Management Quiz 2

the nurse just received shift report. which client should the nurse assess first

the client who is 6 hours post op vein ligation who has absent pedal pulses

the charge nurse on the vascular unit is reviewing lab blood work. which result warrants intervention by the charge nurse

the client whose platelet count is 65,00 per mL of blood

which client should the nurse assess first after receiving shift report

the client with a right above the knee amputation who is reporting right foot pain

the rn charge nurse of a long term health facility is making assignments. which client should be assigned to the most experienced UAP

the client with an AKA who needs a full body lift to get into the wheelchair

the nurse is admitting a client diagnosed with AAA who is mormon. which action by the nurse indicates cultural sensitivity to the client

the nurse keeps the client's undershirt on during baths

which med is most appropriate for the staff nurse to assign to the LPN to admin

the oral pentoxifylline to the client who has intermittent claudication

the nurse is reviewing the literature to identify evidence based practice research that supports a new procedure using a new product when changing the central line catheter dressing. which research article would best support the nurse's proposal for a change in the procedure

the review of literature article that cited numberous studies supporting the product

the nurse is preparing to administer meds to clients on a vascular unit. Which med should the nurse question

vitamin k to a client with INR of 2.8

the male post op femoral popliteal bypass client notifies the desk via the intercom system he has fallen and now bleeding. which interventions should the nurse implement. rank them

- apply pressure - assist the client to a recumbent position in bed - redress the site with sterile dressing - notify surgeon - make out an occurence report

the nurse is preparing to administer the third unit of packed red blood cells to a client diagnosed with ruptured aortic aneurysm. which interventions should the nurse implement. select all that apply

- change the blood admin set - check the client's current vital signs

the nurse is preparing to admin a unit of packed red blood cells to an elderly client who is 1 day post op AAA. which interventions should the nurse implement

- have the client sign the permit to receive blood - start an IV access with normal saline at a keep open rate - obtain the unit of blood from the blood bank - check the unit of blood with another nurse at the bedside - initiate the transfusion at a slow rate for 1 5 minutes

which action by the UAP indicates to the RN staff nurse with the UAP understands the correct procedure for applying compression stockings to the client recovering from a pulmonary embolus

- the UAP can insert one finger under the proximal end of the stocking - the UAP checked to make sure the client's toes were warm after putting the stockings on

which of staff nurses personal attributes is an important consideration for the unit manager when discussing making an experienced nurse preceptor for new grads

- the nurses ability to organize work - the ability of the nurse to interact with others - the quality of care the nurses provide - the nurse's willingness to be a preceptor

the nurse on a vascular disorder unit asks the charge nurse what should I be looking for when I read a research article. which response indicates the charge nurse understands how to read a nursing research article

- you should be able to determine why the research was done - you should evaluate which research method was used for the study - you should read the method section to find out what setting was used - you should find info about how the data was collected

the nursing staff confronts the hospice nurse overseeing the care of a client in a long term care facilty. the nursing staff wants to send the client who is diagnosed with gangrene on the left leg secondary to peripheral occlusive disease to the hospital for treatment. which intervention should the nurse implement first

check with the client to see whether or not the client wants to go to the hospital

the nurse is caring for clients on a vascular disorder unit. which lab data requires immediate intervention by the nurse

a PTT of 98 seconds for a client with DVT

the home health nurse enters the yard of a client and is bitten on the leg by the client's dog. which intervention should the nurse implement first

clean the dog bite with soap and water and apply antibiotic ointment

the unit manager on the vascular unit is planning a change in the way postmortem care is provided. what is the first step in the change process

collect data

at 2230 the nurse is preparing to admin pain meds to a client who rates his pain as a 4 on the numeric pain scale. which med should the nurse admin

administer hydrocodone 5 mg PO

a 90 year old male client was recently widowed after more than 60 years of marriage. the client was admitted to a long term care facilty and is refusing to eat. which intervention is an example of the ethical principle of autonomy

allow the client to refuse to eat if he wants to

the RN clinic nurse is making assignments. which assignment or delegation is most appropriate

ask the UAP to prepare room for next client

the client diagnosed with artherosclerosis tells the clinic nurse her stomach hurts after she takes her morning meds. the client is taking a calcium channel blocker, a daily acetysalicyic acid and a statin. the meds have not changed during the past year. which info should the nurse implement first

assess the client for abnormal bleeding

the UAP tells the RN staff nurse the client has a blood pressure of 78/46 and pulse of 116 with vital machine. which intervention should the nurse do first

assess the clients cardiovascular status

the RN charge nurse on a vascular unit is working with a new unit secretary. which statement concerning laboratory data is most important for the charge nurse to tell the unit secretary

be sure to inform me of any lab information that is called to the unit

the client in the day surgical unit is scheduled to have vein ligation on the right leg. the client states I am having surgery on my left leg. which intervention should the nurse implement first

call a time out until clarifying which leg is having vein ligation

at 1000 a client who has had femoral popliteal bypass surgery on the right leg is reporting severe right upper quadrant pain 10 out of 10 on the pain scale. based on this info what should the client do

call the surgeon for an increase in pain medication

the home health nurse in the office is notified the client on warfarin has an INR of 3.8. which action should the home health nurse do first

contact the client and ask whether or not she has any abnormal bleeding

the home health nurse completed a home assessment on a client and finds out there are no smoke detectors in the home. the client tells the nurse they just cannot afford them. which action should the nurse implement first

contact the local fire department to see if they can provide smoke detectors for client

the rn charge nurse on a vascular post surgical floor observes a new grad telling an elderly client's spouse not to push the clients pain controlled analgesia pump button. what action should the nurse implement first

continue to perform charge nurse's other duties

the client diagnosed with AAA died unexpectedly and the nurse must notify the significant other. what statement by the nurse is best over the telephone

could you come to the hospital? the client is not doing well

the home health nurse is caring for a client diagnosed with arterial hypertension who has had a cerebrovascular accident. which priority intervention should the nurse discuss with the client when teaching about arterial hypertension

explain the need for the client to take antihypertensives as prescribed

the rn staff nurse asks the UAP to apply the SCDs to a client on strict bedrest. the UAP tells the nurse that she has never done this procedure. What should be the priority?

demonstrate the procedure

the fire alarm starts going off in the family practice clinic. which action should the nurse take first

determine whether there was a fire in the clinic

the occupational nurse is caring for the client who just severed two fingers form the right hand. which intervention should the occupational nurse implement first

don non sterile gloves on both hands

the staff nurse and the UAP are caring for clients on the vascular unit. which task should the nurse delegate to the UAP

elevate the leg of the client who is 1 day post op femoral-popliteal bypass

the staff nurse in the vascular critical care unit is working with an LPN who was pulled into the unit because of high census. what task is most appropriate to assign to LPN

hang the bag of heparin for patient with pulmonary embolus

the nurse is teaching the client diagnosed with arterial occlusive disease. which statement indicates more teaching

i must wear knee high stockings

the nurse is admitting a client diagnosed with DVT in the right leg. which statement by the client warrants immediate intervention by the nurse

i take a baby acetylsalicyclic acid everyday at breakfast

a client on the vascular unit tells the day shift primary nurse that the night nurse did not answer the call light for almost an hour. which statement would be most appropriate by the day shift primary nurse

i will notify my charge nurse to come back and talk to you about the situation

the charge nurse observes the UAP crying after the death of a client. what is the best response to the UAP

it can be difficult when a client dies. would you like to take a break

the nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. which statement by the client warrants immediate intervention by the nurse

my legs were so cold i had to put a heating pad on them

the clinic nurse is assessing a client who is reporting leg calf pain. the right calf is edematous and warm to the touch. which intervention should the nurse implement first

notify the HCP immediately

the elderly client diagnosed with DVT is reporting chest pain during inhalation. which intervention should the nurse implement first

place oxygen on the client via nasal cannula

the client reports chest pain from deep inspiration. which intervention should the nurse implement first

place the client on oxygen

the matriarch family has died on the vascular unit. the family tells the nurse the daughter is coming to the hospital from a nearby city to see the body. which intervention should the nurse implement

plan to allow the daughter to see the client in the room

the rn staff nurse and UAP are caring for clients on a vascular unit. which task is most appropriate for the nurse to delegate

provide indwelling catheter care to client on bedrest

the nurse tells the HCP for an order for pain meds for a client who is 2 days post aortic aneurysm repair. the HCP gives the nurse an order for meperidine 50 mg IVP now and then every 4 hours as needed. which action should the nurse take first

read back the orders to the HCP before hanging up the phone

the nurse is admitting a 72 year old patient and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arm. the client states she fell in an ashtray and doesn't want to talk about it. which nursing intervention is priority

report the situation to adult protective services

the clinic nurse overhears another staff nurse telling the pharm rep if you bring us lunch from the best place in town I will make sure you get to see the HCP. which action should the clinic nurse take

report this behavior to the clinic's director of nurses immediately

the RN staff nurse is caring for clients on the vascular unit. which nursing task is most important to delegate to a UAP

request the UAP elevate feet of the client diagnosed with chronic venous insuff

the client tells the RN charge nurse that the UAP did not know how to take a blood pressure. which action should the charge nurse implement first

retake the BP and inform the client of the BP reading

the nurse is administering 1 united of packed red blood cells to a client. fifteen minutes after initation of blood the client becomes restless and reports itching on the trunk and arms. what should the nurse do first

stop transfusion at the hub

the staff nurse observes an LPN crushing nifedipine XL before administering the medication to a client with arterial hypertension who has difficulty swallowing pills. which intervention should the nurse implement first

tell the LPN this med cannot be crushed

the male client diagnosed with peripheral vascular disease tells the nurse I know my foot is really bad. my doctor told me I don't have any choice and i must have an amputation but I don't want one. which action supports the nurse being the client's advocate

tell the client she will go with him to discuss his decision with the doctor

the charge nurse in the vascular ICU assigns three clients to the staff nurse. the staff nurse thinks this is an unsafe assignment. what action should the staff nurse implement first

tell the supervisor that he or she is concerned about the unsafe assignment

the UAP is caring for a client diagnosed with chronic venous insuff. which action would warrant immediate intervention from a nurse

the UAP is cutting the client's toenails after soaking the client's feet in tepid water

the RN nurse educator on a vascular unit is discussing delegation guidelines to a group of new grads. which statement from the group indicates the need for more teaching

the UAP will be practicing on my brand new nursing license

the nurse has just received am shift report. what client would the nurse assess first

the client diagnosed with DVT who is refusing to stay in bed

the nurse has received the shift report. which client should the nurse assess first

the client diagnosed with DVT who is reporting dyspnea and coughing

which client should the nurse on the vascular unit assess first after receiving shift report

the client diagnosed with lymphedema whose ABGs are ph 7.33, PaO2 89, paco2 of 72, and HCO3 25

the nurse has been pulled from a medical unit to work on the vascular unit for the shift. which client should the charge nurse assign to the medical nurse

the client diagnosed with varicose veins who is reporting deep aching pain of the legs

the nurse is caring for clients on a vascular surgical floor. which client should be assessed first

the client is 1 day AAA who is reporting numbness and tingling of both feet

the nurse has finished receiving morning change of shift report. which client should be assessed first?

the client on strict bedrest who is reporting calf pain and has reddened calf

which lab data should the nurse in the long term care unit notify the health care provider about

the client receiving digoxin who has a digoxin level of 2.6

a client is 2 days post op AAA. what data require immediate intervention from the nurse

the client refuses to take deep breaths and cough

the UAP tells the RN clinic nurse one of the medical interns asked me out on a date. I told him no but he keeps asking. which statement is the nurse's best response

you should inform the clinics director of the nurses