Leadership LaCharity questions

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm (refer to figure). Which action will the nurse take first? figure shows V tach. 1. Defibrillate at 200 joules. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine 1 mg IV. 4. Intubate and manually ventilate.

1. Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available.

A decrease of _ or more points on the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.

2

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 (2.3 x 109/L). 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2. *Norm WBC 4,500 to 11,000* Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? 1. Ask the client about his or her bowel movements. 2. Have the client complete a diet diary for the past 2 days. 3. Instruct the client to increase oral intake to 2 to 3 L/day. 4. Ask the client to describe his urine output.

3

The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening.

2

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.

2 If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order 1-5 A. Older woman with advanced Alzheimer disease who requires total care for all activities of daily living. She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. B. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. C. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. D. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. E. Older man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses.

1= B 2= C 3= D 4= E 5= A All of the clients are in relatively stable condition. The client with the pneumothorax has priority because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated before and after removal of the chest tube. The woman who will be leaving the unit for diagnostic testing should be assessed and prepared, as needed, before she leaves for the procedure. In a client with meningitis, a headache is not unexpected, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; caring for her last prevents delaying care for all the others. In addition, elderly clients with dementia benefit if the caregiver does not act rushed or hurried.

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

2. The new graduate RN who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the unlicensed assistive personnel (UAP). The client being transferred to the nursing home, and the newly admitted client with spinal cord injury should be assigned to experienced nurses.

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take first? 1. Give acetaminophen 650 mg PO. 2. Administer ondansetron 4 mg IV. 3. Infuse normal saline at 500 mL/hr. 4. Increase oxygen flow rate to 6 L/min.

3. Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline. Treatment of nausea and headache are appropriate and should be implemented next. There is no indication that this client is hypoxemic, although clients with Ebola may develop multiorgan failure and require respiratory support.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

3. SIADH results in a relative sodium deficit caused by excessive retention of water. sodium is so diluted by water retention that pt becomes hyponatremic.

After the nurse receives a change-of-shift report, which patient should be seen first? 1. A 26-year-old patient with thalassemia who has a hemoglobin level of 8 g/dL (80 g/L) and orders for a blood transfusion 2. A 44-year-old patient admitted 3 days previously for sickle cell crisis who is scheduled for a computed tomographic (CT) scan 3. A 50-year-old patient with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. A 69-year-old patient with chemotherapy-induced neutropenia who has an oral temperature of 100.1°F (37.8°C)

4. Any temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection, so actions such as drawing blood for culture and administering antibiotics should be initiated quickly. The other patients need to be assessed as soon as possible but are not critically ill.

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1 Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume.

The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco2) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? 1. "When the Paco2 is acutely elevated, the blood pH should be lower than normal." 2. "This client should be taught to breathe and rebreathe in a paper bag." 3. "An elevated Paco2 always means that a client has an acidosis." 4. "When a client's Paco2 is increased, the respiratory rate should decrease to compensate."

1 This client's Paco2 is elevated (normal is 35 to 45 mm Hg). Whenever the Paco2 level changes acutely, the pH changes to the same degree, in the opposite direction. As the amount of CO2 begins to rise above normal in brain blood and tissues, these central receptors trigger the neurons to increase the rate and depth of breathing (hyperventilation). For these reasons, answers 2, 3, and 4 are inaccurate.

According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief 6. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain

1 2 3 4 Long-acting oral opioids are not recommended in the postoperative period. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine is not recommended.

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply. 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by the client's health care provider.

1 2 3 4 5 Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan. Migraine pain is caused by vasodilation in the cranial blood vessels (why you want to avoid medications that vasodilate like nitro), while headache pain is caused by vasoconstriction. During a migraine, inflammation of the tissue surrounding the brain, i.e., neurogenic inflammation, exacerbates the pain.

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

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The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. 1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

1 2 3 5 Current guidelines indicate that antiretroviral therapy for HIV should be initiated as soon as possible after HIV diagnosis. Although ongoing substance abuse is a risk factor for poor adherence, antiretroviral therapy can be initiated when strategies to improve adherence are used. Strategies include directly observing patients taking medications, needle exchange programs, and referring patients for substance abuse treatment.

The charge nurse assigns the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would the RN provide for the LPN/LVN? Select all that apply. 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour. 6. Instruct the patient to perform range of motion on the affected wrist.

1 2 3 5 Postoperatively, patients undergoing open carpal tunnel release surgery experience pain and numbness, and their discomfort may last for weeks to months. Hand movements may be restricted for 4 to 6 weeks after surgery. All of the other directions are appropriate for the postoperative care of this patient. It is important to monitor for drainage, tightness, and neurovascular changes. Raising the hand and wrist above the heart reduces the swelling from surgery, and this is often done for several days.

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

1 2 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle 6. Reminding the client to void in a urinal every hour while awake

1 2 4 5 All of the strategies except straight catheterization may stimulate voiding in clients with a spinal cord injury (SCI). Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. To use a urinal, the client must have bladder control, which is often absent after SCI. In addition, every hour while awake would be too often and ignore the bladder filling at night.

The emergency department nurse receives a call about a patient with a traumatic finger amputation. What instructions does the nurse provide to the patient's wife? Select all that apply. 1. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. 2. Put the finger in a watertight, sealed plastic bag. 3. Place the bag directly on ice. 4. Elevate the affected extremity above the patient's heart. 5. Examine the amputation site and apply direct pressure with layers of dry gauze. 6. After performing these steps, call 911 and check the patient for breathing.

1 2 4 5 For a person who has a traumatic amputation in the community, first call 911 and then assess the patient for airway or breathing problems. Examine the amputation site, and apply direct pressure with layers of dry gauze or cloth. Elevate the extremity above the patient's heart to decrease the bleeding. Do not remove the dressing to prevent dislodging the clot. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. Put the finger in a watertight, sealed plastic bag. Place the bag in ice water, never directly on ice, with 1 part ice and 3 parts water. Avoid contact between the finger and the water to prevent tissue damage. Do not remove any semidetached parts of the digit. Be sure that the part goes with the patient to the hospital.

When the nurse is educating a group of women of childbearing age about the Zika virus, which information will be included? Select all that apply. 1. Women who are pregnant will be asked about possible Zika exposure at each prenatal visit. 2. Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika. 3. There is a high risk for maternal death when women are infected with the Zika virus during pregnancy. 4. Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission. 5. Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure.

1 2 4 5 National guidelines recommend that all pregnant women be assessed for Zika exposure at each prenatal visit, that women who may have been exposed be tested, that women who are anticipating pregnancy should avoid travel to areas where they might be exposed to Zika, and that barrier methods be used if the sex partner has been exposed to Zika infection. Congenital defects to the fetus occur if there is Zika infection during pregnancy, but the maternal infection is usually mild and nonfatal.

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

1 2 4 5 6 Bedding should be washed in hot water to destroy dust mites.

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. 1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 3. "When was your last bowel movement?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 5. "Over the past month have you had any dizziness or tinnitus?" 6. "Do you have episodes of drowsiness or decreased alertness?"

1 2 4 6 Collect data about risk factors related to the development of acidosis. Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis.

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

1 2 4 6 Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to pace activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller more frequent meals may be less tiring. Teach the patient to avoid breath-holding while performing any activity because this interferes with gas exchange.

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply. 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

1 2 5 The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential.

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

1 3 4 5 The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.

All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

1 3 5 UAP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the UAP to report heart rate and blood pressure findings. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.

Which clients must be assigned to an experienced RN? Select all that apply. 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1 3 5 6 These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, vomiting and diarrhea are usually self-limiting. The client with chronic back pain would be considered physically stable. Although all clients will benefit from care provided by an experienced RN, the client with abdominal cramps and the client with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse.

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply. 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

1 4 6 Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice.

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions? take off gown. remove N95 respirator. Perform hand hygiene. remove gloves. Take off goggles.

1 remove gloves. 2 Take off goggles. 3 take off gown. 4 remove N95 respirator. 5 Perform hand hygiene. This sequence will prevent contact of the contaminated gloves and gown with areas (e.g., the hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to the nurse and to other clients. *If the nurse is wearing a disposable gown, the gown and gloves can be removed simultaneously by grasping the front of the gown and breaking the ties and then peeling the gloves off while removing the gown.*

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

1. A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

The nurse is assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. What is the priority concern? 1. Treating infection specific to cat bites 2. Suturing the puncture wounds 3. Administering tetanus vaccine 4. Maintaining mobility of finger joints

1. Cats' mouths contain a virulent organism, Pasteurella multocida, which can lead to septic arthritis or bacteremia. Appropriate first aid includes rigorous washing of the wound site with soap and water to combat infection. Puncture wounds, especially those caused by bites, are usually not sutured. There is also a risk for tendon damage and loss of joint mobility caused by deep puncture wounds, but an orthopedic surgeon would be consulted after initial emergency care is started. A tetanus shot can be given before discharge.

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

1. Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? 1. A 36-year-old patient with chronic kidney failure who will need a subcutaneous injection of epoetin alfa 2. A 39-year-old patient with hemophilia B who has been admitted to receive a blood transfusion 3. A 50-year-old patient with newly diagnosed polycythemia vera who will require phlebotomy 4. A 55-year-old patient with a history of stem cell transplantation who has a bone marrow aspiration scheduled

1. LPNs/LVNs should be assigned to care for stable patients. Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. Blood transfusions should be administered by RNs because evaluation for and management of transfusion reactions require RN-level education and scope of practice. The other patients will require teaching about phlebotomy and bone marrow aspiration that should be implemented by the RN.

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

1. Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high-protein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.

In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1. The UAP can assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.

After the nurse receives the change-of-shift report, which patient should be assessed first? 1. A 20-year-old patient with possible acute myelogenous leukemia who has just arrived on the medical unit 2. A 38-year-old patient with aplastic anemia who needs teaching about decreasing infection risk before discharge 3. A 40-year-old patient with lymphedema who requests help in putting on compression stockings before getting out of bed 4. A 60-year-old patient with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen

1. The newly admitted patient should be assessed first because the baseline assessment and plan of care need to be completed.

The nurse is admitting a patient with nephrotic syndrome. Which assessment finding supports this diagnosis? 1. Edema formation 2. Hypotension 3. Increased urine output 4. Flank pain

1. The underlying pathophysiology of nephrotic syndrome involves increased glomerular permeability, which allows larger molecules to pass through the membrane into the urine and be removed from the blood. This process causes massive loss of protein, edema formation, and decreased serum albumin levels. Key features include hypertension and renal insufficiency (decreased urine output) related to concurrent renal vein thrombosis, which may be a cause or an effect of nephrotic syndrome. Flank pain is seen in patients with acute pyelonephritis.

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? 1. The patient reports a blistering rash. 2. The patient's fluid intake is 2 L/day. 3. The patient's potassium is 3.4 mg/dL (3.4 mmol/L). 4. The patient enjoys spending time outside in the sun.

1. Because TMP-SMX can cause Stevens-Johnson syndrome (a life-threatening skin condition), a blistering rash indicates a need to discontinue the medication immediately. Two L/day of fluid is adequate to prevent crystalluria and renal damage associated with TMP-SMX. TMP-SMX can cause hyperkalemia; the nurse will report the potassium level to the provider, but the low potassium level is not caused by the medication. Patient teaching about photosensitivity is needed, but the nurse does not need guidance from the provider to implement this action.

A 88-year-old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time? 1. Oseltamivir 75 mg PO 2. Guaifenesin 600 mg PO 3. Acetaminophen 650 mg PO 4. Influenza vaccine 180 mcg IM

1. Because antivirals are most effective when used early in influenza infection, the nurse should administer the oseltamivir as soon as possible to decrease the severity of the infection and risk of transmission to others. Guaifenesin and acetaminophen will help with the symptoms of cough and muscle aching but will not shorten the course of the client's illness or decrease risk of transmission. The influenza vaccine may still help in preventing future influenza caused by another virus.

During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

1. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability.

The nurse recognizes that there are ethical considerations in helping clients to achieve relief from pain. Which nursing action is the best example of the principle of nonmaleficence? 1. Client seems excessively sedated but continues to ask for morphine, so the nurse conducts further assessment and seeks alternatives to opioid medication. 2. Client has no known disease disorders and no objective signs of poor health or injury, but reports severe pain, so nurse advocates for pain medicine. 3. Client is older, but he is mentally alert and demonstrates good judgment, so the nurse encourages the client to verbalize personal goals for pain management. 4. Client repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication.

1. Nonmaleficence is to prevent harm. If the client is excessively sedated, the nurse knows that giving additional opioid medication could do more harm than good, so the nurse would conduct further assessments and seek alternative options for pain relief. The client's report of pain should be believed, so based on the principle of justice, the nurse advocates for pain medication even though an organic cause of disease is not identified. By encouraging the client to have a voice in her or his own pain management goals, the nurse is applying the principle of autonomy. By explaining the benefits of pain medication, the nurse is applying the principle of beneficence (doing good/what's best for the pt) to help the client recognize the balance between pain control and safety.

The nurse manager in a public health department is implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will be delegated to unlicensed assistive personnel (UAP) working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

1. Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with UAP education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills.

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%

1. The blood gas component responsible for respiratory acidosis is carbon dioxide, thus increasing the ventilator rate will blow off more carbon dioxide and decrease or correct the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

A client is crying and grimacing but denies pain and refuses pain medication because "my brother is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem.

1. This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the client.

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? Select all that apply. 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

2 3 4 Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions.

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

2 3 6 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma.

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

2 5 6 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions.

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is most important to discuss with the health care provider before administration of the medication? 1. The client's oxygen saturation is 92%. 2. The client receives lisinopril 10 mg/day. 3. The client's blood pressure is 150/90 mm Hg. 4. The client's potassium is 3.3 mEq/L (3.3 mmol/L).

2. Because combination angiotensin receptor blocker-neprilysin blockers markedly increase the risk for angioedema in clients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril-valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension is increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril-valsartan.

For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and client's response to the last dose of analgesic. 4. Give the maximum as needed (PRN) dose within the minimum time frame for relief.

2. Complete information should be obtained from the family during the initial comprehensive history taking and assessment. If this information is not obtained, the nursing staff must rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

2. Manual ventilation of the patient will allow the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.

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

2. Teach the UAP that compared with light-skinned adults, adults with dark skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status.

The client is diagnosed by the emergency department health care provider (HCP) with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone to prevent reoccurrence, and the client has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the client took ergotamine 3 hours ago. 3. The HCP is considering metoclopramide, and this is a first-time migraine for the client. 4. The HCP is considering prochlorperazine, and the client drove himself to the hospital.

2. The American Headache Society developed recent guidelines for treatment of acute migraines. Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Dexamethasone may cause increased glucose levels. Prochlorperazine can cause drowsiness.

While administering vancomycin 500 mg IV to a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client's neck and face are becoming flushed. Which action should the nurse take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2. "Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing.

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

2. BNP is substances that are produced in the heart and released when the heart is stretched and working hard to pump blood. Norm BNP is Less than 125 pg/mL for patients aged 0-74 years. & Less than 450 pg/mL for patients aged 75-99 years. >450 for pt <50 yo & >900 in pts >50yo is indicative of HF. Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the client has heart failure. BNP is used for dx of HF.

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient exclaims, "I'm afraid I'm going to die right here!" 2. The prescribed patient medications include midazolam 2 mg IV immediately. 3. The patient is diaphoretic and tremulous and reports dizziness. 4. The symptoms occurred suddenly while the patient was driving to work.

2. Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient's diagnosis of panic attack and do not indicate an urgent need to communicate with the provider.

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100°F (37.8°C).

2. Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued.

When the nurse is assessing a patient with chronic kidney disease who is receiving epoetin alfa (erythropoietin) injections, which finding most indicates a need to talk with the health care provider (HCP) before giving the medication? 1. Hemoglobin level is 8.9 g/dL (89 g/L). 2. Blood pressure is 198/92 mm Hg. 3. The patient does not like subcutaneous injections. 4. The patient has a history of myocardial infarction.

2. Epoetin alfa can cause hypertension, and blood pressure should be controlled before administering the medication. Because patients with chronic kidney disease have chronic anemia, a hemoglobin level of 8.9 g/dL (89 g/L) is not unusual. Although the nurse could ask the HCP about IV administration of the medication, subcutaneous administration requires a lower dose of the medication and is preferred. Epoetin alfa can cause angina or myocardial infarction, but the risk is highest when hemoglobin levels are greater than 11 g/dL (110 g/L).

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently? 1. Client with peripheral arterial disease who complains of leg cramps when walking 2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Client with a new permanent pacemaker who has severe itchiness at the wound site 4. Client with angina who took nitroglycerin twice in the last week while exercising

2. Lightheadedness and syncope may indicate that the client's heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other clients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled.

A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which action prescribed by the health care provider will the nurse implement first? 1. Administer morphine sulfate 4 to 8 mg IV. 2. Give oxygen at 4 L/min per nasal cannula. 3. Start an infusion of normal saline at 200 mL/hr. 4. Apply warm packs to painful joints.

2. National guidelines for sickle cell crisis indicate that oxygen should be administered if the oxygen saturation is less than 95%. Hypoxia and deoxygenation of the blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control (including administration of morphine and application of warm packs to joints) and hydration are also important interventions for this patient and should be accomplished rapidly.

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider? 1. Clopidogrel 75 mg/day 2. Ibuprofen 200 mg every 4 hours as needed 3. Metoprolol succinate 50 mg/day 4. Nitroglycerin patch 0.4 mg/hr

2. Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for clients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the client but should be verified because the orders were received by telephone.

For which client with severe migraine headaches would the nurse question an order for sumatriptan? 1. A 58-year-old client with gastrointestinal reflux disease 2. A 48-year-old client with hypertension 3. A 65-year-old client with mild emphysema 4. A 72-year-old client with hyperthyroidism

2. Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal angina because of the potential for coronary vasospasm.

Which client would the charge nurse assign to the step-down unit nurse who was floated to the intensive care unit for the day? 1. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis 2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent 3. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip 4. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

2. The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group and should be assigned to the float nurse from the step-down unit. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen 800 mg PO TID.

2. The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical actions may need some further clarification by the nurse. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not usually necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of nonsteroidal anti-inflammatory drugs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with exacerbations of SLE.

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection? 1. A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis 2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection 3. A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the emergency department. The child with the rash should be quickly isolated from the other clients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB.

After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department. Which action prescribed by the health care provider will the nurse implement first? 1. Transport to the radiology department for cervical spine radiography. 2. Transfuse factor VII concentrate. 3. Type and cross-match for 4 units of packed red blood cells (PRBCs). 4. Infuse normal saline at 250 mL/hr.

2. When a hemophiliac patient is at high risk for bleeding, the priority intervention is to maximize the availability of clotting factors. The other prescribed actions also should be implemented rapidly but do not have as high a priority as administering clotting factors.

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Client reports eating a green salad for lunch every day.

2. norm therapeutic INR is 2-3. pt will need an increase in Warfarin dose. Although foods that are high in vitamin K will have an impact on INR and foods high in vitamin K will *help the blood clot* therefore having the opposite effect of Warfarin and can cause Warfarin to not be as effective, this is not a concern when these foods are eaten consistently because the warfarin dose can be adjusted accordingly.

Which postoperative client is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism related to immobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain

2. venous thromboembolism can lead to pulmonary embolism, and this is an immediate life-threatening concern.

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

3 UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

3. Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

3. According to Centers for Disease Control and Prevention guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection.

A patient with an absolute neutrophil count of 300/μL (0.3 × 109/L) is admitted to the oncology unit. Which staff member should the charge nurse assign to provide care for this patient, under the supervision of an experienced oncology RN? 1. LPN/LVN who has floated from the same-day surgery unit 2. RN from a staffing agency who is being oriented to the oncology unit 3. LPN/LVN with 2 years of experience on the oncology unit 4. RN who recently transferred to the oncology unit from the emergency department

3. Because many aspects of nursing care need to be modified to prevent infection when a patient has a low absolute neutrophil count, care should be provided by the staff member with the most experience with neutropenic patients. The other staff members have the education required to care for this patient but are not as clinically experienced. When LPN/LVN staff members are given acute care patient assignments, they must work under the supervision of an RN. The LPN/LVN in this case would report to the RN assigned to the patient.

The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine solution 3. 0.5% chlorhexidine in alcohol 4. Betadine followed by 70% isopropyl alcohol

3. Chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections. The other solutions provide some decrease in the number of microorganisms on the skin but are not as effective as chlorhexidine.

A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is most important for the nurse to discuss with the health care provider? 1. Heart rate is 52 beats/min. 2. Client is also taking carvedilol for angina. 3. Client reports having chronic constipation. 4. Blood pressure is 106/56 mm Hg.

3. Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the client plan of care.

A victim of heat stroke arrives in the emergency department. His skin is hot and dry; his body temperature is 105°F (40.6°C). He is confused and demonstrates bizarre behavior. His blood pressure is 85/60 mm Hg, pulse 130 beats/min, and respirations are 40 breaths/min. Which task should be assigned to an experienced LPN/LVN? 1. Insert a rectal probe to measure core body temperature. 2. Administer aspirin or another antipyretic. 3. Insert an indwelling urinary drainage catheter. 4. Assess respiratory effort, hemodynamics, and mental status.

3. Inserting an indwelling urinary catheter is within the scope of practice of an experienced LPN/LVN. Experienced unlicensed assistive personnel should be directed to insert the rectal probe to monitor the core temperature. Initial assessment of new clients and critically ill clients should be performed by the RN. Aspirin and other antipyretics are not given because they won't work to decrease the body temperature and may be harmful. The care of this client would also include arterial blood gases; possible endotracheal intubation; IV fluids; blood for electrolytes, cardiac and liver enzymes, and complete blood count; muscle relaxants (benzodiazepines) if the client begins to shiver; monitoring urine output and specific gravity to determine fluid needs; cooling interventions; and discontinuing cooling interventions when core body temperature is reduced to 102°F (38.9°C).

The nurse is providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that the nurse intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

3. Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing.

The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next? 1. Prepare to defibrillate the client. 2. Offer to take over chest compressions. 3. State: "Epinephrine 1 mg IV has been given." 4. Continue to monitor the client's responsiveness.

3. The American Heart Association recommends "closed loop" communication between team members who are involved in resuscitation of a client. The other actions may also be needed, but the initial action after administering a medication is to assure that the team leader knows that the prescribed medication has been administered.

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see first? 1. Client who has a 16-mm induration after a tuberculosis (TB) skin test 2. Client who has human immunodeficiency virus and a low CD4 count 3. Client who has swine influenza (H1N1) and reports increased dyspnea 4. Client who has been exposed to Zika virus and has a rash and joint pain

3. The client with increased dyspnea should be seen first because rapid actions such as oxygen administration and IV fluids may be needed. The other clients will require further assessment, counseling, or treatment, but they do not have potentially life-threatening symptoms or diagnoses.

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the health care provider about the change in status. 4. Reassure the client that embolization is common in endocarditis.

3. The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the health care provider should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain.

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the client? 1. The nurse should personally ask the client to authorize HIV testing. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a client's HIV status and/or order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the client to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health).

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

3. diaphoresis is early sign: 6-12hr all others are late signs: 48-72hr

The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4 The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

An inexperienced graduate nurse is reviewing the medication administration record (MAR) for a client who has a patient-controlled analgesia (PCA) pump for pain management. The new nurse compares the MAR and the health care provider's (HCP's) prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? 1. Ask the client if he typically needs extra medication in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA.

4 The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the client to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help.

The health care provider (HCP) has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? 1. Prepare the medication and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions.

4. Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research where placebos are used, but clients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy. If the HCP is insistent, suggest that he or she could give the placebo. (Note: Use "could," not "should," when talking to the HCP. This provides a small opportunity to rethink the decision. "Should" elicits a more defensive response.) Although following a personal ethical code is correct, the nurse must ensure that the client is not abandoned and that care continues.

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

4. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client.

4. The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the nondominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.

4. (why tf would I not insert the IV before they get so hypovolemic that I can't get an IV in Idk but I guess NCLEX wants us to jump ship and rely on the HCP for everything. alright rant over)

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

4. A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection. According to current national guidelines, the other actions are also appropriate, but the initial action will be to communicate the test results to the patient. Rapid HIV testing must be confirmed by another test, usually the Western blot test. Antiretroviral therapy is recommended for all HIV-positive patients. Risk factor information will be used in tracking patient contacts and in teaching the patient how to reduce the risk for transmission to others.

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine 20 mg IV 2. Furosemide 40 mg IV 3. Digoxin 0.25 mg PO 4. Warfarin 2.5 mg PO

4. Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed.

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of most concern? 1. The patient reports that stools are black. 2. The patient complains of occasional constipation. 3. The patient takes a multivitamin tablet every day. 4. The patient takes an antacid with the iron to avoid nausea.

4. Concurrent use of antacids with iron supplements will decrease absorption of the iron and decrease the efficacy in resolving the patient's anemia. Black stools are expected when taking oral iron. The patient's occasional constipation may indicate a need for information about prevention of constipation while taking iron. Use of a multivitamin tablet is safe when taking iron supplements (although the patient may need to avoid taking combined vitamin and mineral supplements).

The nurse is checking medication prescriptions that were received by telephone for a client with hypertensive crisis and tachycardia. Which medication is most important to clarify with the health care provider? 1. Carvedilol 12.5 mg PO BID daily 2. Hydrochlorothiazide 25 mg PO daily 3. Labetalol 20 mg IV over a 2-min time period now 4. Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

4. Hydroxyzine is a first-generation antihistamine that is used to treat patients with anxiety and pruritus. It is likely that the correct medication is hydralazine, a vasodilator that is used to treat hypertension. Hydroxyzine and hydralazine are "look-alike, sound-alike" drugs that have been identified by the Institute for Safe Medication Practices (ISMP) as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the hydroxyzine, which is likely an error.

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)

4. Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not of as urgent concern.

The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

4. Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen).

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4. The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because *spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm.* The other assessments are also necessary but are not as high a priority.

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 154/78 mm Hg. 2. Pedal pulses are palpable at + 1. 3. Left groin has a 3-cm bruised area. 4. Apical pulse is 122 beats/min and regular.

4. The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern.

A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

4. Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the antiretroviral therapy is effective. The CD4 level, total lymphocytes, and complete blood count will also be used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy.