. Obtain a walker that is appropriate for the client’s height. 4. Notify the social worker of the HCP’s order for a walker.
17. Which task would be most appropriate for the nurse to delegate to the UAP working on a surgical unit?
1. Escort the client to the smoking area outside. 2. Obtain vital signs on a newly admitted client.
3. Administer a feeding to the client with a gastrostomy tube. 4. Check the toes of a client who just had a cast application.
18. The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse?
1. The client who had surgery for an inguinal hernia and who is being prepared for discharge.
2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy.
3. The client who has completed scheduled chemotherapy treatment and who is receiving 2 units of blood.
4. The client who has end-stage renal disease and who has had an arteriovenous fis- tula created.
19. The LPN is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement?
1. Bathe the client who is incontinent of urine. 2. Document the amount of food the client eats. 3. Conduct the afternoon bingo game in the lobby. 4. Perform routine dressing changes on assigned clients.
20. The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, “I am taking saw palmetto for my enlarged prostate.” Which action should the nurse implement first?
1. Notify the client’s HCP to write an order for the herbal supplement. 2. Ask the client why he is taking an herb for his enlarged prostate.
3. Consult with the pharmacist to determine any potential drug interactions. 4. Look up saw palmetto in the Physician’s Desk Reference (PDR).
Managing Clients and Nursing Staff
21. The ED nurse is requesting a bed in the intensive care unit (ICU). The ICU charge nurse must request a transfer of one client from the ICU to the surgical unit to make room for the client coming into the ICU from the ED. Which client should the ICU charge nurse request to transfer to the surgical unit?
1. The client diagnosed with flail chest who has just come from the operating room with a right-sided chest tube.
2. The client diagnosed with acute diverticulitis who is 1 day postoperative for creation of a sigmoid colostomy.
3. The client who is 1 day postoperative for total hip replacement (THR) whose incisional dressing is dry and intact.
4. The client who is 2 days postoperative for repair of a fractured femur and who has had a fat embolism.
22. A terrible storm causes the electricity to go out in the hospital and the emergency generator lights come on. Which action should the charge nurse implement?
1. Request all family members to leave the hospital as soon as possible. 2. Instruct the staff to plug critical electrical equipment into the red outlets. 3. Have the UAP place a portable flashlight on each bedside table.
4. Contact the maintenance department to determine how long the electricity will be out.
23. The HCP is angry and yelling in the nurse’s station because the client’s laboratory data are not available. Which action should the charge nurse implement first?
1. Contact the laboratory for the client’s results. 2. Ask the HCP to step into the nurse’s office.
3. Tell the HCP to discuss the issue with the laboratory. 4. Report the HCP’s behavior to the chief nursing officer.
24. The staff nurse is concerned about possible increasing infection rates among clients with peripherally inserted central catheters (PICCs). The nurse has noticed several clients with problems in the last few months. Which action would be appropriate for the staff nurse to implement first?
1. Discuss the infections with the chief nursing officer. 2. Contact the infection control nurse to discuss the problem. 3. Assume the employee health nurse is monitoring the situation.
4. Volunteer to be on an ad hoc committee to research the infection rate.
25. The charge nurse on the 30-bed surgical unit has been told to send one staff member to the medical unit. The surgical unit is full, with multiple clients who require custo- dial care. Which staff member would be most appropriate to send to the medical unit? 1. Send the UAP who has worked on the surgical unit for 5 years.
2. Send the RN who has worked in the hospital for 8 years in a variety of areas. 3. Send the LPN who has 3 years experience, which includes 6 months on the med-
ical unit.
4. Send the new graduate nurse who is orienting to the surgical unit.
26. The nurse educator is discussing fire safety with new employees. List in order of performance the following actions the nurse should teach to ensure the safety of clients and employees in the case of fire on the unit.
1. Extinguish. 2. Rescue. 3. Confine. 4. Alert.
27. The client tells the nurse, “I am having surgery on my right knee.” However, the operative permit is for surgery on the left knee. Which action should the nurse implement first?
1. Notify the operating room team. 2. Initiate the time-out procedure.
3. Clarify the correct extremity with the client. 4. Call the surgeon to discuss the discrepancy.
28. The elderly female client fell and fractured her left femur. The nurse finds the client crying, and she tells the nurse, “I don’t want to go to the nursing home but my son says I have to.” Which response would be most appropriate by the nurse?
1. “Let me call a meeting of the health-care team and your son.” 2. “Has the social worker talked to you about this already?” 3. “Why are you so upset about going to the nursing home?” 4. “I can see you are upset. Would you like to talk about it?”
29. The primary nurse informs the shift manager that one of the UAPs is falsifying vital signs. Which action should the shift manager implement first?
1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client’s vital signs and compare with the UAP’s results. 3. Talk to the UAP about the primary nurse’s allegation.
4. Complete a counseling record and place in the UAP’s file.
30. The client scheduled for a D&C is upset because the HCP told her she has syphilis. The client asks the nurse, “This is so embarrassing, do you have to tell anyone about this?” Which statement is the nurse’s best response?
1. “This must be reported to the Public Health Department and your sexual partners.”
2. “According to the Health Information Privacy and Portability Act (HIPPA), I cannot report this to anyone without your permission.”
3. “You really should tell your sexual partners so they can be treated for syphilis.” 4. “I realize you are embarrassed. Would you like to talk about the situation?”