A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in

the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen.

Which of the following is the appropriate action by the nurse?

• Tell the client that a catheter will be inserted.

• Document the client’s refusal in the chart.

• Assess the client for urinary retention.

• Obtain a provider’s prescription for a blood alcohol level.

• A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a

licensed practical nurse?

• Pick up the meal trays after lunch.

• Administer a nasogastric tube feeding.

• Plan break times for assistive personnel.

• Determine adequacy of ventilator settings.

• A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure.

Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA)

• Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field

• Opens the sterile pack by first unfolding the top flap away from her body

• Prepares a container of sterile solution on the field after putting on sterile gloves

• Removes the outside packaging of a sterile instrument before dropping it onto the sterile

field

• Holds the sterile solution bottle with the label facing up

• A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV

pump is not working properly. Which of the following actions should the nurse take first?

• Auscultate the client’s lungs.

• Notify the provider.

• Place a faulty equipment tag on the pump.

• Complete an incident report.

• A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and

an assistive personnel. Which of the following tasks should the nurse assign to the LPN?

• Reinforcing teaching with a client who is learning to self-administer insulin

• Ambulating a client who is scheduled for discharge later in the day

• Administering morphine IV bolus to a client who is __ hr postoperative

• Admitting a new client who has chronic back pain to the unit

• A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile

gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic

technique?

• The nurse applies goggles.

• The nurse turns her back to the sterile field.

• The nurse holds her hands above her waist.

• The nurse puts on a face mask.

• A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel

(AP). Which of the following actions should the nurse take to evaluate the delegated task?

• Review vital sign trends at the end of the shift.

• Recheck vital signs that are outside the expected reference range.

• Ask the AP to write a summary of the delegated tasks during the shift.

• Compare the vital signs the AP obtained with those taken by another AP on a previous shift.

• A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?

• Obtaining a stool sample from a client who has renal failure

• Monitoring a client who has a fluid restriction

• Assessing a client who just returned from hemodialysis

• Reviewing dietary instructions for a client who has kidney stone