On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

What drugs the client used for the suicide attempt.

When the client last took drugs for bipolar disorder.

Whether the client ever attempted suicide in the past.

Which family member has the client's suicide note.

Answer and Explanation

The Correct Answer is A

Choice A reason: Knowing the type and amount of drugs ingested is critical for immediate medical intervention and treatment.

Choice B reason: While important, the timing of the last dose for bipolar disorder is less urgent than the details of the suicide attempt.

Choice C reason: Past suicide attempts are relevant for a psychiatric evaluation but are not the immediate concern in an acute overdose situation.

Choice D reason: The location of the suicide note is less critical than the medical information needed to treat the client's overdose.

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Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.

Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.

Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.

Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

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On admission to the emergency department, a client who was diagnosed with bipolar disorder 3 years ago reports taking a handful of medications this morning and left a suicide note for the family. Which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is D

Explanation

A client is scheduled for an IV pyelogram today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray?

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?