Management-Hurley- FE, MS, and Cardiac-Delegation Quiz 1

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.* •How to monitor and record daily weight •Importance of stopping exercise if heart rate increases •Symptoms of worsening heart failure •Purpose of chronic antibiotic therapy •How to read food labels for sodium content •Date and time for follow-up appointments

•How to monitor and record daily weight •Symptoms of worsening heart failure •How to read food labels for sodium content •Date and time for follow-up appointments •To avoid rehospitalization, 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 beta-blockers, 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.

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? •0.9% saline at 50 mL/hr IV •Furosemide 20 mg orally each morning •Apply cardiac telemetry monitoring •Hydrochlorothiazide (HCTZ) 25 mg orally each morning

•Hydrochlorothiazide (HCTZ) 25 mg orally each morning •Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? •Hypokalemia •Hyperkalemia •Hyponatremia •Hypernatremia

•Hyponatremia •SIADH results in a relative sodium deficit caused by excessive retention of water.

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? •Blood pressure every 15 minutes •Place two 18-gauge IV lines •Oxygen at 3 L via nasal cannula •IV 5% dextrose in water (D5W) to run at 250 mL/hr

•IV 5% dextrose in water (D5W) to run at 250 mL/hr •To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other interventions are appropriate for a client with shock.

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? •Clopidogrel 75 mg/day •Ibuprofen 200 mg every 4 hours as needed •Metoprolol succinate 50 mg/day •Nitroglycerin patch 0.4 mg/hr

•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.

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? •Increase in ventilator rate from 6 to 10 breaths/min •Decrease in ventilator rate from 10 to 6 breaths/min •Increase in oxygen concentration from 30% to 40% •Decrease in oxygen concentration from 40% to 30%

•Increase in ventilator rate from 6 to 10 breaths/min •The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? •Check to see that the client keeps his oxygen in place at all times •Inform the nurse immediately if the client's respiratory rate and depth increases •Record any episodes of reflux or constipation •Keep the client's ice water pitcher filled at all times

•Inform the nurse immediately if the client's respiratory rate and depth increases •If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's *priority* concern? •Ask the client about his or her bowel movements •Have the client complete a diet diary for the past 2 days •Instruct the client to increase oral intake to 2 to 3 L/day •Ask the client to describe his urine output

•Instruct the client to increase oral intake to 2 to 3 L/day •An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids.

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? •Blood pressure is 106/54 mm Hg •International normalized ratio (INR) is 1.2 •Bruises are noted at sites where blood has been drawn •Client reports eating a green salad for lunch every day

•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.

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? •Weighing all residents with heart failure each morning •Listening to lung sounds and checking for edema each week •Reviewing all heart failure medications with residents every month •Updating activity plans for residents with heart failure every quarter

•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.

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? •Serum potassium is 3.4 mEq/L (3.4 mmol/L) •Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L) •Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L) •Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L)

•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.

Based on this information in a client's medical record, (health history: denies any chronic health problems, takes no medications currently; physical exam: height - 5 feet and 6 inches, weight - 115 lb or 52.2 kg, BMI of 18.6; social and diet history: work as an accountant, 1 glass of wine once or twice weekly, eats "fast food" frequently) 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? •Symptoms of acute stroke and myocardial infarction •Adverse effects of alcohol on blood pressure •Methods for decreasing dietary caloric intake •Low-sodium food choices when eating out

•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.

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)? •Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated •Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing •Obtaining information about allergies from a client who is scheduled for left leg contrast venography •Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

•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.

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? •Respiratory alkalosis •Respiratory acidosis •Metabolic alkalosis •Metabolic acidosis

•Metabolic acidosis •Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen).

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*? •Lower the client's left foot below heart level •Administer oxygen at 4 L/min to the client •Notify the health care provider about the change in status •Reassure the client that embolization is common in endocarditis

•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.

A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would the nurse be sure to teach the patient? •Pain and numbness are expected to be experienced for several days to weeks •Immediately after surgery, the patient will no longer need assistance •After surgery, the dressing will be large, and there will be lots of drainage •The patient's pain and paresthesia will no longer be present

•Pain and numbness are expected to be experienced for several days to weeks •Postoperative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with an open procedure. Patients often need assistance postoperatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small, and there should not be a lot of drainage.

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? •Blood pressure decrease from 114/65 to 106/58 mm Hg •Respiratory rate drop from 18 to 12 breaths/min •Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min •Persisting chest pain at a level of 1 (on a scale of 0 to 10)

•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.

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked *immediately*? •Sodium •Potassium •Magnesium •Calcium

•Potassium •Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels.

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? •Sodium level •Blood glucose level •Potassium level •Alkaline phosphatase level

•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.

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)? •Sodium level •Potassium level •Chloride level •Calcium level

•Potassium level •Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly.

The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the unlicensed assistive personnel (UAP)? *Select all that apply.* •Providing oral care every 3 to 4 hours •Monitoring for indications of dehydration •Administering 0.45% saline by IV line •Record urine output when client voids •Assessing daily weights for trends •Help the client change position every 2 hours

•Providing oral care every 3 to 4 hours •Record urine output when client voids •Help the client change position every 2 hours •Providing oral care, assisting clients to reposition, and recording urine output are within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.

The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? •Administering IV fluids as prescribed by the physician •Providing straws and offering fluids between meals •Developing a plan for added fluid intake over 24 hours •Teaching family members to assist the client with fluid intake

•Providing straws and offering fluids between meals •UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN.

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*? •Put the client on "nothing by mouth" (NPO) status •Teach the client about the procedure •Insert an IV catheter in the client's forearm •Attach the client to a cardiac monitor

•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.

A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hour. Based on the heparin concentration on the label (40 usp/mL), the nurse will set the infusion pump to deliver __________ mL/hr.

• 17.5 mL/hr •Each mL of the solution contains heparin 40 units; 700 units/hour equals 17.5 mL/hr.

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? •"Do you think your family may want you to make some lifestyle changes?" •"Can you tell me why you don't feel that you need to make any changes?" •"You are still in the stage of denial, but you will want this information later on." •"Even though you don't want to change, it's important that you have this teaching."

•"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.

When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching? •"I take my ibuprofen every morning as soon as I get up." •"My daughter removed all of the throw rugs in my home." •"My husband helps me every afternoon with range-of-motion exercises." •"I rest in my reclining chair every day for at least an hour."

•"I take my ibuprofen every morning as soon as I get up." •Ibuprofen can cause abdominal discomfort or pain and ulceration of the gastrointestinal tract. In such cases, it should be taken with meals or milk. Removal of throw rugs helps prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis.

The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL [2.25 to 2.63 mmol/L]). Which statement by the client indicates the need for additional teaching? •"I will call my doctor if I experience muscle twitching or seizures." •"I will make sure to take my vitamin D with my calcium each day." •"I will take my calcium citrate pill every morning before breakfast." •"I will avoid dairy products, broccoli, and spinach when I eat."

•"I will avoid dairy products, broccoli, and spinach when I eat." •Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium. The other three options indicate correct understanding of calcium therapy.

Which statement by a client with hypovolemia related to dehydration is the *best* indicator to the nurse of the need for additional teaching? •"I will drink 2 to 3 L of fluids every day." •"I will drink a glass of water whenever I feel thirsty." •"I will drink coffee and cola drinks throughout the day." •"I will avoid drinks containing alcohol."

•"I will drink coffee and cola drinks throughout the day." •Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all adults to drink more fluids, especially water. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol. These beverages should not be used to prevent or treat dehydration.

During morning care, a patient with a below-the-knee amputation asks the unlicensed assistive personnel (UAP) about prostheses. How will the nurse instruct the UAP to respond? •"You should get a prosthesis so that you can walk again." •"Wait and ask your doctor that question the next time he comes in." •"It's too soon to be worrying about getting a prosthesis." •"I'll ask the nurse to come in and discuss this with you."

•"I'll ask the nurse to come in and discuss this with you." •The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly, the health care provider can also discuss prostheses with the patient, but the patient's wish to learn should receive a quick response. The nurse can then notify the health care provider about the patient's request.

A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain. What is the nurse's *best* response? •"Phantom limb pain is not explained or predicted by any one theory." •"Phantom limb pain occurs because your body thinks your leg is still present." •"Phantom limb pain will not interfere with your activities of daily living." •"Phantom limb pain is not real pain but is remembered pain."

•"Phantom limb pain is not explained or predicted by any one theory." •Three theories are being researched with regard to phantom limb pain. The peripheral nervous system theory holds that sensations remain as a result of the severing of peripheral nerves during the amputation. The central nervous system theory states that phantom limb pain results from a loss of inhibitory signals that were generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain phantom limb pain because stress, anxiety, and depression often trigger or worsen a pain episode.

The client has an order for hydrochlorothiazide (HCTZ) 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? *Select all that apply.* •"Take this medication in the morning." •"This medication should be taken in two divided doses when you get up and when you go to bed." •"Eat foods with extra sodium every day." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement."

•"Take this medication in the morning." •"Inform your prescriber if you notice weight gain or increased swelling." •"You should expect your urine output to increase." •"Your health care provider may also prescribe a potassium supplement." •HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so the nurse should teach the client about eating foods rich in potassium and that the health care provider may prescribe a potassium supplement. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the prescriber.

The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's *best* response? •"It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." •"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •"Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." •"The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

•"The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." •Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate.

The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's *best* response? •"The client's low phosphorus is probably due to malnutrition." •"The client is just worn out from not getting enough rest." •"The client's skeletal muscles are weak because of the low phosphorus." •"The client will do more for himself when his phosphorus level is normal."

•"The client's skeletal muscles are weak because of the low phosphorus." •A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question.

The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? •"When the Paco2 is acutely elevated, the blood pH should be lower than normal." •"This client should be taught to breathe and rebreathe in a paper bag." •"An elevated Paco2 always means that a client has an acidosis." •"When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

•"When the Paco2 is acutely elevated, the blood pH should be lower than normal." •This client's Paco2 is elevated (normal is 35 to 45 mm Hg). Whenever the Paco2 level changes acutely, the pH changes to the same degree, in the opposite direction. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to increase the rate and depth of breathing (hyperventilation). For these reasons, answers 2, 3, and 4 are inaccurate.

Which actions should the nurse delegate to an unlicensed assistive personnel (UAP) for the client with diabetic ketoacidosis? *Select all that apply.* •Checking fingerstick glucose results every hour •Recording intake and output every hour •Measuring vital signs every 15 minutes •Assessing for indicators of fluid imbalance •Notifying the provider of changes in glucose level •Assisting the client to reposition every 2 hours

•Recording intake and output every hour •Measuring vital signs every 15 minutes •Assisting the client to reposition every 2 hours •The UAP's training and education includes how to measure vital signs, record intake and output, and reposition clients. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP.

While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors (health history: hypertension for 10 years, takes hydrochlorothiazide 25 mg daily, blood pressure range 110/60 to 132/72 mmHg; family history: client's mother and 2 siblings have had myocardial infarctions; social history: 20 pack-year history of cigarette use, walks 2 to 3 miles daily). Which interventions will be important to include in the discharge plan for this client? *Select all that apply.* •Referral to community programs that assist in smoking cessation •Teaching about the impact of family history on cardiovascular risk •Education about the need for a change in antihypertensive therapy •Assistance in reducing emotional stress •Discussion of the risks associated with having a sedentary lifestyle

•Referral to community programs that assist in smoking cessation •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.

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? *Select all that apply.* •Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Assess skin turgor by pinching the skin over the back of the hand •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •Seeking a dietary consult to increase fluids on meal trays

•Reminding the client to avoid commercial mouthwashes •Encouraging mouth rinsing with warm saline •Observing the lips, tongue, and mucous membranes •Providing mouth care every 2 hours while the client is awake •The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider.

A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report? •Repeated episodes of nausea and vomiting •Reports of pain associated with exertion •Failure to eat all the food on the breakfast tray •Client hair loss during the morning bath

•Repeated episodes of nausea and vomiting •Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.

The nurse observes the unlicensed assistive personnel (UAP) performing all of these interventions for a patient with carpal tunnel syndrome (CTS). Which action requires that the nurse intervene *immediately*? •Arranging the patient's lunch tray and cutting his meat •Providing warm water and assisting the patient with his bath •Replacing the patient's splint in hyperextension position •Reminding the patient not to lift very heavy objects

•Replacing the patient's splint in hyperextension position •When a patient with CTS has a splint to immobilize the wrist, the wrist is placed either in the neutral position or in slight extension, not hyperextension. The other interventions are correct and are within the scope of practice of a UAP. UAPs may remind patients about elements of their care plans such as avoiding heavy lifting.

The unlicensed assistive personnel (UAP) reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? •Respiratory acidosis •Respiratory alkalosis •Metabolic acidosis •Metabolic alkalosis

•Respiratory alkalosis •The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis. Eliminating carbon dioxide would lead to an alkalosis. Metabolic imbalances would be related to renal changes.

The nurse is caring for a patient who had a dual-energy x-ray absorptiometry (DEXA) scan and is now prescribed calcium with vitamin D twice a day. The patient asks the nurse the purpose of this drug. What is the nurse's *best* response? *Select all that apply.* •"When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." •"When your vitamin D level is high, your bones release calcium to keep your blood calcium level in the normal range." •"When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." •"When blood calcium is normal, long bones are formed increasing a person's height." •"The extra calcium and vitamin D will help protect your bones from damage such as fractures." •"You can also get extra vitamin D by increasing your intake of beef and pork sources."

•"When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." •"When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." •"The extra calcium and vitamin D will help protect your bones from damage such as fractures." •Vitamin D and its metabolites are produced in the body and transported in the blood to promote the absorption of calcium and phosphorus from the small intestine. A decrease in the body's vitamin D level can result in osteomalacia (softening of bone) in an adult. When serum calcium levels are lowered, parathyroid hormone (PTH, or parathormone) secretion increases and stimulates bone to promote osteoclastic activity and release calcium to the blood. PTH reduces the renal excretion of calcium and facilitates its absorption from the intestine. Sources of vitamin D include sunlight, fatty fish, and vitamin D-enriched foods.

A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding would the nurse instruct the student to report *immediately*? •Respiratory rate of 8 to 10 breaths/min •Decrease in pain level from 6 to 2 (on a scale of 1 to 10) •Request by the client that the room door be closed •Heart rate of 90 to 100 beats/min

•Respiratory rate of 8 to 10 breaths/min •A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention.

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? *Select all that apply.* •"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"When was your last bowel movement?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Over the past month have you had any dizziness or tinnitus?" •"Do you have episodes of drowsiness or decreased alertness?"

•"Which drugs to you take on a daily basis?" •"Do you have any problems with breathing?" •"Have you experienced any activity intolerance or fatigue in the past 24 hours?" •"Do you have episodes of drowsiness or decreased alertness?" •Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis.

After the nurse receives change-of-shift report, which patient should be assessed *first*? •A 42-year-old patient with carpal tunnel syndrome who reports pain •A 64-year-old patient with osteoporosis awaiting discharge •A 28-year-old patient with a fracture who reports that the cast is tight •A 56-year-old patient with a left leg amputation who reports phantom pain

•A 28-year-old patient with a fracture who reports that the cast is tight •The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. Although all of the other patients' concerns are important and the nurse will want to see them as soon as possible, none of their complaints is urgent, but the patient with the tight cast may have risk for injury to a limb.

An experienced LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? •Reassess the client's blood pressure and heart rate •Review the client's morning calcium level •Request a neurologic consult today •Check the client's pupillary reaction to light

•Review the client's morning calcium level •A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs.

The RN is reviewing the client's morning laboratory results. Which of these results is of *most* concern? •Serum potassium level of 5.2 mEq/L (5.2 mmol/L) •Serum sodium level of 134 mEq/L (134 mmol/L) •Serum calcium level of 10.6 mg/dL (2.65 mmol/L) •Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

•Serum magnesium level of 0.8 mEq/L (0.4 mmol/L) •Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

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? •A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today •A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV •A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care •A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

•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.

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*? •A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today •A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change •A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure •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)

•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.

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is *most* at risk for respiratory acidosis? •A 68-year-old client with chronic emphysema •A 58-year-old client who uses antacids every day •A 48-year-old client with an anxiety disorder •A 28-year-old client with salicylate intoxication

•A 68-year-old client with chronic emphysema •Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis.

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? •Reports of increased fatigue and activity intolerance •Weight increase of 0.5 kg over a 1-week period •Sinus bradycardia at a rate of 48 beats/min •Traces of edema noted over both ankles

•Sinus bradycardia at a rate of 48 beats/min •Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, a heart rate of 48 beats/min indicates a need to decrease the carvedilol dose.

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*? •Prepare to defibrillate the client •Offer to take over chest compressions •State: "Epinephrine 1 mg IV has been given." •Continue to monitor the client's responsiveness.

•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.

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? •A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis •A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent •A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip •A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

•A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent •The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

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? •Stools have been black in color •Bruising is present at the right groin •Home blood pressure today was 104/52 mm Hg •Home radial pulse rate has been 55 to 60 beats/min

•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.

The charge nurse is making assignments for the day shift. Which patient should be assigned to the nurse who was floated from the postanesthesia care unit (PACU) for the day? •A 35-year-old patient with osteomyelitis who needs teaching before hyperbaric oxygen therapy •A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility •A 68-year-old patient with osteoporosis given a new orthotic device whose knowledge of its use must be assessed •A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement

•A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement •The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system-related nursing care are needed to provide teaching and assessment and prepare a report to the long-term care facility.

The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes *priority* at this time? •Weigh the client every morning •Maintain accurate intake and output records •Restrict fluids to 1500 mL/day •Administer furosemide 40 mg IV push

•Administer furosemide 40 mg IV push •Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but are not urgent.

A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? •Administer sodium polystyrene sulfonate 15 g orally •Administer spironolactone 25 mg orally •Assess the electrocardiogram (ECG) strip for tall T waves •Administer potassium 10 mEq (10 mmol/L) orally

•Administer sodium polystyrene sulfonate 15 g orally •The client's potassium level is high (normal range is 3.5 to 5 mEq/L or 3.5 to 5 mmol/L). Sodium polystyrene sulfonate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. A KCl supplement can also raise the potassium level even higher. The beginning nursing student does not have the skill to assess ECG strips.

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*? •Insert an IV catheter •Auscultate heart sounds •Administer sublingual nitroglycerin •Draw blood for troponin I measurement

•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 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? •Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities •Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation •Teaching the client energy conservation techniques to decrease myocardial oxygen demand •Explaining the rationale for alternating rest periods with exercise to the client and family

•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.

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

•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.

The charge nurse observes an LPN/LVN assigned to provide all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? •Administering 600 mg of ibuprofen to the patient •Encouraging the patient to perform exercises recommended by a physical therapist •Applying ice and gentle massage to the patient's lower extremities •Reminding the patient to drink milk and eat cottage cheese

•Applying ice and gentle massage to the patient's lower extremities •Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by a physical therapist would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health.

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? •Arterial line indicates a blood pressure of 190/112 mm Hg •Cardiac monitor shows frequent premature atrial contractions •There is no response to verbal stimulation •Urine output is 40 mL of amber urine

•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 RN is mentoring a student nurse who is caring for a patient with carpal tunnel syndrome of the right hand with neurovascular check ordered every 2 hours. For which action by the student nurse must the RN intervene? •Student nurse checks the patient's radial pulse every 2 hours •Student nurse checks for sensation in the patient's right hand •Student nurse assesses color, temperature, and pain in right wrist and hand •Student nurse instructs the patient to avoid movement because of the pain

•Student nurse instructs the patient to avoid movement because of the pain •Performing complete neurovascular assessment (also called a "circ check") includes palpation of pulses in the extremities below the level of injury and assessment of sensation, movement, color, temperature, and pain in the injured part. If pulses are not palpable, use of a Doppler helps find pulses in the extremities. After surgery, the patient should be given pain medication and encouraged to move the fingers frequently. Some hand movements such as lifting heavy objects may be restricted for 4 to 6 weeks after surgery.

The nurse delegates the measurement of vital signs to an experienced unlicensed assistive personnel (UAP). Osteomyelitis has been diagnosed in a patient. Which vital sign value would the nurse instruct the UAP to report *immediately* for this patient? •Temperature of 101°F (38.3°C) •Blood pressure of 136/80 mm Hg •Heart rate of 96 beats/min •Respiratory rate of 24 breaths/min

•Temperature of 101°F (38.3°C) •An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital sign values are normal or high normal.

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

•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's assessment reveals all of these data when a patient with Paget disease is admitted to the acute care unit. Which finding should the nurse notify the health care provider about *first*? •There is a bowing of both legs, and the knees are asymmetrical •The base of the skull is invaginated (platybasia) •The patient is only 5 feet tall and weighs 120 lb •The skull is soft, thick, and larger than norma

•The base of the skull is invaginated (platybasia) •Platybasia (basilar skull invagination) causes brainstem manifestations that threaten life. Patients with Paget disease are usually short and often have bowing of the long bones that results in asymmetrical knees or elbow deformities. The skull is typically soft, thick, and enlarged.

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

•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.

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? •The client was treated with alteplase about 8 months ago •The client takes famotidine for gastroesophageal reflux disease •The client has ST-segment elevations on the electrocardiogram (ECG) •The client reports having continuous chest pain since 8:00 am

•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.

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take *next*? •Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems •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 •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 •Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects

•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.

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)? •Teaching family members the signs of infection •Monitoring capillary perfusion once every 8 hours •Evaluating foot sensation and movement each shift •Assisting the client in cleaning around the Unna boot

•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.

The nurse is caring for a patient with osteoporosis who is at increased risk for falls. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? •Identifying environmental factors that increase risk for falls •Monitoring gait, balance, and fatigue level with ambulation •Collaborating with the physical therapist to provide the patient with a walker •Assisting the patient with ambulation to the bathroom and in the halls

•Assisting the patient with ambulation to the bathroom and in the halls •Assisting with activities of daily living, including assisting with ambulation to the bathroom, is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses.

A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report *immediately*? •The patient reports pain •The patient appears confused •The patient's blood pressure is 136/88 mm Hg •The patient voided using the bedpan

•The patient appears confused •Fat embolism syndrome is a serious complication that often results from fractures of long bones. Its earliest manifestation is altered mental status caused by a low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and the patient's voiding; however, this information is not urgent to report.

During assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider *immediately*? •The patient reports pressure and pain •The cast is in place and is dry and intact •The skin is pink and warm to the touch •The patient can move all the fingers and the thumb

•The patient reports pressure and pain •Pressure and pain may be caused by increased compartment pressure and can indicate the serious complication of acute compartment syndrome. This situation is urgent. If it is not treated, cyanosis, tingling, numbness, paresis, and severe pain can occur. The other findings are normal and should be documented in the patient's chart.

The nurse is caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should be delegated to the unlicensed assistive personnel (UAP)? •Initiating placement of a splint for immobilization during the day •Assessing the patient's wrist and hand for discoloration and brittle nails •Assisting the patient with daily self-care measures such as bathing and eating •Testing the patient for painful tingling in the four digits of the hand

•Assisting the patient with daily self-care measures such as bathing and eating •Helping with activities of daily living (e.g. bathing, feeding) is within the scope of practice of UAPs. Placing a splint for the first time is appropriate to the scope of practice of physical therapists. Assessing and testing for paresthesia are not within the scope of practice of UAPs and is appropriate for professional nurses.

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report *immediately*? •The patient wants to change position in bed •There is a small amount of clear fluid at the pin sites •The traction weights are resting on the floor •The patient reports pain and muscle spasm

•The traction weights are resting on the floor •When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient's pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction.

The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the *major* focus for the patient's care today? •To attain pain control over phantom pain •To monitor for signs of sufficient tissue perfusion •To assist the patient to ambulate as soon as possible •To elevate the residual limb when the patient is supine

•To monitor for signs of sufficient tissue perfusion •Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial because it may promote knee flexion contracture.

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? •Creatine kinase MB level •Troponin I level •Myoglobin level •C-reactive protein level

•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.

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.* •Attaching cardiac monitor leads •Giving heparin 5000 units IV push •Administering morphine sulfate 4 mg IV •Obtaining a 12-lead electrocardiogram (ECG) •Asking the client about pertinent medical history •Having the client chew and swallow aspirin 162 mg

•Attaching cardiac monitor leads •Obtaining a 12-lead electrocardiogram (ECG) •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.

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? •Serum potassium •B-type natriuretic peptide •Blood urea nitrogen •Hematocrit

•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.

The nurse is caring for a postoperative patient with a hip replacement. Which patient care actions can be delegated to the experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Inspect heels and other bony prominences every 8 hours •Turn and reposition the patient every 2 hours •Assure that the patient's heels are elevated off the bed •Assess the patient's calf regions for redness and swelling •Check vital signs and oxygen saturation via pulse oximetry •Assess for pain and administer pain medication

•Turn and reposition the patient every 2 hours •Assure that the patient's heels are elevated off the bed •Check vital signs and oxygen saturation via pulse oximetry •The UAP's scope of practice includes repositioning patients and checking vital signs, and an experienced UAP would know how to check pulse oximetry and elevate the patient's heels off the bed. Assessing and inspecting patients is more appropriate to the educational level of the professional nurse.

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? •Apical pulse 68 beats/min and irregular •Digoxin taken with meals •Vision that is becoming "fuzzy" •Lung crackles that clear after coughing

•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.

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? •Famotidine 20 mg IV •Furosemide 40 mg IV •Digoxin 0.25 mg PO •Warfarin 2.5 mg PO

•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, double-checking is not needed.

The nurse is preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points should the nurse be sure to include? *Select all that apply.* •Wear a hip protector when ambulating •Remove throw rugs and other obstacles at home •Exercise to help build your strength •Expect a few bumps and bruises when you go home •Rest when you are tired •Avoid consuming three or more alcoholic drinks per day

•Wear a hip protector when ambulating •Remove throw rugs and other obstacles at home •Exercise to help build your strength •Rest when you are tired •The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk of falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles and improve coordination. Women should not consume more than one drink per day, and men should not consume more than two drinks per day.

The nurse is preparing a discussion of musculoskeletal health maintenance for a group of older adults. Which key points would the nurse be sure to include? *Select all that apply.* •Be aware of and consume foods rich in calcium and vitamin D •Wear hats and long sleeves to avoid sun exposure at all times •Consider exercise with low impact to avoid risk for injury •If you smoke, consider a smoking cessation program •Excessive alcohol intake can interfere with vitamins and nutrients for bone growth •Weight-bearing activities decrease the risk for osteoporosis

•Be aware of and consume foods rich in calcium and vitamin D •Consider exercise with low impact to avoid risk for injury •If you smoke, consider a smoking cessation program •Excessive alcohol intake can interfere with vitamins and nutrients for bone growth •Weight-bearing activities decrease the risk for osteoporosis •Many health problems of the musculoskeletal system can be prevented through health promotion strategies and avoidance of risky lifestyle behaviors. Weight-bearing activities such as walking can reduce risk factors for osteoporosis and maintain muscle strength. Young men are at the greatest risk for trauma related to motor vehicle crashes. Older adults are at the greatest risk for falls that result in fractures and soft tissue injury. High-impact sports, such as excessive jogging or running, can cause musculoskeletal injury to soft tissues and bone. Tobacco use slows the healing of musculoskeletal injuries. Excessive alcohol intake can decrease vitamins and nutrients the person needs for bone and muscle tissue growth.

The RN is receiving a patient with peripheral vascular disease from the postanesthesia care unit (PACU) after a Syme amputation of the right lower extremity. At which level on the diagram would the RN expect to find the amputation? •A is pointing to the toes •B is pointing to the middle of the foot •C is pointing to the ankle •D is pointing to the shin

•C - the ankle •When a patient has a Syme amputation, most of the foot is removed but the ankle remains. Advantages of this surgery over below the knee include that the patient can still be weight bearing (with a prosthesis) and there is less pain.

The nurse is preparing a patient for magnetic resonance imaging (MRI). Which action can the nurse delegate to the experienced unlicensed assistive personnel (UAP)? •Teach the patient what to expect during the test •Instruct the patient to remove metal objects including zippers •Witness that the patient has signed the consent form •Check and record preprocedure vital signs

•Check and record preprocedure vital signs •The UAP's scope of practice includes checking and recording patient vital signs. Teaching and instructing, as well as witnessing consent forms, is appropriate to the professional RN's scope of practice. The UAP could remind the patient about removal of metal objects after the patient receives instructions.

The charge nurse assigns the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would the RN provide for the LPN/LVN? *Select all that apply.* •Check the patient's vital signs every 15 minutes in the first hour •Check the dressing for drainage and tightness •Elevate the patient's hand above the heart •The patient will no longer need pain medication •Check the neurovascular status of the fingers every hour •Instruct the patient to perform range of motion on the affected wrist

•Check the patient's vital signs every 15 minutes in the first hour •Check the dressing for drainage and tightness •Elevate the patient's hand above the heart •Check the neurovascular status of the fingers every hour •Postoperatively, patients undergoing open carpal tunnel release surgery experience pain and numbness, and their discomfort may last for weeks to months. Hand movements may be restricted for 4 to 6 weeks after surgery. All of the other directions are appropriate for the postoperative care of this patient. It is important to monitor for drainage, tightness, and neurovascular changes. Raising the hand and wrist above the heart reduces the swelling from surgery, and this is often done for several days.

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? •Blood pressure of 152/88 mm Hg •Heart rate of 134 beats/min •Oxygen saturation of 91% •Chest pain level of 3 (on a scale of 0 to 10)

•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.

The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? •History of myocardial infarction (MI) 1 year ago •Antacid use for occasional indigestion •Shortness of breath with extreme exertion •Chronic renal insufficiency

•Chronic renal insufficiency •Risk factors for acid-base imbalances in older adults include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. The MI occurred 1 year ago and is no longer a risk factor.

The nurse is working with unlicensed assistive personnel (UAP) to provide care for six patients. At the beginning of the shift, the nurse carefully tells the UAP what patient interventions and tasks he or she is expected to perform. Which "Four Cs" guide the nurse's communication with the UAP? *Select all that apply.* •Clear •Comprehensive •Concise •Credible •Correct •Complete

•Clear •Concise •Correct •Complete •Clear, concise, correct, complete are the "Four Cs" of communication. Implementing the four Cs of communication helps the nurse ensure that the UAP understands what is being said; that the UAP does not confuse the nurse's directions; that the directions comply with policies, procedures, job descriptions, and the law; and that the UAP has all the information necessary to complete the tasks assigned.

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? •Client reports frequent urination •Client's blood pressure is 138/86 mm Hg •Client complains about a frequent dry cough •Client says, "I get dizzy sometimes if I stand up fast."

•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.

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? •Client requiring discharge teaching about coronary artery stenting before going home today •Client receiving IV furosemide to treat acute left ventricular failure •Client who just transferred in from the radiology department after a coronary angioplasty •Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

•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.

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? •Heart rate is 52 beats/min •Client is also taking carvedilol for angina •Client reports having chronic constipation •Blood pressure is 106/56 mm Hg

•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.

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? •Blood glucose level is 144 mg/dL (8 mmol/L) •Cardiac monitor shows sinus bradycardia, rate 56 beats/min •Client reports chest pain that occurred yesterday •Client took metformin 500 mg this morning

•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.

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

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

•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 is providing care for a patient with a rotator cuff tear. What treatment does the nurse expect the health care provider will prescribe *first* for this patient? •Arthroscopic repair of the rotator cuff tear •Elimination of movements in the affected shoulder •Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy •Pendulum exercises that start slow and progress over 2 weeks

•Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy •For the patient with a torn rotator cuff, the health care provider usually treats the patient conservatively with NSAIDs, intermittent steroid injections, physical therapy, and activity limitations while the tear heals. Physical therapy treatments may include ultrasound, electrical stimulation, ice, and heat.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's *priority* action at this time? •Place an 18-gauge IV in the nondominant arm •Elevate the client's head of bed at least 45 degrees •Instruct the UAP to provide the client with a pitcher of ice water •Contact and notify the health care provider immediately

•Contact and notify the health care provider immediately •The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm (Ventricular Fibrillation). Which action will the nurse take *first*? •Defibrillate at 200 joules •Start cardiopulmonary resuscitation (CPR) •Administer epinephrine 1 mg IV •Intubate and manually ventilate

•Defibrillate at 200 joules •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.

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? •Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs •Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake •Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes •Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

•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.

The nurse is preparing a patient who had carpal tunnel release surgery for discharge. Which information is important to provide for this patient? •The surgical procedure is a cure for carpal tunnel syndrome (CTS) •Do not lift any heavy objects •Frequent doses of pain medication will no longer be necessary •The health care provider should be notified immediately if there is any pain or discomfort

•Do not lift any heavy objects •Hand movements, including heavy lifting, may be restricted for 4 to 6 weeks after surgery. Patients experience discomfort for weeks to months after surgery. The surgery is not always a cure; in some cases, CTS may recur months to years after surgery.

The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish the patient's bone strength and determine if osteoporosis is present? •Computed tomography (CT) scan •Magnetic resonance imaging (MRI) scan •Dual-energy x-ray absorptiometry (DXA or DEXA) scan •Joint x-rays

•Dual-energy x-ray absorptiometry (DXA or DEXA) scan •Testing bone density (how strong the bones are) is the only way to know for sure if a patient has osteoporosis. A diagnostic test commonly prescribed by health care providers is DXA or DEXA. This type of scan focuses on two main areas, the hip and the spine. However, the forearm can be tested if the hip or spine cannot be tested. The other tests may be prescribed but are not as commonly used to test bone strength.

The nurse is supervising a new graduate RN caring for a patient with a fracture of the right ankle who is at risk for complications of immobility. For which action should the supervising nurse intervene? •Encouraging the patient to go from a lying to a standing position •Administering pain medication before the patient begins exercises •Explaining to the patient and family the purpose of the exercise program •Reminding the patient about the correct use of crutches

•Encouraging the patient to go from a lying to a standing position •Moving directly from a lying to a standing position does not allow the patient to establish balance. The supervising nurse should instruct the new graduate RN about moving the patient from a lying position first, then to a sitting position, and finally to a standing position, which will allow the patient to establish balance before standing. Administering pain medication before the patient begins exercising decreases pain with exercise. Explanations about the purpose of the exercise program and proper use of crutches are appropriate interventions with this patient.

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? •Document the medication on the client's chart as "refused." •Mix the medication with food and administer it to the client •Explain that his decreased activity level may cause constipation •Reinforce that the docusate has been prescribed for a good reason

•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 client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? •Flattened neck veins when the client is in the supine position •Full and bounding pedal and post-tibial pulses •Pitting edema located in the feet, ankles, and calves •Shallow respirations with crackles on auscultation

•Flattened neck veins when the client is in the supine position •Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume.

A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would the nurse clarify with the health care provider? •Give fluoxetine 40 mg once a day •Administer acetaminophen with codeine 1 or 2 tablets every 4 hours as needed •Assist the patient to the bedside chair every shift •Reinforce the dressing to the right residual limb as needed

•Give fluoxetine 40 mg once a day •Doses of fluoxetine, a drug used to treat depression, that are greater than 20 mg should be given in two divided doses, not once a day. The other three orders are appropriate for a patient who underwent amputation 4 days earlier.

The emergency department (ED) nurse should question which health care provider order when providing care for an older adult with a fracture of the left ulna? •Get x-rays of left forearm •Give meperidine IM for pain •Monitor vital signs every hour •Elevate left arm on pillows

•Give meperidine IM for pain •Meperidine should not be used because of its toxic metabolites that can cause seizures and other adverse drug events, especially in the older adult population. X-rays are used to confirm the diagnosis. Vital signs and elevation are common actions for a patient in the ED, and elevation can decrease the swelling in the affected extremity.

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? •Call the client's healthcare provider •Have the client sit down •Check the client's blood pressure •Administer as needed (PRN) oxygen by nasal cannula

•Have the client sit down •Administer as needed (PRN) oxygen by nasal cannula •Check the client's blood pressure •Call the client's healthcare provider •Because the increased heart rate may be associated with a drop in blood pressure and with lightheadedness, the nurse's first action should be to decrease risk for a fall by having the client sit down. Cardiac ischemia may be causing the client's tachycardia, and administration of supplemental oxygen should be the next action. Assessment of blood pressure should be done next. Finally, the health care provider should be notified about the client's response to activity because changes in therapy may be indicated.

The emergency department nurse receives a call about a patient with a traumatic finger amputation. What instructions does the nurse provide to the patient's wife? *Select all that apply.* •Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth •Put the finger in a watertight, sealed plastic bag •Place the bag directly on ice •Elevate the affected extremity above the patient's heart •Examine the amputation site and apply direct pressure with layers of dry gauze •After performing these steps, call 911 and check the patient for breathing

•Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth •Put the finger in a watertight, sealed plastic bag •Elevate the affected extremity above the patient's heart •Examine the amputation site and apply direct pressure with layers of dry gauze •For a person who has a traumatic amputation in the community, first call 911 and then assess the patient for airway or breathing problems. Examine the amputation site, and apply direct pressure with layers of dry gauze or cloth. Elevate the extremity above the patient's heart to decrease the bleeding. Do not remove the dressing to prevent dislodging the clot. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. Put the finger in a watertight, sealed plastic bag. Place the bag in ice water, never directly on ice, with 1 part ice and 3 parts water. Avoid contact between the finger and the water to prevent tissue damage. Do not remove any semidetached parts of the digit. Be sure that the part goes with the patient to the hospital.