1. The nurse performs triage after a multiple car crash involving 32 victims. What Finding indicates a client will require a black tag for triage?

Answers: A-D

-Penetrating head wound.

-Second and third degree burns to 60% of the body.

-Open fracture to lower left leg

-Sucking chest wound.

2. The nurse manager of the perioperative department assesses a change or cross- Train staff to fill in the deficits left by four nurses leaving the unit. Prior to Implementation, which steps should the manager take in order to facilitate a Smooth transition? Place the options in order of implementation, from first to last.

Items to be Ordered

1.Evaluate the outcome of the implemented staffing change.

2.Discuss the implementation of the process with all involved verbally And in writing

3. Assess the organization's communication hierarchy.

4.Determine who will be affected by the new staffing process.

5. Meet with the directors of the ancillary units this change will affect.

3. A client admitted to the labor and delivery unit is to receive magnesium sulfate for preeclampsia. The registered nurse (RN) delegates tasks to the licensed practical/vocational nurse (LP/LVN). Which task is most appropriate for the RN to delegate to the LPN/LVN? Answers:

A - D

A Notify the health care provider of decreased fetal movement and deep tendon reflexes upon the last assessment.

B Pull calcium gluconate from the medication dispensary for the client.

C Assess the client and fetus prior to the start of magnesium sulfate infusion.

D In two hours after the start of the magnesium sulfate, assess and document fetal findings.

4. The acute care unit hires a new manager to oversee the clinical operation of the unit. What behaviors demonstrated by the new manager indicate that their style of leadership is democratic? Select all that apply.

A - E

1. Encourages group participation when developing protocols for clients on ventilators.
2. The manager gives very little direction when making changes to unit policies.
3. A nurse completes a BS and is not acknowledged by the manager for this achievement.
4. After a unit project is completed, the manager credits the team with the outcome.
5. The manager gives constructive feedback to a new employee within 30 days of hire.

5. A nurse identifies that a co-worker has labile mood swings, frequently tardy, and leaving for long breaks throughout the shift and has an unkempt appearance. The co-worker has requested that the nurse co-sign narcotic wastes after stating the syringe was placed in the biohazard container. Which actions by the nurse are appropriate? Select all that apply. Answers: A - E

A. Confront the co-worker and ask if they are using illegal substances.

B. Talk to the other staff members on the unit to see if they are observing the same behaviors.

C. Use a video to record the co-worker's behavior to present to the supervisor.

D. Inform the co-worker of the inability to sign for a narcotic waste that was not observed.

E Discuss the concerns with the nurse manager.

6. Nursing Notes

Vital Signs

Time 1730

1730 Blood Pressure 85/48 . Heart Rate 160 Respiratory Rate 34 Sp02 Temperatur e 102.0 F (38.9 ) 89% RA

Client had been found by assistive personnel at 1300, lethargic and confused. Report from emergency department nurse indicated the client was treated for a urinary tract infection 3 weeks ago, for which he took a course of levofloxacin PO 500 mg daily. Assisted living facility staff indicated the client's daughter is the health care surrogate. Her contact information was provided.

RN called client's daughter.

The following six questions are part of an unfolding case study.

A 90-year-old client is admitted to the medical unit from an assisted living facility. Which information is most important for the nurse to obtain from the daughter? Select all that apply.

Answers: A - H

A. Past medical history

B. Social history

C Code status

D Family medical history

E Ambulation ability

F Post-mortem care preferences

G Organ donation status

H Advance directive