Lacharity Ch 7 Test 2 GOLD

1. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

1. Ans: 2. Troponin I level Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization

10. You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

10. Ans: 3. Administer sublingual nitroglycerin. The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority. Focus: Prioritization

11. An 80-year-old client on the coronary step-down unit tells you that he does not want to take the ordered docusate (Colace) because he does not have any problems with constipation. Which action is most appropriate? 1. Document the medication on the client's chart as "refused." 2. Mix the medication with food and administer it to the client. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

11. Ans: 3. Explain that his decreased activity level may cause constipation. The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as "refused" or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it, unless someone else has health care power of attorney and has authorized use of the medication. Focus: Prioritization

12. You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate 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)

12. Ans: 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute MI is to completely eliminate the pain. 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. Focus: Prioritization

13. You are preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had an MI and her husband. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

13. Ans: 2. "Can you tell me why you don't feel that you need to make any changes?" For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give you more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle. Focus: Prioritization

14. You are caring for a hospitalized client with heart failure who is receiving captopril (Capoten) and spironolactone (Aldactone). Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood urea nitrogen level 3. Potassium level 4. Alkaline phosphatase level

14. Ans: 3. Potassium level Hyperkalemia is a common adverse effect of both ACE inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening. Focus: Prioritization

15. The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel (Plavix). Which medication is most important to clarify further with the health care provider? 1. Aspirin (Ecotrin) 162 mg daily 2. Omeprazole (Prilosec) 20 mg daily 3. Metoprolol (Lopressor) 50 mg daily 4. Nitroglycerin patch (Nitrodur) 0.4 mg/hr

15. Ans: 2. Omeprazole (Prilosec) 20 mg daily Since proton pump inhibitors such as omeprazole affect the metabolism of clopidogrel and decrease its effectiveness, the health care provider may want to discontinue the omeprazole in this client with unstable angina. The other medications should also be verified, but current national guidelines for clients with unstable angina indicate that providers should consider avoiding proton pump inhibitors in those who require clopidogrel. Focus: Prioritization

16. At 10:00 AM, a hospitalized client receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

16. Ans: 1. Put the client on "nothing by mouth" (NPO) status. Because TEE is performed after the throat is numbed using a topical anesthetic and possibly after IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the TEE but do not need to be implemented immediately. Focus: Prioritization

17. You assess a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 144/78 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

17. Ans: 4. Apical pulse is 122 beats/min and regular 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. Focus: Prioritization

18. You are working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to an experienced 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

18. Ans: 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated Measurement of ankle and brachial blood pressures for ankle-brachial index calculation is within the UAP's scope of practice. Calculating the ankle-brachial index 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. Focus: Delegation

19. While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. 19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV 3. 50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care 4. 75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

19. Ans: 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses. Focus: Assignment

2. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)

2. Ans: 4. Chest pain level of 3 (on a scale of 10) Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization

20. You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min

20. Ans: 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of MI. Focus: Prioritization

21. Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate.

21. Ans: 1. Defibrillate at 200 J. 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. Focus: Prioritization

22. Two weeks ago, a 63-year-old client with heart failure received a new prescription for carvedilol (Coreg) 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

22. Ans: 3. Sinus bradycardia at a rate of 48 beats/min Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, the slow heart rate does require further follow-up, because bradycardia may progress to more serious dysrhythmias such as heart block. Focus: Prioritization

23. You have just received a change-of-shift report about these clients on the coronary step-down unit. Which one will you assess first? 1. 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. 56-year-old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. 77-year-old who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6° F (38.1° C)

23. Ans: 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change The client's symptoms indicate acute hypoxia, so immediate further assessments (such as assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon, because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client. Focus: Prioritization

24. As the charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and UAPs, you have developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to delegate to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

24. Ans: 2. Listening to lung sounds and checking for edema each week LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice. Focus: Delegation

25. During a home visit to an 88-year-old client who is taking digoxin (Lanoxin) 0.25 mg daily to treat heart failure and atrial fibrillation, you obtain this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse of 68 beats/min and irregularly irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

25. Ans: 3. Vision that is becoming "fuzzy" The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregularly irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure. Focus: Prioritization

26. You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

26. Ans: 2, 4, 3, 1 2. Have the client sit down. 4. Administer PRN oxygen by nasal cannula. 3. Check the client's blood pressure. 1. Call the client's physician. The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization

27. A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you 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 client's physician about the change in status. 4. Reassure the client that embolization is common in endocarditis.

27. Ans: 3. Notify the client's physician about the change in status. 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 physician 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. Focus: Prioritization

28. A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for you to delegate to the UAP? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

28. Ans: 4. Assisting the client in cleaning around the Unna boot Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members. Focus: Delegation

29. 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, you obtain 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.

29. Ans: 1. Arterial line indicates a blood pressure of 190/112 mm Hg. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and/or 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. Focus: Prioritization

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (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

3. Ans: 1, 4, 6 1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED 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. Focus: Delegation

30. You are developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. Which nursing activity included in the care plan will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

30. Ans: 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously-taught information are activities that can be delegated to other nursing personnel under the supervision of the RN. Focus: Delegation

31. You are 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 (Pepcid) 20 mg IV 2. Furosemide (Lasix) 40 mg IV 3. Digoxin (Lanoxin) 0.25 mg PO 4. Warfarin (Coumadin) 2.5 mg PO

31. Ans: 4. Warfarin (Coumadin) 2.5 mg PO 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. Focus: Prioritization

32. 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

32. Ans: 2. B-type natriuretic peptide 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. Focus: Prioritization

4. Based on this information in a client's medical record, which topic will you plan on including in the initial teaching plan for a client who has a new diagnosis of stage 1 hypertension? Health History- Denies any chronic health problems, currently takes no medications. Physical Exam- 5'6" , 115lbs, BMI 18.6. Social and Diet HX- Accountant, 1 glass of wine 1-2 times week, Eats fast food frequently. 1. Benefits and adverse effects of beta-blockers 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4. Ans: 4. Low-sodium food choices when eating out Research indicates that reducing sodium intake will lower blood pressure. Lifestyle management is appropriate initial therapy for this client with stage 1 hypertension and no cardiovascular disease or risk factors. Antihypertensive medications would not be prescribed unless lifestyle changes were attempted for several months without a decrease in blood pressure. This client's assessment data indicate that she is not overweight and does not drink alcohol excessively, so discussing changes in these risk factors would not be appropriate. Focus: Prioritization

5. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client coughs often during the visit. 4. Client says, "I get dizzy sometimes."

5. Ans: 3. Client coughs often during the visit. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization

6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

6. Ans: 1, 2 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization

7. You are the charge nurse for the coronary care step-down unit. Which client is best to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

7. Ans: 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have ACS and with collaborative treatments such as coronary angioplasty and coronary artery stenting. Focus: Assignment

8. At 9:00 pm, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine (Pepcid) for esophageal reflux. 3. The client has ST-segment elevations on the 12-lead ECG. 4. The client has had continuous chest pain since 8:00 AM.

8. Ans: 4. The client has had continuous chest pain since 8:00 AM. Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. Focus: Prioritization

9. You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN? 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

9. Ans: 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice. Focus: Delegation