Case Study 3: Multiple Clients on a Medical-Surgical Unit

The LPN/LVN reports to the RN that Mr. R was unable to take his oral medications because of difficulty swallowing. The RN assesses Mr. R and finds that he is having dysphagia. What is the RN's best instruction for the LPN/LVN? A. "Keep Mr. R NPO, and I will contact his health care provider" B. "Try giving his medications with applesauce or pudding" C. "Check with the pharmacist to find out if they have liquid forms of Mr. R's medications" D. "Assess Mr. R's ability to speak and move his tongue"

A

The UAP is delegated the task of measuring morning vital signs for all six clients. Which finding would the nurse instruct the UAP to report immediately? A. Oral temperature higher than 102°F (38.9°C) B. Blood pressure higher than 140/80 mm Hg C. Heart rate lower than 65 beats/min D. Respiratory rate lower than 18 breaths/mini care provider

A

The oral temperature of Mr. B, the client newly admitted from a long-term care facility with decreased urine output and altered level of consciousness, is now102.6°F (39.2°C). What is the nurse's best action? A. Notify the HCP B. Administer acetaminophen 2 tablets orally C. Ask the LPN/LVN to give an acetaminophen suppository D. Remove extra blankets from the client's bed

A

Which factor does the nurse suspect most likely precipitated Mr. B's elevated temperature? A. Bladder infection B. Increased metabolic rate C. Kidney failure D. Nosocomial pneumonia

A

The RN is assessing Ms. J's chest pain. Which questions would the RN be sure to ask the client? Select all that apply. A. "When did you first notice the chest pain?" B. "Did your pain start suddenly or gradually?" C. "How long has the chest pain lasted?" D. "Have you experienced confusion or loss of memory with the pain?" E. "Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain ever?" F. "What were you doing when the chest pain started?".

A, B, C, E, F

Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which postpone tasks would be best assigned to the LPN? Select all that apply A. Check bilateral pedal pulses every 15 minutes during the first hour B. Check right groin area for bleeding every 15 minutes during first hour C. ContinueIV fluids normal saline at 50 mL/hour D. Assist client to bathroom as needed during first 6 hours after procedure E. Administer morphine sulfate 2 mg IV push as needed for pain F. Give client's daily multivitamin and stool softener on return to medical unit

A, B, C, F

Which clients should the team leader assign to theLPN/LVN for nursing care, under the RN's supervision? Select all that apply. A. Mr. C B. Ms. J C. Mr. R D. Ms. S E. Mr. B F. Mr. L

A, C, D, F

Near the end of the shift, the LPN/LVN reports that the UAP has not totaled clients' intake and output for the past 8 hours. What is the nurse's best action? A. Confront the UAP and instruct him to complete this assignment at once B. Assign this task to the LPN/LVN C. Ask the UAP if he needs assistance completing the intake and output records D. Notify the nurse manager to include this on the UAP's evaluation."

C

The UAP asks the RN why it is important to notify someone whenever a client with heart problems reports chest pain. What is the RN's best response? A. It's important to keep track of the chest pain episodes so we can notify the health care provider B. The client may need morphine to treat the chest pain C. Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment D. Our unit policy includes specific steps to take in the treatment of clients with chest pain

C

The UAP reports to the RN that Mr. L, the client with chronic emphysema, says he is feeling short of breath after walking to the bathroom. What action should the RN take first? A. Notify the HCP B. Increase oxygen flow to 6 L/min via nasal cannula C. Assess oxygen saturation by pulse oximetry D. Remind the client to cough and deep-breathe

C

The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT). What is the nurse's best action? A. Instruct the UAP to put the client in a wheelchair and take her to the lab B. Call the cardiac lab and ask to delay the test until later in the day C. Contact the HCP to ask if the client should still have the GXT D. Ask the client if she is continuing to have chest pain

C

The health care provider's (HCP's) prescribed actions for Ms. J, who is currently experiencing chest pain, areas follows. Which intervention should be completed first? A. Administer nitroglycerin 0.6 mg sublingually as needed for chest pain. B. Administer morphine 2 mg IV push as needed for chest pain. C. Check blood pressure and heart rate. D. Lab tests to include cardiac markers and daily electrocardiogram."

C

Which key point would the nurse be sure to include when teaching Mr. C about the post procedure care for cardiac catheterization? A. "There are no restrictions after the procedure." B. "You will be able to get out of bed within 2 hours after the procedure" C. "You will have to stay almost flat in bed with limited position changes for 4 to 6 hours" D. "Family visitors will be restricted until the next day"

C

Which tasks should the nurse delegate to the newly hired UAP? Select all that apply. A. Asking Ms. S memory-testing questions B. Teaching Ms. J about treadmill exercise testing C. Checking vital signs on all six clients D. Recording oral intake and urine output for Mr. B E. Assisting Mr. L to walk to the bathroom F. Helping Mr. R with morning care.

C, D, E, F

The LPN/LVN reports to the RN that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if the client can be restrained. What is theRN's best response? A. "Yes, this client had a heart attack, and we must keep her on the cardiac monitor" B. "Yes, but be sure to use soft restraints so that the client's circulation is not compromised." C. "No, we must have a health care provider's order before we can apply restraints in any situation." D. "No, but try covering the lead wires with the sheet so that the client does not see them

D

The RN is the leader of a team providing care for six clients. The team includes the RN, an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP) who is in his fourth week of orientation to the acute care unit. The clients are as follows:

Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is scheduled for a graded exercise test later today Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago Ms. S, an 83-year-old woman with heart disease, a his-tory of myocardial infarction, and mild dementia Mr. B, a 93-year-old newly admitted man from a long-term care facility, with decreased urine output, altered level of consciousness, and an elevated temperature of 99.5°F (37.5°C). Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema.

During shift change report, the night RN informs the team that Ms. S is to be transferred back to her long-term care facility after lunch. What action should be taken for this client? A. Instruct the UAP to awaken her for vital signs B. Allow her to sleep for an hour or two while the other clients are assessed C. Assign the LPN to immediately pack up the client's belongings D. Call the nursing home to find out if the transfer can wait until tomorrow

B

The HCP's prescribed interventions for Mr. R, who had a stroke 4 days ago, include assisting the client with meals. Which staff member would be best to assign this task? A. Physical therapist B. UAP C. LPN/LVN D. Occupational therapist

B

The RN is working on a care plan for Mr. B. Which care intervention is most appropriate to delegate to the UAP? A. Checking the client's level of consciousness every shift B. Assisting the client with ambulation to the bath-room to urinate C. Teaching the client the side effects of antibiotic therapy D. Administering sulfamethoxazole-trimethoprim orally every 12 hours

B

The UAP reports that Mr. L's heart rate, which was 86 beats/min in the morning, is now 98 beats/min.What would be the most appropriate question for the nurse to ask Mr. L? A. "Have you just returned from the bathroom?" B. "Did you recently use your albuterol inhaler?" C. "Are you feeling short of breath?" D. "How much do you smoke?"

B

Which client should the RN assess first?. A. Mr. C B. Ms. J C. Mr. B D. Mr. L

B