Quiz #4

The charge nurse is delegating and assigning patient care to his or her team members for the shift. A. LPN/LVN B. UAP C. RN _______Check and record vital signs for each patient. _______ Administer docusate sodium, 50 mg orally to a patient passing hard stool. _______ Bathe bedridden confused patient. _______ Complete an assessment on a newly admitted patient for altered level of consciousness. _______Measure out put and empty patient's urinary catheter bag at end of shift. _______Place a urinary catheter as ordered by the health care provider(HCP). _______Teach a rehab patient to call for help when getting out of bed to the bathroom. _______ Check fingerstick blood glucose and administer sliding scale insulin as ordered if glucose is elevated.

*UAP* = Check and record vital signs for each patient. *LPN/LVN* = Administer docusate sodium, 50 mg orally to a patient passing hard stool. *UAP* = Bathe bedridden confused patient. *RN* = Complete an assessment on a newly admitted patient for altered level of consciousness. *UAP* = Measure out put and empty patient's urinary catheter bag at end of shift. *LPN/LVN* = Place a urinary catheter as ordered by the health care provider(HCP). *RN* = Teach a rehab patient to call for help when getting out of bed to the bathroom. *LPN/LVN* = Check fingerstick blood glucose and administer sliding scale insulin as ordered if glucose is elevated.

The LPN/LVN is working with an AP to provide care for Ms. S before her transfer back to the long-term care facility. In preparation for the transfer, the LPN/ LVN may delegate the AP to assist this patient with/by (a)______, (b)______, and (c)______, as needed. 1. getting out of bed 2. washing her hands and face 3. feeding the patient rapidly and giving her fluids from her tray after every bite 4. notifying the long-term care facility that the patient is ready for transfer 5. instructing her to pack her belongings as soon as possible 6. ambulating to the bathroom

A. 1 B. 2 C. 6 Assisting patients with getting out of bed, performing morning care, and ambulating to the bathroom are within the scope of practice for an AP and are appropriate for the LPN/LVN to delegate to an AP. If the patient needed assistance with feed- ing, it would be best to go slowly at the patient's speed. Because this patient is confused, asking her to pack her belongings may be confusing, so it would be better to assist her in packing. The RN would be responsible for giving the report on the patient and letting them know when she is to be transferred.

The AP informs the LPN/LVN that the patient now has a rapid heart rate of 118 per minute and that she states her chest hurts a little. The LPN/LVN would first (a)______. Then the priority would be to (b)______and (c)_______. The next prioriwould be to (d)______ and (e)______. 1. notify the HCP 2. apply oxygen 3. assess the patient 4. check pulse oximetry 5. gather more information 6. notify the RN

A. 6 B. 3 C. 5 D. 1 E. 2 The first action would be to notify the RN who would then assess the patient and gather more information. Next it would be essential to notify the HCP and follow orders including application of oxygen, which will help in the delivery of oxygen to the myocardium. Alternately the nurse could notify the rapid response team (RRT) if that were a choice. Applying oxygen per order (by HCP, RRT, or unit standing order) would be important. The patient is breathing and not yet in need of a ventilator.

The RN reviews Ms. J's laboratory results. Which laboratory finding is of greatest concern? 1. Serum potassium level of 7.1 mEq/L (7.1 mmol/L) 2. Serum creatinine level of 7.3 mg/dL (645 μmol/L) 3. Blood urea nitrogen level of 180 mg/dL (64.3 mmol/L) 4. Serum calcium level of 7.8 mg/dL (1.95 mmol/L)

Ans: 1 A patient with a serum potassium level of 7 to 8 mEq/L (7 to 8 mmol/L) or higher is at risk for electrocardiographic changes and fatal dysrhythmias. The HCP should be notified immediately about this potassium level. Although the serum creatinine and blood urea nitrogen levels are high, these levels are commonly reached before patients experience symptoms of CKD. The serum calcium level is low but not life threatening.

The AP is delegated the task of measuring morning vital signs for all six patients. Which finding would the nurse instruct the AP to report immediately? 1. Oral temperature higher than 102°F (38.9°C) 2. Blood pressure higher than 140/80 mm Hg 3. Heart rate lower than 65 beats/min 4. Respiratory rate lower than 18 breaths/min

Ans: 1 A temperature elevation to 102°F (38.9°C) is likely an indicator of an infectious process. The other criterion parameters are near normal, and assessment or evaluation would instead be based on abnormalities from each patient's baseline.

The health care provider's (HCP's) prescribed actions for this patient include all of the following. Which intervention should the nurse complete first? 1. Send an arterial blood gas (ABG) sample to the laboratory. 2. Schedule pulmonary function tests. 3. Repeat chest radiography each morning. 4. Administer albuterol via MDI 2 puffs every 4 hours.

Ans: 1 Baseline ABG results are important in planning the care of this patient. The unit clerk can schedule the pulmonary function tests and chest radiography. The albuterol therapy is a routine order and the patient may need this after the ABG is drawn.

Ms. J states that she feels increasingly short of breath. The nurse team leader is supervising an LPN/LVN and an AP. Which nursing care action for Ms. J is the most appropriate to assign 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

Ans: 1 Checking residual urine with a bedside bladder scanner is within the scope of practice of the LPN/LVN, who would remain under the supervision of the RN. Planning care and discussing options such as renal replacement therapies require additional education and training, which are within the scope of practice for the professional RN. Although in many acute care hospitals, LPN/LVNs auscultate breath sounds as a part of their observations, RNs follow up for overall assessment and synthesis of data. Because Ms. J is a potentially unstable patient with respiratory changes that may indicate worsening of her condition, the more appropriate person to assess her lung sounds would be the RN

The nurse reports the morning assessment findings (see question 11) 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 (20 mmol) orally every morning. 4. Weigh the patient every morning.

Ans: 1 Furosemide is a loop diuretic. The uses of this drug include treatment of pulmonary edema, which is most directly related to the new finding. Intake and output records and daily weights are important in documenting the effectiveness of the medication. A side effect of this drug is hypokalemia, and some patients are also prescribed a potassium supplement when taking this medication.

The HCP prescribes captopril 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 HCTZ in the morning." 2. "If you miss a dose of captopril, 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."

Ans: 1 HCTZ is a thiazide diuretic used to correct edema and lower blood pressure, and it should be taken in the morning so that its diuretic effects do not keep the patient up during the night. A side effect of HCTZ is loss of potassium, and patients may require potassium supplementation. Captopril is an angiotensin-converting enzyme inhibitor that lowers blood pressure. It is never appropriate to take twice the dose of this drug.

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°F (38°C), her blood pressure is 168/92 mm Hg, 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

Ans: 1 Hyperacute rejection occurs within 48 hours after transplant surgery. Increased temperature, increased blood pressure, and pain at the transplant site are manifestations.

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 AP? 1. Measuring vital signs and post dialysis 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

Ans: 1 Measuring vital signs and weighing the patient are within the education and scope of practice of the AP. The AP could remind the patient to request assistance when getting out of bed after the RN has instructed the patient to do so. Assessing the HD access site for bleeding, bruit, and thrill require additional education and skill and are appropriately performed by a licensed nurse.

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 the highest 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.

Ans: 1 Morphine sulfate has been ordered to relieve the chest discomfort that is common when a patient has an acute myocardial infarction. Relief from the chest pain is the highest priority at this time. Ranitidine is a histamine 2 blocker used to prevent gastric ulcers. Scheduling an ECG or drawing blood for coagulation studies, although important, will not help relieve chest discomfort.

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 two tablets of acetaminophen. 3. Measure the area of the rash. 4. Check for numbness and tingling.

Ans: 1 Serious side effects of cefotaxime include rashes, fever, and chills, as well as diarrhea, bruising, numbness, tingling, and bleeding. If the patient is taking this drug as an outpatient, the HCP should be notified immediately. Because the drug is being given IV, the first step would be to stop the infusion. The HCP should be notified, and the patient should be assessed for additional symptoms of a serious reaction to the drug. The HCP will prescribe a different antibiotic for the patient.

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 AP. 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 the condition of the patient's feet daily.

Ans: 1 The newly hired AP would need to be taught how to use a glucometer and perform a fingerstick before having this task delegated to him or her. In addition, the RN would need to ensure that the APs had learned the skill before performing it independently. All of the other care tasks are appropriate to the staff members.

The results of Ms. J's 24-hour urine collection reveal a creatinine clearance of 65 mL/min (1.09 mL/sec). 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.

Ans: 1 The normal creatinine clearance is 107 to 139 mL/min for men (1.78 to 2.32 mL/sec) and 87 to 107 mL/min (1.45 to 1.78 mL/sec) for women tested with a 24-hour urine collection. A low result indicates that the kidneys are functioning at a lower than expected level. The patient has CKD

The LPN/LVN reports to the RN that Mr. R 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 or 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."

Ans: 1 The patient who has difficulty chewing or swallowing foods and liquids (dysphagia) is at risk for aspiration pneumonia. At this time, the best action is to keep the patient NPO and contact the HCP. Attempting to give him oral foods, drugs, or fluids increases his risk for aspiration. Assessing his speech and tongue movement is important but not as urgent as keeping him NPO. The patient likely will require screening or use of an evidence-based bedside swallowing screening tool to determine if dysphagia is present. A referral to a speech-language pathologist for a swallowing evaluation per stroke protocol is needed. If dysphagia is present, develop a collaborative plan of care to prevent aspiration and support nutrition and prevent constipation or dehydration.

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

Ans: 1 The patient's temperature elevation indicates an infectious process. For older adult patients, changes in level of consciousness are frequently an early sign of bladder or urinary tract infections.

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.

Ans: 1 The scope of practice for an experienced LPN/LVN includes administering oral medications. Although the LPN could certainly check the patient's vital signs, pack his personal belongings, and change his incontinence pad, these interventions are also within the scope of practice for an AP.

The oral temperature of Mr. B, the patient newly admitted from a long-term care facility with decreased urine output and altered level of consciousness, is now 102.6°F (39.2°C). What is the nurse's best action? 1. Notify the HCP. 2. Administer acetaminophen 2 tablets orally. 3. Assign the LPN/LVN to give an acetaminophen suppository. 4. Remove extra blankets from the patient's bed.

Ans: 1 This patient's temperature elevation is most likely caused by an infection. The HCP must be notified to modify the patient's plan of care. Administering acetaminophen and removing extra blankets may decrease the patient's temperature, but they will not treat the infection.

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 most effective when administered within the first 6 hours of a coronary event." 2. "Thrombolytic drugs are much more effective when used for patients who have had a recent stroke." 3. "Thrombolytic drugs work better for patients 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."

Ans: 1 Thrombolytic therapy using fibrinolytics dissolves thrombi in the coronary arteries and restores myocardial blood flow. Intracoronary fibrinolytics may be delivered during cardiac catheterization. Thrombolytic agents are most effective when administered within the first 6 hours of a coronary event. They are used in men and women, young and old.

Ms. S's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs) and short runs of ventricular tachycardia (more than 3 PVCs in a row). 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

Ans: 1 With frequent PVCs, the patient is at risk for life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation. The patient is already showing short runs of ventricular tachycardia (greater than three PVCs in a row). Amiodarone is an antidysrhythmic drug used to control ventricular dysrhythmias. Nitroglycerin and morphine can be given for chest pain relief. Atenolol is a beta-blocker, which can be used to control heart rate and decrease blood pressure.

The RN is assessing Ms. J's chest pain. Which questions would the RN be sure to ask the patient? 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 0 to 10, with 10 being the worst pain ever?" 6. "What were you doing when the chest pain started?"

Ans: 1, 2, 3, 5, 6 The RN should thoroughly evaluate the nature of the patient's pain. Asking the patient when the pain started focuses on the onset. Asking if the pain was sudden or slow in onset deals with the manner of onset. Asking how long the pain has lasted speaks to the duration of symptoms. Having the patient grade the pain on a scale of 0 to 10 evaluates the intensity. Asking the patient what he or she was doing when the pain started helps delineate factors that can lead to pain onset. Patients do not usually experience confusion or memory loss with cardiac pain.

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 at least once per shift. 6. Check for peripheral edema and note any increase. 7. Assess level of consciousness and cognition. 8. Ask patient about headache or blurred vision.

Ans: 1, 2, 3, 5, 6, 7, 8 The usual fluid restriction for patients with chronic kidney failure is 500 to 700 mL plus urine output. All of the other actions are appropriate for a patient with fluid overload. Remember that it is essential for the nurse to compare findings with previous shifts and days to determine if symptoms are worsening.

Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which postprocedural 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 the first hour. 3. Continue IV fluids normal saline at 50 mL/hr. 4. Assist patient to bathroom as needed during first 6 hours after the procedure. 5. Administer morphine sulfate 2 mg IV push as needed for pain. 6. Give patient's daily multivitamin and stool softener on return to medical unit.

Ans: 1, 2, 3, 6 The LPN/LVN is experienced and post cardiac catheterization care would be familiar to her. Basic assessments such as checking peripheral pulses, watching for bleeding, and monitoring IV fluid flow, as well as administering oral drugs are within his or her scope of practice. Most IV drugs are administered by RNs; however, some LPN/LVNs may administer these drugs with additional training. The patient would most likely be on bed rest, keeping the affected extremity straight for 4 to 6 hours after the procedure

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 intensive care unit (ICU). 6. Remind the patient to practice incentive spirometry every hour while awake.

Ans: 1, 2, 3, 6 The patient's major problem at this time is impaired gas exchange with hypoxemia based on the ABG results. Strategies to compensate include administration of low-flow oxygen as well as interventions to improve gas exchange, such as having the patient cough and take deep breaths and perform incentive spirometry. These strategies may improve the patient's condition and prevent the need to initiate a code, transfer to the ICU, or both. A rapid response is for hospitalized patients with early signs of deterioration on non-ICUs to prevent respiratory or cardiac arrest. The team includes members that may not be routinely in the ER (e.g. RT, pharmacist, ICU nurse).The patient's symptoms call for initia- tion of a rapid response to treat him now and prevent the need for a code. A saline lock is a good idea, but giving the patient too much fluid may worsen his condition by producing a fluid overload. Transfer to the ICU at this point is not warranted because the patient is unstable.

The RN assesses Mr. W 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. Respiratory rate 15 to 25 breaths/min 4. Inspiratory and expiratory wheezes 5. Blue-tinged dusky appearance 6. Symmetrical lung expansion

Ans: 1, 2, 4, 5 The presence of wheezing, enlarged neck muscles, bluish dusky appearance, and forward bent posture are all classic manifestations in a patient with COPD. The respiratory rate is usually higher than normal and during an exacerbation can be as high as 30 to 40 breaths/min. Lung expansion in patients with COPD is usually asymmetrical.

Which risk factors from Ms. S's history would suggest a possible cardiac problem to the nurse? 1. Hypertension for 12 years 2. Smoked for 43 years; quit smoking 1 year ago 3. Surgery for gallbladder removal 1year ago 4. Ms.S's father died at age 42 years from a heart attack 5.Patient's weight is 278 lb (126 kg) 6. Diet includes fast foods three to five times a week 7. Patient is an African-American female 8. History of gastroesophageal reflux disease 9. Report of chest pressure and indigestion associated with nausea

Ans: 1, 2, 4, 5, 6, 7, 9 Risk factors for cardiac problems include hypertension, family history, obesity, and high-fat diets (which may cause elevation of cholesterol). African-Americans have higher rates of high blood pressure, high cholesterol, obesity, and diabetes, which are major risk factors for heart disease. Symptoms of chest pressure with indigestion and nausea are signs that suggest a heart problem. Gallbladder surgery and GERD would not be risk factors. Quitting smoking would be a risk factor, and the years that the patient smoked would be a strong risk factor.

Mr. W is receiving an IV dose of potassium 10 mEq/100 mL (10 mmol/100 mL) normal saline to run over 1 hour. The AP asks the nurse why it takes so long to infuse such a small amount of fluid. What should the nurse explain to the AP? 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 to 10 mmol/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." 7. "The patient is not taking in sufficient dietary potassium to keep the level within normal limits." 8. "Giving the potassium slowly will give use time to teach the patient about dietary sources of potassium."

Ans: 1, 2, 4, 6 A dilution no greater than 1 mEq (1 mmol) of potassium to 10 mL of solution is recommended for IV administration. The maximum recommended infusion rate is 5 to 10 mEq/hr (5 to 10 mmol/hr); this rate is never to exceed 20 mEq/ hr (20 mmol/hr) under any circumstances. In accordance with National Patient Safety Goals, potassium is not given by IV push to avoid causing cardiac arrest. Oral potassium can cause nausea and vomiting (give it with food to prevent this), but this does not answer the AP's question. Lack of dietary intake and teaching about dietary sources of potassium do not answer the AP's question.

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

Ans: 2 Assisting patients with activities of daily living (including ambulation to the bathroom) is appropriate to the educational preparation and scope of practice of the AP. An LPN/LVN could administer the oral drug. Teaching, assessing, and administering medications fall within the scope of practice for licensed nurses.

After the rapid response, the respiratory therapist (RT) provides the patient with a handheld 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 assistive personnel (AP)? 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

Ans: 1, 2, 4, 6 Assisting patients with activities of daily living such as toileting is within the scope of practice of APs. After licensed nurses or RTs have taught the patient to use incentive spirometry, the AP can play a role in reminding the patient to perform it. APs can participate in encouraging patients to drink adequate fluids. Assessing and teaching are not within the scope of practice of APs. Performing pulse oximetry is appropriate for experienced APs after they have been taught how to use the pulse oximetry device to gather additional data. Before delegating this task, the nurse would be sure to assess the AP's skills.

Which patient admission tasks should the nurse delegate to the experienced assistive personnel (AP)? 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.

Ans: 1, 2, 4, 6 Checking vital signs and recording intake and output fall within the scope of practice for any AP. An experienced AP will have been taught to use pulse oximetry to check oxygen saturation and to use a glucometer to check a patient's fingerstick blood glucose. In Canada, however, glucose monitoring is considered an advanced skill and would not be performed by an AP. Placing an IV line and teaching require additional education and training that are more within the scope of practice for a licensed nurse.

Because Ms. S continues to experience chest discomfort and has elevated levels of cardiac markers, the following interventions have been prescribed by the health care provider. Which interventions should the nurse delegate to an experienced AP? 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 patient to the bedside commode 7. Helping the patient with morning care and partial bed bath 8. Assessing the patient's pain level 9.Reminding the patient to report any episodes of chest discomfort

Ans: 1, 2, 6, 7 Measuring vital signs, recording intake and output, and assisting patients with activities of daily living (e.g., morning care, partial or complete bed bath, bedside commode) are all within the scope of practice of the AP. Administration of IV drugs, venipuncture for laboratory tests, interpreting ECG's, and assessments are beyond the scope of practice of APs and are applicable to the practice scope of the professional nurse. In some facilities, APs may receive additional training to perform venipuncture, but the RN would need to assess the AP's ability to safely perform this skill before delegation.

Mr. W has lost 15 lb (6.8 kg) 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.

Ans: 1, 3, 4, 5 A dietitian can help with the selection of foods that are easy to chew, do not form gas, and are high in calories and protein. Serum prealbumin levels are a good indicator of nutritional status and should be monitored. Small meals can help prevent meal-related dyspnea. Using a bronchodilator before meals will reduce bronchospasm. The second response does not demonstrate respect for the patient's role in his care. Dry foods stimulate coughing.

Ms. S has returned to the CCU after 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 patient 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 patient'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

Ans: 1, 3, 4, 5, 6 All of these interventions are within the scope of practice of an experienced LPN/LVN. The LPN/LVN would be instructed when to notify the RN or the HCP of any abnormal findings. Preparing a teaching plan requires additional education and is more suited to the RN's scope of practice. Taking vital signs and reminding the patient about bed rest could also be delegated to the AP.

Which patients should the team leader assign to the LPN/LVN for nursing care under the RN's supervision? Select all that apply. 1. Mr. C (unstable angina) 2. Ms. J (chest pain) 3. Mr. R (stroke) 4. Ms. S (heart disease and dementia) 5. Mr. B (decreased urine output, altered level of consciousness) 6. Mr. L (SOB and chronic emphysema)

Ans: 1, 3, 4, 6 It is important to recognize that the RN continues to be accountable for the care of all patients by the team. Appropriate patient assignments for the LPN/LVN include patients whose conditions are stable and not complex. Ms. J is currently experiencing chest pain, and Mr. B is a complex new admission. These patients will benefit from the advanced skills of the RN.

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

Ans: 2 Assisting patients with activities of daily living such as feeding is most appropriate to the scope of practice of the AP. The RN would be sure to instruct the AP to avoid rushing the patient and to report any difficulty with swallowing.

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. Patient is Hispanic 6. Coronary artery disease (CAD) 7. Cataracts 8. Long-term use of OTC ranitidine

Ans: 2, 4, 5, 6 Major risk factors for CKD include hypertension and diabetes. CAD has a related pathophysiology to hypertension. Hispanics and African- Americans have an increased risk for CKD over Caucasian patients. Pregnancy, cataracts, long-term use of famotidine, and GERD are not risk factors for CKD.

Which activities could the nurse delegate to AP assisting Ms. S during phase 1 of cardiac rehabilitation? Select all that apply. 1. Assist with Ms. S's morning bath as needed. 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 captopril and HCTZ. 5. Assist with progressive ambulation in the hall. 6. Assess Ms. S for additional chest pain or pressure.

Ans: 1, 3, 5 Cardiac rehabilitation is the process of actively assisting the patient with cardiac disease in achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. It can be divided into three phases. Phase 1 begins with the acute illness and ends with discharge from the hospital. Activities dur- ing this phase that could be delegated to an AP include assisting with morning care such as a bath, assisting a patient to the bathroom, and assisting with progressive ambulation in the hall. The nurse would be sure to in- struct to AP to stop any activity that caused chest pain or pressure and report this at once. Referrals, administering drugs, and assessing patients require additional educational preparation and are suitable for professional nurses.

Near the end of the shift the RN is admitting Mr. E, an 88-year-old patient, from long-term care to the acute care medical/surgical unit. The patient was alert until early this morning and has become confused. His history includes smoking cigarettes for 55 years, but he quit at age 70. He has a history of post-traumatic stress disorder (PTSD) and has had sur- gery for appendicitis and gallbladder removal. Over the past 36 hours the patient developed headache, muscle aches, cough with thick clear sputum, and chest discomfort. *Vital Signs:* Temperature 101.4 °F (38.6 °C) Pulse 104 beats/min Respirations 30 breaths/min Blood pressure 108/62 mmHg *Assessment Findings:* Warm dry skin, crackles bilaterally with wheezes, tachycardia with normal heart sounds, and a pulse oximetry reading of 89 on oxygen at 2 L by nasal cannula. The patient does not tolerate lying flat in bed. *Admission Lab* Complete blood count reveals elevated white blood cell (WBC) count. Electrolytes (Na+ 135, K+ 3.8, Cl-98) Which of the following findings with this patient are factors that increase the risk for a diagnosis of pneumonia? Select all that apply. 1. Patient age 2. PTSD 3. Smoked cigarettes 55 years 4.

Ans: 1, 3, 5, 6, 7, 9 Older patients are at increased risk for pneumonia in the community and in health care settings. A history of chronic lung disease is also a risk factor. Assessment findings include the presence of crackles over areas with interstitial fluid, and wheezes are heard if inflammation or exudate narrows the airways. Elevated WBC count is a common find-ing in older adults as are changes in level of conscious- ness. PTSD would not be a risk factor for pneumonia. Generally, with pneumonia, sputum is purulent, blood-tinged, or rust colored. The electrolytes listed in this case study are all within normal limits.

Based on Ms. S's admission vital signs, which HCP orders would the nurse expect? Select all that apply. 1. Continuous cardiac monitoring 2. Blood pressure checks every 10 minutes 3. Oxygen at 2 L per nasal canula 4. Instruct patient to breathe and rebreathe into a paper bag. 5. Acetaminophen 650 mg as needed for temperature greater than 99°F (37.2°C) 6. Check apical heart rate with each set of vital signs

Ans: 1, 3, 6 Because the patient's heart rate is rapid and irregular, she should be on a continuous cardiac monitor and her apical pulse should be monitored. Her O2 saturation is low normal and her heart rate is rapid and irregular, so supplemental oxygen will be useful to her heart. Although her blood pressure is high and needs to be monitored, every 10 minutes would not allow for patient rest (it would be sensible in an emergency but not routinely). Adding oxygen to increase myocardial oxygen levels may help restore Ms. S's respiratory rate to normal. Using a bag is a strategy for a patient who is hyperventilating and is not appropriate in this case. Acetaminophen is usually ordered for a higher temperature. Also, the HCP would likely want to discover the reason for any very elevated temperature so it could be treated.

The AP reports that Mr. L's heart rate, which was 86 beats/min in the morning, is now 98 beats/min. 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?"

Ans: 2 A common side effect of beta-adrenergic agonists such as albuterol is increased heart rate. Drugs such as albuterol are commonly prescribed for patients with COPD to use as needed to dilate the airways when experiencing shortness of breath. Although the other factors are important and may be related to the patient's COPD, they may not have contributed to the increase in heart rate.

All of these laboratory values were obtained for Ms. S in the emergency department. Which value would be of most concern to the nurse and have immediate implications for the care of the patient? 1. Potassium level of 3.5 mEq/L (3.5 mmol/L) 2. Troponin T level of more than 0.20 ng/mL (0.2 μg/L) 3. Glucose level of 123 mg/dL (6.83 mmol/L) 4. Slight elevation of white blood cell count

Ans: 2 A troponin T level of more than 0.20 ng/mL (0.2 μg/L) is an elevated level and indicates myocardial injury or infarction (heart attack). Although the other laboratory values are all abnormal except the potassium, which is low normal, none of them is life threatening. The low normal potassium level would be the second highest concern and might require supplementation to keep it within normal limits.

During admission assessment, Ms. J has all of these findings. For which finding should the nurse notify the HCP immediately? 1. Bilateral 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

Ans: 2 All of these findings are important, but only the presence of crackles in both lungs is urgent because it signifies fluid-filled alveoli and interruption of adequate gas exchange and oxygenation, worsening of the patient's condition, and possibly pulmonary edema. The patient's peripheral edema is not new. The faint pulses are most likely caused by the presence of peripheral edema. The dry and peeling skin is a result of chronic diabetes and merits careful monitoring to prevent infection, but it is not immediately urgent

Which patient should the RN assess first? 1. Mr. C (unstable angina) 2. Ms. J (chest pain) 3. Mr. B (decreased urine output, altered level of consciousness) 4. Mr. L (SOB and chronic emphysema)

Ans: 2 Although it is important that the nurse see all of these patients, Ms. J's assessment takes priority. Her chest pain may indicate coronary artery blockage and acute heart attack. None of the other patients' needs are life threatening

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

Ans: 2 Because Ms. S is not scheduled to be transferred until after lunch, it is not urgent to get her ready at this time. Allowing her to rest while the staff takes care of other patients whose needs are more urgent is acceptable. The RN could instruct the AP to keep the patient's breakfast tray and warm it up when she is ready to eat.

Ms. S's condition is stable, and she has been transferred to the cardiac step-down unit. What should the step-down nurse instruct the AP to report immediately? 1. Temperature of 99°F (37.2°C) with morning vital sign monitoring 2. Chest pain episode occurring during morning care 3. Systolic blood pressure increase of 8 mm Hg after morning care 4. Heart rate increase of 10 beats/min after ambulation

Ans: 2 Chest pain can be an indicator of additional myocardial muscle damage. Additional episodes of chest pain significantly affect the patient's plan of care. Small increases in heart rate and blood pressure after activity are to be expected. The patient's temperature, only 0.2°F (0.1°C) higher than at admission, is not a priority at this time, but it will need continued monitoring.

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 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.

Ans: 2 Discharge planning and IV administration of antibiotics are more appropriate to the scope of practice of the RN. Nevertheless, in some states, LPN/LVNs with special training may administer IV antibiotics. (Be aware of state regulations and nursing practice laws in your state.) Administering oral medications is appropriate to assign to LPN/LVNs, and in this case, furosemide may help clear up the crackles. Although the LPN/LVN could weigh the patient, this intervention is also appropriate to the scope of practice of the AP.

After discussing renal replacement therapies with the HCP and nurse, Ms. J is considering hemodialysis (HD). 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."

Ans: 2 Even after beginning HD, patients are still required to restrict fluid intake. In addition, patients on HD have nutritional restrictions (e.g., protein, po- tassium, phosphorus, sodium restrictions). All of the other patient statements indicate an appropriate understanding of HD.

The patient 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 nurses's best response? 1. "It is a procedure that is usually done on patients 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 to 8 hours, and we will check your vital signs often."

Ans: 2 The nurse's best response should be attentive to and answer the patient's question. For the cardiac catheterization, the patient is taken to a special lab where the cardiologist uses an invasive catheter with injectable dye to locate and diagnose narrowed sections of coronary arteries. For percutaneous coronary intervention, a catheter is placed with a balloon, which can be inflated to open the narrowed section, and a stent (an expandable metal mesh device) can be left in place to keep the artery opened. Options 1, 3, and 4 do not accurately answer the patient's question about the procedure.

What is the priority nursing concern for this patient? 1. Skin care because of incontinence 2. Clearance of thick secretions 3. Rapid heart rate 4. Elevated temperature

Ans: 2 The patient's major problems at this time relate to airway and breathing including thick sputum, difficulty breathing, and respiratory distress. The patient's skin care, blood pressure, and elevated temperature will need to be followed up on soon but are not as urgent at this time as his respiratory status

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

Ans: 2 Without stent placement, the artery often reoccludes because of the artery's normal elasticity and memory. Patients who undergo percutaneous coronary intervention are required to take DAT consisting of aspirin and a platelet inhibitor to prevent recurrence of artery blockage, chest pain, and MI. Patients are not kept on bed rest for 24 hours; rather, they are instructed to do no heavy lifting for several days after this procedure, and they are often prescribed a beta-blocker to slow heart rate and lower blood pressure.

The team leader RN observes the AP 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 patient 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

Ans: 2, 4 Checking vital signs usually includes measuring oral body temperature. Because the patient just finished drinking fluids, an oral temperature measurement would be inaccurate at this time. If the fluids were cold, the temperature would be falsely low; if the fluids were hot, the temperature would be falsely high. Changing the oxygen flow rate without prescription or instruction is not acceptable practice. All of the other actions are appropriate and within the scope of practice of the AP. An AP's scope of practice includes reminding patients of content that has already been taught.

Mr. W 's ABG results include the following: pH = 7.37 Paco2 = 55.4 mm Hg Pao2 = 51.2 mm Hg HCO3− = 38 mEq/L (38 mmol/L) 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

Ans: 3 The pH is on the low side of normal, and the Paco2 is elevated, which indicates an underlying respiratory acidosis. The HCO3− level is elevated, which indicates compensation and since the pH is within normal limits it is completed compensation. Both the Pao2 and the oxygen saturation levels are low, which points to hypoxemia. These blood gas results are typically expected when a patient has a chronic respiratory problem such as COPD.

Mr. W's ED lab values include a serum potassium of 2.8 mg/dL (2.8 mmol/L). What is the priority nursing action at this time? 1. Teach 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.

Ans: 3 A low serum potassium places the patient at risk for cardiac dysrhythmias, which can be life threatening. The HCP should be notified immediately and will likely order IV or oral potassium supplements to move the patient's level back into the normal range. Later, before discharge, the nurse would certainly want to teach the patient about potassium-rich foods, but this is not urgent. Oxygen is essential for the patient's respiratory problem but will not correct the low potassium, nor will IV normal saline

The AP asks the RN why it is important to notify someone whenever a patient 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 patient 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 patients with chest pain."

Ans: 3 Acute chest pain can indicate myocardial ischemia, coronary artery blockage, or myocardial damage. The AP's question should be answered with the most accurate response. Although the unit may have protocols that the AP should be familiar with, option 4 is not the most accurate response.

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 patient's blood pressure is higher than 100/80 mm Hg. 2. Give the drug if the patient's respiratory rate is greater than 30 breaths/min. 3. Hold the drug if the patient's heart rate is less than 55 beats/min. 4. Give the drug if the patient's blood pressure is less than 90/50 mm Hg.

Ans: 3 Atenolol is a beta-blocker drug. Do not give beta-blockers if the pulse rate is below 55 or the systolic blood pressure is below 100 mm Hg without first checking with the HCP. The beta-blocking agent may lead to persistent bradycardia or further reduction of systolic blood pressure, leading to poor peripheral and coronary perfusion.

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

Ans: 3 Barrel chest and clubbed fingers are signs of chronic COPD. The patient had a productive cough on admission to the hospital. Bilateral crackles are a new finding and indicate fluid-filled alveoli and pulmonary edema. Fluid in the alveoli affects gas exchange and can result in worsening ABG concentrations.

Which key point would the nurse be sure to include when teaching Mr. C about the postprocedural 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."

Ans: 3 Cardiac catheterization is usually accomplished by inserting a large-bore needle into the femoral vein or artery (or both). Patients are routinely restricted to bed rest, with the affected extremity kept straight, for 4 to 6 hours after the procedure to prevent hemorrhage. Family members are usually permitted to visit as soon as the patient returns to the room

Which action prescribed by the health care provider (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 patient on a cardiac monitor. 4. Check levels of cardiac markers every 6 hours.

Ans: 3 Cardiac monitoring is the highest priority because the patient's heart rate is rapid and irregular, and the patient is experiencing chest pressure. The patient is at risk for life-threatening dysrhythmias such as frequent premature ventricular contractions. Measuring vital signs every 2 hours, checking levels of cardiac markers, and recording a 12-lead ECG every 6 hours are important to accomplish, but cardiac monitoring takes first precedence at this time.

Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates the immediate notification of the HCP? 1. Weight decrease of 4.5 lb (2 kg) 2. Systolic blood pressure decrease of 14 mm Hg 3. Decreased level of consciousness 4. Small blood spot near the center of the dressing

Ans: 3 Changes in level of consciousness during or after HD can signal dialysis disequilibrium syndrome, a life-threatening situation that requires early recognition and treatment with anticonvulsants. This should be immediately reported to the HCP so that appropriate treatment can be prescribed. Decreases in weight and blood pressure are to be expected as a re- sult of dialysis therapy. A small amount of drainage is common after HD.

Which task associated with the patient's 24-hour urine collection is appropriate for the nurse to delegate to the AP? 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

Ans: 3 Teaching, instructing, and assessing are all functions that require additional education and preparation appropriate to the scope of practice for professional nurses. Providing the patient with ice for the urine collection and reminding the patient to collect her urine fit the scope of practice of the AP. Remember that the AP can remind a patient about anything that has already been taught.

The RN is precepting a new nurse orientating 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 laboratory studies from the temporary dialysis line 4. Administering acetaminophen with codeine PO for moderate postoperative pain

Ans: 3 Temporary dialysis lines are to be used only for HD. The preceptor nurse would stop the new nurse before the temporary HD system is interrupted. Breaking into the system increases the risk for complications such as infection. The blood pressure should always be assessed on the nondialysis arm. Postoperative patients should always be monitored for bleeding. Acetaminophen with codeine, when ordered by the HCP, is an appropriate analgesic for moderate to severe pain.

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

Ans: 3 The AP is new to the unit and may need assistance or instruction regarding the completion of this assignment.

While making the 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."

Ans: 3 The RN should be supportive and nonjudgmental. Listening and encouraging the patient to verbalize her concerns (e.g., grief, feeling of failure) are essential at this time. Asking someone else to come in to talk with the patient is not responding to her concern. Suggesting that she can get on the transplant list again is not acknowledging Ms. J's grief for los- ing the transplanted kidney.

The AP reports to the RN that Mr. L, the patient 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 oxygen flow to 6 L/min via nasal cannula. 3. Assess oxygen saturation by pulse oximetry. 4. Remind the patient to cough and deep breathe.

Ans: 3 The nurse should gather more information before notifying the HCP. A pulse oximetry assessment provides information about the patient's gas exchange and oxygenation status. Patients with chronic obstructive pulmonary disease (COPD) usually receive low-dose oxygen (1 to 3 L) because their stimulus for breathing is a low oxygen level. Coughing and deep breathing help mobilize secretions and can be helpful, but these are not the first priority.

The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT). What is the nurse's best action? 1. Instruct the AP to put the patient 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 patient should still have the GXT. 4. Ask the patient if she is continuing to have chest pain.

Ans: 3 The patient had chest pain during the night and this morning. She may be experiencing acute coronary syndrome, a term used to describe patients who have either unstable angina or an acute myocardial infarction. In this situation, the best action by the RN is to contact the HCP and ask if the patient's GXT should be cancelled. Sending her to take the GXT would increase the risk of cardiac damage and should not be done. Asking if the patient is still having chest pain is important and may reinforce the need to cancel the test.

The AP tells the nurse that Mr. W 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."

Ans: 3 The patient with COPD often has chronic fatigue and needs help with activities. Teaching the patient not to rush through activities is important because rushing increases dyspnea, fatigue, and hypoxemia. Reminding a patient of what has already been taught is within the scope of practice for an AP. Patients with COPD should be kept on low-flow oxygen because their stimulus to breathe is a low arterial oxygen level.

Which assessment finding would the nurse instruct the AP to report immediately? 1. Incontinence of urine and stool 2. 1-lb (0.45-kg) weight loss since admission 3. Patient cough productive of greenish-yellow sputum 4. Eating only half of breakfast and lunch

Ans: 3 The patient's temperature was elevated on admission, and his cough was productive. The changes in Mr. W's sputum could indicate an ongoing infection. The HCP needs to be notified and an appropriate treatment plan started. All of the other pieces of information are important but not urgent. The patient's incontinence is not new.

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. Complete lab tests including cardiac markers and daily electrocardiogram.

Ans: 3 When the patient experiences chest pain, vital signs should be checked immediately to establish a baseline. Nitroglycerin is usually tried every 5 minutes for three doses before morphine to relieve the chest pain. Hypotension is a side effect of nitroglycerin. Blood pressure and heart rate are monitored after each dose of nitroglycerin is administered. When nitroglycerin fails to relieve chest pain, IV morphine is the next action, and the HCP should be notified.

Which tasks should the nurse delegate to the newly hired AP? 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 patients 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

Ans: 3, 4, 5, 6 Assessment and teaching are more appropriate to the educational preparation of licensed nursing staff. Checking vital signs, monitoring and recording intake and output, assisting patients to the bathroom, and helping patients with morning care are all within the educational scope of the AP

The LPN/LVN rechecks Ms. J's O2 saturation after she has been on oxygen at 2 L/min per nasal cannula and finds the reading is now 93%. What is the LPN/LVN's best action? 1. Increase the oxygen to 3 L/min per nasal cannula. 2. Ask the respiratory therapist to start Ms. J on incentive spirometry. 3. Teach Ms. J to take 10 deep breaths every hour while awake. 4. Notify the team leader RN and record the finding.

Ans: 4 An oxygen saturation of 93% on 2 L/min is acceptable, and the best action is to notify the team lead and record the value.

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 regarding the action of 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.

Ans: 4 Atenolol is a beta-blocker drug with actions that slow the heart rate and decrease the blood pressure. HCPs often have blood pressure (BP) and heart rate (HR) guidelines (e.g., low BP and/or HR) for when to give and when to hold these drugs. The nurse should instruct the patient to call for help getting out of bed when the drug is newly prescribed or if the drug results in dizziness and syncope symptoms. The other instructions and actions may be included in the patient's care but will not affect the administration of atenolol.

Which action is best for the nurse to delegate to a new assistive personnel (AP) orienting to the CCU when caring for Ms. S? 1. Placing the patient 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. Checking and recording the patient's intake and output

Ans: 4 Checking and recording intake and output are within the scope of practice for APs. Initiating telemetry, performing venipuncture, and obtaining ECGs require additional education and training and would not be delegated to a new AP. Attaching ECG leads may be done by APs in some facilities, as may venipuncture and ECG recording. The APs perform- ing these tasks, however, would require additional specialized training. These actions are generally considered to be within the scope of practice of licensed nurses.

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

Ans: 4 DAT is suggested for all patients with acute coronary syndrome, incorporating aspirin and either clopidogrel or ticagrelor. The major side effect for each of these agents is bleeding. Observe for bleeding tendencies, such as nosebleeds or blood in the stool. Medications will need to be discontinued if evidence of bleeding occurs.

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 phosphorus." 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."

Ans: 4 Epoetin alfa is used to treat anemia and is given two to three times a week; however, it is given by either the IV or subcutaneous route, not by mouth. Most commonly epoetin alfa is given subcutaneously. All of the other statements about medications for patients with CKD are accurate.

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

Ans: 4 Increasing oxygen flow for a patient based on an HCP's prescription is within the scope of practice of LPN/LVNs. APs may measure vital signs. Arterial draws for laboratory tests are not within the LPN/LVN's scope of practice unless they have had additional special training. The RN would need to assess the LPN/LVN's skill before assigning this task. Handheld nebulizers are usually operated by RTs.

The nurse delegates to the AP 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 patient's chart and discovers that vital sign measurements have not been recorded. What is the nurse's best action? 1. Take the vital signs because the AP is not competent to complete this task. 2. Notify the nurse manager immediately. 3. Reprimand the AP at the nurses' station. 4. Speak to the AP privately to determine why the values were not recorded.

Ans: 4 Measuring and recording vital sign values are within the scope of practice of the AP. When the AP makes a mistake, it is best to communicate specifically, stressing the importance of recording vital sign values after they have been obtained. Supervision should be done in a supportive rather than confrontational manner. Notifying the nurse manager is not appropriate at this time. Reprimanding the AP in front of others also is not appropriate.

Before discharging Ms. S, the HCP orders an electrocardiogram (ECG). This test reveals normal sinus rhythm with a heart rate of 87 beats/min. What is the nurse's best action at this time? 1. Delay the patient's discharge until she is seen by the HCP. 2. Administer the patient'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 and prepare for discharge.

Ans: 4 Normal sinus rhythm with a rate of 87 beats/ min is a normal finding. There is no need to delay the patient's discharge, give early medications, or draw additional cardiac markers. The nurse would document this as a normal finding and prepare the patient for discharge.

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 subcutaneously 3. Calcium 1 tablet PO 4. Sodium polystyrene sulfonate 15 g PO

Ans: 4 Sodium polystyrene sulfonate removes potassium from the body by exchanging sodium for potassium in the large intestine. Diuretics such as furosemide generally do not work well in chronic kidney failure. The patient may need a calcium supplement and subcutaneous epoetin alfa; however, these drugs do nothing to decrease potassium levels

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 patient can be restrained. What is the RN's best response? 1. "Yes, this patient 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 patient's circulation is not compromised." 3. "No, we must have an HCP's order before we can apply restraints in any situation." 4. "No, but try covering the lead wires with the sheet so that the patient does not see them."

Ans: 4 Standards of practice for the use of restraints require that nurses attempt alternative strategies before asking that a patient be restrained. An HCP's written order is required for continued use of restraints but can be obtained after the fact if the patient's actions endanger his or her well-being. Remember that when a patient is restrained, a flow sheet should be at the bedside and the restraints frequently assessed (every 1 to 2 hours) and released (every 2 hours).

The AP checks morning vital signs and immediately reports the following values to the nurse. Which takes priority when notifying the HCP? 1. Heart rate of 96 beats/min 2. Blood pressure of 160/90 mm Hg 3. Respiratory rate of 34 breaths/min 4. Oral temperature of 103.5°F (39.7°C)

Ans: 4 The heart rate and blood pressure are slightly increased from admission, and the respiratory rate is slightly decreased. The continued elevation in temperature indicates a probable respiratory tract infection that needs to be recognized and treated

The RN observes the patient's use of the albuterol MDI. The patient takes two 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 treatments. 3. Ask the AP to help get the patient into a chair. 4. Instruct the patient about proper techniques for using an MDI.

Ans: 4 The patient is demonstrating improper use of the MDI by taking two puffs in rapid succession, which can lead to incorrect dosage and ineffective action of the albuterol. Teaching is the first priority. The patient is taught to wait for at least 1 minute between MDI puffs. As the nurse works with this patient, it may be determined that he would benefit from the use of a spacer. Sitting up in a chair may also be useful, but these interventions are not the first priority. Notifying the provider that the patient needs to continue with nebulizer treatments is not within nursing scope of practice and does not address the problem, which is that the patient does not know how to properly use his MDI.

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

Ans: 4 The treatment for hyperacute rejection is immediate removal of the transplanted kidney and a return to dialysis until another kidney becomes available. Increased doses of immunosuppressant drugs are used to treat acute rejection, conservative management is used for chronic rejection, and IV antibiotics are administered for infections.

Case Study #2 Dyspnea and shortness of Breath

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing cold-like symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking two packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department (ED), Mr. W undergoes chest radiography, and admission laboratory tests are per- formed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W 's vital sign values are as follows: BP = 154/92 HR = 118 bpm O2 Sat = 88% on 1 L O2 Nasal Cannula RR = 38 bpm Temp = 100.9 F (oral)

Case Study #4: Shortness of Breath, Edema, and Decreased Urine Output

Ms. J is a 63-year-old Hispanic woman who is being admitted directly to the medical unit after visiting her health care provider (HCP) because of shortness of breath and increased swelling in her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease (CKD). Ms. J states that her symptoms have become worse over the past 2 to 3 months and that she uses the bathroom less often and urinates in small amounts. Her medical history includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes (14 years), an appendectomy at age 28, cataract surgery to the left eye 2 years ago and right eye 1 year ago, and four pregnancies with healthy births. She also has gastroesophageal reflux disease (GERD), which is controlled with over-the-counter (OTC) famotidine 20 mg as needed. Ms. J's vital sign values on admission were as follows: BP 162/96 mmHg HR = 88bpm O2 Sat = 89% on RA RR = 28 bpm Temp = 97.8F The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission laboratory tests for which patient samples are to be collected on the unit include serum electro- lyte levels, kidney function tests, complete blood count, and urinalysis. A 24-hour urine collection for the determination of creatinine clearance has also been ordered.

Case Study 1: Chest Pressure, Indigestion, and Nausea

Ms. S is a 58-year-old African-American woman who was admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea. She started feeling ill about 10 hours before she called her daughter, who brought her to the ED for admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate that was in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She states, "It just gets worse and worse." Ms. S has been under a health care provider's (HCP's) care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker for 43 years but quit 1 year ago. Her past medical history includes gall bladder disease and gastroesophageal reflux disease (GERD). In the ED, admission laboratory tests, including levels of cardiac markers, were performed, and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU vital sign values on admission are as follows: Blood pressure: 174/92 mmHg Heart rate: 120 to 130 beats/min irregular O2 saturation: 91% on room air Respiratory rate: 30 to 34 breaths/min Temperature: 99.8°F (37.7°C) (oral)

For each nursing action listed below, check to specify whether the action is essential, non-essential or contraindicated. Place on cardiac monitor Get a baseline set of vital signs Draw admission laboratory tests Place a saline lock Change adult pad Send for a chest x-ray Order a lunch tray Increase oxygen 2 L per nasal cannula as ordered by the ED health care provider. Keep head of bed elevated at least 45 degrees. Place a urinary catheter with a drainage bag

Place on cardiac monitor = *Essential* Get a baseline set of vital signs = *Essential* Draw admission laboratory tests = *Essential* Place a saline lock = *Essential* Change adult pad = *Contraindicated* Send for a chest x-ray = *Essential* Order a lunch tray = *Nonessential* Increase oxygen 2 L per nasal cannula as ordered by the ED health care provider. = *Essential* Keep head of bed elevated at least 45 degrees. = *Essential* Place a urinary catheter with a drainage bag = *Contraindicated* Baseline data that are essential to decisions for the care of this patient take priority at this time. These include vital signs, cardiac rhythm, lab values, and chest x-ray findings. Placement of a saline lock is essential for administration of fluids and emergency drugs.The patient's oxygen saturation is only 88% on 1 L, so increasing it to 2 L may improve oxygenation, as may elevating the head of the patient's bed. Changing the patient's incontinence pad is important to protect his skin but is not urgent. In addition, this could require placing him in a supine position, which would make breathing more difficult and force him to struggle to move into an upright position for easier breathing. Ordering a lunch tray may be premature because the interventions for this patient's care are undecided when he is first admitted to the ED. Placing a urinary catheter may lead to a urinary tract infection.

Case Study #3: Multiple Patients on a Medical-Surgical Unit

The RN is the leader of a team providing care for six patients. The team includes the RN, an experienced LPN/LVN, and a newly educated assistive personnel (AP) who is in his fourth week of orientation to the acute care unit. (Note to student: Use the information from the shift change report below to make brief notes about these six patients and refer to the notes as you work through the case study.) The patients are as follows: • Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is sched- uled for a graded exercise test later today. • Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago • Ms. S, an 83-year-old woman with heart disease, a his- tory of myocardial infarction, and mild dementia • Mr. B, a 93-year-old newly admitted man from a long- term care facility, with decreased urine output, altered lev- el of consciousness, and an elevated temperature of 99.5°F (37.5°C) • Mr. L, a 59-year-old man with mild shortness of breath (SOB) and chronic emphysema