For correct answer choice:

Establish a calm and reassuring environment is correct. The first priority is to help alleviate the client’s anxiety by creating a safe and calm atmosphere. This can reduce the client’s hyperventilation and promote feelings of security, enabling better communication and assessment.

For incorrect answer choices:

Administer oxygen therapy as prescribed is incorrect. While oxygen therapy may be necessary if the client is hypoxic, it is not the immediate priority. The primary focus should be on addressing the client’s anxiety and ensuring they feel safe.

Assess the client’s vital signs and perform a physical examination is incorrect. Although vital sign assessment is important, establishing a calm environment may be more effective in reducing anxiety and hyperventilation before detailed assessments can be completed.

Initiate a psychiatric evaluation is incorrect. A psychiatric evaluation is important but should follow the initial steps of providing emotional support and creating a calm environment to help the client stabilize.

For correct answer choice:

The student nurse uses alcohol-based hand sanitizer after patient care is correct. Alcohol-based hand sanitizers are not effective against C. diff spores. Immediate intervention is required to remind the student that handwashing with soap and water is necessary for infection control in patients with C. diff.

For incorrect answer choices:

The student nurse wears gloves and a gown while entering the room is incorrect. This is the appropriate precaution for contact isolation with C. diff, as it helps prevent the spread of infection.

The student nurse instructs the patient’s family to wear gloves during visits is incorrect. This is correct, as family members must follow contact precautions to avoid spreading the infection.

The student nurse wipes down the bedside table with a bleach-based disinfectant is incorrect. This is an appropriate action, as bleach is effective in killing C. diff spores on surfaces.

For correct answer choice:

A 50-year-old stable patient recovering from a hip replacement who needs assistance with ambulation is correct. This patient has a predictable care plan focused on rehabilitation and assistance with mobility, which is an appropriate assignment for a new graduate RN who is still developing skills in patient care and time management.

For incorrect answer choices:

A 72-year-old patient with chronic obstructive pulmonary disease (COPD) and shortness of breath on oxygen therapy is incorrect. Managing a patient with COPD requires monitoring for respiratory status and potential complications, which may be too advanced for a new graduate nurse.

A 58-year-old patient admitted with a gastrointestinal bleed, receiving a blood transfusion is incorrect. Blood transfusions require close monitoring for reactions and involve more complex care, making this assignment inappropriate for a new graduate RN.

A 63-year-old patient with chest pain awaiting the results of cardiac enzymes is incorrect. This patient is at risk for acute coronary syndrome and requires close monitoring. The patient can experience sudden changes in condition, which is too risky for a new graduate nurse to manage independently.

For correct answer choice:

A patient recovering from a nephrectomy with stable vitals and a low risk of infection is correct. This patient is stable, which allows for safe monitoring, making them the priority for room assignment. The stability of their condition means they can be assigned to a room with less urgency compared to patients with more acute needs.

For incorrect answer choices:

A patient with severe pneumonia experiencing difficulty breathing and high fever is incorrect. This patient is experiencing respiratory distress, which demands immediate attention and monitoring, making them a higher priority for nursing care rather than room assignment.

A patient post-surgery for a hip replacement who is confused and at risk for falls is incorrect. Although this patient requires supervision to prevent falls, the immediate urgency of respiratory or life-threatening complications in other patients takes precedence in room assignment.

A patient recovering from a laparoscopic cholecystectomy who requires regular pain management is incorrect. While pain management is necessary, this patient’s condition is less critical than those with respiratory or confusion-related risks, allowing for room assignment later.

For correct answer choice:

Administer bumetanide intravenously to a client with acute heart failure who has crackles in the lungs is correct. This is the highest priority action due to the patient's signs of acute heart failure, indicating fluid overload and potential respiratory failure. Administering the diuretic will help decrease fluid retention and improve the patient’s breathing.

For incorrect answer choices:

Begin transfusion of the second unit of packed red blood cells to a patient with hemoglobin of 7 g/dL is incorrect. While this is also an important task, it can be deferred until more critical issues, such as respiratory distress, are addressed. The patient can tolerate some time without the transfusion.

Replace an empty IV syringe in a patient-controlled analgesia (PCA) pump for pain management is incorrect. Pain management is essential but should not take precedence over addressing life-threatening conditions like heart failure. This can be done after stabilizing patients with more critical needs.

Change the heparin infusion bag that is nearly empty and running at a steady rate is incorrect. Although ensuring proper anticoagulation is necessary, this task is not as urgent as treating a patient with acute heart failure. The heparin can continue to infuse while the nurse addresses the immediate needs of the heart failure patient.

For correct answer choice:

Sit the patient upright at 90 degrees before feeding is correct. This is the correct position to reduce the risk of aspiration, which is a significant concern in stroke patients with potential swallowing difficulties. Upright positioning helps the patient safely swallow food and liquids.

For incorrect answer choices:

Feed the patient small bites while checking for fatigue is incorrect. While feeding slowly and checking for fatigue is important, it’s more critical to ensure that the patient is properly positioned to prevent aspiration before any feeding begins.

Encourage the patient to drink water with every bite is incorrect. Encouraging fluids may not be safe for a stroke patient if there are swallowing issues. This should be assessed by the nurse before giving the assistant instructions.

Ensure that suction equipment is at the bedside while feeding is incorrect. Although suction equipment may be needed if the patient has swallowing difficulties, positioning is the most important initial step to prevent complications like aspiration.

For correct answer choice:

A 45-year-old client newly diagnosed with a pulmonary embolism is correct. This client should be prioritized due to the life-threatening nature of a pulmonary embolism (PE), which can cause sudden respiratory compromise. Immediate assessment is crucial to ensure oxygenation and hemodynamic stability.

For incorrect answer choices:

A 60-year-old client scheduled for a colonoscopy in 2 hours is incorrect. While this client requires preparation and monitoring, a colonoscopy is not an urgent condition compared to a PE. The client can be assessed after more urgent cases are addressed.

A 25-year-old client with a migraine requesting pain medication is incorrect. Migraines can cause significant discomfort, but this client is not experiencing an immediately life-threatening condition, making this less urgent than a PE.

A 30-year-old client who is 24 hours post-laparoscopic cholecystectomy is incorrect. Postoperative clients should be monitored, but the absence of complications makes this client a lower priority than one with a PE.

For correct answer choice:

Monitor for signs of bleeding at the biopsy site is correct. Liver biopsy poses a high risk for internal or external bleeding due to the vascular nature of the liver. Hemorrhage is the most serious complication, so it’s crucial to monitor for signs of bleeding at the site immediately after the procedure.

For incorrect answer choices:

Check the patient’s vital signs every 15 minutes is incorrect. While monitoring vital signs is part of post-procedure care, checking for hemorrhage is the immediate priority after a liver biopsy, as bleeding can lead to a rapid decline in vital signs.

Ensure the patient remains in the right lateral position is incorrect. The right lateral position helps apply pressure on the biopsy site to prevent bleeding, but it is secondary to actively assessing for signs of bleeding, which takes priority.

Assess for signs of infection around the biopsy site is incorrect. Infection is a concern, but it is typically a later complication. The immediate risk after a liver biopsy is bleeding, which is why monitoring for hemorrhage is the priority.

For correct answer choice:

A 63-year-old patient with multiple sclerosis who presents with an oral temperature of 101.8°F and reports flank pain is correct. The elevated temperature and flank pain suggest a potential infection, such as a urinary tract infection or pyelonephritis, which may require immediate intervention, making this patient the priority for assessment.

For incorrect answer choices:

A 45-year-old patient scheduled for a craniotomy in 30 minutes who requires preoperative education is incorrect. While this patient needs education before surgery, they are stable, and the preoperative preparation can be managed after addressing the more urgent situation of potential infection in the multiple sclerosis patient.

A 23-year-old patient experiencing a migraine headache accompanied by severe nausea and retching is incorrect. Although migraines can cause significant discomfort, they do not present an immediate life-threatening situation, allowing this patient to be assessed after addressing more critical patients.

A 59-year-old patient with Parkinson’s disease who requires a swallowing evaluation prior to breakfast is incorrect. This evaluation is important to prevent aspiration, but it is not as urgent as assessing the patient with potential infection and systemic symptoms, making it a lower priority.

For correct answer choice:

Infuse a bolus of IV crystalloid fluids is correct. The first action in septic shock is fluid resuscitation with IV crystalloids (such as normal saline or lactated Ringer's). This is essential to restore circulating volume and increase cardiac output, which is crucial to improving hemodynamic stability.

For incorrect answer choices:

Start the patient on broad-spectrum antibiotics is incorrect. Broad-spectrum antibiotics should be administered as soon as possible, but only after ensuring that the patient is stabilized with fluids to prevent further hypotension and shock.

Administer a high-dose corticosteroid is incorrect. Corticosteroids are reserved for specific situations, like when septic shock is refractory to fluids and vasopressors. They are not first-line treatment.

Begin continuous vasopressor therapy is incorrect. Vasopressors like norepinephrine are given after fluid resuscitation if hypotension persists, but they should not be the initial intervention. Correcting fluid volume takes precedence.

For correct answer choice:

A 68-year-old client with a new onset of stroke symptoms including facial droop is correct. This client exhibits signs of an acute stroke, which is a medical emergency. Immediate assessment and intervention are critical to prevent permanent neurological damage. Time-sensitive care (e.g., thrombolytics) can significantly improve outcomes.

For incorrect answer choices:

A 72-year-old client scheduled for discharge after knee replacement surgery is incorrect. While discharge planning is important, this client is stable and ready for discharge, making them a lower priority than a client with potential stroke.

A 45-year-old client with a history of asthma requesting a nebulizer treatment is incorrect. Asthma can become critical, but in this case, the client is stable and requesting treatment. This is less urgent than assessing a client with new stroke symptoms.

A 55-year-old client with hypertension awaiting routine medication administration is incorrect. This client requires monitoring, but hypertension management is a longer-term issue and less urgent than a suspected stroke.

For correct answer choice:

The client reporting new onset chest pain and a history of coronary artery disease is correct. Chest pain in a client with a history of coronary artery disease is a potential sign of myocardial infarction. This requires immediate assessment and intervention, as it is potentially life-threatening.

For incorrect answer choices:

The client with diabetes whose morning fasting blood glucose level is 110 mg/dL is incorrect. This is within the normal range for fasting blood glucose and does not require urgent intervention. This client can be seen after addressing the client with chest pain.

The client with a known history of chronic kidney disease scheduled for dialysis later in the day is incorrect. This client is stable and awaiting a routine procedure (dialysis). Although chronic kidney disease is serious, it does not pose an immediate threat at this time.

The client with stable angina who is requesting his regular morning dose of Nitroglycerin is incorrect. Although Nitroglycerin is important for managing angina, this client is not experiencing acute or new symptoms, and thus can be managed after addressing the client with new onset chest pain.

For correct answer choice:

The student nurse enters the room without an N95 respirator is correct. Immediate intervention is required as an N95 respirator is crucial for protection against airborne diseases like TB. The failure to wear proper PPE (Personal Protective Equipment) endangers both the student and others by increasing the risk of exposure.

For incorrect answer choices:

The student nurse asks the patient about any recent travel history is incorrect. This is an appropriate action because obtaining travel history helps determine potential sources of infection or additional risk factors for the spread of TB.

The student nurse explains to the patient that visitors must wear a mask is incorrect. This is appropriate, as anyone entering the room should be instructed to wear masks to prevent the spread of infection.

The student nurse ensures the door to the room remains closed at all times is incorrect. Keeping the door closed is important for maintaining the negative pressure in the room, which helps contain airborne pathogens.

For correct answer choice:

The patient with renal insufficiency on long-term hemodialysis is correct. Chronic kidney disease leads to decreased production of erythropoietin, a critical hormone for red blood cell production. This patient is at a higher risk of anemia and requires careful monitoring and interventions such as erythropoiesis-stimulating agents and iron supplementation.

For incorrect answer choices:

The patient recovering from minor surgery with a Jackson-Pratt drain in place is incorrect. This patient could experience minimal blood loss, but it is not as high a risk for anemia as renal insufficiency and hemodialysis, which directly impair red blood cell production.

The patient who has been NPO for 48 hours before a surgical procedure is incorrect. Although prolonged NPO status can result in dehydration or electrolyte imbalances, anemia is less of an immediate concern unless there is significant blood loss during surgery.

The patient who has been following a vegan diet for the past year is incorrect. Vegans are at some risk of iron-deficiency anemia due to a lack of heme iron sources, but with proper dietary management and supplementation, this is a lower priority compared to patient with renal insufficiency.

For correct answer choice:

Assist the client with a stroke in repositioning in bed is correct. Nursing assistants are trained to assist with basic activities of daily living (ADLs), including repositioning clients. This is a safe and appropriate task for delegation, as it does not require advanced clinical judgment or assessment skills.

For incorrect answer choices:

Monitor intake and output for a client with heart failure is incorrect. While nursing assistants can record intake and output, the interpretation and monitoring of these values, particularly in a client with heart failure, require the clinical judgment of a licensed nurse.

Assess the pain level of a client post-abdominal surgery is incorrect. Pain assessment is a skilled task that requires clinical judgment, which is within the scope of practice for licensed nurses, not nursing assistants.

Administer a tube feeding for a client with dysphagia is incorrect. Administering tube feedings requires specialized skills and knowledge. The nurse is responsible for assessing the client's tolerance and any potential complications, making this task inappropriate for delegation to a nursing assistant.

For correct answer choice:

Administering prescribed oral antihypertensive medications is correct. LPNs/LVNs are trained to administer routine medications, including oral antihypertensives, as part of their scope of practice.

For incorrect answer choices:

Performing a focused neurological assessment is incorrect. Performing comprehensive assessments, especially focused neurological exams, requires the clinical judgment of an RN. LPNs can collect data but not assess complex conditions.

Teaching the patient about lifestyle changes to prevent stroke is incorrect. Patient education on critical topics like stroke prevention is an RN's responsibility due to the complexity of the information and the need for clinical judgment.

Collecting data on the patient’s vital signs and reporting any abnormalities is incorrect. LPNs/LVNs are responsible for collecting and reporting vital signs, making this task suitable for delegation.

For correct answer choice:

The 3-year-old with asthma and an oxygen saturation of 88% on room air is correct. An oxygen saturation of 88% indicates hypoxemia, which is a critical finding in a pediatric asthma patient. To improve oxygenation and prevent respiratory failure. immediate intervention is required.

For incorrect answer choices:

The 6-year-old with bronchitis, who just started IV antibiotics is incorrect. While this patient requires monitoring, starting IV antibiotics is not immediately life-threatening compared to hypoxemia.

The 17-year-old with a pleural effusion, whose pain has decreased to 3/10 after medication is incorrect. Since the pain has been controlled, this patient can be assessed after stabilizing the hypoxemic child.

The 11-year-old recovering from pneumonia, who is ready for discharge is incorrect. This patient is stable and awaiting discharge, making them the lowest priority for immediate assessment.

For correct answer choice:

A patient with chronic kidney disease who is stable but undergoing routine dialysis is correct. This patient may have underlying risks of infection or other complications associated with dialysis, making them the least suitable roommate for a post-operative nephrectomy patient who needs to avoid exposure to potential infection sources.

For incorrect answer choices:

A patient with a cellulitis infection whose WBC count is mildly elevated is incorrect. While cellulitis involves infection, the risk is relatively localized and manageable with proper infection control precautions. This patient may pose less risk to the nephrectomy patient compared to someone undergoing dialysis.

A patient living with HIV whose immune system is currently moderately compromised is incorrect. Although the immune-compromised status of the HIV patient could raise concerns, they are less likely to transmit infectious diseases compared to a dialysis patient, given standard precautions and care.

A patient recovering from a facial injury with low platelet levels and ongoing bleeding issues is incorrect. While bleeding issues are a concern, they do not pose as significant a risk to the nephrectomy patient as the complications and infection risks from a chronic dialysis patient.

For correct answer choice:

Measure and record the patient's intake and output every shift is correct. This is an appropriate task for a nursing assistant, as it involves routine monitoring and documentation. Intake and output measurements help in monitoring the patient’s fluid balance and can be delegated safely.

For incorrect answer choices:

Administer the patient’s medications as prescribed by the physician is incorrect. Medication administration is outside the scope of practice for a nursing assistant. This task requires a licensed nurse or healthcare provider.

Perform a comprehensive respiratory assessment every 4 hours is incorrect. Respiratory assessments require clinical judgment and the ability to recognize signs of respiratory compromise, making this task unsuitable for delegation to a nursing assistant.

Monitor the patient for changes in bowel and bladder function is incorrect. While nursing assistants can assist with bowel and bladder care, monitoring for changes (e.g., incontinence, retention) involves assessment skills and should be done by a licensed nurse.

For correct answer choice:

A 68-year-old patient with stable amyotrophic lateral sclerosis (ALS) receiving palliative care is correct. This patient has a stable condition and is receiving palliative care, which involves symptom management rather than complex acute care interventions. It is a more predictable assignment for a traveling nurse still adjusting to neurologic care.

For incorrect answer choices:

A 45-year-old patient with a recent traumatic brain injury requiring hourly neurological assessments is incorrect. This patient is in a critical phase and requires close monitoring and frequent assessments. This makes them an inappropriate assignment for a nurse still learning the unit's protocols.

A 55-year-old patient with an acute exacerbation of multiple sclerosis (MS) and new onset of vision problems is incorrect. This patient is experiencing a worsening condition that requires a higher level of monitoring and intervention, which may not be suitable for a nurse new to the unit.

A 30-year-old patient with Guillain-Barre syndrome (GBS) in the intensive care unit, now requiring ventilatory support is incorrect. This patient is critically ill and requires intensive care with a focus on respiratory support, making it inappropriate for a nurse still acclimating to the unit.