PC Unit 2
You are a 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 the correct order the steps that the student nurse should teach the patient. 1. Open your mouth and places the mouth piece 1-2 inches away 2. Tilt your head back and breathe out fully 3. Remove the inhaler cap and shake the inhaler 4. Hold your breath for at least 10 secs 5. Press down firmly on the canister and breathe deeply through your mouth 6. Wait at least 1 minute between puffs
3. Remove the inhaler cap and shake the inhaler 2. Tilt your head back and breathe out fully 1. Open your mouth and places the mouth piece 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 secs 6. Wait at least 1 minute between puffs
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A. Perform postural drainage and chest physiotherapy every 4 hours. B. Allow the patient to decide whether she needs aerosolized medications. C. Place the patient in a private room to decrease the risk of further infection. D. Plan activities to allow at least 8 hours of uninterrupted sleep.
A
A client who has frequent watery stool is admitted to the unit due to dehydration possibly caused by C. difficile. Which nursing action should the charge nurse delegate to an LPN/LVN? A. Giving the ordered metronidazole (Flagyl) 500 mg PO to the client. B. Reconsidering the client's medical history for any risk factors for diarrhea. C. Doing ongoing assessments to determine the client's hydration status. D. Explaining the purpose of ordered stool cultures to the client family.
A
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? A. Determine the level of consciousness B. Push the call button for help C. Turn the client face up to assess D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician
A
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? A. Perform endotracheal intubation and initiate mechanical ventilation. B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. C. Administer furosemide (Lasix) 100 mg IV push stat. D. Call a code for respiratory arrest.
A
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant? A. Assisting the patient to sit up on the side of the bed. B. Instructing the patient to cough effectively. C. Teaching the patient to use incentive spirometry. D. Auscultation of breath sounds every 4 hours.
A
The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first? A. Place the client on airborne and contact precautions B. Introduce normal saline at 75 mL/hr C. Give methylprednisolone (SOLU-Medrol) 1 g intravenously (IV) D. Take blood, urine, sputum cultures
A
The nurse is caring for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action can be delegated to the nursing assistant? A. Implement contact precautions when caring for the client. B. Monitor the results of ordered laboratory culture and sensitivity tests. C. Teach the client and family members about means to prevent transmission of VRE. D. Interact with other departments when the client is transported for ordered tests.
A
The nurse is caring for four clients receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection? A. A client who has a non-tunneled central line in the left internal jugular vein. B. A client with an implanted port in the right subclavian vein. C. A client with a peripherally inserted central catheter (PICC) line in the right upper arm. D. A client who has midline IV catheter in the left antecubital fossa
A
The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities
A
The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? A. Suggest that the patient's oxygen be humidified. B. Suggest that a simple face mask be used instead of a nasal cannula. C. Suggest that the patient be provided with an extra pillow. D. Suggest that the patient sit up in a chair at the bedside.
A
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing. B. Plan a nursing care regimen that gradually increases activity intolerance. C. Assist the patient with basic activities of daily living. D. Consult with the physical therapy department about reconditioning exercises.
A
There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room? A. A client with a cough who may have tuberculosis B. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C) C. A client with diarrhea caused by C. difficile D. A client with a wound infected with Vancomycin-resistant enterococci (VRE)
A
Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration? A. Warfarin (Coumadin) 1.0 mg by mouth (PO) B. Morphine sulfate 2 to 4 mg IV C. Cephalexin (Keflex) 250 mg PO D. Heparin infusion at 900 units/hr
A
You are admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism? A. The patient was recently in a motor vehicle accident B. The patient participated in an aerobic exercise program for 6 months C. The patient gave birth to her youngest child 1 year ago D. The patient was on bed rest for 6 hours after a diagnostic procedure
A
You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? A. Frequent swallowing B. Hypotonic bowel sounds C. Complaints of a sore throat D. Heart rate of 112 beats/min
A
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's
A, B
You are acting as a preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply. A. A 38-year old with moderate persistent asthma awaiting discharge. B. A 63-year old with a tracheostomy needing tracheostomy care every shift. C. A 56-year old with lung cancer who has just undergone left lower lobectomy. D. A 49-year old just admitted with a new diagnosis of esophageal cancer.
A, B
A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. A. Use a lift sheet when moving and positioning the patient in bed. B. Use an electric razor when shaving the patient each day. C. Use a soft-bristled toothbrush or tooth sponge for oral care. D. Use a rectal thermometer to obtain a more accurate body temperature. E. Be sure the patient's footwear has a firm sole when the patient ambulates.
A, B, C, E
You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? Select all that apply. A. Avoid potential environmental asthma triggers such as smoke. B. Use the inhaler 30 minutes before exercising to prevent bronchospasm. C. Wash all bedding in cold water to reduce and destroy dust mites. D. Be sure to get at least 8 hours of rest and sleep every night. E. Avoid foods prepared with monosodium glutamate (MSG).
A, B, D, E
The nurse is assigned to a client who has been diagnosed with disseminated herpes zoster. Which PPE will the nurse plan to use when preparing to assess the client? Select all that apply. A. Gloves B. Goggles C. Gown D. N95 respirator E. Surgical Face Mask F. Shoe covers
A, C, D
A 25-year-old client comes to the outpatient unit with complaints of diarrhea, abdominal pain, shortness of breath, and epistaxis. Which action should the nurse take first? A. Learn whether the client has had recommended immunizations. B. Ask the client about any recent travel to Asia or the Middle East. C. Have the client pinch the anterior nares firmly for 5 minutes. D. Request an ambulance to take the client quickly to the hospital.
B
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female client with a pressure ulcer that needs dressing change.
B
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid: A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates
B
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? A. Call for help to get the client back in bed B. Establish whether the client is responsive C. Assist the client back to bed D. Ask the client what happened
B
Nurse Jenny of Nurseslabs Medical Center is planning care for a client who had undergone colposcopy. Which of the following actions should the RN take first? A. Discuss the client's fear regarding potential cervical cancer. B. Assist with silver nitrate application to the cervix to control bleeding. C. Give instructions regarding douching and sexual relations. D. Administer pain medications.
B
Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent: A. Pain B. Wound infection C. Depression D. Thrombophlebitis
B
Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first? A. Decontaminate the client's clothing. B. Decontaminate the open wound on the client's thigh. C. Decontaminate the examination room the client is placed in. D. Save the client's vomitus for analysis by the radiation safety staff.
B
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse? A. Give potassium 10 mEq orally B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally C. Give spironolactone (Aldactone) 25 mg orally D. Assess the electrocardiogram (ECG) strip for tall T waves
B
The high-pressure alarm on a patient's ventilator goes off. When you enter 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 you take next? A. Reassure the patient that the ventilator will do the work of breathing for him. B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning. D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
B
The monitor watcher from the telemetry units informs the assigned nurse that the client developed prominent U waves. Which laboratory value should the nurse monitor? A. Sodium level B. Potassium level C. Calcium level D. Magnesium level
B
The nurse is caring for a client with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of the following nursing actions can a nurse assign to an LPN/LVN? A. Assess risk for further skin breakdown. B. Collect wound cultures during dressing changes. C. Create methods to improve the client's oral protein intake. D. Educate the client about home care of the leg ulcer.
B
The school nurse is asked which action will take to have the most impact on the incidence of infectious diseases in school. The correct response is: A. Grant written information about infection control to all parents. B. Ensure that students are immunized according to national guidelines. C. Make soap and water easily accessible in the classrooms. D. Educate students on how to cover their mouths when coughing.
B
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with respiratory distress syndrome (RDS)? A. Theophylline (Theolair, Theochron) B. Surfactant (Exosurf) C. Dexamethasone (Decadron) D. Albuterol (Proventil)
B
When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching? A. "Everyone in my family needs to go and see the doctor for TB testing." B. "I will continue to take my isoniazid until I am feeling completely well." C. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." D. "I will change my diet to include more foods rich in iron, protein, and vitamin C."
B
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant? A. Assessing the patient's respiratory status every 4 hours B. Taking vital signs and pulse oximetry readings every 4 hours C. Checking the ventilator settings to make sure they are as prescribed D. Observing whether the patient's tube needs suctioning every 2 hours
B
You are 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 you immediately? A. The patient has fine bibasilar crackles. B. The patient's respiratory rate is 8 breaths/min. C. The patient sits up and leans over the night table. D. The patient has a large barrel chest.
B
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant? A. Instructing the patient to alternate rest and activity periods B. Encouraging, monitoring, and recording nutritional intake C. Monitoring cardiorespiratory response to activity D. Planning activities for periods when the patient has the most energy
B
You are supervising a nursing student who is providing care for a patient with thoracotomy with a chest tube. What findings would you clearly instruct the nursing student to notify you about immediately? A. Chest tube drainage of 10 to 15 mL/hr. B. Continuous bubbling in the water seal chamber. C. Complaints of pain at the chest tube site. D. Chest tube dressing dated yesterday.
B
You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly prove to the RN? Select all that apply. A. Position the patient supine and turned on his side. B. Apply direct lateral pressure to the nose for 5 minutes. C. Maintain universal body substances precautions. D. Apply ice or cool compresses to the nose. E. Instruct the patient not to blow the nose for several hours.
B, C, D, E
A client is admitted to the unit with the diagnosis of Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be charged to a nursing assistant? A. Administer intravenous (IV) fluids as prescribed by the physician. B. Develop a plan for added fluid intake over 24 hours. C. Provide straws and offer fluids between meals. D. Educate family members to assist the client with fluid intake.
C
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant? A. Discuss weight-loss strategies such as diet and exercise with the patient. B. Teach the patient how to set up the BiPAP machine before sleeping. C. Remind the patient to sleep on his side instead of his back. D. Administer modafinil (Provigil) to promote daytime wakefulness.
C
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? A. A client scheduled for cardiac ultrasound this morning. B. A client with syncope being discharged today. C. A client with chronic bronchitis on nasal oxygen. D. A client with diabetic foot ulcer that needs a dressing change.
C
The assigned LPN of the unit reports to you that a client's blood pressure and heart rate have decreased, and when her face is assessed, one side twitches. What is the most appropriate thing to do as a nurse? A. Assess the client's pupillary reaction to light. B. Obtain a neurologic exam request for the client. C. Review the client's morning calcium level. D. Retake the client's blood pressure and heart rate.
C
The charge nurse from the unit receives a call from the pediatrician wanting to admit an 8-year-old child with rubeola (measles). Which of the following is of most concern in deciding whether to admit the child to the unit? A. The unit is not staffed with the usual number of RNs. B. There are several children receiving chemotherapy on the unit. C. No negative-airflow rooms are available on the unit. D. The infection control nurse liaison is not on the unit today.
C
The charge nurse is delegating tasks to her subordinates in the medical unit. Which infection control activity should she assign to an experienced nursing assistant? A. Asking clients about the use of immunosuppressant medications. B. Demonstrating correct hand washing to client visitors. C. Disinfecting blood pressure cuffs after clients are discharged. D. Screening clients for upper respiratory tract symptoms.
C
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from bronchoscopy and biopsy. C. A 72-year old who needs teaching about the use of incentive spirometry. D. A 69-year old with COPD who is ventilator dependent.
C
The nurse just received the client's morning laboratory results. Which of these results is of most concern? A. Serum sodium level of 134 mEq/L B. Serum potassium level of 5.2 mEq/L C. Serum magnesium level of 0.8 mEq/L D. Serum calcium level of 10.6 mg/dL
C
You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? A. Administer ordered antibiotics as scheduled B. Hyperoxygenate the patient before suctioning C. Maintain the head of the bed at a 30 to a 45-degree angle D. Suction the airway when coarse crackles are audible
C
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant? A. Teaching the patient about the importance of adequate fluid intake and hydration. B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed. C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake. D. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
C
You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient's only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician? A. The patient says that her right leg aches all night B. The right calf is warm to the touch and is larger than the left calf C. The patient is unable to remember her husband's first name D. There are multiple ecchymotic areas on the patient's arms
C
You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant? A. Pulmonary embolism B. Bronchitis C. Pneumothorax D. Pneumonia
C
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene? A. Suctioning the tracheostomy tube before performing tracheostomy care B. Removing old dressings and cleaning off excess secretions C. Removing the inner cannula and cleaning using universal precautions D. Replacing the inner cannula and cleaning the stoma site.
C
You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? A. Assessing for bilateral breath sounds and symmetrical chest movements. B. Auscultating over the stomach to rule out esophageal intubation. C. Marking the tube 1 cm from where it touches the incisor tooth or nares. D. Ordering a chest radiograph to verify that tube placement is correct.
C
You have just finished assisting the physician 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 important to report to the physician? A. The patient starts crying and says she can't go on with treatment much longer. B. The patient complains of sharp, stabbing chest pain with every deep breath. C. The patient's blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min. D. The patient's dressing at the thoracentesis site has 1 cm of bloody drainage.
C
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? Select all that apply. A. Assess for indicators of fluid imbalance. B. Review fingerstick glucose results every hour. C. Measure vital signs every 15 minutes. D. Document intake and output every hour.
C, D
A 7-year-old girl who has just endured allogeneic stem cell transplantation will need protective environmental stimulation. Which nursing task should the nurse delegate to the nursing assistant? Select all that apply. A. Educating the client to perform careful handwashing after using the bathroom. B. Communicating with the family members about the grounds for isolation. C. Stock the client's room with the required PPE items. D. Reminding the visitors to wear a face mask, gloves, and gown. E. Posting the precautions for protective isolation on the door of the client's room
C, D, E
A 56-year-old male is newly admitted to the medical unit. Which factor alerts the nurse that this client has a risk for acid-base imbalances? A. The client takes antacids for occasional indigestion. B. The client gets short of breath with extreme exertion. C. The client has a history of myocardial infarction 1 year ago. D. The client has chronic renal insufficiency.
D
A client going through intense chemotherapy treatment is admitted to the unit. Which of these would the nurse instruct the nursing assistant to report to prevent an acid-base imbalance? A. Hair loss during the morning bath. B. Complaints of pain associated with exertion. C. Failure to eat all the food on the breakfast tray. D. Prolonged episodes of nausea and vomiting.
D
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? A. Administer pain medications B. Administer IV fluids C. Administer dopamine D. Administer oxygen via nasal cannula
D
A group of nursing students is assigned to care for a client with a nasogastric tube connected to a wall suction. One student asks why the client's respiratory rate has decreased. Choose the best response. A. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps fix the problem." B. "The client is hypoventilating because of anxiety, and we will have to stay observant for the development of respiratory acidosis." C. "It's common for clients with uncomfortable equipment such as nasogastric tubes to have a lower rate of breathing." D. "The client may have a metabolic alkalosis due to the nasogastric suctioning, and the decreased respiratory rate is a compensatory mechanism."
D
A mother of a 14-year-old client receiving chemotherapy for leukemia calls out to the unit concerning her other child having chickenpox. Which of these actions will the nurse anticipate taking next? A. Plan to admit the client to a private room in the hospital. B. Teach the mother about contact and airborne precautions. C. Educate the mother about the correct use of acyclovir (Zovirax). D. Administer varicella-zoster immune globulin to the client.
D
A newly admitted client is suspected to have avian influenza ("bird flu") due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first? A. Give first dose of oseltamivir (Tamiflu) B. Instill 5% dextrose in water at 100 mL/hr C. Collect blood and sputum specimens for testing D. Start oxygen using a non-rebreather mask
D
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
D
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm Hg D. Tympanic temperature of 101.4ºF (38.6ºC)
D
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience working on. Which client should be assigned to her? A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. B. A client with balanced skeletal traction and needs assistance with morning care. C. A client who had an above-the-knee amputation yesterday and currently has a temperature of 101.4ºF. D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
D
Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first? A. Call for a social worker to meet with the family. B. Check the child's blood pressure, pulse, respiration, and temperature. C. Administer pain medications D. Speak with the parents about how the fracture occurred.
D
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client? A. Hepatitis A vaccine B. Lyme's disease vaccine C. Hepatitis B vaccine D. Pneumococcal vaccine
D
Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to: A. Role modeling behaviors of the preceptor B. The philosophy of the new nurse's school of nursing C. The orientation provided to the new nurse D. Lack of trust in the members of the healthcare team
D
The newly hired nurse is assigned by the charge nurse to care for a client with acute renal failure and hypernatremia. Which action can the nurse assign to the nursing assistant? Select all that apply. A. Administer 0.45% saline by IV line B. Assess daily weights for trends C. Check for indications of dehydration D. Render oral care every 3 to 4 hours
D
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately? A. Decrease in pain level from 6 to 2 (on a scale of 10) B. Heart rate of 90 to 100 beats/min C. Request by the client that the room door be closed D. Respiratory rate of 8 to 10 breaths/min
D
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status.
D
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A. Evaluating the patient's complaint of chest pain. B. Monitoring laboratory values for changes in oxygenation. C. Assessing for symptoms of respiratory failure. D. Auscultating the lungs for crackles.
D
In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning? Remove N95 Respirator Take off goggles preform hand hygiene take off gown remove gloves
remove gloves take of gown take off goggles remove respirations hand hygiene
