Management Final

Which factor reported by Ms. H to the nurse supports the diagnosis of Cushing disease? 1. Cessation of menses at age 33 years 2. Increased craving for salty foods 3. Weight loss of 25 lb 4. Nausea, diarrhea, and loss of appetite

1. Cessation of menses at age 33 years

The nurse overhears the UAP talking to someone on the phone. The UAP says, "Yes, Mr. D is doing much better than when he first got here. I will tell him that you called, and I will give him your message." What will the nurse do first? 1. Ask the UAP about the phone conversation that was just overheard. 2. Remind the UAP that release of information is outside her scope of practice. 3. Report the UAP to the nurse manager for client privacy violation 4. Give positive feedback for trying to help the client and the caller

1. Ask the UAP about the phone conversation that was just overheard

Ms. B develops diaphoresis, an increased heart rate (124 bpm), and tremors. She also reports an increasing headache. Which action should the nurse take first? 1. Check the fingerstick glucose level 2. Check the serum potassium level 3. Place the patient on a cardiac monitor 4. Decrease IV fluids to 100 mL/hr

1. Check the fingerstick glucose level

Which laboratory values would the nurse expect to find for Ms. H? SATA 1. Elevated serum cortisol level 2. Decreased serum sodium level 3. Elevated serum glucose level 4. Decreased lymphocyte count 5. Increased serum calcium level 6. Decreased urine androgen level

1. Elevated serum cortisol level 3. Elevated serum glucose level 4. Decreased lymphocyte count

Which actions will the nurse delegate to the UAP in providing care for Ms. B? SATA 1. Encouraging the patient to take in adequate oral fluids 2. Measuring vital signs every 15 minutes 3. Recording intake and output accurately every hour 4. Getting a baseline weight to guide therapy 5. Administering oral antinausea medication 6. Assisting the patient up to the bathroom

1. Encouraging the patient to take in adequate oral fluids 2. Measuring vital signs every 15 minutes 3. Recording intake and output accurately every hour 4. Getting a baseline weight to guide therapy 6. Assisting the patient up to the bathroom

In caring for Mr. D, the nurse is vigilant for signs and symptoms of hypokalemia. What signs and symptoms should the nurse watch for? SATA 1. Fatigue 2. Cold, clammy skin 3. Muscle weakness 4. Hypotension 5. Weak pulse 6. Shallow respiration

1. Fatigue 3. Muscle weakness 4. Hypotension 5. Weak pulse 6. Shallow respiration

Which tasks are appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? SATA. 1. Measuring and reporting Mr. D's vital signs every 15 minutes 2. Checking and reporting Mr. D's blood glucose level 3. Bagging and labeling Mr. D's belongings 4. Updating the roommate regarding Mr. D's status 5. Measuring emesis and cleaning the basin as needed 6. Obtaining an infusion pump from the supply room

1. Measuring and reporting Mr. D's vital signs every 15 minutes 2. Checking and reporting Mr. D's blood glucose level 3. Bagging and labeling Mr. D's belongings 5. Measuring emesis and cleaning the basin as needed 6. Obtaining an infusion pump from the supply room

Which serious complications may result from alcohol withdrawal delirium? SATA 1. Myocardial infarction 2. Electrolyte imbalance 3. Aspiration pneumonia 4. Anaphylaxis 5. Sepsis 6. Suicide

1. Myocardial infarction 2. Electrolyte imbalance 3. Aspiration pneumonia 5. Sepsis 6. Suicide

What does the nurse anticipate the HCP will order for the initial fluid replacement? 1. Normal saline (0.9% sodium chloride) 2. Half-strength saline (0.45% sodium chloride) 3. 5% dextrose in water and half-strength saline 4. Normal saline with potassium chloride

1. Normal saline (0.9% sodium chloride)

Which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Repeating measurement of vital signs 2. Gathering equipment for nasogastric (NG) tube insertion 3. Obtaining the blood glucose level every 2 hours 4. Offering ice chips or small sips of water

1. Repeating measurement of vital signs

Mr. S has recovered so the RN and the student nurse are preparing for discharge teaching. Which key points would be included in the teaching plan? SATA 1. Stair climbing is initially strictly limited 2. A bedside commode is required even if there is a first-floor bathroom 3. Heavy lifting (usually more than 15 to 20 lb) is avoided 4. Use caution for activities that involve pulling, pushing, or straining 5. Expect to experience abdominal fullness, chest pain, and shortness of breath 6. Driving a car will be restricted for several weeks

1. Stair climbing is initially strictly limited 3. Heavy lifting (usually more than 15 to 20 lb) is avoided 4. Use caution for activities that involve pulling, pushing, or straining 6. Driving a car will be restricted for several weeks

The RN is preparing a health teaching plan for Ms. Q. Which key aspects would be included? SATA 1. Weight reduction strategies 2. Avoidance of tobacco and caffeine 3. Drink no more than three alcohol-containing drinks per day 4. Exercise 6 to 7 days a week for at least 1 hour 5. Use of relaxation techniques to decrease stress 6. Restrict dietary sodium as recommended by the American Heart Association (AHA)

1. Weight reduction strategies 2. Avoidance of tobacco and caffeine 5. Use of relaxation techniques to decrease stress 6. Restrict dietary sodium as recommended by the American Heart Association (AHA)

In the initial emergency care of Mr. D, which HCP prescriptions would the nurse question? SATA 1. Start a peripheral IV line with a large-bore catheter 2. Obtain a urine specimen with a small-bore straight catheter 3. Administer regular insulin subcutaneously 4. Maintain the client in a semi-Fowler position 5. Initiate continuous electrocardiographic (ECG) monitoring 6. Encourage intake of oral fluids as tolerated

2. Obtain a urine specimen with a small-bore straight catheter 3. Administer regular insulin subcutaneously 6. Encourage intake of oral fluids as tolerated

Mr. D says to the nurse, "Please don't call my mother. If she knows I'm in the hospital, she'll make me quit school and move back home. I know I messed up, but I really don't want to move back in with my parents." What is the best therapeutic communication response? 1. "None of the staff will say anything, but you should tell her yourself." 2. "Your mom loves you, and she is just concerned about your well-being." 3. "It sounds like you want to be independent and responsible for yourself." 4. "You are an adult, and you have a right to make your own decisions."

3. "It sounds like you want to be independent and responsible for yourself."

What is the priority nursing concept to consider in planning the initial emergency interventions for Mr. D? 1. Gas exchange 2. Acid-base imbalance 3. Fluid and electrolyte imbalance 4. Adherence

3. Fluid and electrolyte imbalance

The RN is reviewing the lipid profile for Ms. Q, who has been diagnosed with atherosclerosis. Which finding is of most concern? 1. Total serum cholesterol level of 220 mg/dL 2. Triglyceride level of 165 mg/dL 3. Low-density lipoprotein (LDL) cholesterol level of 155 mg/dL 4. High-density lipoprotein (HDL) cholesterol level of 38 mg/dL

3. Low-density lipoprotein (LDL) cholesterol level of 155 mg/dL

Mr. S underwent surgery 3 days ago and was transferred back to the vascular surgery unit. The student nurse reports that the patient has no bowel sounds present. What does the RN tell the student is the best action? 1. Check the nasogastric tube for kinks 2. Notify the surgeon immediately 3. Obtain an abdominal radiograph immediately (STAT) 4. Document the finding in the chart

4. Document the finding in the chart

Mr. D, a 19-year-old pre-med student, has been brought to the ED by his roommate, who is a medical student and family friend. Mr. D reports abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for finals." He is alert and conversant but is having trouble focusing on the nurse's questions. VS: Blood glucose: 685 mg/dL, BP: 100/60 mm Hg, HR: 120 beats/min, RR: 32 breaths/min, Temp: 100.8 F The nurse has completed the triage assessment and history taking. Now what is the priority action? 1. Page the ED health care provider (HCP) to come to triage 2. Call the client's parents for permission to treat 3. Notify the client's primary HCP 4. Take the client immediately to a treatment room

4. Take the client immediately to a treatment room

After the change-of-shift report, the RN makes rounds on the patients. List the priority order for assessing these patients. 1. Ms. C 2. Mr. R 3. Mr. Z 4. Ms. Q 5. Mr. S 6. Ms. A

5. Mr. S 4. Ms. Q 2. Mr. R 6. Ms. A 1. Ms. C 3. Mr. Z

An adolescent with a history of asthma arrives in the emergency department experiencing respiratory distress. The primary health care provider admits the adolescent. Implementing which prescription is the nurse's priority? Dyspnea; flaring of nares; productive cough (sputum is frothy, clear, and gelatinous); wheezing; adolescent indicates shortness of breath, chest discomfort, headache, and feeling tired Orders: bed rest, CBC, SMA: 12, Albuterol 2.5 mg via nebulizer one dose, chest physiotherapy BID, incentive spirometer, oxygen via mask at 8 L, referral to allergist VS: T 98.8F, P 108, R 30, BP 130/86 A. Administer the nebulizer treatment to facilitate breathing B. Obtain a blood specimen to send to the laboratory for tests C. Notify the respiratory therapist to perform chest physiotherapy D. Send a requisition to central supply for an incentive spirometer

A. Administer the nebulizer treatment to facilitate breathing

Which is the priority nursing action immediately after the insertion of a subclavian central venous access catheter for a client who is to begin total parenteral nutrition (TPN)? A. Obtain a chest x-ray to determine placement B. Auscultate the lungs to evaluate breath sounds C. Draw a blood sample to assess blood glucose level D. Assess the right upper extremity for neurological deficits

B. Auscultate the lungs to evaluate breath sounds

Which intervention would be a priority for the nurse to include in the plan of care for a client with a gunshot wound who has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils? A. Monitoring skin integrity B. Monitoring bowel patterns C. Monitoring respiratory rate D. Monitoring nutritional status

C. Monitoring respiratory rate

A client with hyperemesis gravidarum is receiving rehydration infusion therapy at home. Which is the priority nursing activity for the home health nurse? A. Determining fetal well-being B. Monitoring for signs of infection C. Monitoring the client for signs of electrolyte imbalance D. Teaching about changes in nutritional needs during pregnancy

C. Monitoring the client for signs of electrolyte imbalance

During the immediate postinjury period, which action is the priority focus of nursing care for a client with a spinal cord injury? A. Inhibiting urinary tract infections B. Preventing contractures and atrophy C. Avoiding flexion and hyperextension of the spine D. Preparing the client for vocational rehabilitation

C. Avoiding flexion and hyperextension of the spine

Which task would the nurse classify as low priority when planning client care for the day? A. Drawing arterial blood gases on a client in respiratory distress B. Turning and positioning a client after hip replacement surgery C. Teaching self-administration of insulin injections before discharge D. Obtaining and recording vital signs every 2 hours on a postoperative client

C. Teaching self-administration of insulin injections before discharge

Which statement made by the nurse indicates a need for further teaching when educating staff about integrating The Joint Commission's National Patient Safety Goals (NPSG) into the behavioral health unit? A. "We should screen all clients for the risk of suicidal ideations." B. "It is important to perform hand hygiene for at least 15 seconds." C. "It is required to obtain a current medication list upon admission." D. "We should use one client identifier before giving medications."

D. "We should use one client identifier before giving medications."

Which client would the triage nurse classify as requiring the least priority of care? A. Extreme respiratory distress; COPD B. Severe respiratory distress; Asthma C. Moderate shortness of breath; Tuberculosis D. Foreign body aspiration; Pneumonia

D. Foreign body aspiration; Pneumonia

The nurse is preparing to transfer Mr. D to the ICU and notices the cardiac monitor display. Which ECG pattern is cause for greatest concern?

V-Tach

The nurse is preparing a teaching plan for Ms. C, who has Raynaud disease. Which key points should be included? SATA 1. "Avoid exposure to cold by wearing warm clothes." 2. "Nifedipine will help decrease and relieve your symptoms." 3. "Keep your home at a comfortably warm temperature." 4. "The problems you experience are caused by vasospasms." 5. "Stress reduction techniques can help prevent symptoms." 6. "Warm beverages such as hot coffee and tea will help decrease symptoms."

1. "Avoid exposure to cold by wearing warm clothes." 2. "Nifedipine will help decrease and relieve your symptoms." 3. "Keep your home at a comfortably warm temperature." 4. "The problems you experience are caused by vasospasms." 5. "Stress reduction techniques can help prevent symptoms."

The RN has assigned the student nurse to teach Mr. R about foot care related to his PAD. Which teaching points would the RN instruct the student nurse to include? SATA 1. "Keep your feet clean by washing with a mild soap in room temperature water." 2. "Wear comfortable, well-fitting shoes except when at home." 3. "Cut the toenails straight across and keep them clean and filed." 4. "Apply lubricating lotion to feet to prevent dried and cracked skin." 5. "Use a heating pad to keep your feet warm, especially at night." 6. "Avoid extended pressure on your feet and ankles."

1. "Keep your feet clean by washing with a mild soap in room temperature water." 3. "Cut the toenails straight across and keep them clean and filed." 4. "Apply lubricating lotion to feet to prevent dried and cracked skin." 6. "Avoid extended pressure on your feet and ankles."

What precautions should the RN instruct the student nurse to be sure to teach the patient while taking nifedipine? SATA 1. "Side effects of this drug can include facial flushing and headaches." 2. "Be sure to check your respiratory rate before taking this drug." 3. "When you get out of bed, do so slowly because of the potential for hypotension." 4. "You should be sure to consume foods rich in potassium such as bananas." 5. "Avoid grapefruit and grapefruit juice while taking this drug." 6. "Take over-the-counter calcium tablets every day while on this drug."

1. "Side effects of this drug can include facial flushing and headaches." 3. "When you get out of bed, do so slowly because of the potential for hypotension." 5. "Avoid grapefruit and grapefruit juice while taking this drug."

Ms. H had a complete adrenalectomy, and the nurse is preparing to teach her about cortisol replacement therapy. Which key points should be included in the teaching plan? SATA 1. "Take your medication in divided doses, with the first dose in the morning and the second dose between 4:00 and 6:00 pm" 2. "Take your medications on an empty stomach to facilitate absorption." 3. "Weigh yourself daily using the same scale and wearing the same amount of clothes." 4. "Never skip a dose of medication." 5. "Call your doctor if you experience persistent nausea, severe diarrhea, or fever." 6. "Report any rapid weight gain, round face, fluid retention, or swelling to your doctor."

1. "Take your medication in divided doses, with the first dose in the morning and the second dose between 4:00 and 6:00 pm" 3. "Weigh yourself daily using the same scale and wearing the same amount of clothes." 4. "Never skip a dose of medication." 5. "Call your doctor if you experience persistent nausea, severe diarrhea, or fever." 6. "Report any rapid weight gain, round face, fluid retention, or swelling to your doctor."

Mr. D, a 19-year-old pre-med student, has been brought to the ED by his roommate, who is a medical student and family friend. Mr. D reports abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for finals." He is alert and conversant but is having trouble focusing on the nurse's questions. VS: Blood glucose: 685 mg/dL, BP: 100/60 mm Hg, HR: 120 beats/min, RR: 32 breaths/min, Temp: 100.8 F To clarify pertinent data, what questions are appropriate to ask Mr. D? SATA 1. "When did your symptoms start?" 2. "How many times have you vomited?" 3. "When were you diagnosed with diabetes?" 4. "Where does your abdomen hurt?" 5. "Did you take any insulin today?" 6. "Do you have any allergies?"

1. "When did your symptoms start?" 2. "How many times have you vomited?" 4. "Where does your abdomen hurt?" 5. "Did you take any insulin today?" 6. "Do you have any allergies?"

The nurse is caring for a male patient with hyperaldosteronism who is not a candidate for adrenalectomy surgery. Which interventions would the nurse expect the HCP to prescribe? SATA 1. Administer oral spironolactone 2. Monitor for and report dry mouth, thirst, and lethargy 3. Avoid or limit potassium-rich foods 4. Glucocorticoid replacement therapy 5. Instruct patient to report gynecomastia or erectile dysfunction 6. Acetaminophen for headaches

1. Administer oral spironolactone 2. Monitor for and report dry mouth, thirst, and lethargy 3. Avoid or limit potassium-rich foods 5. Instruct patient to report gynecomastia or erectile dysfunction 6. Acetaminophen for headaches

The UAP reports to the RN that Mr. Z, with Buerger disease, awoke from a nap reporting pain in the arch of his left foot. Which actions should the RN take? SATA 1. Assess the patient's pain 2. Administer prescribed nifedipine 3. Place the patient in a supine position and elevate the foot 4. Lower the room temperature 5. Instruct the patient to avoid cold temperatures 6. Check the patient's toes for any signs of gangrene or ulcers

1. Assess the patient's pain 2. Administer prescribed nifedipine 5. Instruct the patient to avoid cold temperatures 6. Check the patient's toes for any signs of gangrene or ulcers

At 8:30am, the UAP reports that Ms. Q, with chronic hypertension, has a BP of 198/94 mmHg. Which is the priority action, and who is the most appropriate person to accomplish this action at this time? 1. Assign the LPN/LVN to give Ms. Q's 9:00am furosemide and enalapril now 2. Instruct the UAP to get Ms. Q back into bed immediately 3. Tell the UAP to recheck Ms. Q's BP every 15 minutes 4. Send the LPN/LVN to recheck Ms. Q's BP to ensure that the reading is correct

1. Assign the LPN/LVN to give Ms. Q's 9:00am furosemide and enalapril now

Ms. A has a nursing concern of increased risk for injury. Which action will the RN delegate to the UAP? 1. Assisting the patient with morning care and repositioning in bed 2. Monitoring the patient's daily international normalized ratio 3. Checking the patient every 4 hours for signs of bleeding 4. Teaching the patient to call for assistance when getting out of bed

1. Assisting the patient with morning care and repositioning in bed

Ms. A returns from her diagnostic test with a diagnosis of DVT, which is to be treated medically. Which interventions and actions does the nurse expect the HCP to prescribe? SATA 1. Bed rest 2. Elevation of the left leg 3. Compression stockings 4. Daily massage of the left calf 5. Continue subcutaneous LMWH 6. Check daily international normalized ratio (INR) levels

1. Bed rest 2. Elevation of the left leg 3. Compression stockings 5. Continue subcutaneous LMWH

Which person(s) should be allowed to have access to Mr. D's medical records? SATA 1. ED provider who is managing Mr. D in the ED 2. ED nurse who is caring for Mr. D in the ED 3. ICU who will receive Mr. D upon transfer to ICU 4. Nursing student who wants to write a paper about diabetic ketoacidosis 5. Roommate of Mr. D who is a medical student and a family friend 6. Discharge nurse who will provide instructions and referrals at discharge

1. ED provider who is managing Mr. D in the ED 2. ED nurse who is caring for Mr. D in the ED 3. ICU who will receive Mr. D upon transfer to ICU 6. Discharge nurse who will provide instructions and referrals at discharge

The nurse is selecting personal protective equipment (PPE) to don before inserting the NG tube. Which factors will the nurse consider before making the selection? SATA 1. Facility policies for procedures 2. Likelihood of exposure to blood and body fluids 3. Patient's ability and willingness to cooperate 4. Own skill level and proficiency at procedure 5. Patient's health history and medical conditions 6. Availability of PPE at the bedside or on the unit

1. Facility policies for procedures 2. Likelihood of exposure to blood and body fluids 3. Patient's ability and willingness to cooperate 4. Own skill level and proficiency at procedure 5. Patient's health history and medical conditions

Which tasks can the nurse direct an experienced UAP to perform to facilitate Mr. D's transfer to the ICU? SATA 1. Giving Mr. D's roommate directions to the ICU waiting room 2. Independently transporting Mr. D to the ICU 3. Collecting and organizing the chart and laboratory reports 4. Obtaining a portable oxygen tank and cardiac monitor 5. Connecting Mr. D's ECG leads to the portable cardiac monitor 6. Obtaining the last set of vital sign values

1. Giving Mr. D's roommate directions to the ICU waiting room 4. Obtaining a portable oxygen tank and cardiac monitor 5. Connecting Mr. D's ECG leads to the portable cardiac monitor 6. Obtaining the last set of vital sign values

Which medications does the nurse anticipate including in the discharge teaching for Mr. S's self-management of gastritis? 1. H2-receptor antagonists, proton pump inhibitors, and antacids 2. Diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors 3. Mucolytics, expectorants, and nonopioid antitussives 4. MHG-CoA reductase inhibitors (statins) and bile-acid sequestrants

1. H2-receptor antagonists, proton pump inhibitors, and antacids

What are three components of emergency management of a patient with adrenocortical insufficiency? SATA 1. Hormone replacement with hydrocortisone 2. Administration of potassium-sparing diuretics 3. Hypoglycemia management with IV glucose 4. Subcutaneous insulin before meals and at bedtime 5. Hyperkalemia management with a potassium-binding and potassium-excreting resin 6. Fluid restrictions to maintain body weight and prevent edema

1. Hormone replacement with hydrocortisone 3. Hypoglycemia management with IV glucose 5. Hyperkalemia management with a potassium-binding and potassium-excreting resin

The UAP informs the nurse that Ms. B's blood pressure is now 84/50. Which prescribed action by the HCP would the nurse implement first? 1. Infuse normal saline at 250 mL/hr 2. Type and cross-match for 2 units of packed red blood cells 3. Insert a second large-bore IV catheter 4. Administer prednisone 10 mg PO

1. Infuse normal saline at 250 mL/hr

All of these interventions for Mr. S are prescribed by the HCP. Which action should the RN assign to the LPN/LVN? 1. Insert a urinary catheter 2. Administer morphine sulfate 2 mg IV push 3. Place a second IV saline lock line 4. Measure vital signs every 15 minutes

1. Insert a urinary catheter

Mr. R tells the student nurse that when he walks for only a block or two, he experiences discomfort that is burning and cramping and that it is so painful that it makes him stop. What is the best way for the student to document this finding? 1. Intermittent claudication 2. Rest pain 3. Dependent rubor 4. Arterial ulcer

1. Intermittent claudication

The ABG results for Mr. D are: pH 7.25, PaO2 97, PaCO2 25, HCO3 19. What physical assessment finding is most likely to accompany these laboratory results? 1. Kussmaul respirations 2. Dilated pupils 3. Increased urination 4. Elevated blood pressure

1. Kussmaul respirations

The HCP prescribes NG tube insertion. The nurse places the patient in a high Fowler position, provides an emesis basin, and inspects the nostrils for patency. List the correct order of actions for the procedure. 1. Measure tube from the tip of the nose, to the earlobe, to the xiphoid process 2. Insert the lubricated tube into the most patent nostril 3. Ask the patient to sip water as the tube is passed 4. When tube is just above the oropharynx, instruct the patient to bend the chin forward 5. Check pH to verify tube placement; obtain an order for a radiograph

1. Measure tube from the tip of the nose, to the earlobe, to the xiphoid process 2. Insert the lubricated tube into the most patent nostril 4. When tube is just above the oropharynx, instruct the patient to bend the chin forward 3. Ask the patient to sip water as the tube is passed 5. Check pH to verify tube placement; obtain an order for a radiograph

As the charge nurse, which patients would be appropriate to assign to a newly graduated RN who has just completed orientation to the unit? SATA 1. Ms. L with pheochromocytoma, who is scheduled for adrenalectomy and needs preoperative teaching 2. Ms. B with adrenal gland hypofunction, whose blood pressure is dropping and who is experiencing Addisonian crisis 3. Ms. H with Cushing disease, who is very anxious and fearful about her scheduled adrenal surgery 4. Mr. J with hyperaldosteronism, whose current serum potassium level is 3.2 5. Mr. M with rule-out Addison disease, who is newly admitted with muscle weakness, weight loss, and hypotension 6. Ms. A, who was admitted 2 days ago to rule out hyperaldosteronism

1. Ms. L with pheochromocytoma, who is scheduled for adrenalectomy and needs preoperative teaching 4. Mr. J with hyperaldosteronism, whose current serum potassium level is 3.2 6. Ms. A, who was admitted 2 days ago to rule out hyperaldosteronism

The HCP orders a STAT blood transfusion. In the event of an emergency, a type-specific non-cross-matched blood product could be used. Which blood product could be used in this case? 1. O negative 2. AB negative 3. AB positive 4. A negative

1. O negative

Ms. L is a 59-year-old woman who is admitted after experiencing intermittent episodes of high blood pressure accompanied by headaches, diaphoresis, and chest pain. She tells the admitting nurse that she gets frightened and feels a "sense of doom" when these episodes occur. The endocrinologist has ordered hospitalization to rule out pheochromocytoma. Which assessment action should the nurse avoid when admitting Ms. L? 1. Palpating the patient's abdomen 2. Checking the patient's extremity reflexes 3. Testing the pupillary reaction to light 4. Measuring baseline weight with the patient standing

1. Palpating the patient's abdomen

A nursing concern of risk for infection related to immunosuppression and inadequate primary defenses has been identified for Ms. H. Which nursing care actions should the RN delegate to the UAP? SATA 1. Providing the patient with a soft toothbrush 2. Instructing the patient to avoid activities that can result in skin trauma 3. Reminding the patient to change positions in bed every 2 hours 4. Assessing the patient's skin for reddened areas, excoriation, and edema 5. Ensuring that the patient has tissues and a bag for disposal of used tissues 6. Teaching the patient to avoid crowded areas and people with cold symptoms

1. Providing the patient with a soft toothbrush 3. Reminding the patient to change positions in bed every 2 hours 5. Ensuring that the patient has tissues and a bag for disposal of used tissues

The nurse suspects that Mr. S may be at risk for alcohol withdrawal effects. What is an early manifestation? 1. Startles easily 2. Paranoid delusions 3. Slurred speech 4. Grand mal seizure

1. Startles easily

A computed tomography (CT) scan reveals that Mr. S has an aneurysm that is 7.5 cm in diameter. Which preoperative care tasks should the RN delegate to the nursing student under supervision? SATA 1. Teaching Mr. S about coughing and deep breathing 2. Assessing all peripheral pulses for postoperative comparison 3. Administering bowel preparation magnesium sulfate orally 4. Drawing blood for the laboratory for typing and screening 5. Discussing the reasons for the surgery 6. Pack Mr. S's belongings in preparation for postop transfer to the surgical intensive care unit (SICU)

1. Teaching Mr. S about coughing and deep breathing 2. Assessing all peripheral pulses for postoperative comparison 3. Administering bowel preparation magnesium sulfate orally 6. Pack Mr. S's belongings in preparation for postop transfer to the surgical intensive care unit (SICU)

The RN is supervising a nursing student who will assess Ms. H. Which findings will the RN teach the student nurse to expect in a patient with Cushing disease? SATA 1. Truncal obesity 2. Weight loss 3. Bruising 4. Hypertension 5. Thickened skin 6. Dependent edema

1. Truncal obesity 3. Bruising 4. Hypertension 6. Dependent edema

Ms. C asks the student nurse how the drug nifedipine will help with her Raynaud disease. What is the student nurse's best response? 1. "It will slow down your heart rate and decrease your pain." 2. "It will cause vasodilation and decrease the vasospasms that cause your pain." 3. "It will lower your blood pressure and decrease the workload of your heart." 4. "It will help keep your fluid and electrolytes in balance to decrease your pain."

2. "It will cause vasodilation and decrease the vasospasms that cause your pain."

Ms. A, whose calf is swollen from peripheral venous disease, asks why she must have an injection of low-molecular-weight heparin (LMWH). What is the RN's best response? 1. "LMWH will dissolve the clots in your legs." 2. "LMWH will prevent new clots from forming." 3. "LMWH will thin your blood and slow down clotting." 4. "LMWH will prevent the clots from migrating to your lungs."

2. "LMWH will prevent new clots from forming."

The nurse is talking to Mr. S about his alcohol consumption. Which statement represents the most common defense mechanism that is used by people who have problems with alcoholism? 1. "You would drink, too, if you were married to my wife." 2. "My wife and I have a couple of beers after work. It's no big deal." 3. "If you think I drink a lot, you should see my wife put it away." 4. "I would rather talk to my wife about this situation when I get home."

2. "My wife and I have a couple of beers after work. It's no big deal."

Mr. S needs to be admitted to the medical-surgical unit for observation and continued management of acute gastritis with bleeding. The ED nurse is calling the receiving nurse on the medical-surgical unit. Prioritize the following information according to the SBAR format. 1. "Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours." 2. "This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding." 3. "Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an esophagogastroduodenoscopy (EGD)." 4. "Mr. S is currently alert and oriented but is anxious. The last vital signs are blood pressure 140/80, pulse 90, respirations 24, pulse ox 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 mL/hr in each IV line. He received one unit of PRBCs and one unit of FFP. He has a NG tube in the right nare. Initially, there was a small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction."

2. "This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding." 1. "Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours." 4. "Mr. S is currently alert and oriented but is anxious. The last vital signs are blood pressure 140/80, pulse 90, respirations 24, pulse ox 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 mL/hr in each IV line. He received one unit of PRBCs and one unit of FFP. He has a NG tube in the right nare. Initially, there was a small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction." 3. "Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an esophagogastroduodenoscopy (EGD)."

The nurse is reviewing the potassium values that were obtained when Mr. D first arrived in the ED. Which serum potassium level is most concerning? 1. 3.5 mEq/L 2. 2 mEq/L 3. 5.8 mEq/L 4. 6 mEq/L

2. 2 mEq/L

An insulin infusion is ordered for Mr. D to begin at 0.1 units/kg/hr. Mr. D weighs 155 lb. The pharmacy delivers a premixed bag of 100 units of regular insulin in 100 mL of normal saline. Nurse A has calculated the infusion pump setting as 10 mL/hr. What will the charge nurse do next? 1. Tell nurse A to obtain a pump and start the infusion as calculated 2. Advise nurse A to recalculate the infusion rate 3. Call the HCP and ask for the exact pump setting to be clarified 4. Allow nurse A to administer the infusion using her own judgement

2. Advise nurse A to recalculate the infusion rate

The ED nurse is trying to call a report to the ICU but is told, "We were not notified about the admission." What should the nurse do first? 1. Call the admissions office supervisor to resolve the delay 2. Ask the unit secretary to call the admissions office now 3. Write an incident report; a delay violates Joint Commission guidelines 4. Ask the ICU nurse to take the report regardless of clerical omission

2. Ask the unit secretary to call the admissions office now

Mr. S and his wife ask for privacy so that they can talk. Later when you return to check on him, the NG tube is on the floor, there is a strong odor of alcohol on Mr. S's breath, and he appears very drowsy. What should you do first? 1. Politely ask the wife to leave and call security to check the room for illicit substances. 2. Assess the patient's mental status and ask what happened to the NG tube 3. Explain that his behavior is unacceptable and counterproductive to his therapy. 4. Reinsert an NG tube and call the physician for an order for a start blood alcohol test.

2. Assess the patient's mental status and ask what happened to the NG tube

The nurse is talking to Mr. S about self-care measures that he should take to prevent recurrence of acute gastritis. For Mr. S, what is the most important point to emphasize? 1. Eat a well-balanced diet that includes protein and carbohydrates 2. Avoid drinking excessive amounts of alcoholic beverages 3. Use caution in taking aspirin, other nonsteroidal anti-inflammatory drugs, and corticosteroids 4. Drink at least eight glasses of noncaffeinated fluid each day

2. Avoid drinking excessive amounts of alcoholic beverages

After the SBAR report is completed, Mr. S is prepared for transport to his room on the medical-surgical unit. He is greeted by the medical-surgical nurse who will assume responsibility for this care. He is tired but also anxious to see the HCP and to be informed about the plan of care so that he can "get out of here as soon as possible." The HCP recommends that Mr. S have an EGD to stop the bleeding. The nurse sees that the HCP has written on the order sheet: "Have patient sign consent form for EGD." What should the nurse do first? 1. Assess the patient's understanding of the procedure, explain the risks, and obtain the patient's signature if he appears to understand 2. Call the HCP and politely state that obtaining the patient's consent for a procedure is outside of the scope of nursing practice 3. Ask the charge nurse to clarify if HCPs would typically write this type of order and, if so, how it should be handled 4. Decline to follow the order, write an incident report, and call the unit manager to report the HCP for writing an inappropriate order

2. Call the HCP and politely state that obtaining the patient's consent for a procedure is outside of the scope of nursing practice

Which patient care action would the nurse assign to an experienced LPN/LVN? 1. Interpret Ms. B's lab values 2. Change Ms. B's dressing to her right side 3. Prepare a nursing care plan for Ms. B 4. Administer IV promethazine for nausea

2. Change Ms. B's dressing to her right side

After receiving her morning dose of enalapril, Ms. Q states that she experienced dizziness when getting out of bed to use the bathroom. What is the RN's priority assessment? 1. Ask the patient about presence of a nagging cough 2. Check orthostatic BPs lying, sitting, and standing 3. Assess the patient for signs of allergy such as rashes 4. Check the patient's bladder for urinary retention

2. Check orthostatic BPs lying, sitting, and standing

The laboratory informs the nurse that the phlebotomist may have mislabeled or drawn the sample for STAT blood tests from another patient, not Mr. S. What should the nurse do first? 1. Call the phlebotomist to come back 2. Draw a new blood sample and label it 3. Report the phlebotomist to his or her supervisor 4. Ask the phlebotomist to explain what happened

2. Draw a new blood sample and label it

The health care provider (HCP) has ordered several immediate (STAT) interventions for Mr. S. Which task would the nurse perform first? 1. Draw blood for complete blood count, and type and crossmatch 2. Establish two peripheral IV lines with 16-gauge catheters 3. Insert an NG tube and observe gastric contents 4. Repeat the vital signs and apply pulse oximeter

2. Establish two peripheral IV lines with 16-gauge catheters

The nurse sees that Mr. S's international normalized ratio (INR) value is 2.5. Which action should the nurse take next? 1. No action should be taken because this is an expected finding related to gastrointestinal bleeding 2. HCP should be notified for possible prescription of fresh-frozen plasma (FFP) 3. Laboratory findings should be reevaluated at completion of treatments 4. The blood bank should be contacted for additional units of packed red blood cells

2. HCP should be notified for possible prescription of fresh-frozen plasma (FFP)

The RN is the team leader working with a licensed practical nurse/licensed vocational nurse (LPN/LVN), an experienced unlicensed assistive personnel (UAP), and a senior nursing student to provide nursing care for six patients in a vascular surgery unit. The patients are as follows: Ms. C, a 38-year-old woman with systemic lupus erythematosus who has developed symptoms of Raynaud phenomenon. She reports numbness, tingling, and cold in her wrists and hands bilaterally. Mr. R, a 57-year-old man with chronic peripheral arterial disease who reports severe pain due to an arterial ulcer on his left great toe. Mr. Z, a 44-year-old man with Buerger disease who wants to discuss enrolling in a smoking cessation program. Ms. Q, a 69-year-old overweight woman with chronic hypertension whose blood pressure at the end of night shift was 208/96. Mr. S, a 72-year-old man for whom an abdominal aortic aneurysm (AAA) must be ruled out, and who is reporting severe, worsening back pain. Ms. A, a 65-year-old woman with peripheral venous disease and left calf swelling who is scheduled for venous duplex ultrasonography this morning. The nurse understands that which conditions are at increased risk for development when a patient has hypertension? SATA 1. Gastric ulcers 2. Kidney disease 3. Stroke (brain attack) 4. Emphysema 5. Myocardial infarction 6. Parkinson disease

2. Kidney disease 3. Stroke (brain attack) 5. Myocardial infarction

At noon, the LPN/LVN goes to cardiopulmonary resuscitation (CPR) training and is replaced by an RN floated from the postanesthesia care unit (PACU). Which patients should the team leader assign to the PACU RN? SATA 1. Ms. C, who needs teaching about how to avoid exacerbation of symptoms for her condition 2. Mr. Z, who still needs information about available smoking cessation programs 3. Ms. Q, whose BP is still elevated and needs frequent BP monitoring 4. Ms. A, who is worried because the HCP just told her she has a deep vein thrombosis (DVT) 5. Mr. S, who reports that his back pain is getting much worse 6. Mr. R, whose left great toe arterial ulcer continues to be painful even after the student nurse administered his pain medication

2. Mr. Z, who still needs information about available smoking cessation programs 3. Ms. Q, whose BP is still elevated and needs frequent BP monitoring

When Mr. S is assessed, which assessment technique would the RN instruct the student nurse to avoid? 1. Auscultating the abdomen for a bruit 2. Palpating the abdomen to detect a mass 3. Observing the abdomen for a pulsation 4. Performing a pain assessment

2. Palpating the abdomen to detect a mass

In providing nursing care for Ms. L, which action should the nurse delegate to the UAP? 1. Working with the patient to identify stressful situations that may lead to a hypertensive crisis 2. Reminding the patient not to smoke, drink caffeinated beverages, or change positions suddenly 3. Assessing the patient's hydration status and reporting manifestations of dehydration or fluid overload 4. Telling the patient to limit activity and remain in a calm, restful environment during headaches

2. Reminding the patient not to smoke, drink caffeinated beverages, or change positions suddenly

The RN is teaching the student nurse who is caring for Mr. R how to differentiate peripheral arterial from peripheral venous ulcers. Which characteristics would the RN stress are indications of arterial ulcers? SATA 1. Claudication is absent 2. Rest pain is present 3. Ulcers occur at ends of and between toes 4. Brown pigmentation is often present 5. Pallor is seen when raising the extremity, and dependent rubor is seen when lowering it 6. Treatment involves damp-to-dry dressing changes

2. Rest pain is present 3. Ulcers occur at ends of and between toes 5. Pallor is seen when raising the extremity, and dependent rubor is seen when lowering it

The ED nurse is reviewing the ICU admission orders. There is a prescription for an IV potassium infusion. Related specifically to the potassium infusion, which information would the ICU nurse be most interested in knowing? 1. Mental status and cognition have improved with therapy 2. Urinary output is 60 mL/hr, and urine is a clear yellow color 3. Admitting blood pressure (BP) was 100/60 mmHg; last BP is 125/76 mmHg 4. There are two existing peripheral IV lines, and both flush easily

2. Urinary output is 60 mL/hr, and urine is a clear yellow color

The HCP orders a 24-hour urine collection for vanillylmandelic acid (VMA), metanephrine, and catecholamine testing. Which instruction given to Ms. L by a nursing student would cause the nurse to intervene? 1. "You will be on a special diet for 2 to 3 days before the urine collection for this test." 2. "You should not drink caffeinated beverages or eat citrus fruits, bananas, or chocolate." 3. "You will take your usual medications, including the aspirin and the beta-blocker for your high blood pressure." 4. "In 2 to 3 days, you will begin the 24-hour urine collection after discarding the first void in the morning."

3. "You will take your usual medications, including the aspirin and the beta-blocker for your high blood pressure."

The RN is teaching a UAP about fluid retention when a patient such as Ms. H is diagnosed with Cushing disease. Which method does the RN instruct the UAP is best for indicating fluid retention? 1. Strict intake and output measures 2. Measuring urine specific gravity 3. Checking daily weights with the same scale 4. Comparing ankle swelling on a day by day basis

3. Checking daily weights with the same scale

Cushing disease is diagnosed in Ms. H because of hypercortisolism (increased secretion of cortisol), and she is scheduled for an adrenalectomy. Which preoperative actions should the nurse assign to the LPN/LVN? SATA 1. Assessing the patient's cardiac rhythm 2. Reviewing the patient's laboratory results 3. Checking the patient's fingerstick glucose results 4. Administering insulin on a sliding scale as needed 5. Discussing goals and outcomes of care with the patient 6. Giving the patient oral preoperative medications

3. Checking the patient's fingerstick glucose results 4. Administering insulin on a sliding scale as needed 6. Giving the patient oral preoperative medications

The ED nurse is preparing the SBAR report before the ICU transfer. Which detail would be most important to include as background to ensure that Mr. D's right to privacy is maintained? 1. Client is a premed student who was studying for finals, and this interfered with his normal routine 2. Roommate is a medical student and a family friend, and he brought Mr. D to the ED 3. Client has not informed family that he is in the hospital, and he is reluctant to allow notification 4. Client arrived alert and conversant, but he initially had trouble focusing on questions

3. Client has not informed family that he is in the hospital, and he is reluctant to allow notification

For the initial emergency care of Mr. D, what is the priority collaborative treatment goal? 1. Correction of hyperglycemia with IV insulin 2. Correction of acid-base imbalance using IV bicarbonate 3. Correction of fluid imbalance with IV fluids 4. Correction of potassium imbalance with IV potassium

3. Correction of fluid imbalance with IV fluids

Mr. S, a 50-year-old man, has driven himself to the emergency department (ED) after vomiting bright red blood twice within the past 6 hours. He arrives alert and oriented x3 but appears anxious. He is able to provide only a vague history but admits to drinking "a few" last weekend. He knows that he is "supposed to stop drinking" and takes "something for his stomach," but he cannot recall the name of the medication. He reports intermittent dizziness and fatigue that has been worsening over the past 2 days. His skin is dry and pale. His abdomen is slightly distended. He reports pain (4 on a scale of 1 to 10) in the midepigastric area. Capillary refill is prolonged, blood pressure is 140/90, pulse rate is 110 bpm, respiratory rate is 24, and temperature is 99F. What is the priority nursing concept to consider in planning emergency interventions for Mr. S? 1. Pain 2. Anxiety 3. Fluid and electrolyte balance 4. Adherence

3. Fluid and electrolyte balance

As the nurse is getting ready to transfer Mr. D to the ICU, the unit secretary hands the nurse the last blood glucose result, which is 150 mg/dL. What should the nurse do first? 1. Proceed with the transfer because the blood glucose is trending toward the normal value 2. Stop the insulin infusion, proceed with the transfer, and inform the ICU nurse on arrival 3. Immediately notify the HCP and anticipate an order for IV fluid of 10% glucose 4. Slow the insulin infusion and obtain an order to have the blood glucose redrawn

3. Immediately notify the HCP and anticipate an order for IV fluid of 10% glucose

During the EGD procedure, Mr. S is given midazolam hydrochloride. What is the priority assessment related to this medication? 1. Monitor for cardiac dysrhythmias 2. Assess for adequate relief of pain 3. Monitor for depth and rate of respirations 4. Assess for relief of nausea and vomiting

3. Monitor for depth and rate of respirations

Ms. B is a 68-year-old woman admitted to the medical unit through the emergency department (ED) after being hit in the abdomen by an automobile while walking home. An 18-gauge IV catheter was inserted in the left forearm, and normal saline was started at 100 mL/hr. ED vital signs were BP 118/80, HR 82, RR 26, Temp 98.4F. Ms. B has a small dressing to a wound on her right side with a small amount of serosanguinous drainage present. The UAP checks her vital signs while she is lying down with the head of her bed elevated and reports that the patient's BP is now 92/58, and she describes feelings of weakness, fatigue, and abdominal pain. When the nurse assesses Ms. B, it is also discovered that she is nauseated and has just vomited 560 mL of greenish fluid and undigested food from breakfast. Laboratory values from the ED were as follows: aldosterone 3 ng/dL (low), cortisol 2 mcg/dL (low), potassium 5.2 mEq/L, sodium 136 mEq/L. Based on the assessment of Ms. B, what is the nurse's first action? 1. Administer an antiemetic 2. Measure abdominal girth 3. Notify the health care provider (HCP) 4. Start another IV and hang another bag of normal saline

3. Notify the health care provider (HCP)

Mr. S continues to report severe back pain. On assessment, the RN detects a bruit and notices pulsation in the left lower quadrant. What is the nurse's best first action? 1. Measure abdominal girth 2. Place the patient in a high sitting position 3. Notify the patient's health care provider (HCP) 4. Administer pain medication

3. Notify the patient's health care provider (HCP)

A nursing concern of poor peripheral perfusion has been identified for Ms. C. Which actions should the RN delegate to the experienced UAP? SATA 1. Assessing for peripheral pulses, edema, capillary refill, and skin temperature 2. Inspecting the skin for the presence of tissue breakdown and arterial ulcers 3. Reminding the patient to perform active range-of-motion exercises as tolerated 4. Reinforcing with the patient the need to take in adequate fluids during the day 5. Assisting the patient to sit at the bedside and then transfer to a chair 6. Administering daily oral doses of nifedipine

3. Reminding the patient to perform active range-of-motion exercises as tolerated 4. Reinforcing with the patient the need to take in adequate fluids during the day 5. Assisting the patient to sit at the bedside and then transfer to a chair

The nurse is most likely to seek out which laboratory results to determine if there are untoward effects associated with vomiting, NG suction, or lavage? 1. WBC counts 2. H/H 3. Serum electrolytes 4. BUN and serum creatinine

3. Serum electrolytes

The nurse is performing additional assessment and history taking for Mr. S. Which finding should be immediately reported to the HCP? 1. Melena stools 2. History of nonsteroidal anti-inflammatory drug use 3. Tense and rigid abdomen 4. Risk factors for human immunodeficiency virus

3. Tense and rigid abdomen

After the NG tube is inserted, which assessment finding is cause for greatest concern? 1. The patient reports that the tube is irritating nose and throat feels sore 2. Gastric contents have a coffee-ground appearance 3. The patient demonstrates coughing and cannot speak clearly 4. Gastric fluid is bright red and has small clots

3. The patient demonstrates coughing and cannot speak clearly

Which nursing assessment findings supports the possible diagnosis of DVT for Ms. A? 1. Spasm of her left calf 2. Shortness of breath 3. Unilateral swelling of her left calf 4. Sharp chest pain

3. Unilateral swelling of her left calf

What are priority interventions to perform for this patient? SATA 1. Prepare for endotracheal intubation 2. Assist with central line placement 3. Check stool for occult blood 4. Administer supplemental oxygen 5. Monitor vital signs and oxygen saturation 6. Monitor hemoglobin and hematocrit

4. Administer supplemental oxygen 5. Monitor vital signs and oxygen saturation 6. Monitor hemoglobin and hematocrit

A nursing concern of chronic pain has been identified for Mr. R, who has chronic peripheral arterial disease (PAD). Which action by the nursing student causes the RN to intervene? 1. Administering a narcotic analgesic 45 minutes before an ulcer dressing change 2. Asking the patient if he has ever tried progressive muscle relaxation 3. Assessing the patient's response to pain medication administration 4. Agreeing to hold the patient's docusate at the patient's request

4. Agreeing to hold the patient's docusate at the patient's request

After the EGD procedure, Mr. S returns to the medical-surgical unit. He is drowsy but readily arouses to light stimuli. His vital signs are BP 110/74, HR 82, RR 20, T 99F. What is the priority intervention? 1. Offer cool oral fluids for sore throat 2. Raise the side rails of the bed 3. Apply a small ice pack to the periorbital area 4. Assess the presence of the gag reflex

4. Assess the presence of the gag reflex

Which member of the health care team is demonstrating a behavior that is an example of a barrier to interprofessional collaboration? 1. ICU nurse asks the ED nurse to hold the client for 30 minutes until shift change is over 2. Admitting endocrinology specialist directs the ED nurse to change the rate of all IV fluids 3. ED provider reviews the triage nurse's admission notes before completing the provider summary 4. ED nurse tells the charge nurse that the UAP failed to record vital signs in a timely fashion

4. ED nurse tells the charge nurse that the UAP failed to record vital signs in a timely fashion

A labor and delivery (L&D) nurse calls the ED charge nurse and says, "I heard that Mr. S is in the ED throwing up blood. He's my ex-husband, so I looked up his medical record. How's he doing?" What should the ED charge nurse do first? 1. Invite the L&D nurse down to the ED to see Mr. S in person 2. Ask Mr. S if he wants information released to his ex-wife 3. Report the L&D nurse for violation of patient privacy 4. Explain to the L&D nurse that no information can be given out

4. Explain to the L&D nurse that no information can be given out

The nurse is preparing to administer a blood transfusion to Mr. S. First, the nurse inspects the bag for leaks, clots, or unusual color and compares the bag label with the chart and the blood bag forms. Place the steps of transfusion in the correct order. 1. Prime the correct tubing and filter with normal saline 2. Take vital signs before starting the transfusion 3. Transfuse the first 10 mL slowly; monitor the patient closely 4. Have two nurses (or HCPs) compare the blood band identification with the tag on the blood bag 5. Document the outcomes, names of personnel, and starting and ending times 6. Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete

4. Have two nurses (or HCPs) compare the blood band identification with the tag on the blood bag 1. Prime the correct tubing and filter with normal saline 2. Take vital signs before starting the transfusion 3. Transfuse the first 10 mL slowly; monitor the patient closely 6. Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete 5. Document the outcomes, names of personnel, and starting and ending times

Ms. H is admitted to the acute medical-surgical unit for a workup for Cushing disease. Which vital sign value reported to the RN by the UAP is of most concern for a patient with Cushing disease (hypercortisolism)? 1. Heart rate of 102 2. Respiratory rate of 26 3. Blood pressure of 156/88 4. Oral temperature of 101.8F

4. Oral temperature of 101.8F

Despite the nurse's best efforts at therapeutic communication, Mr. S refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose." What should the nurse do first? 1. Physically restrain him and insert the tube 2. Explain the "against medical advice" (AMA) form 3. Notify the nursing supervisor and patient advocate 4. Page the HCP and document the attempt

4. Page the HCP and document the attempt

The HCP instructs the nurse to give 1 L of IV fluid over the next hour. The available IV pump delivers fluid in mL/hr and allows three digits for programming the flow rate. What should the nurse do first? 1. Try to find a pump that will accurately deliver the fluid 2. Program the IV pump for 1 L/hr and start the infusion 3. Ask the HCP to revise the rate to accommodate the available equipment 4. Program the IV pump for 999 mL/hr and start the infusion

4. Program the IV pump for 999 mL/hr and start the infusion

Which client in the postoperative unit would be a safety priority for the nurse to monitor for fluid volume overload? A. Client with lymph node dissection B. Client with laparoscopic cholecystectomy C. Client with surgical intervention for hemorrhoids D. Client with liver transplantation

A. Client with lymph node dissection

Which priority nursing intervention would the nurse implement for a client on diuretic therapy who has developed metabolic alkalosis? A. Fall prevention measures B. Monitoring electrolytes C. Administering antiemetics D. Adjusting the diuretic therapy

A. Fall prevention measures

Which nursing goal would be priority for an adolescent who has a history of fighting, stealing, vandalizing property, running away from home, and has been suspended from school repeatedly? A. Preventing violence B. Encouraging insight C. Supporting self-esteem D. Promoting social interaction

A. Preventing violence

Which priority concern would the nurse monitor for while working with clients withdrawing from cocaine? A. Risk for self-injury B. Potential for seizure C. Danger of dehydration D. Probability of injuring others

A. Risk for self-injury

Which color tag is assigned the lowest priority for care in a mass casualty event? A. Red B. Black C. Green D. Yellow

B. Black

Which is the priority intervention for a dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? A. Apply oxygen B. Place the client in a side-lying position C. Prepare to administer packed red blood cells D. Assess the client's pulse and blood pressure

B. Place the client in a side-lying position

A postmenopausal client with cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she is not feeling well. The nurse reviews the medical record data presented below. After analysis of the available history, laboratory tests, and clinical manifestations, which goal has the highest priority for this client? Medications: Cyclophosphamide, Doxorubicin, Fluorouracil Labs: RBC: 4.2 WBC 3000, H/H 12.5/39%, Platelets 190,000 VS: T 99.8F, P 88, R 24, BP 126/88 A. Promote rest B. Prevent infection C. Avoid bodily harm D. Maintain fluid balance

B. Prevent infection

Which intervention is the primary priority for decreasing a client's risk for morbidity and mortality? A. Treatment B. Prevention C. Rehabilitation D. Surgical therapy

B. Prevention

A client who underwent open heart surgery died 2 days after the surgery because of septicemia. Which tool will the nurse use to determine the cause of the client's death? A. Plan-do-study-act (PDSA) B. Root cause analysis (RCA) C. Failure mode effective analysis (FMEA) D. Computerized physician order entry (CPOE)

B. Root cause analysis (RCA)

For a client admitted to the hospital with partial- and full-thickness burns of the chest and face obtained while attempting to extinguish a brush fire, which concern would the nurse establish as a priority? A. Loss of skin integrity caused by the burns B. Potential infection as a result of the burn injury C. Inadequate gas exchange caused by smoke inhalation D. Decreased fluid volume because of the depth of the burns

C. Inadequate gas exchange caused by smoke inhalation

Based on the information in the chart of a client with emphysema and recovering from an acute myocardial infarction, which prescribed medication would the nurse consider the priority at this time? WBC: 10,000 H/H: 11/34% INR: 2.5 T: 100.4 Pulse: 100 bpm, regular Respirations: 24 BP: 176/96 Using pursed lip breathing, pulse bounding, face appears flushed, reports a headache and dizziness A. Albuterol B. Warfarin C. Metoprolol D. Acetaminophen

C. Metoprolol

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis? A. Observing the nail beds B. Listening to breath sounds C. Monitoring breathing status D. Checking muscle contractions

C. Monitoring breathing status

Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors? A. Orientation to time, place, and person B. Ability to perform daily activities without assistance from others C. Stressors that appear to precipitate the client's disruptive behavior D. Cognitive impairments until complete adjustments are accomplished

C. Stressors that appear to precipitate the client's disruptive behavior

Which priority treatment would the nurse help implement for a newly admitted client with anorexia nervosa? A. Medications to reduce anxiety B. Family psychotherapy sessions C. Separation from family members D. Correction of electrolyte imbalances

D. Correction of electrolyte imbalances

When providing care for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head, which goal is the nurse's priority during the emergent phase of this injury? A. Preventing pain B. Managing leukopenia C. Preventing infection D. Managing fluid loss

D. Managing fluid loss

Which nursing intervention would be the priority for an older client with depression who is prescribed a tricyclic antidepressant? A. Providing psychotherapy to the client B. Teaching strategies to overcome depression C. Encouraging the client to walk for 30 minutes D. Requesting that the health care provider change the medication

D. Requesting that the health care provider change the medication

Which intervention would the nurse classify as the highest priority for an older client with lower-extremity ulcerations due to chronic venous insufficiency? A. Teaching techniques for dressing changes B. Informing the client about insurance companies C. Discussing community resources to obtain support D. Teaching how to transfer from a bed to chair in the least painful manner

D. Teaching how to transfer from a bed to chair in the least painful manner