Hurst 7

The nurse leader is planning to change the method of client documentation on the unit. Some employees accept the change without difficulty; however, some of the employees are resistant to change and try to sabotage the plans for change. Which action should the nurse leader take to reduce resistance to change on the unit? 1. Allow staff on the unit a voice in the plan for change. 2. Discourage discussion between supporters and resisters. 3. Set an implementation date and begin the new method. 4. Announce that the plan for change is set by administration.

1. Correct: Allowing everyone an opportunity to speak may reveal the reasons behind the resistance. If everyone has a voice, each person is more likely to buy into the new method. 2. Incorrect: Supporters and resisters should communicate. Perhaps the supporters can persuade the resisters. Encouraging discussion keeps communication lines open and is more likely to decrease resistance.3. Incorrect: Setting a date for implementation should come after discussion and training on the new process. A target date must be set; however, the groundwork for change must occur first. 4. Incorrect: Staff is more likely to accept change that affects them if they have a voice. Administration can take staff suggestions and possibly make a better plan.

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

1. Correct: In the US the first dose is recommended at birth. In Canada, the first dose is recommended between birth and two months. 2. Incorrect: In both the US and Canada, the first diphtheria vaccination is recommended at 2 months, and the second at 4 months. 3. Incorrect: In both the US and Canada, the first Hib vaccination is recommended at 2 months, the second at 4 months, and the third at 6 months. 4. Incorrect: In both the US and Canada, all healthy children ages 6 months and older should receive a yearly influenza vaccination.

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? 1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. 3. Able to say several single words. 4. Pulls toys while walking. 5. Builds a tower of 4 blocks.

1., & 2. Correct: A 1 year old should be able to get to a standing position without help. May stand alone. Can assist in getting dressed by putting out arm or leg. 3. Incorrect: Children at 18 months are able to say several single words. 4. Incorrect: Children at 18 months are able to pull toys while walking. 5. Incorrect: Children at 2 years of age can build a tower of 4 or more blocks.

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? 1. Diphtheria 2. Hib 3. Influenza 4. Measles 5. Mumps 6. Rubella

1., 2., & 3. In both the US and Canada, the third diphtheria vaccination is recommended at 6 months. The third Hib vaccine is also recommended in both countries at 6 months. Both countries also recommend that everyone 6 months of age and older get a flu vaccine each year. 4. Incorrect: The first measles vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 5. Incorrect: The first mumps vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 6. Incorrect: The first rubella vaccination is recommended at 12 months in Canada and between 12-18 months in the US.

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. 4. Incorrect: Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate.

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1., 2., 3., & 4. Correct: A 1/2-cup serving of fat-free frozen yogurt offers more than 100 milligrams of calcium. Pudding contains approximately 28% of the daily food allowance of calcium. An 8-oz. mug of homemade hot chocolate contains 285 mg of calcium. Cheddar cheese has 204 mg of calcium per serving. 5. Incorrect: 1 cup of watermelon supplies only 11 mg of calcium.

A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.

1., 3., & 4. Correct: Pertussis is a very contagious disease that spreads from person to person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. The nurse should place the child on droplet precautions in addition to standard precautions. For infants older than 1 month of age, macrolides drugs such as erythromycin are the drugs of choice. With droplet precautions you should use client dedicated or disposable equipment to prevent the spread of infection. If this is not possible, you must clean and disinfect shared/reusable equipment between use. This includes IV pumps, cell phones, pagers, other electronics, supplies, equipment. Clean prior to removing from the room. 2. Incorrect: A mist tent with high humidity may be used. The purpose is to improve a child's respiratory status by liquefying pulmonary secretions. 5. Incorrect: This child needs fluids, either by mouth or IV to keep from getting dehydrated, and to liquify secretions.

Which client would be appropriate for the RN to assign to the LPN? 1. Client scheduled for an MRI of the kidneys. 2. Client requiring administration of antineoplastic medications. 3. Client one day post open cholecystectomy with moderate amount serous drainage on dressing. 4. Client post ileal conduit surgery this AM without drainage in the drainage bag. 5. Client diagnosed with osteoarthritis reporting frequent joint stiffness.

1., 3., & 5. Correct: There is nothing in the option regarding the client going for an MRI of the kidneys that would indicate that this client is unstable. This client can be assigned to the LPN. The one day postop client with a moderate amount of serous drainage on the dressing is stable. Skills required to care for this client are within the LPN's scope of practice. The client diagnosed with osteoarthritis reporting frequent joint stiffness can be considered stable and can be cared for by the LPN. The knowledge and skills required to care for these three clients fall within the scope of practice for the LPN. 2. Incorrect: Administration of antineoplastic medications require the skills and knowledge of a qualified registered nurse. 4. Incorrect: An ileal conduit is a procedure that diverts urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL per hour. This client should be assessed and monitored by the RN to ensure that the stents placed in the ureters have not become dislodged or to ensure that edema of the ureters is not occurring.

What developmental milestones does the nurse expect to see in a 9 month old infant? 1. Looks for fallen object. 2. Follows 1-step verbal command without gestures. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something.

1., 3., 4., 5., & 6. Correct: When looking for the developmental milestones of a 9 month old, the nurse should expect to see the infant look for an object that has been dropped or that the infant sees someone hide. The infant can play simple games like peek-a-boo or itsy-bitsy spider. The word "no" should be understood by this age. Picking up things like cereal o's between the thumb and index finger is the pincer grasp that is achieved at this age. By nine months the infant should be able to pull self to a stand and stand while holding on to something. 2. Incorrect: The infant begins to follow simple directions like "pick up the toy" around the age of 1 year.

The nurse is talking with a new parent regarding activities that promote attachment between the parents and the newborn. What activities should the nurse include? 1. Feed baby on demand. 2. Put baby in bed to sleep with parents. 3. Allow baby to cry for at least 5 minutes. 4. Sing to the baby. 5. Stroke baby's face.

1., 4., & 5. Correct: There is a parenting philosophy called "Attachment Parenting." One of the behaviors that typify the parenting philosophy of attachment parenting is on-demand feeding rather than a routine schedule for feeding. A baby needs consistent warmth and responsiveness, especially in the first 12 months of life. Responding to cries and being sensitive to the baby's signals shows the baby can trust the parent to meet needs. Parental touch, calling the baby by name and talking to the baby in a soothing manner also promote attachment. 2. Incorrect: This is a safety issue. A parent could roll over on the baby causing injury or suffocation. The safest place for a newborn in a basinet or crib. 3. Incorrect: Responding to cries in a timely manner and being sensitive to the baby's signals shows the baby can trust the parent to meet needs.

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2 & 4. Correct: Children with AIDS are immunocompromised because of the HIV virus. Vaccines are crucial to provide protection against common childhood diseases. However, only vaccines which contain synthetic or inactivated viral components are acceptable for children with active AIDS. Diphtheria, tetanus, pertussis is inactive and is provided in multiple doses, starting at 2 months of age, with a booster at age 6. Haemophilus influenza is critically important since this flu virus can lead to meningitis, pneumonia or epiglottitis. This vaccine is also administered in multiple injections over a period of months, starting at 2 months, and then yearly throughout life. 1. Incorrect: The combination vaccine of measles, mumps, and rubella contains a live virus. Although research is ongoing, the Center for Disease Control (CDC) suggests while children diagnosed HIV+ may receive the vaccine, those with active AIDS should not be administered this vaccine. 3. Incorrect: Varicella is a live vaccine administered to protect children from chickenpox and the potential for shingles later in life. Though the disease and its dormancy in the body can have serious long-term effects, the vaccine is considered inappropriate for children with AIDS. 5. Incorrect: Oral polio vaccine contains the live polio virus and could be deadly to those with an immunocompromised system. The correct form of polio vaccine for AIDS clients is called IPV, or inactivated polio vaccine, and is given by injection.

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2, 4, 5 and 6. CORRECT: The Bratt diet is useful for children following any type of gastroenteritis which included nausea, diarrhea or severe vomiting. This bland diet is used in the first 24 hours to allow the gut to rest and readjust slowly to foods that are low protein, low fat and low fiber. The BRATT diet is for short term use only and consists of bananas, rice, apple sauce, toast and tea. 1. INCORRECT: Although raisins are normally a natural source of healthy fruit, they have too much fiber for an irritated gastric tract. They are not part of the BRAT diet. 3. INCORRECT: Apples are high in fiber and natural sucrose, which is not appropriate for a child with severe gastroenteritis. However, apple sauce is part of the BRAT diet and is an excellent source of nutrition without stressing a weakened gastrointestinal system.

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. This individual should be provided appropriate comments of appreciation for this accomplishment. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. It would not be appropriate to overload this new employee with extra work. 3. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. The nurse cannot allow the UAP to perform advanced tasks.

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

2. Correct: This is a correct statement. Therapeutic communication means providing information that will help clients make better choices.Not all parents have had their children immunized against pertussis, so this disease is being seen in clients again. DPaT should be given at 2, 4 and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old.1. Incorrect: This is not true. There is a vaccine. DPaT should be given at 2, 4, and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old. 3. Incorrect: Don't be confrontational. This puts the mother on the defensive. This is not therapeutic communication. Giving one's own opinion, evaluating, moralizing or implying one's values by using words such as "nice" "bad" "right" "wrong" "should" and "ought". "You shouldn't do that. It is wrong".​​ Everyone who does not get immunized gets the disease. 4. Incorrect: Do not change the subject. This does not address the mother's concern. Changing the subject, or introducing new topic inappropriately, can create anxiety. The nurse needs to address the mother's question of how the child contracted the disease.

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.

What developmental milestone does the nurse expect to see in a two month old baby? 1. Responds to own name. 2. Holds head up. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Turns head towards sound. 6. Reaches for toy with one hand.

2., & 5. Correct: When checking the developmental milestones of a 2 month old, the nurse should expect to see the baby hold up the head and turn the head toward a sound. 1. Incorrect: A baby can respond to their own name by 6 months, not 2 months. 3. Incorrect: A baby may be able to roll over from abdomen to back by 4 months. 4. Incorrect: At 2 months the baby is not able to push down on legs when feet are on a hard surface. The nurse should expect to see this by time the baby is 4 months old. 6. Incorrect: Reaching for a toy with one hand is seen when the baby is 4 months of age.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2., 3., 4. & 5. Correct: Preschoolers typically require 11 - 13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented.1. Incorrect: Preschoolers typically require 11-13 hours of sleep per day. Nine hours is not enough.

What measures should the school nurse implement for a child diagnosed with peanut allergies? 1. Keep a lidocaine auto-injector readily available. 2. Obtain assessment data about visual acuity, and health conditions that might affect food allergy management. 3. Maintain contact information for parents and primary healthcare provider. 4. Review history of known food allergens and the severity of previous reactions. 5. Train designated personnel to administer prescribed medication in an anaphylaxis emergency.

3, 4, & 5. CORRECT: Schools should maintain parent/legal guardian and primary healthcare provider contact information, including a prescribed emergency plan of care for all students with known food allergies. Food allergy information should be completed for every child identified with a food allergy and maintained in the student health record. A licensed health care professional such as a registered nurse, doctor, or allergist should train, evaluate, and supervise unlicensed assistive personnel or delegated non-health professionals. This training should teach staff how to recognize the signs and symptoms of a reaction, administer epinephrine, contact EMS, and understand state and local laws and regulations related to giving medication to students. 1. INCORRECT: Injectable lidocaine is a local anesthetic used for local or regional anesthesia. It is not a recommended or effective treatment for anaphylaxis. 2: INCORRECT. Allergic reactions can cause the eyes to become red, itchy, burning and watery, along with swollen eyelids. They pose no threat to eyesight, other than possible temporary blurriness.

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

3. Correct: The most critical assessment is to make sure that the client is going home to a safe environment. Then the other assessments could be made. Without a safe environment the client does not need to go home. Information about electrical wiring, back-up power, hygiene and infection control needs all provide a safe environment for this client. 1. Incorrect: This is not the most critical assessment and can be done after making certain the client will be safe. Remember Maslow's Hierarchy of Needs. After you determine needed resources (#4) then financial stability would be next. 2. Incorrect: Long term goals are very important but we are worried about short term needs right now. Remember in a priority question all options are plausible but only one is critical now. 4. Incorrect: Once the environment is considered safe for the needed or required care of the client, then the needed equipment would be next.

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. Correct: Clients' rights (still referred to in a hospital setting as the" Patient Bill of Rights") is a written code of ethical behavior describing the relationship that exists between the client and any facility to which they are admitted, including mental health units and hospice care. These guidelines provide the client a specified level of expectations regarding, for example, access to care, confidentiality and personal dignity. Regardless of the circumstances of the disease or location of treatment, clients have the right to refuse care from any professional personnel, including medical and nursing students. 1. Incorrect: Implied consent is an inferred agreement in which medical interventions are provided when the client cannot formally agree, as in the case of unconsciousness or incompetence. However, this client is clearly conscious and able to choose whether care by students is acceptable. The fact that the facility is a teaching hospital in no way deprives this client of the right to refuse student involvement. 2. Incorrect: The issue is the client's rights were violated when medical students were allowed involvement in this case without express consent or acknowledgement by the client. This response by the nurse ignores the client's rights or feelings by focusing on student abilities to provide care. It is demeaning to the client and does not address the client's concerns or provide alternatives. 3. Incorrect: Alerting the primary healthcare provider will be one component needed to resolve this situation. However, this initial response by the nurse is inappropriate for two reasons; first, this process transfers care of the client away from the nurse. Secondly, it does not provide the client with specific information about rights or resolutions.

The nurse is caring for a 5 year old client who is 12 hours post tonsillectomy. The client is pain free and has advanced to a soft diet. What is the priority nursing intervention? 1. Apply warm compresses to the throat. 2. Encourage gargling to reduce discomfort. 3. Position the child supine. 4. Monitor for frequent clearing of the throat.

4. Correct: Continuous swallowing and frequent clearing of the throat are signs of bleeding.1. Incorrect: This would increase blood flow, causing edema and bleeding, so this should not be done. 2. Incorrect: Gargling increases motion of throat and may cause bleeding. This is also something that could be a developmental challenge for a 5 year old. 3. Incorrect: The blood can drip down into the stomach and the client will wake up and vomit the old blood while lying flat. This puts the client at risk for aspiration so the nurse should place the client in a side lying position.

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler? 1. "It is important to give my child low fat milk after one year of age". 2. "If the child won't eat new foods after three tries, he is not going to eat it". 3. "I think that the sooner one starts to give vitamins to children, the better". 4. "I try to provide whole grains, fruits, vegetables, and meat daily".

4. Correct: Depending on their age, size, and activity level, toddlers need about 1,000-1,400 calories a day. A health promotion strategy to help meet the nutritional needs of the toddler includes offering a wide variety of healthy foods and from all food groups based on the "my plate" food guide. 1. Incorrect: Fat should not be limited in the child under two years of age. In general, kids ages 12 to 24 months old should drink whole milk to help provide the dietary fats they need for normal growth and brain development. 2. Incorrect: Learning to eat new foods is a process that requires many attempts. Keep offering the food. 3. Incorrect: If children eat a wide variety of foods, it is unlikely that vitamin supplementation will be needed.

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? 1. Rock to sleep. 2. Place in a baby swing. 3. Provide a pacifier. 4. Swaddle the baby.

4. Correct: Swaddling makes the baby feel more secure and decreases the baby's sense of falling. 1. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. Rocking the baby will not accomplish this. 2. Incorrect: This startling occurs when the baby has a sense of falling. Placing in a baby swing will not decrease this response. 3. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. A pacifier will not accomplish this.

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? 1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours.

4. Correct: The LPN/VN can administer subcutaneously medications. 1. Incorrect: This is an RN only responsibility and cannot be delegated. 2. Incorrect: The unlicensed assistive personnel (UAP) can be assigned to place equipment in a client's room. 3. Incorrect: Passive ROM exercises can be done by the UAP.

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children at 12 months? 1. Pertussis 2. Rotovirus 3. Tuberculosis 4. Varicella

4. Correct: The first varicella vaccine is recommended at 12 - 18 months in the US and 12-15 months in Canada. 1. Incorrect: The 4th dose of pertussis is given at 15 months in the US and 18 months in Canada. 2. Incorrect: Rotovirus is recommended in the US at 2, 4, and 6 months and at 2 and 4 months in some areas of Canada. 3. Incorrect: Bacille Calmette-Guérin (BCG) is a vaccine for tuberculosis (TB) disease. This vaccine is not widely used in the United States or Canada, but it is often given to infants and small children in other countries where TB is common.

Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on

4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified. 1. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 3. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. This is an appropriate and safe action for the unlicensed nursing assistant to do.

A nurse is caring for a pediatric client who has been diagnosed with hypothyroidism. What is essential for the nurse to teach the parents of this child? 1. Administer the liquid medication with soy milk. 2. Notify primary healthcare provider of slow heart rate. 3. Monitor glucose before meals and at bedtime. 4. Wait 4 hours after giving medication before giving iron supplements.

4. Correct: Wait for 4 hours before giving child iron supplements, antacids that contain calcium or aluminum hydroxide, or calcium supplements as it interferes with medication. 1. Incorrect: Give the medication with a liquid, except soy milk, which interferes with the ability to absorb the thyroid hormone. 2. Incorrect: Bradycardia is seen with hypothyroidism. When taking thyroid medication, we want to watch for signs of hyperthyroidism such as tachycardia, rapid weight loss, sweating, restlessness. 3. Incorrect: Hypothyroidism does not affect glucose.

In what order should the home health nurse see assigned clients? Place in priority order. Client diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. Client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Client diagnosed with rheumatoid arthritis who requires an occupational consult.

The first client the nurse needs to assess is the one diagnosed with multiple sclerosis who called the office to say life is not worth living anymore. The nurse needs to determine if this client has a plan to carry out the threat of suicide. This situation is life threatening. The second client that should be assessed by the nurse is the client diagnosed with systemic lupus erythematosus discharged home from the hospital this AM with a prescription for home healthcare. Consider this client a new admit who requires an assessment and plan of care to be developed. The third client that should be assessed by the nurse is the client diagnosed with acquired immune deficiency syndrome (AIDS) dementia, whose family is requesting hospice information. Assessing this client and educating family about hospice care can be done after the more critical issues with the other two clients are taken care of. There is no indication that this client is unstable, so the nurse can see this client third. Lastly, the nurse should assess the client diagnosed with rheumatoid arthritis who requires an occupational consult. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This consult can be done after caring for the clients who are less stable and require greater care.

The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority. Obtain the client's vitals. Report what happened to the health care provider. Alert the Unit Manager. Complete an incident report.

The first priority in such a situation is to check the client for any immediate problems secondary to receiving the incorrect medication and obtain a set of vitals. The client status is always your priority. Second, the nurse should notify the Health Care Provider of what happened, and implement any counter measures that may be ordered. Third, the Unit manager must be informed of this occurrence, allowing for a review of medication administration protocols and policies. This person is contacted after the client is stable. Take care of the client first. Fourth, the nurse will complete an incident report, per the facility's protocol, to assist in the identification and correction of any safety issues regarding the administration of medications.

The nurse is assigned to care for 4 adult clients. In what order should the nurse care for these clients? The client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L. The client reporting pain 7/10 after returning from debridement surgery 1 hours ago. The client with facial burns 3 days ago who has been crying since recent visitors left.

The nurse should first see is the client with partial thickness leg burns who has a temperature of 102°F (38.8°C) and a blood pressure of 88/46. This client has a fever and hypotension, indicative of life threatening complications of shock. In this case, septic shock. The client admitted with electrical burns 12 hours ago and has a serum potassium level of 5.2 mEq/L should be seen second. This client is at risk for heart problems (dysrhythmias) with the electrical burn and the elevated potassium level. The third client the nurse should see is the client reporting pain 7/10. The nurse needs to administer pain medication. However, remember that pain never killed anyone. Take care of the other two client first. This are at risk for death. The fourth client the nurse should see is the client who has been crying. Don't let facial burns throw you. This burn is 3 days old and swelling would be decreasing at this point. Physical problems take priority over psychological problems. This client is the most stable.