Q6 test 1

Rhabdomyolysis, which leads to necrosis of skeletal muscle, releases intracellular enzymes and proteins into the bloodstream and the extracellular space, most notably of these are: glycerol and fatty acids. • glycerol. • creatine kinase and myoglobin. • ALT, AST

creatine kinase and myoglobin.

A nurse is teaching a nursing student regarding the rhabdomyolysis. It is a syndrome characterized by: A breakdown of skeletal muscle reduce the excretion of myoglobin by the kidneys all of the above reduced serum levels of Creatine kinase

A breakdown of skeletal muscle

A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching? • "I will give my child pureed liver and strained pears." "I will give my child applesauce and green peas." • "I will give my child rice cereal and crackers." • " will give my child strained carrots and mashed egg yolks.

will give my child strained carrots and mashed egg yolks.

The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except: To ensure my safety, a 'time out' will be conducted in the operating room" "I cannot have anthing to drink or eat after midnight on the night before the surgery" "The skin prep area is going to be longer and wider than the anticipated incision" ) "After surgery, I will need to wear the pneumatic compression device while sitting in the chair"

"After surgery, I will need to wear the pneumatic compression device while sitting in the chair"

The nurse teaches new mothers about the reason their infants receive vitamin K. The nurse evaluates instruction as being effective when the mother makes which statement? "Babies could receive vitamin K through a liquid or an injection." "Babies do not need an injection of vitamin K unless bleeding is observed." "Babies do not have enough intestinal bacteria to synthesize vitamin K. Babies will be able to get enough vitamin K through breast milk."

"Babies do not have enough intestinal bacteria to synthesize vitamin K.

A young patient with a history of multiple allergies is prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The patient's mother says to the nurse, "I thought shock was about heart failure." What is the best response by the nurse? • "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure

• "There are many kinds of shock that also include infection, nervous system damage, and loss of blood."

The nurse provides care for several patients. For which patient would the nurse assess acetaminopherr (Tylenol) to be contraindicated? A 55-year old who drinks alcohol rations A 19-year-old with a bladder infection A 2-year-old with a high fever due to the flu A65-year-old with osteoarthritis

• A 55-year old who drinks alcohol

Ms. Teresa is the 7a-7p charge nurse on 24-bed telemetry unit. There are four RNs, two LPs, two UAPs, two telemetry technicians, and one unit secretary working on the unit along with Ms. Teresa. There are 20 clients in the unit Which client should Ms. Teresa assign to the most experienced RN on the unit? The client diagnosed with atrial fibrillation who is receiving the first dose of praxada (dabigatran). The client diagnosed with a myocardial infarction who is exhibiting occasional premature ventricular contractions. The client diagnosed with congestive heart failure who is coughing up pink, frothy sputum. The client diagnosed with mitral valve prolapse who is complaining of shortness of breath when sitting in the chair.

• The client diagnosed with congestive heart failure who is coughing up pink, frothy sputum.

The nurse, caring for a patient recovering from hypovolemic shock, prepares an infusion of Albumin 5% and explains the purpose of this infusion to the patient. Which statement indicates that the patient understands the instructions? "It is a liquid that has electrolytes in it to pull water into my blood vessels." "It is a super-concentrated salt solution that helps me conserve body fluid." "It is a protein that causes my kidneys to conserve fluid. "It is a protein that pulls water into my blood vessels.!

"It is a protein that pulls water into my blood vessels.!

The patient receives morphine for pain. He asks the nurse how it works to relieve pain. What is the best response by the nurse? "It interacts with Kappa and Mu receptors in your body that produce analgesia." "It stimulates the receptors that secrete endorphins in your brain." "It inhibits the primary pain neurotransmitters in your brain." "It promotes the primary pleasure neurotransmitters in your brain."

"It promotes the primary pleasure neurotransmitters in your brain."

patient, addicted to heroin, is being treated for opioid dependence. He has been prescribed methadone (Dolophine). The patient asks how this will help because methadone (Dolophine) is another opioid. What is the best response by the nurse? "Methadone (Dolophine) causes you to have an allergy to heroin." ) "Methadone (Dolophine) cures vour addiction to heroin." • "Methadone (Dolophine) will make you really sick if you use heroin." • "Methadone (Dolophine) does not cause euphoria like heroin does."

"Methadone (Dolophine) does not cause euphoria like heroin does."

The nurse teaches patients about nonpharmacological techniques for pain management. The nurse determines learning has occurred when the patients make which statements)? Select all that apply. "Nonpharmacological techniques include an aerobic exercise." Nonpharmacological techniques have not reached mainstream yet." "Nonpharmacological techniques are not usually valued by nurses." Nonpharmacological techniques may be used in place of drugs." "Nonpharmacological techniques are a good adjunct to pharmacotherapy."

"Nonpharmacological techniques are a good adjunct to pharmacotherapy." Nonpharmacological techniques may be used in place of drugs."

A client is to receive enteral nutrition. Which information should the nurse provide to the client and family? Select all that apply. "Your nutrition will be administered through your veins." "Enteral feedings are chosen when you cannot swallow enough to maintain nutrition." "Most enteral feeding consists of thinned pureed food" "Enteral feedings are milk based." "Nutrition can be given either intermittently or continuously..

"Nutrition can be given either intermittently or continuously.. "Enteral feedings are chosen when you cannot swallow enough to maintain nutrition."

A client is prescribed total parenteral nutrition (TPN). Which education should the nurse provide? Select all that apply. "Your TPN will be infused via an infusion pump." ~ "All of your nutrition can be supplied by TPN." "Once you go home, you will come in twice a week for TPN." | "Since this is going to be a long-term treatment, your TPN will be given through a central line." "You will not be able to return home until the TPN is discontinued."

"Since this is going to be a long-term treatment, your TPN will be given through a central line." "Your TPN will be infused via an infusion pump." "All of your nutrition can be supplied by TPN."

An older adult client admitted with heart failure and a sodium level of 113 Eq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating "The sodium level is high and the behavior is a result of dehydration." "The client may be suffering from dementia, and the hospitalization has worsened the confusion." "The sodium level is low, and the confusion will resolve as the levels normalize." ) "Most older adults get confused in the hospital."

"The sodium level is low, and the confusion will resolve as the levels normalize."

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of Sodium nitroprusside (Nipride). Dobutamine (Dobutrex). Nitroglycerine (Tridil). ) Norepinephrine (Levophed).

) Norepinephrine (Levophed).

The nurse is caring for a first day postoperative surgical client. Prioritize the patient's desired dietary progression. Arrange in sequence the dietary progression from 1 to 4: 1. Full liquid; 2. NPO; 3. Clear liquid: 4. Soft • 2, 1, 4, 3 • 2,3, 1, 4 • 4, 3, 2, 1 • 1,2, 3, 4

2,3, 1, 4

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A client who has a cast on the left leg and reports numbness and paresthesia A client who has diarrhea and requests clear liquids for breakfast A client who has pneumonia and has an axillary temperature of 38° C (101° F) A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150

A client who has a cast on the left leg and reports numbness and paresthesia

A nurse is caring for a client who is wheezing and gasping for air after starting the dose of amoxicillin. Which of the following action's place client on cardiac monitor Administer Epinephrine parental injection provide reassurance to the client initiate 0.9% NS

Administer Epinephrine parental injection

A patient brought to the emergency department for oxycodone overdose has a respiratory rate of 8 and is difficult to arouse. What is the priority nursing intervention? Preparing for intubation and mechanical ventilation Administering an opioid agonist Administering activated charcoal Administering an opioid antagonist

Administering an opioid antagonist

When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cordlike, and is tender to the touch. The patient reports it is aching and painful. What would be an inappropriate nursing intervention for this patient? Elevate the extremity 30 degrees without allowing any pressure on affected area Administer anticoagulants as ordered by MD Instruct the patient to not sit in one position for a long period of time Allow the patient to dangle the legs to help increase circulation and alleviate pain

Allow the patient to dangle the legs to help increase circulation and alleviate pain

The nurse is prioritizing care for a client based upon nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. Alteration in Perfusion Diarrhea Self-care Deficit Anxiety Fatigue Deficient Knowledge

Alteration in Perfusion Diarrhea Self-care Deficit Anxiety Fatigue Deficient Knowledge

A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.) Ambulate an older adult client who has hypertension. Check a blood product with another nurse prior to administration Provide discharge instructions for a client who has a new skin graft. Perform an admission assessment on a client Weigh a client who has heart failure.

Ambulate an older client Weigh a client who has heart failure

Several patients are admitted after being exposed to a substance that was released in their manufacturing plant. The patients are demonstrating flu-like symptoms, unproductive cough, and fever. These patients should be assessed for which type of exposure? Nuclear Detonation Anthrax Smallpox Dirty Bomb

Anthrax

nurse asks the assistive personnel (AP) to take a specimen to the laboratory and the AP refuses. Which of the following actions should the nurse take? Ask the AP about her concerns with the assignment Complete an incident report. Take the specimen to the laboratory. Report the AP to the charge nurse.

Ask the AP about her concerns with the assignment

You are the nurse on a medical unit taking care of a 50-year-old man, S.W., who was admitted 18 hours ago with peptic ulcer disease secondary to suspected chronic alcoholism. You enter S.Wi's room and witnessed new onset of generalized weakness upper and lower extremity. Identify priority nursing assessment that are appropriate for S.W. at this time. Select all that apply. Monitor urine for red or cola color, which might signal rhabdomyolysis or myoglobinuria from muscle damage Assess respiratory status, including airway patency; effort, lung sounds; use of accessory muscles and color of skin, lips, and nail beds. Monitor for weakness or paralysis, dysphasia, or visual disturbances. Check blood glucose and request serum laboratory tests as prescribed Monitor ability to handle secretions and assess gag, cough, and swallow reflexes.

Assess respiratory status, including airway patency; effort, lung sounds; use of accessory muscles and color of skin, lips, and nail beds.

The client is receiving total parenteral nutrition (TPN). What does the best plan by the nurse include to prevent complications from total parenteral nutrition? Assess the client's blood glucose levels. Assess the client's mental status. Assess the client's potassium levels. Assess the client's blood pressure.

Assess the client's blood glucose levels.

A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse? Assessing a client who experiences unilateral calf pain when ambulating Reinforcing a client's dressing for the surgical site of an above-the-knee amputation Taking a telephone prescription about a client who is to be transferred from PACU Reassuring the partner of a client who sustained a closed head injury

Assessing a client who experiences unilateral calf pain when ambulating

A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take? An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions A school-age child who has diabetes mellitus and requires blood glucose monitoring An infant who has pertussis and is receiving oxygen via nasal cannula A toddler who has both arms in casts and needs to be fed his breakfast

Atoddler who has both arms in casts and needs to be fed his breakfast

Which of the following drugs is administered to minimize respiratory secretions preoperatively? Phenergan (promethazine) Demerol (Meperidine) Atropine sulfate Valium (diazepam)

Atropine sulfate

The nurse is planning care for a patient in shock who is prescribed Albumin 5%. What should the nurse include in this patient's plan of care? Auscultate breath sounds for hyper-resonance Auscultate breath sounds for inspiratory stridor Auscultate for an absence of breath sounds in the lower lobes Auscultate breath sounds for crackles

Auscultate breath sounds for crackles

A new unit nurse manager is holding her first staff meeting. The manger greets the the staff and comments that she has been employed to bring about quality improvement. The manger provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leadership style do the new manger's characteristics suggest? Laizzez-faire Autocratic Democratic Situational

Autocratic

A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is a conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating? Negotiating ) Smoothing Cooperating Avoidance

Avoidance

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? Check capillary blood glucose level every 6 hours Turn and reposition the patient every 2 hours. Document intracranial pressure every hour. Monitor cerebrospinal fluid color hourly.

Check capillary blood glucose level every 6 hours

As the nurse you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the preoperative checklist? Conducting the Time Out Ensuring that the history and physical examination has been completed Assess for allergies Informed consent is signed

Conducting the time out

A nurse manger has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant? Confront the nursing assistant to encourage verbalization of feelings regarding the change Use coercion with the nursing assistant Provide a positive reward system for the nursing assistant Ignore the resistance

Confront the nursing assistant to encourage verbalization of feelings regarding the change

A client with congestive heart failure is having difficulty breathing. Before leaving the rom the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? Critical thinking Priority-setting Conflict resolution Delegating a task

Critical thinking

A nurse is assessing a postoperative patient who has a family history of malignant hyperthermia. Which findings would be of most concern to the nurse regarding rhabdomyolysis? Temperature elevation 3 hours after the procedure Dark urine 3 hours after surgery Tachycardia in the first hour after surgery ) Respiratory rate increase to 18 breaths per minute 2 hours after the procedure

Dark urine 3 hours after surgery

The nurse is performing an assessment on a client with a diagnosis of a brain tumor that is located in the brainstem and notes that the client is assuming the posture in the figure. The nurse contacts the primary health care provider and reports that the client is exhibiting which assessment finding? Refer to figure Flaccid quadriplegia Decorticate posturing Decerebrate posturing Opisthotonos

Decebrate posturing

The nurse is admitting a confused older adult client with appendicitis who is combative and yelling at staff. The surgeon is planning surgery in one hour. Which action in the highest priority? Explain to the client the need and urgency of the surgery Assess pain level Evaluate for rebound tenderness Determine if there is family available

Determine if there is family available

A nurse is caring for a client who is receiving total parenteral nutrition (TP). The pharmacy is delayed in supplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? ) Dextrose 5% in water Lactated Ringer's solution O Dextrose 10% in water 0.9% sodium chloride

Dextrose 10% in water

The nurse should have a high suspicion for myoglobinuria and rhabdomyolysis with which type of burn injury? Tar burn Carbon monoxide poisoning Electrical burn Chemical burn

Electrical burn

A train derailed in a local community. The contents of the train caused a hazardous spill, and noxious gasses are being released into the environment. All local and surrounding fire control and Hazmat teams have been mobilized and the event is considered under control. Which type of situation should the nurse prepare for? Human generated accidental disaster Disaster Intentional emergency Emergency

Emergency

The nurse should use which guideline(s) to plan delegation and assignment making activities? Select all that apply The number of anticipated client discharges The clustering of the rooms on the unit Requests from the staff Ensuring client safety Client needs and workers' needs and abilities

Ensuring client safety Client needs and workers' needs and abilities

During a health assessment, a client states, "I only eat carbohydrates and low-fat foods. ITon't understand why I am still gaining weight!". What should the nurse consider before responding to this client? Select all that apply. Excess carbohydrates are converted to fat. A carbohydrate limited diet is the only way to not gain weight. Excess carbohydrates can lead to obesity. Carbohydrates should be high in fiber and low in sugar. Carbohydrates should only be eaten at breakfast.

Excess carbohydrates are converted to fat. Excess carbohydrates can lead to obesity. Carbohydrates should be high in fiber and low in sugar.

What steps would you take if you administered an incorrect dose to your patient via IV?. Please address patient care/assessment and administrative processes you might take.

First I would do an assessment and vitals on my patient to ensure they are stable and there are no adverse effects of that specific medication is occurring. Next once making sure they are stable I would inform them and the charge nurse of the medication dosage error. Lastly I would document the error I made only stating facts and not specifically stating that I made an error or any of my opinions.

Which of the following items on a client's presurgery laboratory results would indicate a need to contact the surgeon? Total cholesterol of 325 mg/di Hemoglobin 6.5 mg/d Blood urea nitrogen (BUN)) 17 mg/di ) Platelet count of 250,000/cu.mm

Hemoglobin

The nurse has completed the admission assessment of a client with acute bipolar disorder. Based on the assessment, what is the priority focus for the nursing plan of care? Client teaching Hydration and nutrition Control the client's hyperactivity Monitor relevant lab values

Hydration and nutrition

The patient has been keeping a "headache diary" of her migraines. Upon review of this diary, the nurse notes that the headaches are described as mild and have happened four times in the last 3 months. The patient reports that she "generally just lies down until they pass" but that her new job will not allow that time. She is requesting information about pain medication. What medications would the nurse expect to be prescribed? select all that apply Ergotamine (Ergostat) Amitriptyline (Elavil) Acetaminophen Ibuprofen morphine

Ibuprofen Acetaminophen

A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the procedure's efficacy? Accurate documentation of how procedure was performed Frequency with which procedure is performed Incidence of complications related to procedure Client satisfaction with performance of procedure

Incidence of complications related to procedure

A nurse is providing teaching to the parent of an infant about the introduction of solid foods. The nurse should recommend that which of the following foods be introduced first? Strained fruits Iron-fortified cereal Cooked egg Whites Pureed meats

Iron fortified cereal

The client is a vegetarian. What information would the nurse give the client as it relates to the avoidance of vitamin deficiencies? Increasing fluids and fiber with the vegetarian diet will help prevent vitamin deficiencies. You are at risk for vitamin C deficiencies by following a vegetarian diet. Look at the types of foods eaten on the vegetarian diet and evaluate for possible vitamin B12 sources. A vegetarian diet is adequate to meet all of your needs, so there should be no vitamin deficiencies.

Look at the types of foods eaten on the vegetarian diet and evaluate for possible vitamin B12 sources.

Several victims of a suspected biologic attack are brought into the emergency department. Which type of personal protective equipment should be provided to these victims? • Gloves • Goggles • Mask Gown

Mask

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP) Monitoring vital signs of a client who had an appendectomy 12 hr ago Obtaining medical history information from a stable client who is being admitted Removal of the nasogastric tube of a client who has been receiving enteral feedings Application of antibiotic ointment to the arm of a client who has dermatitis

Monitoring vital signs of a client who had an appendectomy 12 hr ago

Which of the following are classic sign with rhabdomyolysis? Select all apply Muscle weakness Decrease level of Consciousness Hyperthermia Red-brown urine Muscle pain

Muscle weakness Red brown urine Muscle pain

The National Weather Service has announced the likelihood of a large snow event in a major metropolitan area. For which type of health problem should the nurses in the emergency department prepare? Stress related injuries • Myocardial Infarctions • Burns Crushing Injuries

Myocardial infarction

The nurse is working on a unit with an unlicensed assistive person (UAP). One nurse refuses to utilize the UAP and is consistently leaving nursing tasks for the next shift that have yet to be completed. The nurse is jeopardizing effective care because of: Overdependence on others. The state nurse practice act. The belief that no one else can perform a task as well as the nurse can. Avoidance of responsibility.

The belief that no one else can perform a task as well as the nurse can.

The patient has a patient-controlled analgesia (CA) pump following surgery. The nurse keeps naloxone (Narcan) in the patient's room as per protocol. What does the nurse recognize as the rationale for this protocol? • Naloxone (Narcan) is the antidote if an anaphylactic reaction to the opioid in the patient-controlled analgesia (PCA) pump occurs. Naloxone (Narcan) enhances the effect of the opioid in the patient-controlled analgesia (PCA) pump and increases analgesia. O Naloxone (Narcan) will reverse the effects of the narcotic in the patient-controlled analgesia (PCA) pump if an overdose occurs. ) Naloxone (Narcan) is available to treat any systemic side effects, like constipation, of the opioid in the patient-controlled analgesia (PCA) pump.

Naloxone (Narcan) will reverse the effects of the narcotic in the patient-controlled analgesia (PCA) pump if an overdose occurs.

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of Dobutamine (Dobutrex). Nitroglycerine (Tridil). Norepinephrine (Levophed). I Sodium nitroprusside (Nipride).

Norepinephrine (Levophed).

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to Obtain an oxygen saturation. Attach a cardiac monitor. Check level of consciousness. Check the blood pressure.

Obtain o2 sat

Which of the following are signs of early hypovolemic shock? (Select all that apply.) Prolonged capillary refill time Rapid weak pulse Normal blood pressure Normal respirations Slight increase in pulse

Prolonged capillary refill time Normal blood pressure Normal respirations Slight increase in pulse

The charge nurse on a cardiac unit has received laboratory reports to assess. Which lab report is priority for the charge nurse to assess?

RS, who is scheduled for a coronary artery bypass graft (CAGB)

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LP) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN? I Measure I&0 for a client who has an indwelling urinary catheter. Develop a plan of care for a client who has cholecystitis. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. ) Complete an admission assessment for a client who has COPD

Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.

The nurse is planning care for a client who receives total parenteral nutrition. What will the best plan by the nurse include? Maintain a dedicated percutaneous endoscopic gastrostomy (PEG) tube for the solution. Check the feeding tube for residual prior to initiating feedings. Withhold oral medications while the total parenteral nutrition (TPN) is hanging. Remove the solution from the refrigerator 30 minutes prior to hanging.

Remove the solution from the refrigerator 30 minutes prior to hanging.

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention? Encourage patient intake of 3000 ml/day of fluids if not contraindicated • Repositioning every 3-4 hours • Encourage patient to use the incentive spirometer device every 1-2 hours while awake ) Encourage early ambulation and patient to eat meals in beside chair

Repositioning every 3-4 hours

Which one of the following is the cause of Rhabdomyolysis? Sedatives and narcotics, particularly street heroin Impairment of the breakdown of glycogen and production of lactic acid Autoimmune disease Exercise intolerance with the normal production of lactic acid

Sedatives and narcotics, particularly street heroin

A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery? None of the above are correct The medication should be discontinued for 48 hours prior to the scheduled surgery date Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots To hold his morning dose of Aspirin because the nurse will give it to him before surgery

The medication should be discontinued for 48 hours prior to the scheduled surgery date

The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because: The UAP is not trust worthy The nurse maintains the authority to care for the patients. The UAP cannot report to the next shift The nurse remains accountable for the patient's care

The nurse remains accountable for the patient's care

A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. What will the nurse assess after administering this medication? Vasoconstriction and increased blood pressure Stabilization of fluid loss Increased cardiac output Urinary output of at least 30 mL/hour

Urinary output of at least 30 mL/hour

A charge nurse delegates to a licensed practical nurse (LP) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take? Reassign the task to another nurse. ) Change the client's dressing. Verify the LP knows how to do a dressing change. Report the issue to the unit manager.

Verify the LP knows how to do a dressing change.

A nurse is completing discharge teaching for a patient who is about to be discharged to home following a total hip replacement. The patient asks the nurse why there is a case manager involved and expresses confusion about who is in charge. The patient states, "I thought the doctor manages my care." The best response by the nurse is: a case manager coordinates everyone in your care to ensure your needs are met The case manger delegates your care to the nurse No, I managed my care You are correct, the doctor is responsible for managing your care

a case manager coordinates everyone in your care to ensure your needs are met

The nurse is preparing educational materials for a client with hypertension. Which dietary changes should the nurse focus when preparing this material? Select all that apply. | Using the DASH eating plan Explaining the effects of sodium on blood pressure Teaching how to read nutritional labels Avoiding all sodium in the diet Recognizing foods that are low in sodium

| Using the DASH eating plan Explaining the effects of sodium on blood pressure Teaching how to read nutritional labels Recognizing foods that are low in sodium

A nurse has just received a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? The client who needs help ambulating to the bathroom The client experiencing shortness of breath The client who needs assistance with activities of daily living The client with a pain rating of 3/10

© The client experiencing shortness of breath