MEDSURG II: Prioritization Ch 10 Hematological & Immunological Management

The male client who was just told he has 6 months to live tells the nurse, "This can't be happening. I am too young to die." Which statement is the nurse's best response? 1. "I can contact the chaplain to come talk to you." 2. "I will leave you alone and come back in a little while." 3. "Is there anyone I can call to come be with you?" 4. "If it is all right with you I am going to sit here with you."

Correct answer: 4 1. The nurse should address the client's spiritual faith but at this time this is not the nurse's best response. 2. The nurse should not leave the client alone after receiving this type of news. 3. The nurse should ensure someone is with the client but it is not the nurse's best response. 4. The nurse's best response is to stay with the client and allow the client to ventilate his feelings of denial, fear, and hopelessness.

The intensive care nurse is caring for a client and notes blood oozing out from under the Tegaderm dressing over the peripheral intravenous site, bleeding gums, and blood in the indwelling urinary catheter bag. Which intervention should the nurse implement first? 1. Check the client's hemoglobin/hematocrit (H&H) level. 2. Monitor the client's pulse oximeter reading. 3. Apply pressure to the intravenous site. 4. Notify the client's healthcare provider.

Correct answer: 4 1. The nurse will need to check the client's H&H but not prior to notifying the HCP. The client has disseminated intravascular coagulation (DIC). 2. Monitoring the client's pulse oximeter reading would be an intervention the nurse could implement but it is not the first intervention for a client with DIC. 3. Applying pressure to the IV site will not help stop the bleeding since the client's coagulation factors have been exhausted. The client must receive heparin therapy. 4. The client is exhibiting signs of DIC, which requires intravenous therapy. This is a life-threatening complication that requires immediate medical intervention, so the nurse must notify the HCP first.

The nurse, a licensed practical nurse (LPN), and the unlicensed assistive personnel (UAP) are caring for clients in a critical care unit. Which task would be most appropriate for the nurse to assign/delegate? 1. Instruct the UAP to obtain the client's serum glucose level. 2. Request the LPN to change the central line dressing. 3. Ask the LPN to bathe the client and change the bed linens. 4. Tell the UAP to obtain urine output for the 12-hour shift.

Correct answer: 4 1. The serum blood glucose level requires a venipuncture, which is not within the scope of the UAP's expertise. The laboratory technician would be responsible for obtaining a venipuncture. 2. This is a sterile dressing change and requires assessing the insertion site for infection; therefore, this would not be the most appropriate task to assign to the LPN. 3. The nurse should ask the UAP to bathe the client and change bed linens because this is a task the UAP can perform. The LPN could be assigned higher-level tasks. 4. The UAP can add up the urine output for the 12-hour shift; however, the nurse is responsible for evaluating whether the urine output is what is expected for the client.

The client diagnosed with congestive heart failure and iron deficiency anemia is prescribed a unit of packed red blood cells (PRBC). Rank the interventions in order of performance. 1. Administer furosemide (Lasix), a loop diuretic, between units. 2. Check the client's hemoglobin and hematocrit. 3. Assess the client's lung sounds and periphery. 4. Have the client sign a permit to receive blood. 5. Return the empty blood bags to the laboratory.

Correct Answer: 2, 4, 3, 1, 5 2. Of the steps listed, the nurse should check the client's hemoglobin and hematocrit. Most healthcare facilities have a procedure to administer PRBCs only when the H/H are less than 8 and 24. Blood is a scarce commodity, and unless the client is scheduled for surgery there are other means of providing care of the client without the administration of blood products. 4. The client must consent to receiving blood and blood products. If the client will not allow the blood to be administered, then the procedure stops here. 3. The nurse must determine the client's physical status prior to picking up the blood in case the nurse assesses a client situation that requires the nurse to get in touch with the healthcare provider. 1. If ordered, a diuretic is usually administered between the units of blood to prevent fluid volume overload. 5. The blood bags can be returned to the laboratory after the blood has infused.

The clinic RN manager is discussing osteoporosis with the clinic staff. Which activity is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test on a female client older than 50. 2. Perform a spinal screening examination on all female clients. 3. Encourage the client to walk 30 minutes daily on a hard surface. 4. Discuss risk factors for developing osteoporosis.

Correct answer: 1 1. A secondary nursing intervention includes screening for early detection. The bone density evaluation will determine the density of the bone and is diagnostic for osteoporosis. 2. Spinal screening examinations are performed on adolescents to detect scoliosis. This is a secondary nursing intervention, but not to detect osteoporosis. 3. Teaching the client is a primary nursing intervention. This is an appropriate intervention to help prevent osteoporosis, but it is not a secondary intervention. 4. Discussing risk factors is an appropriate intervention, but it is not a secondary nursing intervention.

The nurse caring for clients on an oncology unit is administering medications. Which medication should the nurse administer first? 1. The anti-nausea medication to the male client who thinks he may get sick. 2. The pain medication to the female client who has pain she rates a 2. 3. The loop diuretic to the female client who had an output greater than the intake. 4. The nitroglycerin paste to the male client who is diagnosed with angina pectoris.

Correct answer: 1 1. Anticipatory nausea is a very real problem for clients diagnosed with cancer and undergoing treatment. If this problem is not rectified quickly and progresses to vomiting, the client may not get relief. This medication should be administered first. 2. This is considered mild pain and can be treated after the anticipatory nausea. 3. This is expected and indicates the medication is working. This medication does not have priority. 4. This is a routine medication and can be administered after the nausea and pain medications. Sublingual nitroglycerin is administered for acute chest pain, angina.

The female client in the preoperative holding area tells the nurse that she had a reaction to a latex diaphragm. Which intervention should the nurse perform first? 1. Notify the operating room personnel. 2. Label the client's chart with the allergy. 3. Place a red allergy band on the client. 4. Inform the client to tell all HCPs of the allergy.

Correct answer: 1 1. Because the client is in the preoperative holding area, the immediate safety need for the client is to inform the operating room personnel so that no latex gloves or equipment will come into contact with the client. Person-to-person communication for a safety issue ensures that the information is not overlooked. 2. The nurse should label the chart with the allergy, but because the client is in the preoperative holding area, this is not the first intervention. 3. The nurse should place a red allergy band on the client, but because the client is in the preoperative holding area, this is not the first intervention. 4. The nurse should always teach the client, but at this time the first intervention is the client's safety, which is why the OR team should be notified.

The nurse administered erythropoietin alpha (Epogen), a biological response modifier, to a client diagnosed with anemia. Which of the following data indicates the client may be experiencing an adverse reaction? 1. BP 200/124. 2. Apical pulse 54. 3. Hematocrit 38%. 4. Long bone pain.

Correct answer: 1 1. Erythropoietin stimulates the bone marrow to produce red blood cells. An adverse reaction to Epogen is hypertension, which this client has, with a BP of 200/124. Hypertension can cause the dose of erythropoietin to be decreased or discontinued. 2. Epogen does not affect the pulse. 3. A hematocrit of 38% would indicate the medication is effective. 4. A side effect of the medication is long bone pain. This can be treated with a non-narcotic analgesic. This is not an adverse reaction.

The husband of a client on the surgical unit comes to the desk and asks the nurse, "What is my wife's biopsy report?" Which intervention is the nurse's best action? 1. Check the chart to see whether the client has allowed the spouse to have information. 2. Obtain the pathology report and tell the husband the results of the biopsy. 3. Call the HCP and arrange a time for the husband to meet with the HCP. 4. Inform the client and husband of the biopsy results at the same time.

Correct answer: 1 1. Even though the spouse of the client is making the request, the nurse should still check to make sure that the client has listed the husband as being allowed to receive information. The Health Insurance Portability and Accountability Act (HIPAA) regulations do not allow for release of information to anyone not specifically designated by the client. 2. The nurse cannot do this unless the client has designated that her husband is allowed to receive information. 3. The HCP as well as the nurse must abide by HIPAA. 4. The HCP is responsible for divulging biopsy results. If the spouse is present when the HCP enters the room and the client allows the spouse to stay, then consent for receiving information is implied.

The home health (HH) nurse is visiting a female client diagnosed with colon cancer who has had a sigmoid colostomy. The client is crying and tells the nurse that she was told the cancer has spread and she will die very soon. Which intervention should the nurse implement? 1. Discuss the possibility of being placed on hospice services. 2. Contact the client's oncologist to discuss the client's prognosis. 3. Ask the client whether she has planned her funeral services. 4. Recommend the client get a second opinion concerning her prognosis.

Correct answer: 1 1. Hospice is a service for clients who have less than 6 months to live. If the client has been told she will die "very soon," then this is probably less than 6 months. If the client does not die within the 6 months, she will not automatically be discharged from hospice. Each client is assessed individually for the need to remain in hospice care. If the client does not want any heroic measures and wants to die at home, then hospice will provide these services. This intervention would be appropriate for the HH nurse. 2. The HH nurse is not responsible for discussing the client's prognosis. The oncologist would have to write a letter stating the client had less than 6 months to live to be placed on hospice services. The client should discuss this with the oncologist, not the HH nurse. 3. Because the client is crying and upset, it would be more appropriate for the nurse to discuss a plan for living and hospice services than to discuss what is going to happen after she dies. At some point this should be done, but this is not an appropriate time. 4. The client does have a right to a second opinion, but the nurse should not tell the client this unless the client is questioning the diagnosis.

The nurse working in a rheumatology clinic is teaching a 34-year old female client with rheumatoid arthritis (RA) about the disease-modifying antirheumatic drug methotrexate. Which information has the highest priority? 1. Teach the client to take measures to ensure she does not become pregnant. 2. Inform the client to keep the follow-up appointments with the clinic. 3. Have the client see a dietician if she loses her appetite. 4. Tell the client to keep a diary of her symptoms to bring to appointments with her.

Correct answer: 1 1. Methotrexate can cause fetal abnormalities or loss of the fetus. The client should be placed on birth control for the duration of administration of this medication and for 2 years post. 2. This is a standard instruction for many disease processes but it is not priority over prevention of pregnancy. 3. This medication can produce nausea and nutritional intake is important, but not over preventing a pregnancy and possible complications. 4. Keeping a diary of symptoms and questions is a good idea but the priority is to prevent an unplanned pregnancy.

The home health (HH) nurse is discussing the care of a client with an HH aide. Which task can the HH nurse delegate to the HH aide? 1. Instruct the HH aide to assist the client with a shower. 2. Ask the HH aide to prepare the breakfast meal for the client. 3. Request that the HH aide take the client to an HCP's appointment. 4. Tell her to show the client how to use a glucometer.

Correct answer: 1 1. The HH aide's responsibility is to care for the client's personal needs, which include assisting with a.m. care. 2. The HH aide is not responsible for cooking the client's meals. 3. The HH aide is not responsible for taking the client to appointments. This also presents an insurance problem, since the client is in the HH aide's car. 4. Even in the home, the HH nurse should not delegate teaching.

Which situation would prompt the healthcare team to utilize the client's advance directive when needing to make decisions for the client? 1. The client with a head injury who is exhibiting decerebrate posturing. 2. The client with a C-6 SCI who is on a ventilator. 3. The client in ESRD who is being placed on dialysis. 4. The client diagnosed with terminal cancer who is mentally retarded.

Correct answer: 1 1. The client must have lost decision-making capacity because of a condition that is not reversible, or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the advance directive. A client who is exhibiting decerebrate posturing is unconscious and unable to make decisions. 2. The client on a ventilator has not lost the ability to make healthcare decisions. The nurse can communicate by asking the client to blink his or her eyes to yes/no questions. 3. The client receiving dialysis is alert and does not lose the ability to make decisions; therefore, the advance directive should not be consulted to make decisions for the client. 4. Mental retardation does not mean the client cannot make decisions for him- or herself unless the client has a legal guardian who has a durable power of attorney for healthcare. If the client has a legal guardian, then the client cannot complete an advance directive.

The nurse hung the wrong intravenous antibiotic for the postoperative client. Which intervention should the nurse implement first? 1. Assess the client for any adverse reactions. 2. Complete the incident or adverse occurrence report. 3. Administer the correct intravenous antibiotic medication. 4. Notify the client's healthcare provider.

Correct answer: 1 1. The nurse should first assess the client prior to taking any other action to determine if the client is experiencing any untoward reaction. 2. An incident report must be completed by the nurse, but not prior to taking care of the client. 3. The nurse should administer the correct medication, but not prior to assessing the client. 4. The client's HCP must be notified but the nurse should be able to provide the HCP with pertinent client information, so this is not the first intervention.

The charge nurse is making assignments on a surgical unit. Which client should be assigned to the least experienced nurse? 1. The client who had a vaginal hysterectomy and still has an indwelling catheter. 2. The client who had an open cholecystectomy and has gray drainage in the tube. 3. The client who had a hip replacement and states something popped while walking. 4. The client who had a Whipple procedure and reports being thirsty all the time.

Correct answer: 1 1. This client has had a common surgical procedure and is not experiencing a complication. The least experienced nurse could care for this client. 2. Green bile in a T-tube is expected, but a gray tint to the drainage indicates an infection. An experienced nurse should be assigned to this client. 3. A popping feeling when ambulating indicates the hip joint may have dislocated. An experienced nurse should be assigned to this client. 4. A Whipple procedure involves removing most of the pancreas. The symptoms indicate the client is not metabolizing glucose (symptom of diabetes mellitus). An experienced nurse should be assigned to this client.

The home health (HH) hospice nurse is making rounds. Which client should the nurse assess first? 1. The client with end-stage heart failure who has increasing difficulty breathing. 2. The client whose family has planned to surprise her with an early birthday party. 3. The client who is complaining of being tired and irritable all the time. 4. The client with chronic lung disease who has not eaten for 3 days.

Correct answer: 1 1. This client may need oxygen or an intervention to keep the client comfortable. This client should be seen first. 2. This client does not have priority over difficulty breathing. 3. This client does not have priority over difficulty breathing. 4. This client does not have priority over difficulty breathing.

A client had an allergic reaction to penicillin, an antibiotic, and was admitted to the hospital 2 weeks ago. The client is being seen at the clinic for a follow-up visit. Which priority intervention should the nurse implement? 1. Recommend the client wear a medical alert bracelet. 2. Encourage the client to tell the pharmacy about the allergy. 3. Tell the client not to be around any person taking penicillin. 4. Allow the client to ventilate feelings about the hospitalization.

Correct answer: 1 1. This is the nurse's priority intervention because any emergency personnel who may come into contact with the client should be aware of the client's allergy. A penicillin allergy can kill the client. 2. The client's pharmacy can be made aware of the allergy, but this is helpful only when the client is having prescriptions filled. 3. Unless the client has an allergy to penicillin dust, which is rare, coming into contact with another person taking penicillin will not cause the client to have an allergic reaction. 4. Therapeutic communication allows the client to ventilate feelings, which is an appropriate intervention, but it is not priority over teaching the client how to prevent a potentially life-threatening reaction.

Which staff nurse should the charge nurse in the intensive care unit (ICU) send to the medical unit? 1. The nurse who has worked in the unit for 18 months. 2. The nurse who is orienting to the critical care unit. 3. The nurse who has been working at the hospital for 2 months. 4. The nurse who has 12 years' experience in this ICU unit.

Correct answer: 1 1. This nurse should be sent to the medical unit because, with 18 months' experience, the nurse is familiar with the hospital routine and would be helpful to the medical unit but is not the most experienced ICU nurse on duty. 2. The nurse who is still orienting to the unit should not be sent to the medical unit. The nurse in orientation should be kept with the nurse preceptor. 3. The nurse who is new to the hospital should not be sent to a new unit with which he or she is unfamiliar. 4. The nurse with 12 years' experience should be kept on in the ICU because his or her expertise would be more helpful for client care than a nurse with 18 months' experience.

Which tasks should the long-term care nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Instruct the UAP to perform the a.m. care for the clients. 2. Tell the UAP to wash the hair of the female clients. 3. Ask the UAP to cut the toenails of the clients. 4. Request the UAP to turn the clients every shift. 5. Instruct the UAP to empty the clients' wastebaskets.

Correct answer: 1, 2 1. The UAP can perform a.m. care; therefore, this can be delegated to the UAP. 2. Washing the hair of female clients can be delegated to the UAP. 3. The UAP should not cut the toenails of clients; this should be referred to a podiatrist. 4. The clients should be turned every 2 hours, not every shift. 5. The housekeeping department should empty the wastebaskets, not the UAP.

The nurse caring for a client newly diagnosed with protein calorie malnutrition secondary to acquired immune deficiency syndrome (AIDS) writes a nursing problem of "altered nutrition: less than body requirements." Which nursing interventions should the nurse implement? Select all that apply. 1. Place the client on daily weights. 2. Have the client identify preferred foods. 3. Refer to the dietician. 4. Monitor bedside glucose levels four times a day. 5. Perform central line dressing changes every 72 hours.

Correct answer: 1, 2, 3 1. The client's daily weights will provide information as to fluid balance and nutrition deficits. 2. The client's preferred foods can be used to help increase the client's appetite and should be provided whenever possible on the meal trays. 3. The dietician can be the nurse's best ally when caring for a client with nutritional problems. 4. Glucose levels are monitored when a client is on total parenteral nutrition (TPN), not for a client newly diagnosed with a nutritional problem. 5. This would be appropriate for a client on TPN.

The nurse administered pain medication 30 minutes ago to a client diagnosed with terminal cancer. Thirty minutes after the medication, the client tells the nurse "I don't think you gave me anything. My pain is even worse than before." Which intervention (s) should the nurse implement? Select all that apply. 1. Attempt to determine whether the client is experiencing spiritual distress. 2. Ask the client to rate the current pain on the numeric pain scale. 3. Reposition the client to relieve pressure on the pain site. 4. Call the HCP to request an increase in pain medication. 5. Explain to the client he or she should relax and let the medication take effect.

Correct answer: 1, 3, 4 1. Spiritual distress can greatly affect the perception of pain. If the client is not receiving relief from pain medication, the nurse should explore other variables that could affect the perception of pain. 2. Clients experiencing chronic pain may or may not be able to rate their pain on a pain scale. The client has provided all the information about the pain that is currently needed. The pain is greater than it was before the medication. 3. This is an alternative to medication that may provide some minimal relief while other interventions are being attempted. 4. The nurse should notify the HCP that the current pain regimen is not effective. 5. This is a condescending statement and would tend to agitate the client more than help.

The staff nurse answers the telephone on a medical unit and the caller tells the nurse that he has planted a bomb in the facility. Which actions should the nurse implement? Select all that apply. 1. Do not touch any suspicious object. 2. Call 911, the emergency response system. 3. Try to get the caller to provide additional information. 4. Immediately pull the red emergency wall lever. 5. Write down exactly what the caller says.

Correct answer: 1, 3, 5 1. The nurse should begin a systematic search of the unit after activating the bomb scare emergency plan, and if any suspicious objects are found the nurse should not touch them, and should notify the bomb squad. 2. The nurse should notify the house supervisor and administration because they are responsible for notifying the police department. 3. The nurse should stay calm and try to keep the caller on the telephone. The nurse should attempt to get as much information from the caller as possible. The nurse can jot a note to someone nearby to initiate the bomb scare procedure. 4. The red emergency levers in hospitals are to notify the fire departments of a fire, not a bomb scare. 5. The nurse should try to transcribe exactly what the caller says; this may help identify who is calling and where a bomb might be placed.

The 28-year-old female client in the outpatient clinic has been told that her test for the human immune deficiency virus (HIV) is positive. Which interventions should the nurse implement? Select all that apply. 1. Discuss having regular gynecological examinations. 2. Assist the client to make her funeral arrangements. 3. Refer the client to a social worker. 4. Encourage the client to take the highly active antiretroviral therapy (HAART). 5. Teach the client to follow a healthy life style.

Correct answer: 1, 4, 5 1. Females who are HIV positive are at risk for multiple gynecological problems. 2. This is not in the scope of practice of a nurse, and clients newly diagnosed are living 20 years or longer with the virus. 3. Nothing in the stem indicated a need for this referral. 4. HAART regimens are responsible for the improved prognosis of HIV+ clients. 5. A healthy life style will improve the client's ability to maintain her health.

The staff nurse is caring for a client who was diagnosed with pancreatic cancer during an exploratory laparotomy. Which client problem is priority for postoperative day 1? 1. Ineffective coping. 2. Fluid and electrolyte imbalance. 3. Risk for infection. 4. Potential for suicidal thoughts.

Correct answer: 2 1. Ineffective coping is a psychological problem that would not have priority on the first day after major abdominal surgery. 2. After major trauma, the body undergoes a fluid shift. The possibility of fluid and electrolyte imbalance is the top priority problem for 1 day after major abdominal surgery. 3. This could be a priority, but a potential or risk is not priority over an actual problem. 4. A potential psychological problem would not have priority on the first day after major abdominal surgery.

The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP? 1. The UAP is not at risk for contracting an illness. 2. The UAP should wear a mask, gown, and gloves. 3. The UAP may skip performing postmortem care. 4. Ask whether the UAP is pregnant before she enters the client's room.

Correct answer: 2 1. The UAP may be at risk of contacting the illness. 2. The UAP should wear appropriate personal proactive equipment when providing any type of care. 3. The UAP should not be told to skip performing assigned tasks. 4. The fetus is not affected by anthrax so a pregnant nurse could care for the client, taking the same precautions as a nurse who is not pregnant.

The home healthcare (HH) agency director is making assignments. Which client should be assigned to the most experienced HH nurse? 1. The client who is recovering from Guillain-Barré syndrome who reports being tired all the time. 2. The client who has multiple Stage 3 and 4 pressure ulcers on the sacral area. 3. The client who is 2 weeks postoperative for laryngectomy secondary to laryngeal cancer. 4. The client who is being discharged from service within the next week.

Correct answer: 2 1. The client diagnosed with Guillain-Barr? syndrome would have been on bed rest for days to weeks and would be in a debilitated state; therefore, reports of being tired all the time would be expected. This client would not require the most experienced nurse. 2. The client with pressure ulcers requires meticulous nursing care and a nurse who has experience with wounds. The most experienced nurse should be assigned this client. 3. The client with a laryngectomy has received teaching prior to and after the procedure and would not require extensive teaching or nursing care; therefore, this client would not require the most experienced nurse. 4. Discharge teaching starts on admission into the home healthcare agency; therefore, most of the teaching would have been completed, and this client would not need the most experienced nurse.

The 24-year-old male client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which priority intervention should the clinic nurse implement? 1. Teach the client to turn, cough, and deep breathe. 2. Discuss the importance of sperm banking. 3. Explain about the testicular prosthesis. 4. Refer the client to the American Cancer Society (ACS).

Correct answer: 2 1. The client must be taught postoperative care, but this is not the priority intervention of the clinic nurse. 2. Sperm banking will allow the client's sperm to be kept until the time the client wants to conceive a child. This is priority because it must be done between the clinic visit and admission to the hospital for the procedure. The unilateral orchiectomy will not result in sterility, but the subsequent treatments may cause sterility. 3. The nurse can discuss the testicular prosthesis, but this is not priority over sperm banking because the prosthesis may or may not be inserted at the time of surgery. 4. A referral to the ACS is appropriate, but is not the most important information a 24-year-old male client needs at this time

Which task should the critical care nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the pulse oximeter reading for the client on a ventilator. 2. Take the client's sterile urine specimen to the laboratory. 3. Obtain the vital signs for the client in an Addisonian crisis. 4. Assist the HCP with performing a paracentesis at the bedside.

Correct answer: 2 1. The client on the ventilator is unstable; therefore, the nurse should not delegate any tasks to the UAP. 2. The UAP can take specimens to the laboratory; it is not medications and not vital to the client. 3. The client in an Addisonian crisis is unstable; therefore, the nurse should not delegate any tasks to the UAP. 4. The UAP cannot assist the HCP with an invasive procedure at the bedside.

The critical care charge nurse is making client assignments. Which client should the charge nurse assign to the nurse who is pregnant? 1. The client with intracavity radiation for cervical cancer who developed ARDS. 2. The client who is HIV positive and admitted for chest pain R/O myocardial infarction. 3. The client who is immunosuppressed and diagnosed with cytomegalovirus (CMV). 4. The client receiving I131 iodine for hyperthyroidism who had a motor vehicle accident (MVA).

Correct answer: 2 1. The client with intracavity radiation could cause problems with the pregnant nurse's fetus, so she should not be assigned to this client. 2. The pregnant nurse can be assigned to a client who is HIV positive. The nurse must adhere to Standard Precautions. 3. The cytomegalovirus could harm the nurse's fetus, so the pregnant nurse should not be assigned to this client. 4. The I131 is radioactive iodine and a pregnant nurse should not be near radiation.

The client is diagnosed with laryngeal cancer and is scheduled for a laryngectomy next week. Which intervention would be priority for the clinic nurse? 1. Assess the client's ability to swallow. 2. Refer the client to a speech therapist. 3. Order the client's preoperative lab work. 4. Discuss the client's operative permit.

Correct answer: 2 1. The client's ability to swallow is not impaired prior to the surgical procedure. 2. The client will not be able to speak after the removal of the larynx; therefore, referral to a speech therapist who will be able to discuss an alternate means of communication is priority. 3. The HCP, not the nurse, is responsible for ordering the preoperative laboratory work. 4. The HCP, not the nurse, is responsible for discussing the operative permit.

The confused client in the critical care unit is attempting to pull out the IV line and the indwelling urinary catheter. Which action should the nurse implement first? 1. Ask a family member to stay with the client. 2. Request the UAP to stay with the client. 3. Place the client in a chest restraint. 4. Notify the HCP to obtain a restraint order.

Correct answer: 2 1. The family may or may not be able to control the client's behavior but the nurse should not ask a family member first. The CCU usually has mandated visiting hours. 2. The nurse should first ensure the client's safety by having someone stay at the bedside with the client, and then call the HCP, and finally apply mitt restraints. 3. This is a form of restraint and is against the law unless the nurse has a healthcare provider's order. This is the least restrictive form of restraint but would not be helpful if the client is pulling at tubes. 4. The nurse must notify the healthcare provider before putting the client in restraints; restraints must be used only in an emergency situation, for a limited time, and for the protection of the client.

A client diagnosed with cancer and receiving chemotherapy is brought to the emergency department (ED) after vomiting bright red blood. Which intervention should the nurse implement first? 1. Check to see which antineoplastic medications the client has received. 2. Start an IV of normal saline with an 18-gauge intravenous catheter. 3. Investigate to see whether the client has a do not resuscitate (DNR) order written. 4. Call the oncologist to determine what lab work to order.

Correct answer: 2 1. The medications are not important at this time. The client is bleeding. 2. The client is at risk for shock. The nurse should take steps to prevent vascular collapse. Starting the IV is the priority. 3. This is not important in the emergency department. 4. Prevention of circulatory collapse is the priority. The nurse could anticipate an order for a complete blood count (CBC) and a type and crossmatch.

The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers? 1. No information can be released to the mortuary service. 2. The nurse should tell the funeral home the client's diagnosis. 3. Ask the family for permission to talk with the mortician. 4. Refer the funeral home to the HCP for information.

Correct answer: 2 1. The mortuary service is considered part of the healthcare team in this case. The personnel in the funeral home should be made aware of the client's diagnosis. 2. The mortuary service is considered part of the healthcare team. In this case, the personnel in the funeral home should be made aware of the client's diagnosis. 3. The nurse does not need to ask the family for permission to protect the funeral home workers. 4. The nurse, not the HCP, releases the body to the funeral home.

The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? 1. Confront the charge nurse with the suspicions. 2. Talk with the night supervisor about the concerns. 3. Ignore the situation unless the nurse cannot do her job. 4. Ask to speak to the nurse educator about the problem.

Correct answer: 2 1. The new graduate must work under this charge nurse; confronting the nurse would not resolve the issue because the nurse can choose to ignore the new graduate. Someone in authority over the charge nurse must address this situation with the nurse. 2. The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation. 3. The new graduate is bound by the nursing practice acts to report potentially unsafe behavior regardless of the position the nurse holds. 4. The nurse educator would not be in a position of authority over the charge nurse.

The nurse notes the unlicensed assistive personnel (UAP) tied a sheet around the client in the chair so the client will not fall out. Which action should the nurse implement first? 1. Praise the UAP for being concerned about the safety of the client. 2. Remove the sheet from the client immediately. 3. Explain to the UAP the sheet is a form of restraint and cannot be tied around the client. 4. Assess the client's need for restraints and notify the healthcare provider for an order.

Correct answer: 2 1. The nurse can praise the UAP for safety concerns but first the sheet must be removed because it is a form of restraint and is illegal. 2. The nurse must remove the sheet since it is a restraint. There must be an HCP's order prior to restraining a client. 3. The nurse should discuss the restraint policy with the UAP but not prior to removing the restraint. 4. The nurse should determine if the client needs restraints for safety and then call and obtain the order, but not prior to removing the sheet. A chest restraint could be used to secure the client to the chair if needed.

The charge nurse observes two unlicensed assistive personnel (UAPs) arguing in the hallway. Which action should the nurse implement first in this situation? 1. Tell the manager to check on the UAPs. 2. Instruct the UAPs to stop arguing in the hallway. 3. Have the UAPs go to a private room to talk. 4. Mediate the dispute between the UAPs.

Correct answer: 2 1. The nurse should stop the behavior occurring in a public place. The charge nurse can discuss the issue with the UAPs and determine whether the manager should be notified. 2. The first action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs' behavior in public. 3. The second action is to have the UAPs go to a private area before resuming the conversation. 4. The charge nurse may need to mediate the disagreement; this would be the third step.

The female nurse is discussing an upcoming surgical procedure with a 76-year-old male client diagnosed with cancer. Which action is an example of the ethical principle of fidelity? 1. The nurse makes sure the client understands the procedure before signing the permit. 2. The nurse refuses to disclose the client's personal information to the CNO. 3. The nurse tells the client his diagnosis when the family did not want him to know. 4. The nurse tells the client that she does not know the client's diagnosis.

Correct answer: 2 1. This is an example of autonomy. The client needs all pertinent information prior to making an informed choice. 2. This is an example of fidelity. Fidelity is the duty to be faithful to commitments and involves keeping information confidential and maintaining privacy and trust. 3. This is an example of veracity, the duty to tell the truth. 4. This is an example of nonmalfeasance, the duty to do no harm. This avoids telling a client facing surgery that he has cancer.

The nurse is caring for clients on an oncology unit. Which client should the nurse assess first? 1. The client diagnosed with leukemia who is afebrile and has a white blood cell (WBC) count of 100,000 mm3. 2. The client who has undergone four rounds of chemotherapy and is nauseated. 3. The client diagnosed with lung cancer who has absent breath sounds in the lower lobes. 4. The client diagnosed with rule out (R/O) breast cancer who had a negative biopsy this a.m.

Correct answer: 2 1. This is an expected lab value for a client diagnosed with leukemia. The client's bone marrow is overproducing immature white blood cells and clogging the bloodstream. 2. This client is complaining of nausea, which is an uncomfortable experience. The nurse should attempt to intervene and treat the nausea. This client should be seen first. 3. Absent breath sounds are expected in a client diagnosed with lung cancer. 4. A negative biopsy is a good result. This client does not need to be seen first.

The female client was admitted to the orthopedic unit for injuries received during a domestic argument. The client tells the nurse, "I am afraid my husband will kill me if I leave him. It was my fault anyway." Which statement is the nurse's best response? 1. "What did you do to set him off like that?" 2. "Do you have a plan for safety if you go back?" 3. "Why do you think it was your fault?" 4. "You should leave him before it is too late."

Correct answer: 2 1. This is blaming the client. No one has the right to abuse the client. 2. The nurse must assess the client's safety and provide a referral to a women's center. This is the nurse's best response. 3. The client does not owe the nurse an explanation of her feelings. This is not a good response to the client. 4. The nurse is advising. The decision whether to leave the abuser or not must be the client's decision.

The client diagnosed with breast cancer who is positive for the BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse's best response? 1. "If it were me in this situation, I would consider having a bilateral mastectomy." 2. "What treatment options has your healthcare provider (HCP) discussed with you?" 3. "You should discuss your treatment options with your HCP." 4. "Have you talked with your significant other (SO) about the treatment options available to you?"

Correct answer: 2 1. This is boundary crossing because the nurse does not have breast cancer. The nurse should assess what information the client is really seeking and then explain the treatment or refer the client, as appropriate. 2. The nurse must assess what information the client actually needs. To do this, the nurse must know what treatment options have been suggested to the client. Assessment is the first step in the nursing process. 3. This may be needed after the nurse further assesses the situation, but this is not the first intervention. 4. The client needs information about treatment options from a designated HCP; the significant other would not have such information/ suggestions.

The primary nurse informs the shift manager that one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? 1. Notify the unit manager of the potential situation of falsifying vital signs. 2. Take the assigned client's vital signs and compare them with the UAP's results. 3. Talk to the UAP about the primary nurse's allegation. 4. Complete a counseling record and place in the UAP's file.

Correct answer: 2 1. This should not be implemented until verification of the allegation is complete, and the shift manager has discussed the situation with the UAP. 2. The shift manager should have objective data about the allegation of falsifying vital signs prior to confronting the UAP; therefore, the shift manager should take the client's vital signs and compare them with the UAP's results before taking any other action. 3. The shift manager should not confront the UAP until objective data are obtained to support the allegation. 4. Written documentation should be the last action when resolving staff issues.

The nurse is caring for a female client diagnosed with systemic lupus erythematosus (SLE). Which of the following client-reported data has priority? 1. The client reports that she has trouble finding makeup to cover the rash across her nose. 2. The client tells the unlicensed assistive personnel (UAP) to close the drapes because sunlight is bad for her. 3. The client notices a bright red color in the bedside commode. 4. The client complains of joint stiffness and requests a pain medication.

Correct answer: 3 1. A butterfly rash is one of the clinical manifestations of SLE; this statement does not alert the nurse to a new finding. 2. Photosensitivity is a clinical manifestation of SLE and does not alert the nurse to a new problem. 3. Bright red in the bedside commode indicates blood, alerting the nurse to possible renal involvement. The healthcare provider must be notified so that diagnostic test can be ordered and steps taken to limit the damage to the kidneys. 4. Joint stiffness is related to the SLE and is a clinical manifestation. The nurse will medicate the client for pain but the priority is to limit damage to the kidneys.

The nurse has received the morning shift report on an oncology unit. Which client should the nurse assess first? 1. The client diagnosed with leukemia who has a white blood cell (WBC) count of 1.2 (103). 2. The client diagnosed with a brain tumor who has a headache rated as a 2 on a pain scale of 1 to 10. 3. The client diagnosed with breast cancer who is upset and crying. 4. The client diagnosed with lung cancer who is dyspneic on exertion.

Correct answer: 3 1. A low WBC count is expected in a client diagnosed with leukemia. This client does not need to be assessed first. 2. A client diagnosed with a brain tumor would be expected to have a mild headache. This client does not need to be assessed first. 3. The client is upset and crying. When all the information in the options is expected and not life threatening, then psychological issues have priority. This client should be seen first. 4. Dyspnea on exertion is expected in a client diagnosed with lung cancer. This client does not need to be assessed first.

The female client with osteoarthritis is 6 weeks postoperative for open reduction and internal fixation of the right hip. The home health (HH) aide tells the HH nurse the client will not get in the shower in the morning because she "hurts all over." Which action would be most appropriate by the HH nurse? 1. Tell the HH aide to allow the client to stay in bed until the pain goes away. 2. Instruct the HH aide to get the client up to a chair and give her a bath. 3. Explain to the HH aide that the client should get up and take a warm shower. 4. Arrange an appointment for the client to visit her healthcare provider.

Correct answer: 3 1. Allowing the client to stay in bed is inappropriate because a client with osteoarthritis should be encouraged to move, which will decrease the pain. 2. A bath at the bedside does not require as much movement from the client as getting up and walking to the shower. This is not an appropriate action for a client with osteoarthritis. 3. Movement and warm or hot water will help decrease the pain; the worst thing the client can do is not to move. The HH aide should encourage the client to get up and take a warm shower or bath. 4. Osteoarthritis is a chronic condition, and the HCP could not do anything to keep the client from "hurting all over."

Which client laboratory data should the nurse report to the HCP immediately? 1. The elevated amylase report on a client diagnosed with acute pancreatitis. 2. The elevated WBC count on a client diagnosed with a septic leg wound. 3. The urinalysis report showing many bacteria in a client receiving chemotherapy. 4. The serum glucose level of 235 mg/dL on a client diagnosed with type 1 diabetes.

Correct answer: 3 1. An elevated amylase would be expected in a client diagnosed with acute pancreatitis. The nurse would not need to call the HCP immediately. 2. An elevated WBC would be expected in a client diagnosed with a septic (infected) leg wound. The nurse would not need to call the HCP immediately. 3. The urinalysis report showing many bacteria is indicative of an infection. Clients receiving chemotherapy are at high risk of developing an infection. The nurse should notify the HCP immediately. 4. This blood glucose level is above normal range but would not be particularly abnormal for a client diagnosed with type 1 diabetes. The nurse would not need to call the HCP immediately.

The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which client problem is priority? 1. Body image disturbance. 2. Impaired coping. 3. Risk for infection. 4. Self-care deficit.

Correct answer: 3 1. Clients diagnosed with acquired immunodeficiency syndrome (AIDS) may have body image disturbance issues related to weight loss and Kaposi's sarcoma lesions, but these are psychological problems, and physiological problems have priority. 2. Impaired coping is a psychological problem, and physiological problems are priority. 3. The basic problem with a client diagnosed with AIDS is that the immune system is not functioning normally. This increases the risk for infection. This is the priority client problem. 4. Self-care deficit is a psychosocial problem, not a physiological problem.

The nurse is called to the room of a male client diagnosed with lung cancer by the client's wife because the client is not breathing. The client has discussed having a DNR order written but has not made a decision. Which interventions should the nurse implement first? 1. Ask the spouse whether she wants the client to be resuscitated. 2. Tell the spouse to leave the room and then perform a slow code. 3. Assess the client's breathing and call a code from the room. 4. Notify the oncologist the client has arrested.

Correct answer: 3 1. It is too late to ask this question. This decision must be made prior to an arrest situation. 2. The nurse should not hesitate to call a code, and a full code must be performed, not a slow code. 3. These are the first steps of a code. 4. This should be done by someone at the desk, not by the nurse responding to the emergency.

The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to the unlicensed nursing personnel (UAP)? 1. Instruct the UAP to apply sequential compression devices to the client on strict bed rest. 2. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray. 3. Request the UAP to prepare the client for a wound debridement at the bedside. 4. Tell the UAP to obtain the intakes and outputs for all the clients on the unit.

Correct answer: 3 1. The UAP can apply sequential compression devices to the client on strict bed rest. 2. The UAP can assist with a portable STAT chest x-ray as long as it is not a female UAP who is pregnant. 3. The client will need to be pre-medicated for a wound debridement; therefore, this task cannot be delegated to the UAP. 4. The UAP can obtain intake and outputs for clients.

The charge nurse in the long-term care center is making assignments for licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs) on the day shift. Which task is most appropriate to assign to the LPN? 1. Instruct the LPN to place anti-thrombosis hose on the client. 2. Ask the LPN to escort the client outside to smoke a cigarette. 3. Tell the LPN to administer the tube feeding to the client. 4. Request the LPN to change the client's colostomy bag.

Correct answer: 3 1. The UAP could place anti-thrombosis hose on the client. 2. The UAP should not escort the client outside to smoke a cigarette, the UAP will be off the unit and this encourages poor health habits. 3. The LPN should administer a tube feeding, not the UAP. 4. The UAP can change a colostomy bag on a client who has had it for an extended period of time, which is implied since the client is in a long-term care center.

Which member of the healthcare team should be assigned to a dying client who is having frequent symptoms of distress? 1. The unlicensed assistive personnel (UAP) who can be spared to sit with the client. 2. The licensed practical nurse (LPN) who has grown attached to the family. 3. The registered nurse (RN) who has experience as a hospice nurse. 4. The registered nurse (RN) who graduated 2 months ago.

Correct answer: 3 1. The charge nurse should not assign a UAP to care for a client in spiritual distress. This is outside of the UAP's functions. 2. The charge nurse should not delegate or assign care based on a personal relationship of the nurse with the family. The nurse most qualified to care for the client's needs should be assigned to the client. 3. A hospice nurse has experience in managing symptoms associated with the dying process. This is the best nurse to care for this client. 4. A new graduate would not have the experience or knowledge to manage the symptoms as effectively as an experienced hospice nurse.

The client tells the home health (HH) nurse, "My oncologist told me they can't do anything else for my cancer. I do not want my children to know, but I had to tell someone. You won't tell them, will you?" Which statement is the nurse's best response? 1. "Since you told me about the prognosis, I must talk to your children." 2. "I don't think it is a good idea not to tell your children; they should know." 3. "I will not say anything to your children, but I will contact the HH doctor." 4. "You are concerned I might talk to your children about your prognosis."

Correct answer: 3 1. The client is an adult and the nurse must respect the client's confidentiality. The nurse does not have to tell the children. 2. This is giving advice and is not the nurse's role. 3. The nurse not telling the children respects the client's wishes and confidentiality but the healthcare providers should be told of new client circumstances, as the information applies to the client's care. 4. This is a therapeutic response but the client did not indicate that she or he thought the nurse would talk about the client's status to the children. The client just wanted to tell someone.

A new graduate nurse is assigned to work with an unlicensed assistive personnel to provide care for a group of clients. Which action by the graduate nurse is the best method to evaluate whether delegated care is being provided? 1. Check with the clients to see whether they are satisfied. 2. Ask the charge nurse whether the UAP is qualified. 3. Make rounds to see that the clients are being turned. 4. Watch the UAP perform all the delegated tasks.

Correct answer: 3 1. The clients would not understand the importance of the specific tasks. Clients will tell the nurse whether the UAP is pleasant when in the room but not whether the delegated tasks have been completed. 2. The nurse retains responsibility for the delegated tasks. The charge nurse may be able to tell the nurse that the UAP has been checked off as being competent to perform the care, but would not know whether the care was actually provided. 3. The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care. 4. The nurse would not have time to complete his or her own work if the nurse watched the UAP perform all of the UAP's work.

Which action would be most appropriate for the clinic nurse who suspects another staff nurse of stealing narcotics from the clinic? 1. Confront the staff nurse with the suspicion. 2. Call the state board of nurse examiners. 3. Notify the director of nurses immediately. 4. Report the suspicion to the clinic's HCP.

Correct answer: 3 1. The clinic nurse should not confront the staff nurse without objective data that support the allegation. 2. The state board of nurse examiners cannot do anything to the nurse until the nurse has been convicted of the crime. Many states have programs to help addicted nurses, and some states may revoke the nurse's license to practice nursing. 3. The clinic nurse should report the suspicions so that appropriate actions can be taken, such as a urine drug screen for the nurse, watching the nurse for the behavior, and possibly notifying the police department. 4. The nurse should follow the chain of command, which does not include the HCP.

A client diagnosed with AIDS dementia is angry and yells at everyone entering the room. None of the critical care staff want to be assigned to this client. Which intervention would be most appropriate for the nurse manager to use in resolving this situation? 1. Explain that this attitude is a violation of the client's rights. 2. Request the HCP to transfer the client to the medical unit. 3. Discuss some possible options with the nursing staff. 4. Try to find a nurse who does not mind being assigned to the client.

Correct answer: 3 1. The feelings of the staff are not a violation of the client's rights. Refusing to care for the client is a violation of the client's rights. 2. Transferring the client to the medical unit solves the problem for the critical care unit, but the client's behavior should be addressed by the healthcare team. This is not the most appropriate intervention for the nurse manager. 3. This would be the most appropriate intervention because it allows the staff to have input into resolving the problem. When staff have input into resolving the situation, then there is ownership of the problem. 4. One nurse cannot be on duty 24 hours a day. The nurse manager should try to allow the staff to identify options to address the client's behavior.

The infection control nurse notices a rise in nosocomial infection rates on the surgical unit. Which action should the infection control nurse implement first? 1. Hold an in-service for the staff on the proper method of hand washing. 2. Tell the unit manager to decide on a corrective measure. 3. Arrange to observe the staff at work for several shifts. 4. Form a hospital-wide quality improvement project.

Correct answer: 3 1. The infection control nurse should evaluate the problem fully before deciding on a course of action. 2. The infection control nurse should assess the staff member's delivery of care and use standard nursing practice before deciding on a course of action with the unit manager. 3. This is an action that will allow the infection control nurse to observe compliance with standard nursing practices such as hand washing. Once the nurse has attempted to determine a cause, then a corrective action can be implemented. 4. The entire hospital has not shown an increased infection rate; only one unit has shown an increase.

The nurse and licensed practical nurse (LPN) are caring for clients on an oncology unit. Which client should be assigned to the LPN? 1. The client diagnosed with acute leukemia who is on a continuous infusion of antineoplastic medications. 2. The client newly diagnosed with cancer of the lung who is being admitted for placement of an implanted port. 3. The client diagnosed with an ovarian tumor weighing 22 pounds who is being prepared for surgery in the morning. 4. The client diagnosed with pancreatic cancer who complains of frequent, unrelenting abdominal pain.

Correct answer: 3 1. The infusion of antineoplastic medications is limited to chemotherapy- and biotherapy- competent registered nurses. A qualified registered nurse should be assigned to this client. 2. This client should be assigned to a registered nurse who can answer the client's questions about the cancer and cancer treatments. 3. This client is pre-op, and the LPN can prepare a client for surgery. A 22-pound tumor indicates a benign ovarian cyst. 4. An experienced registered nurse should be assigned to this client because the client is unstable, with unrelenting pain.

The client diagnosed with sickle cell disease complains of joint pain rated 10 on a pain scale of 1 to 10. Which intervention should the nurse implement first? 1. Administer a narcotic analgesic to the client. 2. Check the ID prior to administering the medication. 3. Assess the client to rule out (R/O) complications. 4. Obtain the medication from the narcotics box.

Correct answer: 3 1. The nurse should assess the client for complications before administering the medication. 2. This should occur, but not before assessing the client for complications. 3. The first step in administering a PRN pain medication is to assess the client for a complication that may require the nurse to notify the HCP or implement an independent nursing intervention. 4. This is not the first intervention.

The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which action by the UAP requires immediate intervention by the nurse? 1. The UAP dons unsterile gloves before emptying a urinary catheter bag. 2. The UAP places clean linen in all of the clients' rooms for the day. 3. The UAP uses a different plastic bag for every client when getting ice. 4. The UAP massages the client's trochanter when turning the client.

Correct answer: 4 1. This is the correct procedure when coming into contact with blood and body fluids. The nurse does not need to intervene. 2. This may be wasteful if the linens are not used because the client is discharged, but it does not warrant immediate intervention by the nurse until the unit has a problem with linen over-usage. This action saves the UAP time. 3. This is the correct procedure for getting ice. The nurse does not need to intervene. 4. Massaging pressure points increases tissue damage and increases the risk of skin breakdown. The nurse should intervene and stop this action by the UAP.

The charge nurse in a long-term care facility is reviewing the male resident's laboratory data and notes the following: H&H, 13/39; WBC count, 5.25 (103); and platelets, 39 (103). Which instructions should the nurse give to the unlicensed assistive personnel(UAP) caring for the client? 1. Place the client in reverse isolation immediately. 2. Administer oxygen during strenuous activities. 3. Do not shave the resident with a safety razor. 4. Check the resident's temperature every 4 hours.

Correct answer: 3 1. The resident's WBC count is within normal limits and indicates an ability to resist infection. The nurse should not place this resident in reverse isolation. 2. The resident's H&H is slightly lower than normal but not low enough to cause dyspnea during activity. The resident does not need oxygen. 3. The resident's platelet count is very low and could cause the resident to bleed. The nurse should initiate bleeding precautions that include not using sharp blades to shave the resident and using soft-bristle toothbrushes. 4. The client is not at risk for developing an infection. The client does not need his temperature checked every 4 hours.

The female client who is dying asks to see her son, but the son refuses to come to the hospital. Which action should the nurse implement first? 1. Call the son and tell him he must come to see his mother before it is too late. 2. Ask the social worker to call the son and see whether the son will come to the hospital. 3. Check with the family to see whether they can discuss the issue with the son. 4. Do nothing because to intervene in a private matter would be boundary crossing.

Correct answer: 3 1. The son has a right to refuse to come to the hospital regardless of what the nurse thinks the son should do. The nurse is unaware of the family dynamics that led to this dilemma. 2. This is only placing another healthcare professional in the picture and would not be the best option. 3. Other family members are more likely to understand the family dynamics and would be the best ones to intervene in the situation. 4. The nurse should attempt to assist in reconciliation between the client and her son if possible.

The unit manager on an oncology unit receives a complaint about the care a client received from the night shift nurse. Which action should the unit manager implement first? 1. Ask the night charge nurse to make sure the nurse does the work. 2. Request the nurse come in to discuss the care provided. 3. Discuss the situation with the client making the complaint. 4. Document this occurrence and place in the nurse's employee file.

Correct answer: 3 1. The unit manager should talk to the client first, not ask the night charge nurse to watch the nurse. This step may be needed if a doubt does surface about the nurse's performance. 2. This is the second step in this process if the manager determines the complaint is valid. 3. The first step is to discuss the complaint with the client. This step lets the client know that the client is being heard, and the manager is able to ask any questions to clarify the complaint. 4. The occurrence may need to be documented and placed in the employee's file, but this is not the unit manager's first intervention.

The charge nurse is making assignments for the surgical unit. Which client should be assigned to the new graduate nurse? 1. The 84-year-old client who has a chest tube that is draining bright red blood. 2. The 38-year-old client who is 1 day postoperative with a temperature of 101.2ºF. 3. The 42-year-old client who has just returned to the unit after a breast biopsy. 4. The 55-year-old client who is complaining of unrelenting abdominal pain.

Correct answer: 3 1. This client is not stable and requires a more experienced nurse. 2. An elevated temperature indicates a potential complication of surgery; therefore, this client requires a more experienced nurse. 3. Of the four clients, the one who is most stable is the client who has just undergone a breast biopsy; therefore, this client would be the most appropriate to assign to a new graduate nurse. 4. Unrelenting pain requires further assessment; therefore, the client should be assigned to a more experienced nurse.

The nurse is completing a head-to-toe assessment on a client diagnosed with breast cancer and notes a systolic murmur that the nurse was not informed of during report. Which action should the nurse implement first? 1. Notify the HCP about the new cardiac complication. 2. Document the finding in the client's chart and tell the charge nurse. 3. Check the chart to determine whether this is the first time a murmur has been identified. 4. Ask the client whether she has ever been told she has an abnormal heartbeat.

Correct answer: 3 1. This should be done if the murmur is a new finding; however, the nurse should investigate the finding further before notifying the HCP. 2. This should be done, but assessing the client's situation is the nurse's priority. 3. Although the client was not admitted for a cardiac problem, she may have had a murmur for a while, and the previous nurse did not pick it up or did not mention it in the report because it was a long-standing physiological finding in this client. The nurse should research the chart for a current history and physical to determine whether the HCP is aware of the condition. 4. The nurse should not ask the client because this could scare or alarm the client needlessly.

The older adult client receiving chemotherapy complains that food just does not taste like it used to. Which intervention should the medical unit nurse implement first? 1. Ask the dietician to consult with the client on food preferences. 2. Medicate the client before meals with an antiemetic medication. 3. Ask the HCP to suggest an over-the-counter nutritional supplement. 4. Check the client's current weight with the client's usual weight.

Correct answer: 4 1. Asking the dietitian to consult with the client is a good intervention, but the nurse should assess the impact of the change in taste on the client. 2. The client did not complain of nausea. Antiemetic medication is used to prevent nausea associated with food odors and attempting to eat. 3. The nurse can recommend an over-the-counter supplement to increase nutrition, but the nurse should first assess the impact of the problem. Over-the-counter supplements are expensive, and the nurse should suggest the client try malts, milkshakes, and fortified soups. Then, if the client does not like or gets tired of the taste, a family member can consume the food and it is not wasted. 4. Checking the client's weight change over a period of time is the first step in assessing the client's nutritional status and the impact of the taste changes on the client.

The home health (HH) care agency director is teaching a class to the HH aides concerning safety in HH nursing. Which statement by the HH aide indicates the director needs to re-teach safety information? 1. "It is all right to call the agency if I am afraid of going into the home." 2. "I should wear my uniform and name tag when I go into the home." 3. "I must take my cellular phone when visiting the client's home." 4. "It is all right if I don't wear gloves when touching bodily fluids."

Correct answer: 4 1. If the HH aide is fearful for any reason, the HH aide should not go into the home and should notify the agency. The employee's safety is important. This statement does not require re-teaching. 2. For safety purposes, the HH aide should be clearly identified when entering the client's neighborhood and home. This statement does not require re-teaching. 3. The HH aide should be able to contact the HH nurse or agency about any potential or actual concerns. This is for the safety of the client as well as the employee. This statement does not require re-teaching. 4. Standard precautions apply in the home as in the hospital. If the HH aide has the potential to touch the client's bodily fluids, then the aide should wear gloves and wash his or her hands. The statement indicates the HH aide needs re-teaching.

The client tells the nurse, "I am not sure my surgeon is telling me the truth about my prognosis." The nurse knows the client has terminal cancer, but the healthcare provider is not telling the client per the family's request. Which statement is the nurse's best response? 1. "I think you should know you have terminal cancer." 2. "You do have a right to a second opinion." 3. "You are concerned your surgeon is not telling you the truth." 4. "I think you should talk to your surgeon about your concerns."

Correct answer: 4 1. If the nurse tells the client the truth at this time, the client may ask, "What happens now? How long do I have to live?" In this situation, the nurse should not tell the client the truth. 2. The client does have a right to a second opinion but in this situation the nurse should encourage the client to talk to the surgeon. 3. This is a therapeutic response that encourages the client to ventilate his or her feelings, but the client needs answers. This is not the best response by the nurse. 4. Since the nurse knows the client is terminal, it would be best for the nurse to encourage the client to talk to the surgeon. The client needs the truth and the surgeon is the person who should tell it to the client.

The female home health (HH) aide calls the office and reports pain after feeling a pulling sensation in her back when she was transferring the client from the bed to the wheelchair. Which priority action should the HH nurse tell the HH aide? 1. Explain how to perform isometric exercises. 2. Instruct her to go to the local emergency room. 3. Tell her to complete an occurrence report. 4. Recommend that she apply an ice pack to the back.

Correct answer: 4 1. Isometric exercises such as weight lifting increase muscle mass. The HH nurse should not instruct the HH aide to do this type of exercises. 2. The HH aide may go to the emergency department, but the HH nurse should address the aide's back pain. Many times, the person with back pain does not need to be seen in the emergency room. 3. An occurrence report explaining the situation is important documentation and should be completed. It provides the staff member with the required documentation to begin a workers' compensation case for payment of medical bills. However, the HH nurse on the phone should help decrease the HH aide's pain, not worry about paperwork. 4. The HH aide is in pain, and applying ice to the back will help decrease pain and inflammation. The HH nurse should be concerned about a co-worker's pain. Remember: Ice for acute pain and heat for chronic pain.

The client diagnosed with lung cancer has a hemoglobin and hematocrit (H&H) of 13.4 mg/dL and 40.1, a WBC count of 7800, and a neutrophil count of 62%. Which action should the nurse implement? 1. Place the client in reverse isolation. 2. Notify the HCP. 3. Make sure no flowers are taken into the room. 4. Continue to monitor the client.

Correct answer: 4 1. The client's lab work does not indicate an increased risk for infection. The client does not need to be placed in reverse isolation. 2. The lab work is within normal limits. The nurse does not need to notify the HCP. 3. The client is not at an increased risk for infection; therefore, the client may have flowers in the room. 4. This client's lab work is within normal limits. The nurse should continue to monitor the client.

The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? 1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse. 2. Write up a counseling record with objective data and give it to the manager. 3. Complete the delegated tasks and do nothing about the insubordination. 4. Address the UAP to discuss why the tasks are not being done as requested.

Correct answer: 4 1. The graduate nurse should handle the situation directly with the UAP first before notifying the charge nurse. 2. This may need to be completed, but not prior to directly discussing the behavior with the UAP. 3. The graduate nurse must address the insubordination with the UAP, not just complete the tasks that are the responsibility of the UAP. 4. The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks.

The clinic nurse administered 200,000 units of intramuscular penicillin to a client. Which priority intervention should the nurse implement? 1. Place a bandage over the intramuscular injection site. 2. Tell the client to put a warm compress over the injection site. 3. Document the medication injection in the client's chart. 4. Inform the client to stay in the waiting room for 30 minutes.

Correct answer: 4 1. The nurse can or cannot place a bandage over the injection site. This is not a priority intervention. 2. Warm compresses will help increase the absorption of the medication, but this is not the priority nursing intervention. 3. The medication injection must be documented in the client's chart in a clinic, just as it must be in an acute care area, but documentation is not priority over a possible life-threatening allergic reaction. 4. The client is at risk for having an allergic reaction to the penicillin, which is a life- threatening complication. Therefore, the client must stay in the waiting room for at least 30 minutes so the nurse can determine whether an allergic reaction is occurring.