Management quiz 3

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

1. A 38 year old patient with moderate persistent asthma awaiting discharge 2. A 63 year old patient with a tracheostomy needing tracheostomy care every shift 6. A 69 year old patient with emphysema to be discharged tomorrow

Because of Mr. K's (PEG tube) advanced age, which complications of enteral feedings may occur? Select all that apply 1. Hyperglycemia 2. Hypotension 3. Aspiration 4. Diarrhea 5. Fluid overload 6. Weight loss

1. Hyperglycemia 3. Aspiration 4. Diarrhea 5. Fluid overload

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

1. The patient was recently in a motor vehicle crash

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

1. The student nurse uses a sterile catheter and glove 3. The student nurse applies suction during catheter removal 4. The student nurse uses a twirling motion when withdrawing the catheter 5. The student nurse uses a no. 12 French catheter

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

1. Two tablets of senna were given yesterday morning

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

1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day 3. Use a soft-bristled toothbrush or tooth sponge for oral care 5. Be sure the patient's footwear has a firm sole when the patient ambulates

The nurse is supervising an RN who floated form the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis. Which directions would the supervising nurse clearly provide to the RN? Select all that apply 1. Position the patient supine and turned on his side 2. Apply direct lateral pressure to the nose for 5 minutes 3. Maintain standard body substance precautions 4. Apply ice or cool compresses to the nose 5. Instruct the patient not to blow the nose for several hours 6. Teach the patient to avoid vigorous nose blowing

2. Apply direct lateral pressure to the nose for 5 minutes 3. Maintain standard body substance precautions 4. Apply ice or cool compresses to the nose 5. Instruct the patient not to blow the nose for several hours 6. Teach the patient to avoid vigorous nose blowing

About 20 minutes after Ms. A is positioned on her right side, her ICP has increased to 30. Which action should the nurse take next? 1. Administer the PRN mannitol 100 mg IV 2. Assess the alignment of Ms. A's head and neck 3. Elevate the HOB to 45 degrees 4. Check Ms. A's pupil size and response to light

2. Assess the alignment of Ms. A's head and neck

The UAP asks, "Why can't Ms. T (ulcerative colitis) get out of bed and do things for herself? She's only 29." What is the team leader's best response? 1. The HCP ordered bed rest for a few days 2. Decreasing activity helps to decrease the diarrhea 3. I see you're frustrated, just do your best to help 4. She is too depressed to get out of bed

2. Decreasing activity helps to decrease the diarrhea

Based on the analysis of the ABG values, which collaborative intervention will the nurse anticipate next? 1. Sodium bicarbonate bolus IV 2. ET intubation and mechanical ventilation 3. Continuous monitoring of Ms. D's respiratory status 4. Nebulized albuterol therapy

2. ET intubation and mechanical ventilation

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

2. Encouraging, monitoring, and recording nutritional intake

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

2. Help him to lie in a side-lying "fetal" position

Based on Ms. A's history, vital signs, and assessment data, the client is most at risk for which types of shock? Select all that apply 1. Cardiogenic 2. Hypovolemic 3. Neurogenic 4. Septic 5. Anaphylactic

2. Hypovolemic 3. Neurogenic

When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. Everyone in my family needs to go and see the doctor for TB testing 2. I will continue to take my isoniazid until I am feeling completely well 3. I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic ba 4. I will change my diet to include more foods rich in iron, protein, and vitamin C

2. I will continue to take my isoniazid until I am feeling completely well

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

3. A 72 year old patient who needs teaching about the use of incentive spirometry

Mr. A (appendectomy) will be discharged with prescriptions for pain medication and an antibiotic. What is the most important point that the nurse will emphasize about the medication? 1. Take the pain med before the pain becomes severe 2. The pain med may make you feel drowsy or sleepy 3. All of the antibiotics should be taken, even if you feel good 4. The antibiotics should not be shared with any other person

3. All of the antibiotics should be taken, even if you feel good

Which is the best way to clearly document Ms. A's level of consciousness? 1. Client is comatose 2. Client is unresponsive 3. Client's GCS score is 4 4. Client has a decreased LOC

3. Client's GCS score is 4

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

3. Reminding the patient to use an incentive spirometer every 1-2 hours while awake

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

3. Removing the inner cannula and cleaning using standard precautions

Which reporting tasks are appropriate to delegate to the UAP? Select all that apply 1. Reporting on the condition of Ms. T's perineal area after application of ointment 2. Reporting the quality and color of NG drainage for Ms. D 3. Reporting whether Mr. R's blood pressure is below 100/60 4. Reporting if any of the clients indicate pain 5. Reporting if Mr. A is seen leaving the unit to smoke a cigarette 6. Reporting that Mr. K's family has questions

3. Reporting whether Mr. R's blood pressure is below 100/60 4. Reporting if any of the clients indicate pain 5. Reporting if Mr. A is seen leaving the unit to smoke a cigarette 6. Reporting that Mr. K's family has questions

After changing of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68 year old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. A 57 year old patient with COPD and a pulse ox reading from the previous shift of 90% 3. A 72 year old patient with pneumonia who needs to be started on IV antibiotics 4. A 51 year old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

4. A 51 year old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

Ms. T is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "I'm being kept alive with tubes." Which explanation will encourage Ms. T to continue with the TPN therapy? 1. It will help you regain your weight 2. It will create a positive nitrogen balance 3. Your HCP has ordered this important therapy for you 4. Your bowel can rest, and the diarrhea will decrease

4. Your bowel can rest, and the diarrhea will decrease

When the nurse is preparing to assist with ET intubation of Ms. D, in which order will these actions be accomplished. 1. Use capnography to check for exhaled carbon dioxide 2. Secure the ET tube in place 3. Preoxygenate with bag-valve mask decide at 100% oxygen 4. Inflate the ET tube cuff 5. Obtain all needed equipment and supplies 6. Insert the ET tube orally through the vocal cords

5. Obtain all needed equipment and supplies 3. Preoxygenate with bag-valve mask decide at 100% oxygen 6. Insert the ET tube orally through the vocal cords 4. Inflate the ET tube cuff 1. Use capnography to check for exhaled carbon dioxide 2. Secure the ET tube in place

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68 year old patient with a history of smoking and emphysema 2. A 57 year old patient who experienced a cardiac arrest 3. A 49 year old postoperative patient who had a colectomy 4. A 29 year old patient who is recovering from flail chest

1. A 68 year old patient with a history of smoking and emphysema

Which tasks can be delegated to the UAP? Select all that apply 1. Assisting Ms. T with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for Mr. R 3. Transporting Ms. H off the unit for a procedure 4. Gently cleansing the nares around Ms. D's NG tube 5. Removing Mr. A's dressing 6. Helping Mr. K to brush his teeth

1. Assisting Ms. T with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for Mr. R 3. Transporting Ms. H off the unit for a procedure 4. Gently cleansing the nares around Ms. D's NG tube 6. Helping Mr. K to brush his teeth

A patient has COPD. Which intervention for airway management should the nurse delegate to the UAP? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed

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

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler 4. Checking oxygen saturation using pulse oximetry

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply 1. Avoid potential environmental asthma triggers such as smoke 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm 3. Wash all bedding in cold water to reduce and destroy dust mites 4. Be sure to get at least 8 hours of rest and sleep every night 5. Avoid foods prepared with MSG 6. Keep a symptom and intervention diary to learn specific triggers for your asthma

1. Avoid potential environmental asthma triggers such as smoke 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm 4. Be sure to get at least 8 hours of rest and sleep every night 5. Avoid foods prepared with MSG 6. Keep a symptom and intervention diary to learn specific triggers for your asthma

Which complication is the nurse most concern about at present? 1. Brainstem herniation 2. Respiratory acidosis 3. Hemorrahge 4. Hypothermia

1. Brainstem herniation

When the nurse assesses Ms. A at 2 PM, her left leg is pale, swollen, and very firm to palpation. The left leg pulses are only faintly audible using a Doppler pulse monitor. Which action is most appropriate at this time? 1. Call the orthopedic surgeon to communicate the assessment 2. Elevate the left leg on two pillows to decrease the swelling 3. Continue to monitor the left leg's appearance and pedal pulses 4. Assess the client for indications of pain, such as restlessness

1. Call the orthopedic surgeon to communicate the assessment

The postcraniotomy care plan for the first postoperative day includes these nursing actions. Which actions can the nurse assign to an experienced LPN/LVN working in the ICU? Select all that apply 1. Checking the gastric pH every 4 hours 2. Performing a neurologic status examination every 2 hours 3. Assessing breath sounds every 4 hours 4. Turning the client side to side every 2 hours 5. Monitoring intake and output hourly 6. Sending a urine specimen to check specific gravity daily

1. Checking the gastric pH every 4 hours 5. Monitoring intake and output hourly 6. Sending a urine specimen to check specific gravity daily

The cardiac monitor shows this rhythm (a-fib). Routine treatment orders for dysrhythmias are in the ED protocols. Which action should the nurse take next? 1. Continue to monitor cardiac rhythm 2. Administer metoprolol 5 mg IV push 3. Prepare to perform cardioversion at 50 J 4. Administer amiodarone 150 mg IV push

1. Continue to monitor cardiac rhythm

A patient with COPD tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply 1. Do not rush through your morning ADLs 2. Avoid working with the arms raised 3. Eat three large meals every day focusing on calories and protein 4. Organize your work area so that what you use most is easy to reach 5. Get all of your activities accomplished then take a nap 6. Don't hold your breath while performing any activities

1. Do not rush through your morning ADLs 2. Avoid working with the arms raised 4. Organize your work area so that what you use most is easy to reach 6. Don't hold your breath while performing any activities

The UAP is assisting with feeding for a patient with severe end-stage COPD. Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein 2. Feed the patient as quickly as possible to prevent early satiety 3. Offer lots of fluids between bites of food 4. Try to get the patient to eat everything on the tray

1. Encourage the patient to eat foods that are high in calories and protein

What information regarding Mr. R (acute pancreatitis) is appropriate to report to the HCP? Select all that apply 1. Hct is decreased by more than 10% 2. Calcium level is less than 9 mg/dl 3. Partial oxygen pressure is less than 60 4. Pain is unrelieved by medication 5. Blood type is O positive 6. NG tube and IV line are intact

1. Hct is decreased by more than 10% 2. Calcium level is less than 9 mg/dl 3. Partial oxygen pressure is less than 60 4. Pain is unrelieved by medication

Psychosocial assessment reveals that Mr. A (appendectomy) faces several financial and personal problems. Which finding has the most impact on discharge teaching for wound care and other follow-up issues? 1. He is homeless and has no family in the city 2. He has no money for the prescribed medications 3. He has no transportation to the follow-up appointment 4. He cannot read or write very well

1. He is homeless and has no family in the city

To provide good continuity of care for Mr. A (appendectomy), who is homeless, which members of the interdisciplinary team should routinely have access to Mr. A's medical records? Select all that apply 1. Hospital social worker who is helping Mr. A to locate resources 2. Surgeon who performed Mr. A's appendectomy 3. An epidemiologist who is collecting data on the homeless 4. All of the UAPs who work in the medical surgical area 5. Administrator of the shelter where Mr. A frequently stays 6. Nurse who works at the shelter where Mr. A frequently stays

1. Hospital social worker who is helping Mr. A to locate resources 2. Surgeon who performed Mr. A's appendectomy 6. Nurse who works at the shelter where Mr. A frequently stays

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurser suggest the student ask to determine nicotine dependence? Select all that apply 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or outside? 6. Do you have a difficult time not smoking in places where it is not allowed?

1. How soon after you wake up in the morning do you smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 6. Do you have a difficult time not smoking in places where it is not allowed?

The UAP tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen 2. Use a simple face mask instead of a nasal cannula 3. Provide the patient with an extra pillow 4. Have the patient sit up in a chair at the bedside

1. Humidify the patient's oxygen

Which of these interventions will be used to meet the goal of maintaining Ms. A's cerebral perfusion pressure at 60 or more? Select all that apply 1. Keep the head of the bed elevated 30 degrees 2. Check pupil reaction to light every hour 3. Reposition the client at least every 2 hours 4. Perform endotracheal suctioning as necessary 5. Check GCS score hourly 6. Administer mannitol 100 mg IV if ICP is above 20 7. Titrate norepinephrine drip to maintain MAP above 80

1. Keep the head of the bed elevated 30 degrees 6. Administer mannitol 100 mg IV if ICP is above 20 7. Titrate norepinephrine drip to maintain MAP above 80

Available staffing in the ED includes an experienced UAP. Which actions should the nurse delegate to the UAP? Select all that apply 1. Measuring vital signs every 15 minutes 2. Attaching the patient to a cardiac monitor 3. Documenting a head-to-toe assessment 4. Checking orientation and alertness 5. Inserting an IV line 6. Monitoring urine output hourly

1. Measuring vital signs every 15 minutes 2. Attaching the patient to a cardiac monitor 6. Monitoring urine output hourly

Which clients would be best to assign to the new RN? Select all that apply 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG tube) 6. Mr. R (acute pancreatitis)

1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 4. Mr. A (appendectomy)

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

1. Observing how well the patient performs pursed-lip breathing

Which parameter indicates a need for an immediate change in the ventilator setting? 1. PaCO2 (25) 2. O2 saturation (96%) 3. HCO3 (20) 4. PaO2 (90)

1. PaCO2 (25)

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

1. Palpating for abdominal distention with the index fingertip 2. Auscultating for bowel sounds with the NG tube attached to low wall suction 3. Performing the physical assessment before asking about pain 6. Checking for skin turgor over the lower abdominal area

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

1. Perform endotracheal intubation and initiate mechanical ventilation

The nurse is the team leader RN working with a student nurse. The student nurse is to teach a patient how to use an MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. 1. Remove the inhaler cap and shake the inhaler 2. Open your mouth and place the mouthpiece 1-2 inches away 3. Breathe out completely 4. Hold your breath for at least 10 seconds 5. Press down firmly on the canister and breathe deeply through your mouth 6. Wait at least 1 minute between puffs

1. Remove the inhaler cap and shake the inhaler 3. Breathe out completely 2. Open your mouth and place the mouthpiece 1-2 inches away 5. Press down firmly on the canister and breathe deeply through your mouth 4. Hold your breath for at least 10 seconds 6. Wait at least 1 minute between puffs

Because of Mr. K (PEG tube), which health care team members are demonstrating the roles and responsibilities that support interprofessional collaboration? Select all that apply 1. The UAP tells Mr. K's family that she will be in at 10 AM to assist Mr. K with hygiene 2. The RN gives the UAP specific instruction about how to clean around Mr. K's PEG tube 3. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter 4. The enterostomal therapist performs care for Mr. K, but staff and family are unsure about follow-up 5. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities 6. The surgeon does mini-grand rounds with nursing student to explain the purpose of Mr. K's PEG tube

1. The UAP tells Mr. K's family that she will be in at 10 AM to assist Mr. K with hygiene 2. The RN gives the UAP specific instruction about how to clean around Mr. K's PEG tube 3. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter 5. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities 6. The surgeon does mini-grand rounds with nursing student to explain the purpose of Mr. K's PEG tube

Ms. A suddenly begins to vomit. Which action should the nurse take first? 1. Use the backboard to log-roll Ms. A to her side 2. Suction Ms. A's airway with a Yankauer suction device 3. Hyperoxygenate Ms. A with a bag-valve mask system 4. Insert an NG tube and connect to low suction

1. Use the backboard to log-roll Ms. A to her side

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

2. Check vital signs every 15 minutes to 1 hour 4. Remind the patient to take deep breath 5. Take the specimens to the laboratory

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

2. Continuous bubbling in the water seal chamber

The night nurse gives a brief and incomplete report. Which question should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H who was admitted for acute cholecystitis? 1. What are her vital signs? 2. Is she going to surgery or radiology this morning? 3. Is she still having pain? 4. Does she need any morning medications?

2. Is she going to surgery or radiology this morning?

Mr. K (PEG tube) needs 1200 kcal/day. The enteral feeding formula provides 1 kcal/ml. Yesterday's formula feedings were 100 ml at 7 AM, 50 mL at 11 AM, 200 mL at 3 PM, and 100 mL at 7 PM. What should the nurse do first? 1. Give additional feedings to catch up on nutritional needs 2. Look at the original prescription to determine frequency and amount 3. Look at weight trends to see if client is losing or maintaining weight 4. Call the nurse who cared for Mr. K yesterday and ask what happened

2. Look at the original prescription to determine frequency and amount

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

2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? 1. Nasal cannula 2. Nonrebreather mask 3. Venturi mask 4. Simple face mask

2. Nonrebreather mask

The HCP prescribes these actions. Which action will the nurse take first? 1. Notify family members of Ms. A's admission 2. Obtain CT scan of head 3. Clean the occipital laceration and apply a dressing 4. Infuse famotidine 20 mg IV every 12 hours

2. Obtain CT scan of head

Ms. A's mother, who has been staying at the bedside, asks the nurse why her daughter is receiving omeprazole, stating that her daughter has no history of peptic ulcers. Which answer is best? 1. Omeprazole will lower the chance that she will aspirate 2. Omeprazole decreases the incidence of gastric stress ulcers 3. Omeprazole will reduce the risk for gastroesophageal reflux 4. Omeprazole prevents gastric irritation caused by the orogastric tube

2. Omeprazole decreases the incidence of gastric stress ulcers

As the shift ends, the nurse is preparing Ms. A for transfer to surgery for an emergency fasciotomy. What is the best option for obtaining informed consent for the fasciotomy? 1. Informed consent is not needed for emergency surgery 2. Permission for surgery can be given by Ms. A's mother 3. Consent for surgery is not required for unconscious clients 4. Authorization can be given by the nursing supervisor

2. Permission for surgery can be given by Ms. A's mother

Mr. R (acute pancreatitis) demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse expect? 1. Hypovolemic shock 2. Pleural effusion 3. Paralytic ileus 4. ARDS

2. Pleural effusion

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

2. Respiratory rate of 8 breaths/min

Based on the initial history and assessment, which action prescribed by the HCP will the nurse implement first? 1. Insert a Foley catheter and monitor urine output hourly 2. Start oxygen and maintain oxygen sat at 90% or higher 3. Place the patient on a cardiac monitor 4. Check the blood glucose level

2. Start oxygen and maintain oxygen sat at 90% or higher

The HCP has been paged and is en route to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. His pulse is 140, and his BP is 140/60. List the following steps, in order of priority, in caring for Mr. R with 1 being the first and 6 being the last. 1. Restart the IV line 2. Stay with the client and call for assistance 3. Replace the nasal cannula for supplemental oxygen 4. Have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask 5. Check the blood glucose level 6. Delegate UAP to take vital signs every 15 minutes

2. Stay with the client and call for assistance 3. Replace the nasal cannula for supplemental oxygen 4. Have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask 1. Restart the IV line 5. Check the blood glucose level 6. Delegate UAP to take vital signs every 15 minutes

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

2. Taking vital signs and pulse oximetry readings every 4 hours

Using the SBAR format, in which order will the nurse communicate this information about the client to the HCP? 1. I am concerned that Ms. A may develop worsening cerebral hypoxia caused by cerebral vasoconstriction and I would like to decrease the respiratory rate setting on the ventilator 2. This is the nurse caring for Ms. A. This client's most recent ABGs indicate that her PaCO2 is too low, possibly worsening her cerebral perfusion 3. Her current ventilator respiratory rate is set at 20, and ABGs show the PaCO2 is 25, with a pH of 7.54. O2 sat is 96% with PaO2 of 90. 4. Ms. A is a 20-year-old woman who had evacuation of an epidural hematoma and has been nonresponsive and ventilator dependent since surgery.

2. This is the nurse caring for Ms. A. This client's most recent ABGs indicate that her PaCO2 is too low, possibly worsening her cerebral perfusion 4. Ms. A is a 20-year-old woman who had evacuation of an epidural hematoma and has been nonresponsive and ventilator dependent since surgery. 3. Her current ventilator respiratory rate is set at 20, and ABGs show the PaCO2 is 25, with a pH of 7.54. O2 sat is 96% with PaO2 of 90. 1. I am concerned that Ms. A may develop worsening cerebral hypoxia caused by cerebral vasoconstriction and I would like to decrease the respiratory rate setting on the ventilator

The RN is teaching a UAP to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. Be aware that patients with darker skin usually show a 3-5% higher oxygen saturation compared with light-skinned patients 2. Usually dark-skinned patients show a 3-5% lower oxygen saturation by pulse oximetry than light-skinned patients 3. With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes 4. More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin

2. Usually dark-skinned patients show a 3-5% lower oxygen saturation by pulse oximetry than light-skinned patients

The RN is teaching the nursing student about enteral feedings for clients such as Mr. K, who has a PEG tube. In the postoperative period, when can enteral feedings be started? 1. Within 6-8 hours after the procedure 2. When bowel sounds occur, usually within 24 hours 3. When the client reports feeling hungry 4. On a schedule determined by the pharmacy

2. When bowel sounds occur, usually within 24 hours

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

2. Your voice should improve in 6-8 weeks after completion of the radiation

The nurse notes that Mr. R (acute pancreatitis) has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? 1. Remove the IV line and restart it at different site 2. Remind the UAP to handle Mr. R very gently 3. Assess for other signs of obvious or occult bleeding 4. Obtain an order for coagulation studies

3. Assess for other signs of obvious or occult bleeding

The nurse notes that Ms. A has abnormal movement when pressure is applied to her nail beds, as shown in the illustration. What is the best way to document this finding? 1. Extensor rigidity 2. Decorticate posturing 3. Decerebrate posturing 4. Traumatic brain injury

3. Decerebrate posturing

Ms. T is receiving an oral dose of sulfasalazine 500 mg every 6 hours for treatment of ulcerative colitis. Which assessment finding is cause for greatest concern? 1. Decreased appetite 2. Nausea and vomiting 3. Decreased urine ouput 4. Headache

3. Decreased urine ouput

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

3. Laxatives can cause perforation if there is a bowel obstruction

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

3. Maintain the head of bed at a 30-45 degree angle

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

3. Marks the tube 1 cm from where it touches the incisor tooth or nares

The LPN/LVN reports that Ms. A's output for the past hour was 1200 mL and that her urine is very pale yellow. Which action is best for the nurse to take at this time? 1. Instruct the LPN/LVN to continue to monitor the urine output hourly 2. Send a urine specimen to the lab to check specific gravity 3. Notify the neurosurgeon and anticipate an increase in the IV rate 4. Assess the client's neurologic status for signs of increased irritability

3. Notify the neurosurgeon and anticipate an increase in the IV rate

The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deterioriating status, the team leader would advocate for which intervention? 1. Perform additional lab tests and continue monitoring 2. Prepare Mr. R for emergency surgery 3. Prepare Mr. R for transfer to the ICU 4. Reestablish NG suction and apply restraints or use one-one-one observation

3. Prepare Mr. R for transfer to the ICU

The HCP told Ms. H (acute cholecystitis) that she would probably need a laparoscopic cholecystectomy; however, the HIDA scan and laboratory results are still pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? 1. Describe the surgical procedure 2. Call the HCP to come and speak with her 3. Provide some written material about gallbladder disease and options 4. Explain general postoperative care, such as coughing and deep breathing exercises

3. Provide some written material about gallbladder disease and options

Which staff member will be best to assign to take primary responsibility for Ms. A's ongoing care? 1. RN from a temporary agency with extensive previous emergency experience who has been working in this ED for 3 days 2. LPN/LVN with 10 years of experience in the ED who is in the last semester of an RN program 3. RN who has worked in the ED for the past 5 years after transferring from the mother and baby unit 4. RN who has 12 years of ICU experience and has floated to the ED today

3. RN who has worked in the ED for the past 5 years after transferring from the mother and baby unit

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the UAP? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how set up the BiPAP machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness

3. Reminding the patient to sleep on his side instead of his back

Ms. D (bowel osbtruction) reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of water bile-colored fluid. Which laboratory values should be checked first? 1. BUN and creatinine 2. Platelet and WBC count 3. Sodium, potassium, and pH of blood 4. Bilirubin, hematocrit, and hemoglobin

3. Sodium, potassium, and pH of blood

What is the best approach by the nurse when communicating concerns about the medical resident's decision making? 1. Call the medical resident's supervisor about the concerns 2. Ask the nursing supervisor to discuss appropriate care with the medical resident 3. Tell the medial resident that lumbar puncture may cause brainstem herniation 4. Explain that lumbar puncture is not within the medical resident's scope of practice

3. Tell the medial resident that lumbar puncture may cause brainstem herniation

The nurse has just finished assisting the HCP with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the HCP? 1. The patient starts crying and says she can't go on with treatment much longer 2. The patient reports sharp, stabbing chest pain with every deep breath 3. The blood pressure is 100/48, and the HR is 102 4. The dressing at the thoracentesis site has 1 cm of bloody drainage

3. The blood pressure is 100/48, and the HR is 102

The nurse is making a home visit to a 50 year old patient who was recently hospitalized with a right leg DVT and a pulmonary embolism. The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night 2. The right calf is warm to the touch and is larger than the left calf 3. The patient is unable to remember her husband's first name 4. There are multiple ecchymotic areas on the patient's abdomen

3. The patient is unable to remember her husband's first name

While the nurse is teaching Mr. A about dressing changes for his appendectomy wound, he says, "When you live on the street, you can't do everything the way you nurses do in the hospital." What is the most important thing to emphasize in helping him to accomplish self care? 1. Change the dressing in the AM and the PM 2. Use the gauze package to make a sterile field 3. Wash your hands before a dressing change 4. Discard any opened packages of unused gauze

3. Wash your hands before a dressing change

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

4. Auscultating the lungs for crackles

Toward the end of the shift, the team leader finds the new RN crying in the bathroom. The new nurse says, "I'm a terrible nurse. I'm so disorganized, and I'm so far behind. I'm going to quit. I hate this job." What is the best thing to do? 1. Have her take a short break off the unit 2. Offer to take one of her clients 3. Ask the UAP to help her 4. Calm her down and help her prioritize

4. Calm her down and help her prioritize

After extubation of a patient, which finding would the nurse report to the HCP immediately? 1. RR of 25 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Crowing noise during inspiration

Which of the assessment data listed about requires the most immediate nursing action? (pt A) 1. Cardiac rhythm 2. Blood pressure 3. O2 saturation 4. ICP

4. ICP

All of these clients must receive their routine morning medications. Which client should receive his or her medication last? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. K (PEG-tube)

4. Mr. K (PEG-tube)

Based on the lab values, which collaborative intervention will the nurse anticipate next? 1. Type and cross-match for 3 units of packed red blood cells 2. Administer magnesium sulfate 1 g IV over the next 3 hours 3. Give insulin aspart dose based on the standard sliding scale 4. Obtain an ET intubation tray and assist with intubation

4. Obtain an ET intubation tray and assist with intubation

A patient with COPD tells the UAP that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 2. Respiratory rate of 27 3. Heart rate of 92 4. Oral temp of 101.2

4. Oral temp of 101.2

Which additional assessment information is most important to obtain at this time (about pt A- 20 year old)? 1. Temperature 2. Breath sounds 3. Pedal pulses 4. Oxygen saturation

4. Oxygen saturation

For Mr. K (PEG tube), several new medications and a change in the enteral feeding solution are included in the discharge plan. Which team member is the nurse most likely to consult before teaching the client and family about these new medications and enteral solution? 1. Nutritionist to verify that the calories and other nutrients are sufficient 2. Home health nurse to verify that follow-up teaching will be performed 3. Social worker to verify that medications and formula are covered by insurance 4. Pharmacist to verify that medications are compatible with the feeding solution

4. Pharmacist to verify that medications are compatible with the feeding solution

A new medical resident is working in the ED today. Which action by the resident indicates a need for immediate intervention by the nurse? 1. Assessing for the Babinski sign 2. Increasing the IV infusion rate to 200 ml/hr 3. Ordering an ECG 4. Preparing to perform a lumbar puncture

4. Preparing to perform a lumbar puncture

Ms. H's (acute cholecystitis) HIDA scan shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are the key signs and symptoms that the nurse will watch for? 1. Rebound tenderness and a sausage-shaped mass in the RUQ 2. Flatulence, dyspepsia, and eructation after eating or drinking 3. RUQ abdominal pain that radiates to the right shoulder or scapula 4. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

4. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

When assessing a 22 year old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen and call the HCP to discuss the patient's status

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen and call the HCP to discuss the patient's status

Because of Ms. T's (ulcerative colitis) severe diarrhea, the nurse is reviewing the lab results. Which lab results are cause for greatest concern? 1. The WBC count is slightly increased 2. The h&h are slightly decreased 3. The ESR rate is increased 4. The serum Na and K levels are decreased

4. The serum Na and K levels are decreased

The RN is supervising the nursing student in administering Ms. D (bowel obstruction) medications through the NG tube. When would the nurse intervene? 1. The student compares medication administration record with the original prescription 2. The student draws up 30 ml of sterile water for flush in a large-bore syringe 3. The student performs three checks of the medication names and dosages 4. The student crushes tablets and puts all medications in the same cup

4. The student crushes tablets and puts all medications in the same cup

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 2. Respiratory rate of 24 3. Blood pressure of 168/90 4. Tympanic temp of 101.4

4. Tympanic temp of 101.4

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8. Which statement by the student indicates correct understanding of this patient's curve shift? 1. When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve 2. When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower 3. When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen 4. When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster

4. When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster

The night shift nurse has just finished giving the RN team leader a report on the six clients. Which client has the highest acuity level and is at greatest risk for shock during the shift? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG tube) 6. Mr. R (acute pancreatitis)

6. Mr. R (acute pancreatitis)