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For a patient who is receiving chemotherapy, which laboratory result is of particular importance? 1. White blood cell count 2. Prothrombin time 3. Electrolyte levels 4. Blood urea nitrogen level

1. White blood cell count The white blood cell count is especially important because chemotherapy can decrease white blood cells, particularly neutrophils (known as neutropenia). This leaves the patient vulnerable to infection. The other tests are important in the total management but are less directly specific to chemotherapy.

37. A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hour. Available: 20,000 units/500mL. The nurse will set the infusion pump to ____mL/hr?

17.5mL/hr

After chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory result requires particular attention? 1. Platelet counts 2. Electrolyte levels 3. Hemoglobin levels 4. Hematocrit levels

2. Electrolyte levels Tumor lysis syndrome can result in severe electrolyte imbalances and potential kidney failure. The other laboratory values are important to monitor to identify general chemotherapy side effects but are less pertinent to tumor lysis syndrome.

42. The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine 20 mg IV 2. Furosemide 40 mg IV 3. Digoxin 0.25 mg PO 4. Warfarin 2.5 mg PO

4. Warfarin 2.5 mg PO Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, doublechecking is not needed.

The nurse is monitoring a patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. "Last night my back really hurt, and I had trouble sleeping." 2. "My leg has been giving out when I try to stand." 3. "My bowels are just not moving like they usually do." 4. "When I try to pass urine, I have difficulty starting the stream."

1. "Last night my back really hurt, and I had trouble sleeping." Back pain is an early sign of spinal cord compression occurring in 95% of patients. The other symptoms are later signs.

The nurse is interviewing a patient who was treated several months ago for breast cancer. The patient reports taking nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain. Which patient comment is cause for greatest concern? 1. "The NSAIDs are really not relieving the back pain." 2. "The NSAID tablets are too large, and they are hard to swallow." 3. "I gained weight because I eat a lot before taking NSAIDs." 4. "The NSAIDs are upsetting my stomach in the morning."

1. "The NSAIDs are really not relieving the back pain." Primary cancers (lung, prostate, breast, and colon) may metastasize to the spine. In spinal cord compression, back pain is a common early symptom. Later symptoms include weakness, loss of sensation, urinary retention or incontinence, and constipation. Reports of pain in distal areas, worsening pain, or difficulty controlling pain can signal metastasis or reoccurrence, which is always a concern for cancer patients. Pain should be reported to the health care provider for evaluation

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered

1. Checking the client's skin for pressure from the device 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 6. Administering oral medications as ordered Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Administering oral drugs is within the scope of practice for an LPN/LVN. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN.

A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration

1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 6. Turning the client to his or her side to avoid aspiration Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.

22. At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

1. Put the client on "nothing by mouth" (NPO) status. Because transesophageal echocardiography is performed after the throat is numbed using a topical anesthetic and with the use of IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the echocardiogram but do not need to be implemented immediately.

1. The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider? 1. Stools have been black in color. 2. Bruising is present at the right groin. 3. Home blood pressure today was 104/52 mm Hg. 4. Home radial pulse rate has been 55 to 60 beats/min.

1. Stools have been black in color. Dark or tarry stools may indicate gastrointestinal bleeding, which is a possible adverse effect of both aspirin and clopidogrel. The client will need to continue on the medications but may need treatment with proton pump inhibitors or histamine2 blockers to decrease risk for gastrointestinal bleeding. The other findings will also be reported to the health care provider but will not require a change in the therapeutic plan for the client.

In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 4. Gathering the supplies to prepare the room for protective isolation 6. Practicing good hand-washing technique Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

1. Turn the client to one side. The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.

32. The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next? 1. Prepare to defibrillate the client. 2. Offer to take over chest compressions. 3. State: "Epinephrine 1 mg IV has been given." 4. Continue to monitor the client's responsiveness.

3. State: "Epinephrine 1 mg IV has been given." The American Heart Association recommends "closed loop" communication between team members who are involved in resuscitation of a client. The other actions may also be needed, but the initial action after administering a medication is to assure that the team leader knows that the prescribed medication has been administered.

An unlicensed assistive personnel (UAP) reports to the RN that a patient with acute kidney failure had a urine output of 350 mL over the past 24 hours after receiving furosemide 40 mg IV push. The UAP asks the nurse how this can happen. What is the nurse's best response? 1. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." 2. "There must be some sort of error. Someone must have failed to record the urine output." 3. "A patient with acute kidney failure retains sodium and water, which counteracts the action of the furosemide." 4. "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium."

1. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." During the oliguric phase of acute kidney failure, a patient's urine output is greatly reduced. Fluid boluses and diuretics do not work well. This phase usually lasts from 8 to 15 days. Although there are occasionally omissions in recording intake and output, this is probably not the cause of the patient's decreased urine output. Retention of sodium and water is the rationale for giving furosemide, not the reason that it is ineffective. Nitrogenous wastes build up as a result of the kidneys' inability to perform their elimination function.

32. A patient on the medical-surgical unit with acute kidney failure is to begin continuous arteriovenous hemofiltration (CAVH) as soon as possible. What is the priority collaborative action at this time? 1. Call the charge nurse and arrange to transfer the patient to the intensive care unit. 2. Develop a teaching plan for the patient that focuses on CAVH. 3. Assist the patient with morning bath and mouth care before transfer. 4. Notify the health care provider (HCP) that the patient's mean arterial pressure is 68 mm Hg.

1. Call the charge nurse and arrange to transfer the patient to the intensive care unit. CAVH is a continuous renal replacement therapy that is prescribed for patients with kidney failure who are critically ill and do not tolerate the rapid shifts in fluids and electrolytes that are associated with hemodialysis. A teaching plan is not urgent at this time. A patient must have a mean arterial pressure (MAP) of at least 60 mm Hg or more for CAVH to be of use. The HCP should be notified about this patient's MAP; it is a priority but not the highest priority. When a patient urgently needs a procedure, morning care does not take priority and may be deferred until later in the day.

The RN supervising a senior nursing student is discussing methods for preventing acute kidney injury (AKI). Which points would the RN be sure to include in this discussion? Select all that apply. 1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise. 3. Immediately report a urine output of less than 2 mL/kg/hr. 4. Record intake and output and weigh patients daily. 5. Question any prescriptions for potentially nephrotoxic drugs. 6. Monitor laboratory values that reflect kidney function.

1. Encourage patients to avoid dehydration by drinking adequate fluids. 2. Instruct patients to drink extra fluids during periods of strenuous exercise 4. Record intake and output and weigh patients daily. 6. Monitor laboratory values that reflect kidney function. Dehydration reduces perfusion and can lead to AKI. Patients should be encouraged to take in adequate fluids, and extra fluids should be taken in during strenuous exercise. Intake and output, as well as daily weights, should be documented. Lab values that indicate kidney function should be followed. The health care provider should be notified for a urine output of less than 0.5 mL/kg/hr that persists for more than 2 hours. Many drugs are potentially nephrotoxic but as still administered. Patients are encouraged to take in extra fluids, and nurses must monitor for any nephrotoxic effects when these drugs are prescribed.

The nurse is providing nursing care for a patient with acute kidney failure for whom volume overload has been identified. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 3. Administering furosemide 40 mg orally twice a day 4. Reminding the patient to save all urine for intake and output measurement 5. Assessing breath sounds every 4 hours 6. Ensuring that the patient's urinal is within reach

1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 4. Reminding the patient to save all urine for intake and output measurement 6. Ensuring that the patient's urinal is within reach Administering oral medications is appropriate to the scope of practice for an LPN/LVN or RN. Assessing breath sounds requires additional education and skill development and is most appropriately within the scope of practice of an RN, but it may be part of the observations of an experienced and competent LPN/LVN. All other actions are within the educational preparation and scope of practice of an experienced UAP.

A patient diagnosed with acute kidney failure had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient under the RN's supervision asks how a patient with kidney failure can have such a large urine output. What is the RN's best response? 1. "The patient's kidney failure was caused by hypovolemia, and we have given him IV fluids to correct the problem." 2. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." 3. "With that much urine output, there must have been a mistake in the patient's diagnosis." 4. "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure."

2. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." Patients with acute kidney failure usually go through a diuretic phase 2 to 6 weeks after the onset of the oliguric phase. The diuresis can result in an output of up to 10 L/day of dilute urine. During this phase, it is important to monitor for electrolyte and fluid imbalances. This is followed by the recovery phase. A patient with acute kidney failure caused by hypovolemia would receive IV fluids to correct the problem; however, this would not necessarily lead to the onset of diuresis.

The nurse is caring for a patient with uterine cancer who is being treated with intracavitary radiation therapy. Unlicensed assistive personnel (UAP) reports that the patient insisted on ambulating to the bathroom and now "something feels like it is coming out." What is the priority action? 1. Assess the UAP's knowledge; explain the rationale for strict bed rest. 2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. 3. Assess the patient's knowledge of the treatment plan and her willingness to participate. 4. Notify the health care provider about dislodgment of the radiation implant.

2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. If the radiation implant has obviously been expelled (e.g., is on the bed linens), use a pair of forceps to place the radiation source in a lead container. The other options would be appropriate after safety of the patient and personnel are ensured.

The nurse is caring for a patient with chronic kidney disease after hemodialysis. Which patient care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Assess the patient's access site for a thrill and bruit. 2. Monitor for signs and symptoms of postdialysis bleeding. 3. Check the patient's postdialysis blood pressure and weight. 4. Instruct the patient to report signs of dialysis disequilibrium syndrome immediately.

3. Check the patient's postdialysis blood pressure and weight Checking vital signs and weighing patients are within the scope of practice for the UAP. However, the nurse must be sure to caution the UAP to check BP in the arm opposite to the access site. Assessing, teaching, and monitoring require additional skills that fit within the scope of practice for the professional nurse.

The nurse is caring for a patient admitted with dehydration secondary to deficient antidiuretic hormone (ADH). Which specific gravity value supports this diagnosis? 1. 1.010 2. 1.035 3. 1.020 4. 1.002

4. 1.002 A patient with dehydration due to deficient ADH would have diluted urine with a decreased urine specific gravity. Normal urine specific gravity ranges from 1.003 to 1.030. A specific gravity of 1.035 would indicate urine that is concentrated.

A patient with advanced age has a PEG tube. Which complications of enteral feedings may occur? Select all that apply. 1. Hyperglycemia 2. Hypotension 3. Aspiration 4. Diarrhea 5. Fluid overload 6. Weight loss

1. Hyperglycemia 3. Aspiration 4. Diarrhea 5. Fluid overload Older adult clients are especially at risk for hyperglycemia, aspiration, diarrhea, and fluid overload. Hypotension and weight loss should not occur because of enteral feedings.

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 6. A 69-year-old patient with emphysema to be discharged tomorrow The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

The oncoming day shift nurse has just received hand over report from the night shift nurse. Which patient is the priority? 1. A patient who developed tumor lysis syndrome around 5:00 am 2. A patient who is currently pain free but had breakthrough pain during the night 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours

1. A patient who developed tumor lysis syndrome around 5:00 am Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed before leaving the unit, and any final preparations for surgery should be completed. A patient with breakthrough pain needs a thorough pain assessment, an investigation of pain patterns, and a chart review of all attempted pharmaceutical and non pharmaceutical interventions; the health care provider may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics.

Which clients would be best to assign to the new RN? Select all that apply. 1. A women diagnosed with acute cholecystitis and a hx of gallstones with reports of "a good night last night". 2. A 60 year old woman admitted w/ a bowel obstruction who reports a decrease in nausea and vomiting since insertion of an NG tube and is NPO receiving fluids. 3. A 29 year old woman admitted w/ an acute exacerbation of ulcerative colitis who appears malnourished, has severe diarrhea and is receiving TPN. 4. A 26 year old man who had an appendectomy and will be d/c this afternoon. 5. An 85 year old man who is A&Ox2 and had a PEG tube placed 5 days ago. He has a large family that asks many questions and constantly argues amongst themselves 6. A 57 year old man w/ severe periumbilical pain that has not been relieved despite opioid analgesics and is belligerent and confused with an elevated WBC and glucose count.

1. A women diagnosed with acute cholecystitis and a hx of gallstones with reports of "a good night last night". 2. A 60 year old woman admitted w/ a bowel obstruction who reports a decrease in nausea and vomiting since insertion of an NG tube and is NPO receiving fluids. 4. A 26 year old man who had an appendectomy and will be d/c this afternoon. 1,2, and 4 are in the most stable condition and represent the least complex cases according to the shift report. The 57 year old man's confusion and belligerence will make pain management especially difficult. Laboratory results and potential complications must be closely monitored. The ulcerative colitis patient is at risk for electrolyte imbalances, especially hypokalemia. She needs repetitive perineal hygiene and skin assessment. TPN and central line management require additional skills. The patient with a PEG tube is in stable condition, but because of the family dynamics, his care should be handled by an experienced nurse.

15. The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN? 1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice.

40. During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

1. Arterial line indicates a blood pressure of 190/112 mm Hg Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability.

The nurse is caring for a patient with esophageal cancer. Which task could be delegated to unlicensed assistive personnel (UAP)? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weights

1. Assisting the patient with oral hygiene Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement.

Which tasks can be delegated to the UAP? Select all that apply. 1. Assisting with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for a patient experiencing acute pancreatitis 3. Transporting a patient with acute cholecystitis off the unit for a procedure 4. Gently cleansing the nares around an NG tube 5. Removing a surgical dressing 6. Helping an elderly man to brush his teeth

1. Assisting with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for a patient experiencing acute pancreatitis 3. Transporting a patient with acute cholecystitis off the unit for a procedure 4. Gently cleansing the nares around an NG tube 6. Helping an elderly man to brush his teeth enasuring vital signs, performing hygienic care, and transporting (stableclients) are within the scope of the UAP's duties. The UAP should not remove the dressing. If the dressing needs to be removed, the nurse should remove it, conduct the wound assessment, clean the area, and redress as needed.

7. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply. 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice.

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 4. Checking oxygen saturation using pulse oximetry The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1. Entering the room without putting on a protective mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

1. Entering the room without putting on a protective mask and gown Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply. 1. How to monitor and record daily weight 2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure 4. Purpose of chronic antibiotic therapy 5. How to read food labels for sodium content 6. Date and time for follow-up appointments

1. How to monitor and record daily weight 3. Symptoms of worsening heart failure 5. How to read food labels for sodium content 6. Date and time for follow-up appointments To avoid re-hospitalization, topics that should be included when discharging a client with heart failure include low-sodium diet, purpose and common side effects of medications such as angiotensin-converting enzyme inhibitors and betablockers, what to do if symptoms of worsening heart failure occur, and follow-up appointments. The nurse will teach the client that a moderate increase in heart rate and respiratory effort is normal with exercise. Antibiotics are not included in the treatment regimen for heart failure, which is not an infectious process.

25. The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN.

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

The RN is observing the nursing student perform an abdominal assessment on a patient who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? Select all that apply. 1. Palpating for abdominal distention with the index fingertip 2. Auscultating for bowel sounds with the NG tube attached to low wall suction 3. Performing the physical assessment before asking about pain 4. Checking the NG collection canister for quantity and quality of drainage 5. Inspecting for visible signs of peristaltic waves or abdominal distention 6. Checking for skin turgor over the lower abdominal area

1. Palpating for abdominal distention with the index fingertip 2. Auscultating for bowel sounds with the NG tube attached to low wall suction 3. Performing the physical assessment before asking about pain 6. Checking for skin turgor over the lower abdominal area The flat palmar surface of the hand is better than the fingertips when palpating for distention. If the wall suction is activated, it will interfere with auscultating for bowel sounds. Asking about pain first will guide the physical assessment steps. The skin on the anterior chest under the clavicle is a better place to check for turgor than the lower abdomen, especially if abdominal distention is present. Checking the drainage and inspecting for peristaltic waves or distention are correct actions.

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation. A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

10. While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors. Which interventions will be important to include in the discharge plan for this client? Select all that apply. 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing emotional stress

1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk The client's major modifiable risk factor is ongoing smoking. The family history is significant, and the client should be aware that this increases cardiovascular risk. The blood pressure is well controlled on the current medication, and no change is needed. There is no indication that stress is a risk factor for this client, and the client's activity level meets the American Heart Association recommendation for at least 150 minutes of moderate activity weekly.

4. Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider? 1. Temperature of 102.1°F (38.9°C) 2. Loud systolic murmur over sternum 3. Blood pressure of 110/88 mm Hg 4. Weak radial and pedal pulses to palpation

1. Temperature of 102.1°F (38.9°C) Because endocarditis is a concern with valvular disease, an elevated temperature indicates a need for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systolic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic stenosis and do not indicate an immediate need for further evaluation or treatment.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which findings supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle crash. Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT) and pulmonary embolus (PE). None of the other findings are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short.

16. The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

3. Administer sublingual nitroglycerin. The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority.

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove. 2. The student nurse applies suction while inserting the catheter. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.

1. The student nurse uses a sterile catheter and glove 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.

The nurse is reviewing the medication administration record for a patient with ulcerative colitis. Which situation needs immediate investigation? 1. Two tablets of lactulose were given yesterday morning. 2. One dose of atropine sulfate was given yesterday morning. 3. IV infusion of infliximab 5 mg/kg was given last evening. 4. IV hydrocortisone 100 mg was given last evening.

1. Two tablets of lactulose were given yesterday morning. Generally, laxatives should not be given to clients with ulcerative colitis. In a patient with ulcerative colitis controlling diarrhea is one of the main treatment goals. Lactulose is a laxative and will increase peristalsis and cramping. Atropine sulfate is an antidiarrheal medication. Antidiarrheal medication can be used for symptomatic relief, but caution is necessary because of the potential for colon dilation or toxic megacolon. Infliximab and hydrocortisone (and sulfasalazine) can be used for clients with ulcerative colitis to reduce the inflammation.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practice for professional nurses. All of the other instructions are appropriate for the UAP when caring for a patient receiving anticoagulants.

19. The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client's spouse. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this

2. "Can you tell me why you don't feel that you need to make any changes?" For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give the nurse more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle.

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips. Elevating the head of the bed may help with oxygenation but will not help with hoarseness. Responses 3 and 4 are important but do not speak directly to the patient's concern.

26. While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today 2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV 3. A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care 4. A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses.

30. The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first? 1. A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. A 77-year-old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change The client's symptoms indicate acute hypoxia, so immediate further assessments (e.g., assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client.

43. A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit 44. A client who is

2. B-type natriuretic peptide Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the client has heart failure.

For a patient with osteogenic sarcoma, which laboratory value causes the most concern? 1. Sodium level of 132 mEq/L (135 mmol/L) 2. Calcium level of 13 mg/dL (3.25 mmol/L) 3. Potassium level of 5.1 mEq/L (4.9 mmol/L) 4. Hematocrit of 40%

2. Calcium level of 13 mg/dL (3.25 mmol/L) The normal range for calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers.

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the health care provider about the change in status.

2. Check the Foley tubing for kinks or obstruction. .The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.

2. Check vital signs every 15 minutes for 1 hour. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

2. Checking and recording the client's vital signs every 4 hours The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses.

11. Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

2. Client receiving IV furosemide to treat acute left ventricular failure An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have acute coronary syndrome and with collaborative treatments such as coronary angioplasty and coronary artery stenting.

39. The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently? 1. Client with peripheral arterial disease who complains of leg cramps when walking 2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Client with a new permanent pacemaker who has severe itchiness at the wound site 4. Client with angina who took nitroglycerin twice in the last week while exercising

2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope Lightheadedness and syncope may indicate that the client's heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other clients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled.

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone 2000 mg IV to treat the infection. 3. Give acetaminophen 650 mg orally to reduce the fever. 4. Give furosemide 40 mg IV to decrease intracranial pressure.

2. Infuse ceftriaxone 2000 mg IV to treat the infection. Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy..

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

2. Encouraging, monitoring, and recording nutritional intake The UAP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice.

A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the health care provider, the nurse would anticipate which initial treatment for this patient? 1. A fluid bolus 2. Fluid restrictions 3. Urinalysis 4. Sodium-restricted diet

2. Fluid restrictions Hyponatremia is a concern; therefore, fluid restrictions would be prescribed. Urinalysis is less pertinent; however, the nurse should monitor for changes in urine specific gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely for patients with SIADH; however, IV normal saline or hypertonic saline solutions may be given very cautiously.

27. What instructions will the nurse give to the UAP about how to reposition a patient with acute pancreatitis tp relieve discomfort related to acute pancreatitis? 1. Place him in a high Fowler position. 2. Help him to lie in a side-lying "fetal" position. 3. Lay the bed flat and put the client's legs on a pillow. 4. Help him to sit on edge of bed and dangle his legs.

2. Help him to lie in a side-lying "fetal" position. For clients with pancreatitis, the fetal position or sitting up and holding the knees to the chest will open the retroperitoneal space, which helps to decrease discomfort. For this patient, having him lie down is preferable to having him sit because of his mental status and condition.

21. The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider? 1. Clopidogrel 75 mg/day 2. Ibuprofen 200 mg every 4 hours as needed 3. Metoprolol succinate 50 mg/day 4. Nitroglycerin patch 0.4 mg/hr

2. Ibuprofen 200 mg every 4 hours as needed Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for clients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the client but should be verified because the orders were received by telephone.

38. The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Client reports eating a green salad for lunch every day.

2. International normalized ratio (INR) is 1.2. An INR of 1.2 is not within the expected therapeutic range of 2 to 3 and indicates a need for an increase in warfarin dose. The blood pressure is in the low-normal range. Although the client will be encouraged to avoid injury, increased bruising is common when clients are taking anticoagulants and not a reason to discontinue the medication. Although foods that are high in vitamin K will have an impact on INR, this is not a concern when these foods are eaten consistently because the warfarin dose will be adjusted accordingly.

31. The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

2. Listening to lung sounds and checking for edema each week LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice.

A patient with a PEG tube needs 1200 kcal/day. The enteral feeding formula provides 1 kcal/mL. Yesterday's formula feedings were 100 mL at 7:00 am, 50 mL at 11:00 am, 200 mL at 3:00 pm, and 100 mL at 7:00 pm. What should the nurse do first? 1. Give additional feedings to catch up on nutritional needs. 2. Look at the original prescription to determine frequency and amount. 3. Look at weight trends to see if client is losing or maintaining weight. 4. Call the nurse who cared for the patient yesterday and asked what happened.

2. Look at the original prescription to determine frequency and amount First the nurse would look at the original prescription. If the prescribed amount seems insufficient, the nurse could contact the HCP and the nutritionist to have the feeding changed. If the prescribed orders were not followed, the charge nurse should be notified to follow up with all nurses who are caring for the patient to prevent reoccurrence. Looking at weight trends is part of the routine assessment for clients with feeding tubes and those at risk for nutritional problems. The patient only received 450 kcal yesterday, but trying to catch up by overfeeding may cause distention, vomiting, fluid overload, or electrolyte imbalances.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. Manual ventilation of the patient will allow the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.

A patient with acute pancreatitis demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse suspect? 1. Hypovolemic shock 2. Pleural effusion 3. Paralytic ileus 4. Acute respiratory distress syndrome

2. Pleural effusion A dry cough, left-sided chest pain when breathing deeply, shortness of breath, and low-grade fever are signs and symptoms of pleural effusion. Clients with acute pancreatitis can develop many complications: pancreatic infection that can lead to septic shock, hemorrhage secondary to necrotizing hemorrhagic pancreatitis, acute kidney failure, paralytic ileus, hypovolemic shock, pleural effusion, acute respiratory distress syndrome, atelectasis, pneumonia, multiorgan system failure, disseminated intravascular coagulation, and type 2 diabetes mellitus.

The nurse is preparing to admit a client with a seizure disorder. Which action can beassigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2. Setting up oxygen and suction equipment The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2. Taking vital signs and pulse oximetry readings every 4 hours The UAP's educational preparation includes measuring vital signs, and an experienced UAP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.

13. The nurse is caring for a client who has heart failure and has a new prescription forsacubitril-valsartan. Which client information is most important to discuss with the health care provider before administration of the medication? 1. The client's oxygen saturation is 92%. 2. The client receives lisinopril 10 mg/day. 3. The client's blood pressure is 150/90 mm Hg. 4. The client's potassium is 3.3 mEq/L (3.3 mmol/L).

2. The client receives lisinopril 10 mg/day Because combination angiotensin receptor blocker-neprilysin blockers markedly increase the risk for angioedema in clients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril- valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension is increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril-valsartan.

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? 1. The client's condition is improving. 2. The client's condition is deteriorating. 3. The client will need intubation and mechanical ventilation. 4. The client's medication regime will need adjustments.

2. The client's condition is deteriorating The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 (2.3 x 109/L). 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2. The white blood cell count is 2300/mm3 (2.3 x 109/L). Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.

A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomography (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

2. Transport the client to the radiology department for a computed tomography (CT) scan The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.

5. A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

2. Troponin I level Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarction (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglobin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myoglobin is nonspecific. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction.

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? Select all that apply. 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs.

2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. Mouthwash should not include alcohol because it has a drying action that leaves the mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.

The new RN asks the team leader if it is okay to give a patient with a bowel obstruction a dose of lactulose using the HCP's standing orders. The patient says, "She feels constipated and takes lactulose on a regular basis at home." What is team leader's best response? 1. "Call the HCP to see if the standing orders apply to the patient" 2. "Give the lactulose according to the standing orders." 3. "Laxatives can cause perforation if there is a bowel obstruction." 4. "The client can't be constipated because she is NPO."

3. "Laxatives can cause perforation if there is a bowel obstruction." Laxatives should not be used for clients with bowel obstructions or fecal impactions because increased peristaltic action can cause rupture and perforation. Assessment for return of bowel function (e.g., passing flatus, hearing bowel sounds) should be performed, and evidence of function should be pointed out to the client. The client should be told that being nothing by mouth will decrease fecal mass and that eventual return of function and normalization of bowel pattern are the therapeutic goals.

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose 2. A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due f the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

3. A 72-year-old patient who needs teaching about the use of incentive spirometry Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

14. A client whose systolic blood pressure is always higher than 140 mm Hg in the clinictells the nurse, "My blood pressure at home is always fine!" What action should the nurse take next? 1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems. 2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day. 3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. 4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week. The American Heart Association recommends home blood pressure monitoring for clients with hypertension or hypertension risk factors because home blood pressure monitoring provides more accurate data about usual blood pressure than periodic monitoring. The other actions may be necessary, but further assessment of the client's usual blood pressure is needed before decisions about therapy can be made.

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3. Checking the client's vital signs Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury.

9. The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client complains about a frequent dry cough. 4. Client says, "I get dizzy sometimes if I stand up fast."

3. Client complains about a frequent dry cough. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy.

23. A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is most important for the nurse to discuss with the health care provider? 1. Heart rate is 52 beats/min. 2. Client is also taking carvedilol for angina. 3. Client reports having chronic constipation. 4. Blood pressure is 106/56 mm Hg.

3. Client reports having chronic constipation. Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the client plan of care.

27. The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of myocardial infarction

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? 1. Perform a complete neurologic assessment. 2. Assess the cranial nerve functions. 3. Contact the Rapid Response Team. 4. Reassess the client in 30 minutes.

3. Contact the Rapid Response Team. A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes.

41. The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.

17. An 80-year-old client on the coronary step-down unit tells the nurse "I do not need to take that docusate. I never get constipated!" Which action by the nurse is most appropriate? 1. Document the medication on the client's chart as "refused." 2. Mix the medication with food and administer it to the client. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

3. Explain that his decreased activity level may cause constipation. The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as "refused" or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it unless someone else has health care power of attorney and has authorized use of the medication.

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

3. Maintain the head of bed at a 30- to 45-degree angle. Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3. Marks the tube 1 cm from where it touches the incisor tooth or nares The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

35. A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the health care provider about the change in status. 4. Reassure the client that embolization is common in endocarditis.

3. Notify the health care provider about the change in status. The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the health care provider should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain

20. The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood glucose level 3. Potassium level 4. Alkaline phosphatase level

3. Potassium level Hyperkalemia is a common adverse effect of both angiotensin-converting enzyme inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

3. Removing the inner cannula and cleaning using standard precautions When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3. Reporting the amount and type of food consumed from the tray The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue and skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the health care provider.

Which reporting tasks are appropriate to delegate to the UAP? Select all that apply. 1. Reporting on the condition of a patient with ulcerative colitis's perineal area after application of ointment 2. Reporting the quality and color of NG drainage 3. Reporting whether a blood pressure is below 100/60 mm Hg 4. Reporting if any of the clients indicate pain 5. Reporting if a patient is seen leaving the unit to smoke a cigarette 6. Reporting that a patient's family has questions

3. Reporting whether a blood pressure is below 100/60 mm Hg 4. Reporting if any of the clients indicate pain 5. Reporting if a patient is seen leaving the unit to smoke a cigarette 6. Reporting that a patient's family has questions The UAP can report on changes in vital sign values; giving parameters for notification is better than asking for general reports on any changes. The UAP can report that a client is having pain but is not expected to assess that pain. The UAP can report that the family has questions but should not be expected to answer questions about the client's care. All staff should be aware of when registered clients come and go on the unit and should keep each other advised. (Note: Clients should also be encouraged to tell someone if they are going off the unit.) Judging response to treatment and evaluating drainage are responsibilities of the RN.

29. Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

3. Sinus bradycardia at a rate of 48 beats/min Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available.

A patient with an NG tube and a bowel obstruction reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of watery bile-colored fluid. Which laboratory values should be checked first? 1. Blood urea nitrogen and creatinine levels 2. Platelet count and WBC count 3. Sodium level, potassium level, and pH of blood 4. Bilirubin level, hematocrit, and hemoglobin level

3. Sodium level, potassium level, and pH of blood With continuous NG suction, there is a loss of sodium and potassium. Also, the loss of acid via suctioning will result in an increase in blood pH or metabolic alkalosis. Full assessment of laboratory data is always important when a change in status is noted, but the other values are less relevant to this client's NG therapy.

. During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse 68 beats/min and irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

3. Vision that is becoming "fuzzy" The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure.

24. The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 154/78 mm Hg. 2. Pedal pulses are palpable at + 1. 3. Left groin has a 3-cm bruised area. 4. Apical pulse is 122 beats/min and regular.

4. Apical pulse is 122 beats/min and regular. The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern

36. A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

4. Assisting the client in cleaning around the Unna boot Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members.

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

6. When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 0 to 10)

4. Chest pain level of 3 (on a scale of 0 to 10) Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing

44. A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is most important for the nurse to communicate to the health care provider (HCP) before the procedure? 1. Blood glucose level is 144 mg/dL (8 mmol/L). 2. Cardiac monitor shows sinus bradycardia, rate 56 beats/min. 3. Client reports chest pain that occurred yesterday. 4. Client took metformin 500 mg this morning.

4. Client took metformin 500 mg this morning. Because use of metformin may lead to acute lactic acidosis when clients undergo procedures that use iodine-based contrast dye, metformin should be held for 24 hours before and 48 hours after coronary arteriogram. The arteriogram will need to be rescheduled. The other information will also be reported to the HCP but would not be unusual in clients with coronary artery disease.

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Crowing noise during inspiration Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger, and an oxygen saturation of 93% is low normal.

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider? 1. Serum potassium is 3.4 mEq/L (3.4 mmol/L). 2. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L). 3. Aspartate aminotransferase (AST) is 30 units/L (0.5 kat/L). 4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L). The client's low-density lipoprotein level continues to be elevated and indicates a need for further assessment (e.g., the client may not be taking the atorvastatin), a change in medication, or both. Although statin medications may cause rhabdomyolysis, which could increase BUN and potassium, the client's BUN and potassium are not elevated. Although ongoing monitoring of liver function is recommended when statins are used, this client's AST is normal.

8. Based on this information in a client's medical record, which topic is the highest priority for the nurse to include in the initial teaching plan for a 26-year-old client who has blood pressures ranging from 150/84 to 162/90 mm Hg? 1. Symptoms of acute stroke and myocardial infarction 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4. Low-sodium food choices when eating out Current guidelines recommend low sodium intake for lifestyle management of hypertension, and the nurse should teach the client about the high sodium content in many fast foods and how to make low-sodium choices. A 26-year-old with this level of hypertension is not likely to have a stroke or myocardial infarction. Weight loss or changes in alcohol intake are not necessary. The client's weight and BMI are normal. Alcohol intake of less than 1 or 2 glasses of wine daily is recommended to prevent hypertension.

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4. Monitor respiratory effort and oxygen saturation level. The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)

4. Oral temperature of 101.2°F (38.4°C) A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern.

18. The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

12. At 9:00 pm, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine for gastroesophageal reflux disease. 3. The client has ST-segment elevations on the electrocardiogram (ECG). 4. The client reports having continuous chest pain since 8:00 am.

4. The client reports having continuous chest pain since 8:00 am. Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are usually not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use.

An older patient needs treatment and relief for severe localized pain related to postherpetic neuralgia that developed during chemotherapy. The nurse is most likely to question the prescription of which type of medication? 1. Lidocaine patch 2. Gabapentinoid 3. Capsaicin patch 4. Tricyclic antidepressant

4. Tricyclic antidepressant Age, malignancy, immunocompromised conditions (e.g., human immunodeficiency virus), and immunosuppressive medications increase the risk for herpes zoster. Lidocaine patches, gabapentinoids (e.g., gabapentin), and tricyclic antidepressants (e.g., imipramine) are first-line choices for postherpetic neuralgia, which can be a long-term sequela to herpes zoster. However, the American Geriatrics Society recommends that tricyclics should be avoided for older adults because of side effects, such as confusion or orthostatic hypotension. Capsaicin patches are considered a secondline option. A lidocaine patch would be a good choice for this patient because it can be applied to the local area with limited systemic effects.

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)

4. Tympanic temperature of 101.4°F (38.6°C) Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not of as urgent concern.