 Show Leadership Form B 1. A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate to the nurse the need for referral to an occupational therapist? a.Facial drooping b.Receptive aphasia c.Unilateral neglect d.Memory loss 2. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an appropriate task for the AP? a.Show a new mother how to change the newborn’s diaper b.Inspect the skin of a newborn who is receiving phototherapy c.Obtain the weight of a newborn who is receiving formula d.Answer the parents’ questions about newborn circumcision 3. A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse assign to a licensed practical nurse? a.Conduct the newborn hearing screening b.Perform a New Ballard screening c.Administer a hepatitis B vaccine d.Obtain vital signs 4. A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? a.I need to have a TB skin test done once per year b.I need to take my prescribed medication for 3 months c.I should have a sputum culture done every 2 to 4 weeks d.I should wear a mask while around my family 5. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experience to safely care for his assigned clients. Which of the following actions should the nurse take? a.Accept the assignment with help from assistive personnel on the unit b.Document the concern in the nurse’s notes
What is the priority action by the nurse?Assessment is the first step of the nursing process and takes priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities.
Which client should the postpartum nurse assess first after receiving the AM shift report?Which client should the postpartum nurse assess first after receiving the a.m. shift report? 1. The client who is complaining of perineal pain when urinating.
What are two factors a nurse should use when prioritizing care?Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).
Which client should the emergency department triage nurse classify as emergent?Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent.
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When prioritizing care which of the following clients should the nurse assess first?
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