Management quiz 4

The nurse reports the morning assessment findings (crackles bilaterally) to the HCP. Which prescribed intervention is most directly related to the nurse's assessment findings? 1. Administer furosemide 20 mg IV push now 2. Keep accurate records of intake and output 3. Administer potassium 20 mEq orally every morning 4. Weigh the patient every morning

1. Administer furosemide 20 mg IV push now

Ms. S tells the nurse that she has worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and the nurse notifies the HCP. Which prescribed action takes priority at this time? 1. Administer morphine sulfate 2 mg IV push 2. Schedule an ECG 3. Draw blood for coagulation studies 4. Administer ranitidine 75 mg PO every 12 hours

1. Administer morphine sulfate 2 mg IV push

Mr. W's ABG results include the following: pH 7.37, PaCO2 55.4, PaO2 51.2, HCO3 38. Based on the patient's ABG results, what are the nurse's priority actions at this time? Select all that apply 1. Administer oxygen at 2 L/min via nasal cannula 2. Initiate a rapid response 3. Teach the patient how to cough and deep breathe 4. Begin IV normal saline at 100 ml/hr 5. Arrange a transfer to the ICU 6. Remind the patient to practice incentive spirometry every hour while awake

1. Administer oxygen at 2 L/min via nasal cannula 2. Initiate a rapid response 3. Teach the patient how to cough and deep breathe 6. Remind the patient to practice incentive spirometry every hour while awake

Mr. W. is to be transferred back to the long-term care facility after lunch. Which nursing care intervention would be best for the RN to assign to the experienced LPN/LVN? 1. Administer the patient's 12:00 PM oral medications 2. Check and record a set of vital signs at 12:00 PM 3. Pack the patient's personal items to be taken with him 4. Change Mr. W's incontinence pad before he is transferred

1. Administer the patient's 12:00 PM oral medications

Ms. S's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent PVCs. Which drug should the nurse be prepared to administer first? 1. Amiodarone IV push 2. Nitroglycerin sublingually 3. Morphine sulfate IV push 4. Atenolol IV push

1. Amiodarone IV push

Ms. J states that she feels increasingly short of breath. The nurse team leader is supervising an LPN/LVN and a UAP. Which nursing care action for Ms. J should be most appropriately assigned to the LPN/LVN? 1. Checking for residual urine with the bedside bladder scanner 2. Planning restricted fluid amounts to be given with meals 3. Assessing breath sounds for increased bilateral crackles 4. Discussing renal replacement therapies with the patient

1. Checking for residual urine with the bedside bladder scanner

Which activities could the nurse delegate to UAP assisting Ms. S during phase 1 of cardiac rehabilitation? Select all that apply 1. Assist with Ms. S's morning bath 2. Refer Ms. S. to a monitored cardiac rehab program 3. Ambulate with Ms. S to the bathroom 4. Administer Ms. S's morning doses of catopril and HCTZ 5. Assist with progressive ambulation in the hall 6. Assess Ms. S for additional chest pain or pressure

1. Assist with Ms. S's morning bath 3. Ambulate with Ms. S to the bathroom 5. Assist with progressive ambulation in the hall

(Mr. B: the client newly admitted from a long-term care facility with decreased urine output and altered LOC) Which factor does the nurse suspect most likely precipitated Mr. B's elevated temperature? 1. Bladder infection 2. Increased metabolic rate 3. Kidney failure 4. Nosocomial pneumonia

1. Bladder infection

(After the rapid response, the respiratory therapist provides the patient with a hand-held nebulizer treatment, and Mr. W is stable enough to be admitted to the acute care unit.) Which interventions would the acute care RN delegate to an experienced UAP? Select all that apply 1. Changing the patient's incontinence pad as needed 2. Performing pulse oximetry every shift 3. Teaching the patient to cough and deep breathe 4. Reminding the patient to use incentive spirometry every hour while awake 5. Assessing the patient's breath sounds every shift 6. Encouraging the patient to drink adequate oral fluids

1. Changing the patient's incontinence pad as needed 2. Performing pulse oximetry every shift 4. Reminding the patient to use incentive spirometry every hour while awake 6. Encouraging the patient to drink adequate oral fluids

Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which postprocedure tasks would be best assigned to the LPN/LVN? Select all that apply 1. Check bilateral pedal pulses every 15 minutes during the first hour 2. Check right groin area for bleeding every 15 minutes during first hour 3. Continue IV fluids normal saline at 50 ml/hr 4. Assist client to bathroom as needed during first 6 hours after procedure 5. Administer morphine sulfate 2 mg IV push as needed for pain 6. Give client's daily multivitamin and stool softener on return to medical unit

1. Check bilateral pedal pulses every 15 minutes during the first hour 2. Check right groin area for bleeding every 15 minutes during first hour 3. Continue IV fluids normal saline at 50 ml/hr 6. Give client's daily multivitamin and stool softener on return to medical unit

Which patient admission tasks should the nurse delegate to the experienced UAP? Select all that apply 1. Check vital signs every 4 hours 2. Record accurate intake and output 3. Place a saline lock in left forearm 4. Check oxygen saturation by pulse oximetry 5. Teach the patient the importance of keeping oxygen in place 6. Check and record the fingerstick blood glucose before lunch

1. Check vital signs every 4 hours 2. Record accurate intake and output 4. Check oxygen saturation by pulse oximetry 6. Check and record the fingerstick blood glucose before lunch

The result of Ms. J's 24 hour urine collection reveals a creatinine clearance of 65 ml/min. How does the nurse best interpret this finding? 1. Creatinine clearance is lower than normal 2. Creatinine clearance is higher than normal 3. Creatinine clearance is within normal range 4. Creatinine clearance indicates adequate kidney function

1. Creatinine clearance is lower than normal

The RN administers the patient's first dose of IV cefotaxime. Within 15 minutes, Mr. W develops a rash with fever and chills. What is the nurse's first action at this time? 1. Discontinue the IV infusion 2. Administer 2 tablets of acetaminophen 3. Measure the area of the rash 4. Check for numbness and tingling

1. Discontinue the IV infusion

The RN assess Mr. W (SOB) in the ED. Which assessment findings are consistent with a diagnosis of COPD? Select all that apply 1. Enlarged neck muscles 2. Forward bent posture 3. RR 15-25 4. Inspiratory and expiratory wheezes 5. Blue-tinged dusky appearance 6. Symmetrical lung expansion

1. Enlarged neck muscles 2. Forward bent posture 4. Inspiratory and expiratory wheezes 5. Blue-tinged dusky appearance

(Ms. J is admitted for a kidney transplantation 6 months later. Her son is the kidney donor.) The RN is caring for Ms. J on the first day postoperatively after a kidney transplant. On assessment, her temperature is 100.4, BP is 168/92, and the patient tells the RN she has pain around the transplant site. What is the best interpretation of these findings? 1. Hyperacute rejection 2. Acute rejection 3. Chronic rejection 4. Transplant site infection

1. Hyperacute rejection

Which risk factors from Ms. S's history would suggest a possible cardiac problem to the nurse? Select all that apply 1. Hypertension for 12 years 2. Smoked for 43 years; quit smoking 1 year ago 3. Surgery for gallbladder removal 1 year ago 4. Ms. S's father died at age 42 years from a heart attack 5. Client's weight is 278 lb 6. Diet includes fast foods three to five times a week

1. Hypertension for 12 years 2. Smoked for 43 years; quit smoking 1 year ago 4. Ms. S's father died at age 42 years from a heart attack 5. Client's weight is 278 lb 6. Diet includes fast foods three to five times a week

Mr. W is receiving an IV dose of potassium 10 mEq/100 mL normal saline to run over 1 hour. The UAP asks the nurse why it takes so long to infuse such a small amount of fluid. What should the nurse explain to the UAP? Select all that apply 1. IV potassium is very irritating to the veins and can cause phlebitis 2. Tissue damaged by potassium can become necrotic 3. Oral potassium can cause nausea, so IV potassium is preferred 4. The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr 5. That's a good question, and I will ask the HCP if I can give the drug IV push 6. The goal is to prevent infiltration into the tissue

1. IV potassium is very irritating to the veins and can cause phlebitis 2. Tissue damaged by potassium can become necrotic 4. The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr 6. The goal is to prevent infiltration into the tissue

Mr. W has lost 15 lb over the past year. On assessment, he tells the nurse that his appetite is not what it used to be, and he becomes short of breath while eating. Which interventions should be included in his nursing care plan? Select all that apply 1. Initiate a dietary consult 2. Stress that he must eat all of his meals or he'll become malnourished 3. Monitor serum prealbumin levels 4. Suggest four to six small meals per day 5. Instruct the patient to use his bronchodilator 30 minutes before meals 6. Encourage dry foods to avoid coughing

1. Initiate a dietary consult 3. Monitor serum prealbumin levels 4. Suggest four to six small meals per day 5. Instruct the patient to use his bronchodilator 30 minutes before meals

The LPN/LVN reports to the RN that Mr. R (left hemisphere stroke) was unable to take his oral medications because of difficulty swallowing. The RN assesses Mr. R and finds that he is having dysphagia. What is the RN's best instruction for the LPN/LVN? 1. Keep Mr. R NPO, and I will contact his HCP 2. Try giving his medications with applesauce and pudding 3. Check with the pharmacy to find out if they have liquid forms of Mr. R's medications 4. Assess Mr. R's ability to speak and move his tongue

1. Keep Mr. R NPO, and I will contact his HCP

Ms. J's care plan includes the nursing concern, excess fluid volume. What interventions are appropriate for this nursing concern? Select all that apply 1. Measure weight daily 2. Monitor daily intake and output 3. Restrict sodium intake with meals 4. Restrict fluid to 1500 ml plus urine output 5. Assess for crackles in the lungs every shift 6. Check for peripheral edema and note any increase

1. Measure weight daily 2. Monitor daily intake and output 3. Restrict sodium intake with meals 5. Assess for crackles in the lungs every shift 6. Check for peripheral edema and note any increase

Six months later, Ms. J is readmitted to the unit. She has just returned from HD. Which nursing care action should the nurse delegate to the UAP? 1. Measuring vital signs and postdialysis weight 2. Assessing the HD access site for bruit and thrill 3. Checking the access site dressing for bleeding 4. Instructing the patient to request assistance getting out of bed

1. Measuring vital signs and postdialysis weight

Because Ms. S continues to experience chest pain and has elevated levels of cardiac markers, the following interventions have been prescribed. Which interventions should the nurse delegate to an experienced UAP? Select all that apply 1. Measuring vital signs every 2 hours 2. Accurately recording intake and output 3. Administering tenecteplase IV push 4. Drawing blood for coagulation studies 5. Assessing the cardiac monitor every 4 hours 6. Assisting the client to the bedside commode

1. Measuring vital signs every 2 hours 2. Accurately recording intake and output 6. Assisting the client to the bedside commode

Pts: Mr. C (unstable angina, needs reinforcement of teaching for cardiac cath this morning); Ms. J (chest pain, exercise test later); Mr. R (left-hemisphere stroke 4 days ago); Ms. S (heart disease, MI hx, mild dementia); Mr. B (decreased urine output, altered LOC, temp of 99.5); Mr. L (mild SOB and chronic emphysema) Which clients should the team leader assign to the LPN/LVN for nursing care, under the RN's supervision? Select all that apply 1. Mr. C 2. Ms. J 3. Mr. R 4. Ms. S 5. Mr. B 6. Mr. L

1. Mr. C 3. Mr. R 4. Ms. S 6. Mr. L

The oral temperature of Mr. B, the client newly admitted from a long-term care facility with decreased urine output and altered LOC, is now 102.6. What is the nurse's best action? 1. Notify the HCP 2. Administer acetaminophen 2 tablets orally 3. Ask the LPN/LVN to give an acetaminophen suppository 4. Remove extra blankets from the client's bed

1. Notify the HCP

The UAP is delegated the task of measuring morning vital signs for all six clients. Which finding would the nurse instruct the UAP to report immediately? 1. Oral temperature higher than 102 2. Blood pressure higher than 140/80 3. HR lower than 65 4. RR lower than 18

1. Oral temperature higher than 102

Mr. W: severe dyspnea, shortness of breath, coldlike sx, productive cough, incontinent, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F Which priority actions will the nurse take when the patient is initially admitted to the ED? Select all that apply 1. Place the patient on a cardiac monitor 2. Get a baseline set of vital signs 3. Draw admission labs and place a saline lock 4. Change the patient's adult pad 5. Send the patient for a chest x-ray 6. Order the patient a lunch tray

1. Place the patient on a cardiac monitor 2. Get a baseline set of vital signs 3. Draw admission labs and place a saline lock 5. Send the patient for a chest x-ray

The RN is delegating and assigning care for Ms. J related to her type 2 diabetes. Which action by the RN indicates that the team leader needs to intervene? 1. RN delegates fingerstick glucose check to newly hired UAP 2. RN assigns administering morning dose of metformin to the LPN/LVN 3. RN refers the patient to a dietitian for education about a diabetic diet 4. RN assesses condition of patient's feet daily

1. RN delegates fingerstick glucose check to newly hired UAP

Ms. S has returned from a cardiac catheterization and a percutaneous coronary intervention procedure. Which follow-up care orders should the nurse assign to an experienced LPN/LVN? Select all that apply 1. Reminding the client to remain on bed rest with the insertion site extremity straight 2. Preparing a teaching plan that includes activity restrictions and risk factor modification 3. Measuring the client's vital signs every 15 minutes for the first hour 4. Assessing the catheter insertion site for bleeding or hematoma formation 5. Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs 6. Administering two tablets of acetaminophen for back pain

1. Reminding the client to remain on bed rest with the insertion site extremity straight 3. Measuring the client's vital signs every 15 minutes for the first hour 4. Assessing the catheter insertion site for bleeding or hematoma formation 5. Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs 6. Administering two tablets of acetaminophen for back pain

Mr. W: severe dyspnea, shortness of breath after MDI, coldlike sx, productive cough, incontinent, hx of COPD, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F The HCP's prescribed actions for this patient include all of the following. Which intervention should the nurse complete first? 1. Send an ABG sample to the laboratory 2. Schedule pulmonary function tests 3. Repeat chest radiography each morning 4. Administer albuterol via MDI 2 puffs every 6 hours

1. Send an ABG sample to the laboratory

The RN reviews Ms. J's laboratory results. Which laboratory finding is of most concern? 1. Serum potassium level of 7.1 2. Serum creatinine level of 7.3 3. BUN level of 180 4. Serum calcium level of 7.8

1. Serum potassium level of 7.1

The HCP prescribes catopril 12.5 mg orally twice daily and hydrochlorothiazide (HCTZ) 25 mg orally daily. Which information would the nurse be sure to include when teaching Ms. S about these drugs? 1. Take your hydrochlorothiazide in the morning 2. If you miss a dose of catopril, take two tablets next time 3. Avoid foods that are rich in potassium, such as bananas and oranges 4. You should expect an increase in blood pressure with these drugs

1. Take your hydrochlorothiazide in the morning

Ms. S's daughter asks the nurse why her mother did not receive a "clot-buster" drug. What is the nurse's best response? 1. Thrombolytic agents, also called clot busters, are more effective when administered within the first 6 hours of a coronary event 2. Thrombolytic drugs are much more effective when used for clients who have had a recent stroke 3. Thrombolytic drugs work better for clients who have a heart attack at a much younger age 4. Contraindications for these drugs include recent surgeries, and your mother had gallbladder surgery a year ago

1. Thrombolytic agents, also called clot busters, are more effective when administered within the first 6 hours of a coronary event

The RN is assessing Ms. J's chest pain. Which questions would the RN be sure to ask the client? Select all that apply 1. When did you first notice the chest pain? 2. Did your pain start suddenly or gradually? 3. How long has the chest pain lasted? 4. Have you experienced confusion or loss of memory with the pain? 5. Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain ever? 6. What were you doing when the chest pain started?

1. When did you first notice the chest pain? 2. Did your pain start suddenly or gradually? 3. How long has the chest pain lasted? 5. Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain ever? 6. What were you doing when the chest pain started?

An LPN/LVN tells the RN that the patient is now receiving oxygen at 2 L/min via nasal cannula and his pulse oximetry reading is now 91%, but he still has crackles in the bases of his lungs. What intervention should the RN assign to the LPN/LVN? 1. Begin creating a plan for discharging the patient 2. Administer furosemide 20 mg orally each morning 3. Get a baseline weight for the patient now 4. Administer cefotaxime IV piggyback every 6 hours

2. Administer furosemide 20 mg orally each morning

During shift change report, the night RN informs the team that Ms. S (heart disease, hx of MI, mild dementia) is to be transferred back to her long-term care facility after lunch. What action should be taken for this client? 1. Instruct the UAP to awaken her for vital signs and breakfast 2. Allow her to sleep for an hour or two while the other clients are assessed 3. Assign the LPN/LVN to immediately pack up the client's belongings 4. Call the nursing home to find out if the transfer can wait until tomorrow

2. Allow her to sleep for an hour or two while the other clients are assessed

The RN is working on a care plan for Mr. B. Which care intervention is most appropriate to delegate to the UAP? 1. Checking the client's LOC every shift 2. Assisting the client with ambulation to the bathroom to urinate 3. Teaching the client the side effects of antibiotic therapy 4. Administering sulfamethoxazole-trimethoprim orally every 12 hours

2. Assisting the client with ambulation to the bathroom to urinate

The team leader RN observes the UAP perform all of these actions for Ms. J. For which actions must the RN intervene? Select all that apply 1. Assisting the patient to replace her oxygen nasal cannula 2. Checking vital signs after the pt has had something cold to drink 3. Ambulating with the patient to the bathroom and back 4. Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min 5. Washing the patient's back, legs, and feet with warm water 6. Reminding Ms. J to perform prescribed incentive spirometry every hour while awake

2. Checking vital signs after the pt has had something cold to drink 4. Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min

Ms. S's conditions (STEMI) is stable, and she has been transferred to the cardiac step-down unit. What should the step-down nurse instruct the UAP to report immediately? 1. Temperature of 99 F with morning vital sign monitoring 2. Chest pain episode occurring during morning care 3. Systolic blood pressure increase of 8 after morning care 4. Heart rate increase of 10 bpm after ambulation

2. Chest pain episode occurring during morning care

Mr. W: severe dyspnea, shortness of breath, coldlike sx, productive cough, incontinent, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F What is the priority nursing concern for this patient? 1. Skin care due to incontinence 2. Clearance of thick secretions 3. Rapid heart rate 4. Elevated temperature

2. Clearance of thick secretions

Which information is most important to prevent recurrence of reocclusion of the coronary artery, chest discomfort, or MI? 1. Remain on bed rest for the next 24 hours 2. Client will be prescribed dual antiplatelet therapy (DAT) 3. Client should do no heavy lifting for 48 hours 4. HCP will prescribe a beta-blocker

2. Client will be prescribed dual antiplatelet therapy (DAT)

During admission assessment, Ms. J has all of these findings. For which finding should the nurse notify the HCP immediately? 1. BIL pitting ankle and calf edema rated +2 2. Crackles in both lower and middle lobes 3. Dry and peeling skin on both feet 4. Faint but palpable pedal and post-tibial pulses

2. Crackles in both lower and middle lobes

(Mr. L: mild SOB and chronic emphysema) The UAP reports that Mr. L's heart rate, which was 86, is now 98. What would be the most appropriate question for the nurse to ask Mr. L? 1. Have you just returned from the bathroom? 2. Did you recently use your albuterol inhaler? 3. Are you feeling short of breath? 4. How much do you smoke?

2. Did you recently use your albuterol inhaler?

Which risk factors in Ms. J's history indicate increased risk for CKD? Select all that apply 1. GERD 2. Hypertension 3. Four pregnancies 4. Type 2 diabetes 5. CAD 6. Cataracts

2. Hypertension 4. Type 2 diabetes 5. CAD

After discussing renal replacement therapies with the HCP and nures, Ms. J is considering hemodialysis. Which statement indicates that Ms. J needs additional teaching about HD? 1. I will need surgery to create an access route for HD 2. I will be able to eat and drink what I want after I start dialysis 3. I will have a temporary dialysis catheter for a few months 4. I will be having dialysis three times every week

2. I will be able to eat and drink what I want after I start dialysis

Pts: Mr. C (unstable angina, needs reinforcement of teaching for cardiac cath this morning); Ms. J (chest pain, exercise test later); Mr. R (left-hemisphere stroke 4 days ago); Ms. S (heart disease, MI hx, mild dementia); Mr. B (decreased urine output, altered LOC, temp of 99.5); Mr. L (mild SOB and chronic emphysema) Which client should the RN assess first? 1. Mr. C 2. Ms. J 3. Mr. B 4. Mr. L

2. Ms. J

The client is scheduled for an emergent cardiac catheterization with possible percutaneous coronary intervention (PCI). Ms. S. asks the nurse what is involved with this procedure. What is the nurse's best response? 1. It is a procedure that is usually done on clients who have heart attacks to diagnose blockages in the arteries that feed the heart 2. The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open 3. Cardiac catheterization is usually performed on an outpatient basis to determine whether or not you have had a heart attack 4. After the cardiac catheterization, you will come back to the coronary care unit, where you will be on bed rest for 6-8 hours, and we will check your vital signs often

2. The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open

All of these lab values were obtained for Ms. S (chest pain) in the emergency department. Which value would be of most concern to the nurse and have immediate implications for the care of the client? 1. Potassium level of 3.5 2. Troponin T level of more than 0.20 3. Glucose level of 123 4. Slight elevation of white blood cell count

2. Troponin T level of more than 0.20

The HCP's prescribed interventions for Mr. R, who had a stroke 4 days ago, include assisting the client with meals. Which staff member would be best to assign this task? 1. Physical therapist 2. UAP 3. LPN/LVN 4. Occupational therapist

2. UAP

Near the end of the shift, the LPN/LVN reports that the UAP has not totaled clients' intake and output for the past 8 hours. What is the nurse's best action? 1. Confront the UAP and instruct him to complete this assignment at once 2. Assign this task to the LPN/LVN 3. Ask the UAP if he needs assistance completing the intake and output records 4. Notify the nurse manager to include this on the UAP's evaluation

3. Ask the UAP if he needs assistance completing the intake and output records

The UAP reports to the RN that Mr. L, the client with chronic emphysema, says he is feeling short of breath after walking to the bathroom. What action should the RN take first? 1. Notify the HCP 2. Increase the oxygen flow to 6 L/min via NC 3. Assess oxygen saturation by pulse oximetry 4. Remind the client to cough and deep breathe

3. Assess oxygen saturation by pulse oximetry

The HCP's prescribed actions for Ms. J, who is currently experiencing chest pain, are as follows. Which intervention should be completed first? 1. Administer nitroglycerin 0.6 mg sublingually as needed for chest pain 2. Administer morphine 2 mg IV push as needed for chest pain 3. Check blood pressure and heart rate 4. Lab tests to include cardiac markers and daily ECG

3. Check blood pressure and heart rate

Which tasks should the nurse delegate to the newly hired UAP? Select all that apply 1. Asking Ms. S memory-testing questions 2. Teaching Ms. J about treadmill exercise testing 3. Checking vital signs on all six clients 4. Recording oral intake and urine output for Mr. B 5. Assisting Mr. L to walk to the bathroom 6. Helping Mr. R with morning care

3. Checking vital signs on all six clients 4. Recording oral intake and urine output for Mr. B 5. Assisting Mr. L to walk to the bathroom 6. Helping Mr. R with morning care

The UAP asks the RN why it is important to notify someone whenever a client with heart problems reports chest pain. What is the RN's best response? 1. It's important to keep track of the chest pain episodes so we can notify the HCP 2. The client may need morphine to treat the chest pain 3. Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment 4. Our unit policy includes specific steps to take in the treatment of clients with chest pain

3. Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment

Mr. W's ABG results include the following: pH 7.37, PaCO2 55.4, PaO2 51.2, HCO3 38. What is the nurse's interpretation of these results? 1. Compensated metabolic acidosis with hypoxemia 2. Compensated metabolic alkalosis with hypoxemia 3. Compensated respiratory acidosis with hypoxemia 4. Compensated respiratory alkalosis with hypoxemia

3. Compensated respiratory acidosis with hypoxemia

Mr. W's (SOB, productive cough) ED lab values include a serum potassium of 2.8. What is the priority nursing action at this time? 1. Teaching the patient about potassium-rich foods 2. Provide the patient with oxygen at 2 L per nasal cannula 3. Contact and notify the HCP immediately 4. Initiate 0.9% saline at 20 ml/hr

3. Contact and notify the HCP immediately

The cardiac lab calls to have Ms. J (having chest pain) sent for her graded exercise test. What is the nurse's best action? 1. Instruct the UAP to put the client in a wheelchair and take her to the lab 2. Call the cardiac lab and ask to delay the test until later in the day 3. Contact the HCP to ask if the client should still have the GXT 4. Ask the client if she is continuing to have chest pain

3. Contact the HCP to ask if the client should still have the GXT

Mr. W: severe dyspnea, shortness of breath after MDI, coldlike sx, productive cough, incontinent, hx of COPD, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F During morning rounds, the nurse notes all of these assessment findings for Mr. W. Which finding indicates a worsening of the patient's condition? 1. Barrel-shaped chest 2. Clubbed fingers on both hands 3. Crackles bilaterally 4. Frequent productive cough

3. Crackles bilaterally

Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates immediate notification of the HCP? 1. Weight decrease of 4.5 lb 2. Systolic BP decrease of 14 3. Decreased LOC 4. Small blood spot near the center of the dressing

3. Decreased LOC

The RN is precepting a new nurse orienting to the unit, who is providing care for Ms. J after her return from surgery to create a left forearm access for dialysis. Which action by the orienting nurse requires that the preceptor intervene? 1. Monitoring the patient's operative site dressing for evidence of bleeding 2. Obtaining a blood pressure reading by placing the cuff on the right arm 3. Drawing blood for lab studies from the temporary dialysis line 4. Administering acetaminophen with codeine PO for moderate postoperative pain

3. Drawing blood for lab studies from the temporary dialysis line

Which task associated with the patient's 24-hour urine collection is appropriate for the nurse to delegate to the UAP? 1. Instructing Ms. J to collect all urine with each voiding 2. Teaching Ms. J the purpose of collecting urine for 24 hours 3. Ensuring that all of Ms. J's urine collected for the test is kept on ice 4. Assessing Ms. J's urine for color, odor, and sediment

3. Ensuring that all of Ms. J's urine collected for the test is kept on ice

The HCP prescribes atenolol 50 mg each morning for Ms. S. Which instruction would the nurse provide for the LPN/LVN assigned to give this drug? 1. Hold the drug if the client's blood pressure is higher than 100/80 2. Give the drug if the client's respiratory rate is greater than 30 3. Hold the drug if the client's heart rate is less than 55 4. Give the drug if the client's blood pressure is less than 90/50

3. Hold the drug if the client's heart rate is less than 55

(Mr. W: severe dyspnea, shortness of breath after MDI, coldlike sx, productive cough, incontinent, hx of COPD, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F) Which assessment finding would the nurse instruct the UAP to report immediately? 1. Incontinence of urine and stool 2. 1-lb weight loss since admission 3. Patient cough productive of greenish-yellow sputum 4. Eating only half of breakfast and lunch

3. Patient cough productive of greenish-yellow sputum

Ms. S- chest pressure, indigestion with nausea Which action prescribed by the HCP for Ms. S takes first priority at this time? 1. Measure vital signs every 2 hours 2. Obtain a 12-lead ECG every 6 hours 3. Place the client on a cardiac monitor 4. Check levels of cardiac markers every 6 hours

3. Place the client on a cardiac monitor

The UAP tells the nurse that Mr. W (SOB) is unable to complete his morning care without assistance and wonders if he is being lazy. What is the nurse's best response? 1. Encourage the patient to do as much as he can as quickly as he can 2. If the patient is short of breath, increase his oxygen flow 3. Remind the patient to take his time and not to rush his morning care 4. He may not need as much help as he is asking for, so try to get him to do more

3. Remind the patient to take his time and not to rush his morning care

While making rounds, the RN finds Ms. J in tears and sobbing. She states, "I just don't want to have to go back to dialysis 3 days a week!" What is the nurse's best response? 1. Would you like me to call someone to come in and sit with you? 2. You can always get on the list for another kidney transplant 3. Tell me some more about how you are feeling 4. Let me call your HCP to come in and speak with you

3. Tell me some more about how you are feeling

Which key point would the nurse be sure to include when teaching Mr. C about the postprocedure care for cardiac catheterization? 1. There are no restrictions after the procedure 2. You will be able to get out of bed within 2 hours after the procedure 3. You will have to stay almost flat in bed with limited position changes for 4 to 6 hours 4. Family visitors will be restricted until the next day

3. You will have to stay almost flat in bed with limited position changes for 4 to 6 hours

The RN team leader assigns the LPN/LVN to give Ms. J's 9:00 AM oral medications. Which key instruction or action will be most important that the RN give the LPN/LVN regarding administering Ms. J's atenolol 50 mg tablet? 1. Give this drug with just a few swallows of water 2. Ask the patient if she has been taking a diuretic at home 3. Instruct the patient to use the bedside commode 4. Check the patient's heart rate and blood pressure

4. Check the patient's heart rate and blood pressure

Before discharging Ms. S (STEMI), the HCP orders an ECG. This test reveals normal sinus rhythm with a heart rate of 88. What is the nurse's best action at this time? 1. Delay the client's discharge until she is seen by the HCP 2. Administer the client's next dose of atenolol 3 hours early before she goes home 3. Contact the HCP and ask about drawing an additional set of cardiac markers 4. Document this finding as the only action

4. Document this finding as the only action

What intervention is required at this time? (Hyperacute rejection) 1. Increased doses of immunosuppressive drugs 2. IV antibiotics 3. Conservative management including dialysis 4. Immediate removal of the transplanted kidney

4. Immediate removal of the transplanted kidney

Which intervention would the RN assign to an experienced LPN/LVN? 1. Drawing a sample for ABG determination 2. Administering albuterol by hand-held nebulizer 3. Measuring vital signs every 2 hours 4. Increasing oxygen delivery to 2 L/min via nasal cannula

4. Increasing oxygen delivery to 2 L/min via nasal cannula

The RN observes the patient's use of the albuterol MDI. The patient takes 2 puffs from the inhaler in rapid succession. Which intervention takes priority at this time? 1. Call the pharmacy to request a spacer for the patient 2. Notify the provider that the patient will need to continue receiving nebulizer treatment 3. Ask the UAP to help get the patient into a chair 4. Instruct the patient about proper techniques for using an MDI

4. Instruct the patient about proper techniques for using an MDI

Which action is best for the nurse to delegate to a new UAP orienting to the CCU when caring for Ms. S? 1. Placing the client on a cardiac telemetry monitor 2. Drawing blood to test cardiac marker levels and sending it to the laboratory 3. Obtaining a 12-lead ECG 4. Monitor and recording the client's intake and output

4. Monitor and recording the client's intake and output

The HCP orders DAT (dual antiplatelet therapy) for Ms. S. What is the nurse's priority concern for this client? 1. Reminding the client to do no heavy lifting while hospitalized 2. Assessing the progression of walking in the halls 3. Teaching the client to apply oxygen for any shortness of breath 4. Monitoring the client for any form of bleeding

4. Monitoring the client for any form of bleeding

The LPN/LVN reports to the RN that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if the client can be restrained. What is the RN's best reponse? 1. Yes, this client had a heart attack, and we must keep her on the cardiac monitor 2. Yes, but be sure to use soft restraints so that the client's circulation is not compromised 3. No, we must have a HCP's order before we can apply restraints in any situatin 4. No, but try covering the lead wires with the sheet so that the client does not see them

4. No, but try covering the lead wires with the sheet so that the client does not see them

(Mr. W: severe dyspnea, shortness of breath after MDI, coldlike sx, productive cough, incontinent, hx of COPD, BP 154/92, HR 118, O2 sat 88 on 1 L/min, RR 38, T 100.9 F) The UAP checks morning vital signs and immediately reports the following values to the nurse. Which takes priority when notifying the HCP? 1. HR of 96 2. BP of 160/90 3. RR of 34 4. Oral temperature of 103.5

4. Oral temperature of 103.5

Which medication should the nurse be prepared to administer to lower the patient's potassium level? 1. Furosemide 40 mg IV push 2. Epoetin alfa 300 units/kg sq 3. Calcium 1 tablet PO 4. Sodium polystyrene sulfonate 15 g PO

4. Sodium polystyrene sulfonate 15 g PO

The nurse delegates to the UAP the task of taking Ms. S's vital signs every 4 hours and recording the vital sign values in the electronic chart. Later the nurse checks the client's chart and discovers the vital sign measurements have not been recorded. What is the nurse's best action? 1. Take the vital signs because the UAP is not competent to complete this task 2. Notify the nurse manager immediately 3. Reprimand the UAP at the nurse's station 4. Speak to the UAP privately to determine why the values were not recorded

4. Speak to the UAP privately to determine why the values were not recorded

Ms. J is preparing for discharge. The RN is supervising a student nurse, who is teaching the patient about her discharge medications. For which statement by the student nurse will the RN intervene? 1. Sevelamer prevents your body from absorbing phosphorous 2. Take your folic acid after dialysis on dialysis days 3. The docusate is to prevent constipation that may be caused by ferrous sulfate 4. You must take the epoetin alfa three times a week by mouth to treat anemia

4. You must take the epoetin alfa three times a week by mouth to treat anemia