A. Newborn 4:
This newborn has hypoglycemia (blood glucose 28 mg/dL; normal >40–45 mg/dL) and symptoms such as mild grunting, poor tone, and hand tremors. These findings require immediate intervention to prevent neurologic injury.

B. Newborn 3:
This newborn’s data is within expected limits for a 48-hour-old baby scheduled for discharge. Breastfeeding, voiding, stooling, and passing the hearing screen are appropriate findings; no revision needed.

C. Newborn 1:
Acrocyanosis is normal in the first 24 hours, but this newborn is only 2 hours old, so this alone is not alarming. However, because the newborn had an Apgar score of 6 at 1 minute (indicating some initial difficulty) and is in the early transition period, close monitoring is essential. The revision here would be to ensure additional observation to confirm stability before assuming the newborn is low risk.

D. Newborn 2:
This newborn underwent a circumcision and is being observed per protocol with no abnormal findings; no plan of care revision is necessary.

A. Client 1:
Cefaclor was scheduled for 0800 and given at 0830 - this is a 30-minute delay, which is generally acceptable unless the medication is time-critical (e.g., insulin, antibiotics for sepsis). Since antibiotics should be given on time, but a 30-min delay is within the acceptable window, this does not require an incident report.

B. Client 2:
The client vomited undigested food and medication 30 minutes after administration. This is a medication effectiveness concern that should be documented and reported because the dose may need to be repeated, and the provider must be notified. An incident report is appropriate.

C. Client 4:
Furosemide was prescribed PO but administered IV at 1400. This is a route error, which is a medication administration error requiring an incident report.

D. Client 3:
Warfarin was administered despite an INR of 3.8 (above the hold parameter of >3.5). This is a clear medication error with potential for harm, requiring an incident report.

E. Client 5:
Gentamicin dose was prescribed at 150 mg IM, but 300 mg IM was given - this is a double dose and a serious medication error requiring immediate incident reporting.

F. Client 6:
Atenolol was appropriately held only if apical pulse <60/min; pulse was 62/min, so administration was within parameters - no error here.

A. Client 1 – Expectant/likely to die despite care (black tag)

This client has an open head trauma and is actively dying. In a mass casualty event, resources are directed toward those with the greatest chance of survival. Clients with injuries incompatible with life despite treatment are tagged black (expectant).

B. Client 2 – Life-threatening injury with high possibility of survival (red tag)

The client has a sucking chest wound with severe respiratory distress, tachycardia, hypotension, and hypoxemia (O₂ sat 85%). These are life-threatening injuries that can be rapidly corrected with airway management and wound sealing, giving a high likelihood of survival if treated immediately. Red tag is for immediate care.

C. Client 3 – Minor injuries that can wait (green tag)

This client has an ankle sprain and abrasions-injuries that are not life-threatening and do not require urgent intervention. These are classified as green tag (walking wounded), meaning treatment can be delayed without negative outcomes.

D. Client 4 – Serious injury but can be delayed without risk (yellow tag)

This client has a partial leg amputation with a tourniquet in place, no active bleeding, and stable vital signs for now. The injury is serious but currently controlled, so care can be delayed while higher-priority cases are managed. Yellow tag is for urgent but not immediate cases.

A. Client 4:
This client has COPD with a fever of 39.5° C and blood-tinged sputum, likely due to an acute infection such as pneumonia. The client is unstable and requires inpatient treatment - not a discharge candidate.

B. Client 5:
This client has diarrhea, dehydration, hypotension (BP 84/50 mm Hg), and tachycardia. These are unstable vital signs and require continued inpatient care - not a discharge candidate.

C. Client 3:
This client is 4 days post–hip arthroplasty, is ambulating well with assistance, and is stable. The client can be discharged with home health or outpatient follow-up to free up a bed during a mass casualty.

D. Client 1:
This client was admitted for chest pain and recently required nitroglycerin for relief. Cardiac instability risk remains, so the client should not be discharged at this time.

E. Client 2:
This client is stable, awaiting elective bariatric surgery the next day. Elective procedures can be postponed, and the client can be discharged during a disaster to make room for critical cases.

A. A client who requires initial education about blood glucose monitoring:
Initial client teaching requires assessment, knowledge of the learning process, and evaluation - all of which are within the RN’s scope, not LPN or AP.

B. A client who requires an enteral feeding:
An LPN can safely administer an established enteral feeding, so this does not have to be reassigned to an RN.

C. A client who requires tracheostomy suctioning:
Tracheostomy suctioning of a stable patient is within the LPN’s scope of practice. Only unstable airway situations or assessment findings requiring intervention would necessitate an RN.

D. A client who requires irrigation of an indwelling urinary catheter:
LPNs are allowed to irrigate indwelling urinary catheters in most settings, so this task does not require RN reassignment.

A. The client reports insomnia:
Insomnia is a common nonmotor symptom in Parkinson’s disease, but it is not immediately life-threatening and can be addressed after urgent concerns are handled.

B. The client has difficulty swallowing:
Dysphagia increases the risk for aspiration and airway obstruction, making it a high-priority finding. Airway compromise always takes precedence in care prioritization (ABC rule).

C. The client has increased difficulty dressing:
Dressing difficulty reflects worsening motor impairment, but it is not an urgent, life-threatening problem and can be addressed with supportive interventions.

D. The client requires additional help to stand:
This indicates decreased mobility and increased fall risk, but it is still a lower priority than airway safety concerns from difficulty swallowing.

A. "A nurse can be charged with libel if she discusses client information in a public area."
This is incorrect-discussing client information in public is a breach of confidentiality (HIPAA violation), not libel.

B. "Documenting negative opinions about a client's personality is considered libel."
Libel is written defamation. Recording subjective, non–care-related negative statements about a client’s personality in the medical record can be considered libel.

C. "Libel is the intentional infliction of emotional distress due to negligent nursing actions."
This describes negligence and emotional harm, not libel.

D. "Failing to complete an incident report following a client injury is an act of libel."
Failure to complete an incident report is an example of poor documentation and policy violation but not libel.

A. A client who has a dislocated shoulder:
This is painful and requires prompt care but is not as urgent as airway/breathing compromise.

B. A client who has audible wheezes:
Audible wheezing indicates airway narrowing or bronchospasm, which is a potential respiratory emergency and must be assessed and treated immediately.

C. A client who reports right lower-quadrant abdominal pain:
This could be appendicitis, which is urgent, but airway/breathing issues take precedence.

D. A client who has a 5 cm (2 in) laceration of the thigh:
This requires cleaning and closure but is less urgent than compromised breathing.

A. A client who provides a detailed description of a recent fall at home:
This does not suggest abuse if the story is consistent and injuries match the explanation.

B. A client who has fingernails that are discolored and broken:
This may indicate neglect of hygiene or fungal infection but is not conclusive evidence of abuse.

C. A client who reports experiencing short-term memory loss:
This could be due to dementia or other conditions; it is not an indicator of abuse by itself.

D. A client who is wearing urine-scented clothing:
Wearing urine-soaked clothing indicates poor hygiene and possible neglect, which is a form of elder abuse and should be reported.

A. Transcribe the medication name using the trade name:
Nurses should use the generic name to avoid confusion and ensure clarity, not the trade name.

B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day":
This is incorrect; using abbreviations in verbal orders increases risk of misinterpretation-nurses should use clear, plain language like “twice daily.”

C. Remind the provider to countersign the prescription in 72 hr:
Countersigning must occur, but the required time frame varies by facility and jurisdiction-focusing on the time frame is less important than verifying accuracy during the read-back.

D. Verify the medication name along with its intended purpose:
Best practice in telephone orders includes reading back the medication name, dose, route, and frequency, and confirming the indication to reduce medication errors.