Uworld Leadership

What is a normal carboxyhemoglobin for nonsmokers?

<5%

What are the five rights of delegation?

A. Right task B. Right circumstance C. Right person D. Right direction or communication E. Right supervision

The office nurse receives 4 telephone messages. Which client should the nurse call back first? -28 year old female client who fell on ice yesterday and has low back pain and spasm -42 year old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights -65 year old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F - 70 year old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

- 70 year old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back --an abdominal aortic aneurysm is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include male sex, age > 65, coronary artery and peripheral vascular diseases, hypertension, and family and smoking hx. AAA dissection or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock. This client's symptoms could indicate impending rupture, which can lead to life-threatening vascular hemorrhage. --Client 3's fever and pain can be associated with a postoperative infection within the bone and surrounding tissue. Although diagnosis and treatment with prescribed antibiotics are crucial to prevent sepsis, it is not as critical as a potential massive hemorrhage.

It is the first day on the job for the newly hired UAP. Which of the following illustrate appropriate delegation instructions for the RN to give the UAP? SATA -"Elevate the right leg on two pillows" -"Measure client for compression stockings" -"Please let me know what the urine looks like" -"Tell me what the client eats at lunch" -"Verify wrist restraints are on correctly"

-"Elevate the right leg on two pillows" -"Tell me what the client eats at lunch" --Assign a new UAP specific tasks that do not require specialized knowledge or skills. The UAP can gather data, but should not be asked to assess/analyze/evaluate or measure client for compression devices. --telling the UAP to let the RN know what the urine looks like is an assessment that the RN should perform. However, the RN is allowed to ask for specific data, such as the amount or if there is a presence of blood clots.

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an appropriate understanding of the study and reason for participation? -"I changed my mind, but once in you're stuck" -"I hope others will be helped through my involvement" -"I know I will get new medication by being in this study" -"If I don't participate, my healthcare provider will be upset"

-"I hope others will be helped through my involvement" --Research with human subjects is reviewed by institutional research boards to ensure ethical principles are followed. The research participant cannot be deceived and must participate voluntarily knowing the risks and purpose of the study; confidentiality must be maintained. Clients in research studies often have altruistic motives. They know they may achieve no personal gain, but others could benefit from their participation. All clients should receive safe, quality care whether they participate in the study or not. Due to randomization, the client has no guarantee of receiving a medication that is more effective rather than the placebo. This misconception should be clarified.

Client call lights come on while the UAP sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients". What is the best response by the nurse? -"Would you mind answering the lights anyways?" -"I need you to answer the lights because we want to provide good client care" -say nothing and answer the lights, but write up a disciplinary action -tell the UAP that this is unacceptable and speak to the nurse manager

-"I need you to answer the lights because we want to provide good client care" --the nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats and should not avoid the issue by just performing the action itself.

A client with a 10 year hx of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on the EKG have lengthened, increased arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? -"I will ask the HCP to come take with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems" -"I will take with the HCP about your concerns, but in the meantime, it's important that you stay here" -"It's important that you stay in the hospital so that we can treat you quickly if you have problems" -"You have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now"

-"I will ask the HCP to come take with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems" --This client, who has a decade of experience taking methadone for chronic pain, is afraid that suddenly stopping this medication may precipitate withdrawal. The client is trying to regain control and avoid this problem by leaving the hospital against medical advice. However, the client remains at risk of life-threatening arrhythmias. Therefore, the nurse should promote negotiation between the client and HCP to develop a plan of care that will address the concerns of each. The plan should advocate for the client to ensure that the concerns are addressed.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A healthcare provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? -"I don't know because I am off duty right now" -"Let's step away from the crowd to discuss it" -"Mrs. Jones was fine when I last checked on her during rounds" -"You will have to talk with the nurse caring for her while I am on break"

-"Let's step away from the crowd to discuss it" --The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privleged healthcare information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately. It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information

While delegating to the UAP, the RN should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? -"I need for you to take vital signs on all clients in rooms 1-10 this morning" -"Mr Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100" -"Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift" -"Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

-"Mr Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100" -The RN should communicate directions to the delegate that include any unique client requirements and characteristics as well as clear expectations on what to do, what to report, and when to ask for assistance. The time frame for option one should be more specific. The instruction in option two to "keep a close eye" on the client leaves the UAP too much room for interpretation. Instructions in option 4 are too broad and do not provide a specific time frame, as well and lacks the method needed to accomplish the task.

The RN is caring for a postoperative client with a Hemovac drain. Which task is inappropriate for the RN to ask the experienced UAP to perform? -"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client" -"Please measure the Hemovac drainage at 2:00 PM and let me know how much there was" -"Please record the amount of the Hemovac drainage on the intake and output record at the end of the shift" -"Please remember to compress the Hemovac device immediately after emptying to restore negative pressure, as you were taught"

-"Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client" --Although the UAP can perform procedures that require observing principles of infection control and transmission of microorganisms, the UAP should not change sterile dressings or perform drain care. That is the responsibility of the RN.

Examples of Aminoglycosides

-"mycin" -gentamicin -tobramycin -amikacin

Examples of ACE inhibitors

-"pril" -lisinopril -ramipril

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by UAP would require the nurse to intervene? SATA -1 UAP repositioning a client who is 8 hours postoperative total hip replacement - 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair - 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours -2 UAPs using the log-rolling technique to move a client with a cervical collar -3 UAPs using a draw sheet to move a client who weighs 220 lbs up in bed

-1 UAP repositioning a client who is 8 hours postoperative total hip replacement -2 UAPs using the log-rolling technique to move a client with a cervical collar --The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required.

The nurse in the ED receives report on 4 clients. Which client should be seen first? -5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min -7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min -10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F -14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F

-14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F --Heatstroke occurs when excessive environmental heat exposure and/or overexertion cause hyperthermia and depletion of fluid and electrolytes, specifically sodium. Eventually, hypothalamic thermoregulation fails and sweating production stops, causing a rapid elevation of core temperature. Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia. Treatment involves stabilization of ABCs and rapid cooling interventions. Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process.

The nurse assesses 4 clients in the ED. Which client should the nurse prioritize first? -12-year-old with right lower quadrant abdominal pain that started in the periumbilical region -14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left -16-year-old with sickle cell disease who has excruciating generalized body pain -34-year-old with sudden-onset, right-sided flank pain radiating to the right groin

-14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left --Testicular torsion is an emergency condition in which blood flow to the testis has stopped. The testicle rotates and twists the spermatic cord, inititally causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated, generally 4-6 hours, making this condition a priority. --right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. surgery is usually required within 24 hours. This client should receive prompt attention, but is not priority. Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids, but is not priority. Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidneys stones are very painful, but in most cases, cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion

The nurse receives report on 4 clients. Which client should be seen first? -10-month-old with audible congestion and mucus-producing cough -10-year-old with an active nose bleed who is applying pressure -12-year-old with urinary frequency and burning, and fever -15-year-old with painful right hip, fever, and limited range of motion

-15-year-old with painful right hip, fever, and limited range of motion --This client is exhibiting localized and systemic infection symptoms, which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection. A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis from compromised blood supply due to infection or injury. This can result in sequelae that are significant in both the short term and long term. Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? -17 year old with suspected meningococcal meningitis who has a fever of 103 F, HA with photophobia, and stiff neck -36 year old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F, and foul-smelling drainage from self-injection sites -45 year old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F and a serum glucose of 295 mg/dL -76 year old with chronic bronchitis who has a fever of 101 F and a productive cough of thick green mucus

-17 year old with suspected meningococcal meningitis who has a fever of 103 F, HA with photophobia, and stiff neck --Characteristics of meningococcal meningitis include fever, HA, nuchal ridigity, photophobia, N/V, and changes in mental status. If any of these are present, prompt testing and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency.

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? SATA -2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection -2 clients with C diff, one in the stool and the other in a wound -a client in sickle cell disease crisis and a client with streptococcal pneumonia -a client who had abdominal surgery today and a client with universal precautions -a young client in Buck's traction with an elderly client with Parkinson's disease

-2 clients with C diff, one in the stool and the other in a wound -a client who had abdominal surgery today and a client with universal precautions -a young client in Buck's traction with an elderly client with Parkinson's disease --when clients must be housed together in less than idea circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client. Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious.

The nurse is triaging clients from the waiting room. The care of which client is a priority? -2 year old who ingested a button battery approximately 30 minutes ago and is asymptomatic -4 year old who started crying and suddenly wont use the left arm after being swung by the arms -child with cerebral palsy and a baclofen pump who has increased muscular spasms -child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball

-2 year old who ingested a button battery approximately 30 minutes ago and is asymptomatic --foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. --osteogenesis imperfecta is a condition in which bones are brittle and fracture easily. Head trauma indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, meaning that bleeding is unlikely, but still requires evaluation at some point.

Which client in the ED should the nurse see first? -2 year old with fever and sore throat who is restless and drooling -6 year old with appendicitis who has right lower quadrant pain and vomiting -9 year old with immune thrombocytopenia who has generalized petechiae -17 year old with cystic fibrosis who is coughing up thick, blood-tinged sputum

-2 year old with fever and sore throat who is restless and drooling --Acute epiglottitis is a life-threatening emergency due to possible airway obstruction from severe swelling of the epiglottis. Symptoms include fever, sore throat, stridor, drooling, restlessness, and tripod positions. The nurse should prepare to assist with emergent endotracheal intubation. --if left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction is more critical.

Four clients enter the ED at the same time. Which should the triage nurse first see? -25 year old client with sudden-onset chest pain and heart rate of 110/min -45 year old client with type 2 diabetes who is traveling and has lost insulin glargine -60 year old client with pain, swelling, erythema, and warmth in the right leg -70 year old client with left lower abdominal pain and diarrhea for 2 days

-25 year old client with sudden-onset chest pain and heart rate of 110/min --An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by the HCP before the other 3 clients. --The client with pain, swelling ,erythema, and warmth in the right leg may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen.

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? -26 year old with splenectomy reports a HA and chills -40 year old with immune thrombocytopenia purpura has petechiae on the arms -60 year old with marked anemia reports SOA when ambulating -68 year old with polycythemia vera has a hematocrit of 66%

-26 year old with splenectomy reports a HA and chills --the spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections. Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or HA needs immediate intervention. --ITP is an autoimmune condition in which clients have abnormal platelet destruction with a count of <150,000/mm3. ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of RBCs and is expected.

The student nurse completes a clinical rotation in the ED. The instructor knows the student is able to prioritize care appropriately when the student visits which client first? -9-year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer -29-year-old with neck swelling and increased pain 2 days after thyroidectomy -43-year-old with blood glucose of 423 mg/dL, dehydration, and trace ketones in urine -72-year-old who is incontinent with acute altered mental status and is yelling at staff

-29-year-old with neck swelling and increased pain 2 days after thyroidectomy --Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation. These complications have a high priority due to potential inference with airway patency. The nurse should assess for S/S of airway compromise and suction equipment should be available to clear the airway of secretions, and a trachestomy tray should be at the bedside in case an emergency trach is required. --acute altered mental status in an elderly client may indicate infection. Diagnostic testing to identify the source of the altered mental status; however, airway complications and circulatory compromise have a higher priority. This client should be seen third.

The nurse receives report on 4 pediatric clients in the ED. Which client should be seen first? -3 week old with fever who is sleeping more than usual and refuses to feed -4 month old who has painless, new-onset, bilateral testicular swelling -8 month old who ingested a bottle of children's bubble soap 30 minutes ago -2 year old with fever, runny nose, cough, and sore throat for the past 2 days

-3 week old with fever who is sleeping more than usual and refuses to feed --sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started. --the 4 month old has signs of hydrocele, a fluid-filled testicular mass. Most hydroceles resolve before the first birthday and are not a medical emergency. Children's bubble soap is non-toxic and is not a priority. The 2 year old likely has an upper respiratory viral or bacterial infection. This localized infection is not a priority over generalized/bloodstream infection

Multiple clients present to the ED. Which client should the triage nurse prioritize for diagnostic testing and definitive care? -26-year-old IV drug user reporting fever and right arm redness and swelling -32-year-old kidney transplant reporting low-grade fever and generalized body pains -69-year-old with diverticulosis reporting left lower quadrant pain and fever -74-year-old with right knee replacement reporting fever and right knee swelling

-32-year-old kidney transplant reporting low-grade fever and generalized body pains --The kidney transplant client is likely immunosuppressed by steroids and anti-rejection drugs. In general, organ transplant clients will have a blunted response to infection, such as a low-grade fever. This client has systemic symptoms, which may indicate a serious underlying infection. Some of these clients develop fulminant sepsis within a few hours if the antibiotics are delayed. As a whole, management of systemic S/S takes priority over that of localized S/S

The nurse is making rounds on a medical-surgical floor. Which client should the nurse see first? -32 year old admitted for opioid withdrawal reporting severe generalized body pains -34 year old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain -42 year old admitted with acute pyelonephritis who needs a first dose of IV antibiotics -67 year old admitted with hepatic encephalopathy who needs a first dose of lactulose

-34 year old started on blood transfusion 10 minutes ago who reports chills, itching, and back pain --acute transfusion reaction is a priority as it can be life-threatening if not immediately stopped and supportive care initiated. If untreated, hypotension, vascular collapse, respiratory distress, and DIC ensue quickly.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires and immediate call back? -28 year old woman is requesting antibiotic to be called to pharmacy due to another bladder infection -55 year old man who takes trazodone is reporting a painful erection of 3 hours duration -78 year old man with sinusitis who takes pseudoephedrine is having difficulty voiding -84 year old man with prostate cancer and spine metastasis is requesting increased pain medication

-55 year old man who takes trazodone is reporting a painful erection of 3 hours duration --priapism is a prolonged, painful erection caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications or a preexisting medical condition. The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the ED.

The nurse receives report on 4 clients. Which client conditions require priority assessment? -34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations -54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain -64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea -70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg

-64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea --Clients who are bedridden, have undergone major surgery, or are taking estrogen-containing contraceptive pills are at high risk of developing DVT's. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot.

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? -28 year old with infective endocarditis and heart rate of 105/min -45 year old with acute pancreatitis and sinus tachycardia of 120/min -65 year old with tachycardia of 110/min after liver biopsy -74 year old on diltiazem drip with atrial fibrillation and heart rate of 115/min

-65 year old with tachycardia of 110/min after liver biopsy --the liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. --tachycardia can be caused by underlying infection and can resolve with the treatment of endocarditis. Pancreatitis is a very painful condition and sinus tachycardia is expected. Atrial fibrillation is commonly treated with CCB such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min, but is not life-threatening.

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? -22 year old with sickle cell anemia admitted for acute pain crisis -26 year old with pneumonia reporting sharp right side chest pain on deep inspiration -55 year old who is 1 day postoperative bowel resection reporting pain at the incision site -67 year old with obstructive sleep apnea reporting pain at the fractured right tibia

-67 year old with obstructive sleep apnea reporting pain at the fractured right tibia --Obstructive sleep apnea is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea and hypopnea, resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure is very important in these clients, especially during sleep. The nurse should assess LOC, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours. --the 22 year old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior use. The nurse needs to assess the pain and any complications from narcotic use, but is not priority.

The office nurse receives 4 telephone messages. Which client should the nurse call back first? -32 year old woman with a temperature of 100.4 F who reports feeling achy following a flu shot yesterday -50 year old man who reports right shoulder pain and difficulty raising the arm above the head after playing baseball 3 days ago -68 year old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday -72 year old woman with urge incontinence who started taking solifenacin 2 days ago and reports constipation and very dry mouth

-68 year old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday --older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing, substernal type of chest pain. These symptoms include atypical pain, SOA, indigestion, nausea, dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to gather more information. The symptoms can indicate a cardiac medical emergency that requires immediate evaluation and intervention. --Solifenacin is a cholinergic antagonist prescribed to treat symptoms associated with an overactive bladder. Common expected adverse effects include dry mouth and constipation.

The nurse in the pediatric client is triaging telephone messages. The nurse should call the parent of which child first? -2 year old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear -4 year old post adenotonsillectomy who is now reporting ear pain -6 year old with strep throat who needs a note to return to school 24 hours after starting antibiotics -7 year old 5 days post tonsillectomy who wants to return to soccer practice today

-7 year old 5 days post tonsillectomy who wants to return to soccer practice today --This child is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon, but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding. --Clients often report ear pain following adenotonsillectomy due to irritation of the 9th cranial nerve in the throat, causing referred pain to the ears. This is a normal finding.

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in ED admissions. Which client would the nurse assess first? -55 year old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident -45 year old with type 1 diabetes mellitus with a blood glucose of 690 mg/dL complaining of abdominal pain and fatigue -7 year old with status asthmaticus and an oxygen saturation of 89% -34 year old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days

-7 year old with status asthmaticus and an oxygen saturation of 89% --The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation indicates mild-to-moderate status asthmaticus. -the clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, this client is second in priority.

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the ER. The nurse suggests the transfer of which client to the HCP? -52 year old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels -60 year old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem -65 year old admitted last night for third-degree heart block who is awaiting permanent pacemaker placement -78 year old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

-78 year old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care --Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any healthcare setting.

The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the HCP? -36 year old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg -56 year old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up -60 year old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL, and reports nausea and itching -82 year old client with a pressure injury who has a change in mental status, temperature of 96.4, pulse of 110/min, and blood pressure of 96/72 mm Hg

-82 year old client with a pressure injury who has a change in mental status, temperature of 96.4, pulse of 110/min, and blood pressure of 96/72 mm Hg --sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (pressure injury) that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response. Because of altered immune function, older adults often do not develop typical signs of infection. Instead, nurses must observe for and immediately report atypical indicators of infection (altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality. -chronic use of central nervous system depressants (alcohol) causes a reflexive increase in catecholamine production (epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. Clients with stable angina often experience orthostatic hypotension, an adverse effect of nitrate drugs. Clients with CKD commonly experience nausea and pruritus due to buildup of nitrogenous wastes in blood. Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis.

What is the scope of practice for a UAP?

-Activities of daily living -hygiene -linen change -routine, stable vital signs -documenting input/output -positioning

The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? -client 1 week postoperative appendectomy who has not had a bowel movement in 4 days -Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating -client postoperative right BTK amputation who is concerned about a new tingling sensation in the right foot -client with a temp of 101.2 who is scheduled for a shoulder arthroplasty the next morning

-Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating --N/V, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection/tissue necrosis. It is urgent and potentially life-threatening --active infection is a relative contraindication for elective surgical procedures and this client should be called back for assessment and likely rescheduling of the surgery, but is not priority over a client with bowel obstruction.

The nurse in a women's health clinic is returning client phone calls. Which client would be the priority to call first? -client 4 days post cesarean delivery who has not had a bowel movement since surgery -client who gave birth vaginally a few days ago who states, "They want to hurt my baby" -Client who gave birth vaginally recently who states, "I think I am experiencing incontinence" -client's spouse who is concerned that the client wants to sleep instead of care for the baby

-Client who gave birth vaginally recently who states, "I think I am experiencing incontinence" --Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications. Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby. Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby. --post-surgical constipation is caused by narcotic and anesthetic administration, decreased ambulation, and manipulation of the bowels during surgery. Fluids, fiber, ambulation, and stool softeners should be encouraged. --Urinary incontinence can occur after vaginal birth due to neuromuscular trauma and can improve with pelvic floor exercises.

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the HCP immediately? -client newly diagnosed with Hodgkin Lymphoma scheduled for chemotherapy who has a fever of 100.9 and white blood cell count of 6,000/mm3 -client with acute cholecystitis scheduled for laparoscopic surgery wo has a fever of 102 F and white blood cell count of 13,000/mm3 -client with C. diff infection receiving metronidazole who has a fever of 101 F and white blood cell count of 18,000/mm3 -Client with colon cancer receiving chemotherapy who has a fever of 100.4 F and white blood cell count of 1,500/mm3

-Client with colon cancer receiving chemotherapy who has a fever of 100.4 F and white blood cell count of 1,500/mm3 --A common adverse effect of chemotherapy is bone marrow suppression and immunosuppression. A decreased neutrophil count, termed neutropenia, increases the client's susceptibility to infection. A fever can signal an infection and, in the presence of neutropenia, can rapidly develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients. --Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. The client's white blood cell count is within normal limits --acute cholecystitis involves inflammation of the gallbladder. Expected manifestations include right upper quadrant pain that can radiate to the right shoulder, N/V, fever, and leukocytosis. The client is scheduled for surgery and is likely on antibiotics. --C. diff is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. expected manifestations include diarrhea, fever, and leukocytosis. Frist-line pharmacologic treatment includes metronidazole (Flagyl) and oral vancomycin.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? -did the study have institutional review board approval? -Do the characteristics of the sample population match those of the nurse's unit? -What are the credentials of the study's researcher? -What was the financial support provided for the study?

-Do the characteristics of the sample population match those of the nurse's unit? --When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for adult clients with terminal cancer might not translate effectively or safely to those clients. Other aspects of the study to evaluate include whether all clinically relevant outcomes were addressed, if the benefits outweigh any potential harm or costs, and if the protocol resulted in improved care.

The nurse cares for a group of clients in the medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? -post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 -post open reduction of the right femur, reporting nausea -Type 1 diabetes mellitus with a blood glucose of 55 mg/dL -Type 2 diabetes mellitus with a blood glucose of 250 mg/dL

-Type 1 diabetes mellitus with a blood glucose of 55 mg/dL --hypoglycemia is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones are then released and the ANS is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

Which pediatric presentation in the ER should the nurse follow up for possible abuse and mandatory reporting? -a 2 month old who rolled off the changing table and is now lethargic -a 3 month old with flat bluish discoloration on the buttock that the mother says has been present since birth -a 3 year old with forehead bruises that the mother says come from running into a table -a 4 year old who pulled boiling water off the stove and has splattered burns on the arms

-a 2 month old who rolled off the changing table and is now lethargic --infants do not start rolling until 4 months of age and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. -congenital dermal melanocytosis are an expected finding. These are seen on the lower back and/or buttock more often in AA, Asian, Hispanic, and NA infants.

Four children are brought to the ED. Which child should be assessed first? -a 13-month old who ingested an unknown quantity of children's multivitamins -a 15-month-old with a fever of 100.5 F after being vaccinated -a 3-year-old with a forehead laceration and colorless nasal drainage -a 4-year-old with enlarged lymph nodes who is crying in pain

-a 3-year-old with a forehead laceration and colorless nasal drainage --Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for CSF leakage. When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in LOC and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics.

The nurse receives a report on 4 clients. Which client should the nurse assess first? -a 29 year old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless -a 34 year old admitted with femur fracture 24 hours ago is confused and has Sp02 of 91% -a 65 year old admitted with serum sodium of 125 mEq/L 8 hours ago is confused -a 78 year old admitted for UTI 6 hours ago is disoriented to time and place

-a 34 year old admitted with femur fracture 24 hours ago is confused and has Sp02 of 91% --Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. Respiratory distress, mental status changes, and petechiae are the classic manifestations. --Moderate hyponatremia can cause altered mental status and can lead to seizures if it becomes severe. This client needs treatment and should be the second priority.

The nursing team consists of a RN, a LPN, and 2 UAPs. The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? -a 1 day old with tracheoesophageal fistula scheduled for surgical repair today -a 6 month old who had diaphragmatic hernia repair 5 days ago -a 12 ear old newly admitted with productive cough and white blood cell count of 15,000/mm3 -a 16 year old admitted for uncontrolled diabetes experiencing Kussmaul breathing

-a 6 month old who had diaphragmatic hernia repair 5 days ago --the RN should delegate stable clients with expected outcome to the LPN. The RN cannot delegate any techniques or procedures that involve evaluation, teaching, or assessment methods.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? -a 1-day post tubal myringotomy client with purulent tympanic drainage -a 4-day post valve replacement client with a temperature of 102 F and petechiae -a 10-day old client with a patent ductus arteriosus who has a continuous murmur -a 6-year old client with epiglottitis who is drooling and has a severe sore throat

-a 6-year old client with epiglottitis who is drooling and has a severe sore throat --Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenza type b was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 D's: drooling, dysphonia, dysphagia, and distressed airway. Children are typically toxic-appearing and may be tripoding with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress.

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? -a 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." -A client's child says, "My parent has been here for 2 days without anything to eat or drink." -A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." -A postoperative client says, "I am very nauseous and just thew up. This pain medicine is making me really sick."

-a 65 year old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." --Celecoxib, a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing would be warranted.

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? -25 year old client with multiple sclerosis who had bladder incontinence last night -a 37 year old client with Gullain-Barre syndrome who has "0" deep tendon patellar reflexes -a 58 year old client with Parkinson disease who is drooling -a 78 year old client with dementia who has new-onset agitation and confusion

-a 78 year old client with dementia who has new-onset agitation and confusion --new-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. --drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings of Parkinson disease. This loss of autonomic movements results from alterations of the basal ganglia and extrapyradmidal portion of the central nervous system.

The RN is discussing care of shared clients with LPN. Which of the following clients require intervention by the RN? SATA -a client receiving a blood transfusion who reports severe anxiety and has a blood pressure 90/60 mm Hg and pulse 110/min -a client receiving oral metoprolol whose heart rate has decreased to 60/min after administration -a client whose blood pressure decreased from 130/8- mm Hg to 110/70 mm Hg following administration of 1 mg hydromorphone IV -a client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered -a client whose pulse increased from 70/min to 100/min after albuterol administration

-a client receiving a blood transfusion who reports severe anxiety and has a blood pressure 90/60 mm Hg and pulse 110/min -a client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered --Nurses caring for clients receiving blood products should immediately intervene upon signs of transfusion reaction (anxiety, hypotension, tachycardia). Clients should be monitored for hemodynamic instability if blood pressure medications are administered during hypotension. Opioids may cause decreased blood pressure due to histamine release.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revisiting the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see first? SATA -a client who fell and hit the head but refuses to go to the ED -a client who is due for a maintenance dose of cyanocobalamin -a client who needs pre-filled insulin syringes -a client who was discharged from the hospital yesterday after heart failure treatment -a client with a stage 3 pressure injury in need of a dressing change

-a client who fell and hit the head but refuses to go to the ED -a client who needs pre-filled insulin syringes -a client with a stage 3 pressure injury in need of a dressing change --in this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and tis should not be postponed.

The charge nurse on a telemetry unit is training a new RN. The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? -a client in atrial fibrillation with an INR of 4.0 who has a warfarin dose due -a client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F, and has a dose of vancomycin due -a client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due -a client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

-a client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due --Ventricular bigeminy is a rhythm in which every other heartbeat is a PVC. PVC's in the presence of a MI indicate ventricular irritability and increase the risk for a more serious dysrhythmia. Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the HCP. --the client with AF should be seen after the MI client. Vital signs are stable, but the INR should be lower (normal 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held.

Four clients comes to the ED simultaneously. Which client should the nurse see first for definitive care? -6 month old with temperature of 101 F who is rubbing the ears and being fussy -10 day old client with a red mark on the neck, the mother is concerned -a client who took a handful of amitriptyline pills, a tricyclic antidepressant drug -a client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin

-a client who took a handful of amitriptyline pills, a tricyclic antidepressant drug --A client with a drug overdose is the highest priority as the actual amount taken and its effects are unknown. In addition, clients who deliberately OD often consume other substances that can potentiate the effect of the drug. OD is especially concerning for a TCA due to the effect this can have on the cardiovascular and central nervous systems. TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed-wetting. --a client with head trauma who is currently on an anticoagulant could have potential intracranial bleeding and should be treated next.

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first? -a client who underwent a colon resection 3 hours ago and is bleeding -a client who was rescued from a burning building and shows evidence of smoke inhalation -a client with gastroenteritis who is throwing up large amounts of vomit -a client with peritonitis who has pain level of "8" on a scale from 1-10

-a client who was rescued from a burning building and shows evidence of smoke inhalation --Smoke inhalation is the leading cause of death in burn clients as it causes thermal injury to the upper airways, chemical injury to the tracheobronchial tree, and carbon monoxide and/or cyanide poisoning. Clients should receive 100% oxygen to displace carbon monoxide and cyanide from hemoglobin. Intubation is indicated if there is evidence of upper airway edema with respiratory distress. An obstructed airway can lead to cardiac arrest if not treated immediately.

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the LPN? -a client experiencing Addisonian crisis with a prescription for hydrocortisone -a client with Cushing syndrome who needs intermittent urinary catheterization -a client with DKA on insulin IV infusion -A client with thyrotoxicosis and new onset atrial fibrillation

-a client with Cushing syndrome who needs intermittent urinary catheterization --The charge nurse should assign the most stable clients to the LPN

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? SATA -a client diagnosed with varicella and a client with pertussis -a client placed in an airborne infection isolation room and a client with heart failure -a client receiving chemotherapy and a client with COPD coughing yellow sputum -a client with PID and a client with coffee ground emesis -two clients diagnosed with tuberculosis

-a client with PID and a client with coffee ground emesis -two clients diagnosed with tuberculosis --For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients. -Varicella requires airborne precautions. Pertussis requires droplet precautions. Both precautions and organisms are different, thus the clients could cross-infect each other. An AIIR in indicated when the client has an organisms transmitted by the airborne route. No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation, an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection.

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first? -a client with an ileostomy bag that has leaked stool all over -a client with COPD, diminished breath sounds, and SpO2 of 91% -a client with DVT who missed the last warfarin dose -a client with sepsis who is developing petechiae

-a client with sepsis who is developing petechiae --Clients with sepsis are at risk for developing DIC, a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding, signs of internal bleeding, and respiratory distress.

All of these events are occurring at the same time. Which one should the registered nurse deal with first? -a HCP is asking to speak to the nurse -a visitor is seen lying on the hallway floor -a client is requesting an analgesic for pain rated an "8" on a 1-10 scale -the IV pump is beeping on a client who is receiving blood

-a visitor is seen lying on the hallway floor --the nurse must deal with the visitor on the floor first, either by approaching/assessing the visitor or asking another nurse/charge nurse to deal with it urgently. The visitor could have fallen and hit the head. Responsiveness must be established and the need for any life-saving measures must be ruled out. Visitor status does not matter, this individual is on hospital property and the nurse is obligated to respond. --Although blood transfusions are urgent and the nurse should assess the site/pump, potential life-saving measures take priority.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? -abrupt, tearing, moving back pain and epigastric pain -severe lower back pain after lifting heavy boxes -sharp calf ache with ambulation that improves with rest -unilateral leg swelling with 2+ pitting edema after an airplane trip

-abrupt, tearing, moving back pain and epigastric pain --An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner and middle layers Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever", "tearing", or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. --severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. --this is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain related to exercise that resolves with rest. --This is a description of a DVT resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism, but is not currently life- threatening

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? SATA -acting as a witness that the client signed the consent form voluntarily -documenting in the medical record the date and time the signature was obtained -educating the client if there is a misunderstanding about the procedure -explaining to the client the right to refuse surgery -verifying that the client is competent to provide informed consent

-acting as a witness that the client signed the consent form voluntarily -documenting in the medical record the date and time the signature was obtained -verifying that the client is competent to provide informed consent --The HCP is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternative treatments, and reinforcing that the client has the right to refuse the procedure. The HCP should be contacted if the client does not have the correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect information.

After morning report, the nurse must perform which action first when caring for assigned clients? -administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea -hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL -replace the empty IV opioid medication syringe in a patient-controlled analgesia pump -replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

-administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea --Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea. The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but it is not as urgent as improving gas exchange in the lungs.

The nurse is delegating client care tasks to a LPN and UAP. Which of the following assignments are most appropriate to assign to the LPN? SATA -administer a client's daily dose of subcutaneous insulin glargine -administer a scheduled oral analgesic to a 2 days postoperative client -complete an admission nursing interview for a client admitted for elective hysterectomy -reinforce teaching on self-administration of insulin to a client with diabetes mellitus -tally the shift's intake and outputs for the entire unit

-administer a client's daily dose of subcutaneous insulin glargine -administer a scheduled oral analgesic to a 2 days postoperative client -reinforce teaching on self-administration of insulin to a client with diabetes mellitus --administration of insulin by LPN varies by state legislation

An unaccompanied 16 year old girl comes to the ER with severe abdominal pain and vomiting. The client has a temperature of 102.2 F and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? -administer care unit the parents or guardians can be reached -admit the client but without giving care until the parents or guardians can be reached -perform a pregnancy test to see if the client qualifies as an emancipated minor -provide health care and follow-up advice but do not give any direct care

-administer care unit the parents or guardians can be reached --An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

Which actions by an RN are reportable to the state board of nursing? SATA -administer hydromorphone without a prescription -being habitually tardy to work -documenting an intervention that was not performed -stealing narcotics -walking off duty in the middle of a shift

-administer hydromorphone without a prescription -documenting an intervention that was not performed -stealing narcotics -walking off duty in the middle of a shift --Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia. Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage or neurological impairment. Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance. A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia.

The RN is working with a LPN and UAP. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the RN to assign to the LPN. SATA -administer oral pain medication for the client's chronic lower back pain -assist the client with the use of a urinal post-procedure -monitor for bleeding at the catheter insertion site every 15 minutes -perform the initial post-procedure vital sign measurements -review the ECG monitor for dysrhythmias

-administer oral pain medication for the client's chronic lower back pain -monitor for bleeding at the catheter insertion site every 15 minutes --In the client who has had a percutaneous coronary intervention, after initial assessment and comparison to pre-procedure baseline, the RN may assign the tasks of medication administration, monitoring of neurovascular status of the involved extremity, and checking for bleeding at the catheter insertion site to the LPN.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? -administered flumazenil to a client who overdosed on lorazepam -administered insulin/dextrose to a client with potassium level of 7.2 mEq/L -administered warfarin to a client with INR of 6.0 -initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

-administered warfarin to a client with INR of 6.0 --a sentinel event is any unanticipated event in a health care setting that results in death or serious physical/psychological injury. The target INR for most conditions in which warfarin is used is normally 2-3.

An RN, LPN, and UAP are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? SATA -administering oral pain medication -assessing characteristics of pain -measuring vital signs before and after analgesic administration -monitoring pain level using a numeric scale -providing discharge teaching about pain management

-administering oral pain medication -monitoring pain level using a numeric scale --The RN is responsible for assessing pain characteristics, developing the care plan, evaluating the effectiveness of the care plan, and providing initial and discharge teaching. A LPN may monitor pain level and administer pain medication.

The RN is performing triage at the pediatric emergency department. Which client should be seen first? -child with HX of cystic fibrosis has new yellow sputum and cough today -crying infant with fiery redness and moist papules in the diaper region -grace-school client with swollen ecchymotic ankle after playing basketball -adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min

-adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min --The client with abdominal pain has abnormal vital signs, which is a sign of systemic condition. Adult criteria apply to adolescent clients in terms of physiological S/S.

Which tasks can the registered nurse safely delegate to the UAP? SATA -ambulate an oxygen-dependent client to the bathroom -assist the client with dentures to perform oral suctioning after the client's meal -document pulse oximetry of a client with chronic obstructive pulmonary disease -instruct a client with pneumonia on use of the incentive spirometer -turn and reposition a client with pneumonia

-ambulate an oxygen-dependent client to the bathroom -assist the client with dentures to perform oral suctioning after the client's meal -document pulse oximetry of a client with chronic obstructive pulmonary disease -turn and reposition a client with pneumonia

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first? -a 6 month old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F and injection site redness. -an 11 month old with inconsolable crying and drawing up of the legs toward the abdomen -a 4 year old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply -a 15 year old whose eyes are red and itchy and have a yellow discharge

-an 11 month old with inconsolable crying and drawing up of the legs toward the abdomen --inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-26 months could indicate intussusception or some other abdominal pathology (appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply,. and cause intestinal tears. It is an emergency and the client should be brought to the ED for further evaluation. --mild to moderate fever and local reactions are common after diphtheria, tetanus, acellular pertussis injections. Severe allergic reaction and encephalopathy are the most serious reactions that require priority attention.

Which issue would a unit quality improvement committee address? -a 10% decrease in client satisfaction in the registration process -a nurse who made 3 medication errors in the past quarter -an increase in catheter-associated urinary tract infections -staff perception of hospital laboratory personnel incivility

-an increase in catheter-associated urinary tract infections --A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met.

A male client has terminal metastatic disease. He arrives at the ED with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? -apply oxygen at 2 L by nasal cannula -ask the client if he wants to change his mind -ask the spouse what she wants done -determine who has medical power of attorney

-apply oxygen at 2 L by nasal cannula --Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition/ Oxygen can provide comfort and is not resuscitative when given by nasal cannula.

The unit is staffed with an experienced RN, an experienced LPN, and UAP. Which tasks can the charge nurse appropriately delegate to the UAP? SATA -apply protective skin ointment after perineal cleansing -determine if a client has adequate relief after administration of an analgesic -document daily weight for a client with congestive heart failure -feed a client who had a stroke 24 hours after admission -perform passive range-of-motion exercises for a client on a ventilator

-apply protective skin ointment after perineal cleansing -document daily weight for a client with congestive heart failure -perform passive range-of-motion exercises for a client on a ventilator

A nurse delegates a tasks to the UAP. The UAP states, "I can't do that." Which is the best initial response for the nurse to make? -ask the UAP the reason for the response -do the task, but discuss the UAP's response with the manager -ignore the UAP's initial response and repeat the delegation request -remind the UAP of the importance of teamwork

-ask the UAP the reason for the response --The nurse should first assess in management situations. The UAP may not have the skills or abilities to do the task or the availability if doing something else. The nurse may need to reprioritize the tasks that the UAP has been delegated or provide additional instructions/education. However, finding out the reason for the response is the first step.

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? -administer the correct medication and obtain current vital signs -alert the graduate nurse and complete an incident report -assess the client and notify the HCP -discontinue the dopamine and inform the nursing supervisor

-assess the client and notify the HCP --When a medication error occurs, client safety is priority. The nurse should assess the client immediately for any adverse effects and inform the HCP. Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority and an incident or occurrence report should be filed within 24 hours. --Discontinuing dopamine without providing another medication for hemodynamic stabilization may harm the client. The nursing supervisor should be informed after client stabilization.

The RN is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to the UAP? -apply a collagenase dressing to a client's pressure ulcer for wound debridement -assist a client 1 day postoperative hip fracture repair to the bathroom -feed a client through a gastrostomy tube after elevating the head of the bed -offer orange juice to a client if the blood glucose level is <70 mg/dL

-assist a client 1 day postoperative hip fracture repair to the bathroom

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to UAP? SATA -administer artificial tears if the client reports eye dryness -assist the client to bathe and change the bed linens to maintain client comfort -lower the room temperature and provide cool cloths on request -reinforce to the client that fever is expected with thyrotoxicosis -return a call to the client's family telling them the client's condition is unchanged

-assist the client to bathe and change the bed linens to maintain client comfort -lower the room temperature and provide cool cloths on request

The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the UAP? SATA -assist the client with using the bedpan -check pulses and sensation of extremities -observe skin for signs of impairment -perform ROM exercises -turn and reposition the client in bed

-assist the client with using the bedpan -perform ROM exercises -turn and reposition the client in bed --Nurses may delegate to UAP tasks that relate to basic hygiene; tasks of daily living; measurement and documentation of vital signs; documentation of I & O; and validated technical skills. Activities requiring assessment may be performed only by the nurse

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? -assess for copious secretions to determine exposure -assist the victims farthest from the source first -assist the victims with the most severe symptoms first -monitor for diplopia to determine extent of exposure

-assist the victims farthest from the source first --the key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources.

The RN is working with UAP. Which task can the RN safely delegate to the UAP? -assisting a 2-day postoperative hip arthroplasty client with morning care -collecting a urine specimen for culture and sensitivity from a client with a Foley cath -initial change of colostomy bag for a client who is 1-day postoperative colostomy -refilling the empty enteral feeding container with tube feeding

-assisting a 2-day postoperative hip arthroplasty client with morning care

The RN is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by NC. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the UAP? SATA -assisting the client the bathroom -deciding if supplemental oxygen is necessary when the client is ambulating -documenting vital signs in the EMR -notifying the nurse immediately if the client's respirations exceed 20/min -reapplying the nasal cannula if it accidentally comes off

-assisting the client the bathroom -documenting vital signs in the EMR -notifying the nurse immediately if the client's respirations exceed 20/min -reapplying the nasal cannula if it accidentally comes off

The postpartum nurse receives report on 4 mother-baby couplets. Which tasks can be delegated to UAP? SATA -assisting the mother with morning hygiene -demonstrating neonate bathing technique -documenting intake and output on the monitor -evaluating caregiver interaction with the neonate -obtaining an axillary temperature on the neonate -swaddling the neonate after diaper changes.

-assisting the mother with morning hygiene -documenting intake and output on the monitor -obtaining an axillary temperature on the neonate -swaddling the neonate after diaper changes. --The RN is responsible for any care requiring clinical judgment. UAPs can assist with ADL's, documenting intake and output, positioning, and taking the vital signs of stable clients.

Which client condition is concerning and requires further nursing assessment and intervention? SATA -before liver biopsy, pulse is 80/min and BP is 120/80 mm Hg; 1 hour afterwards, pulse is 112/min and BP is 90/60 mm Hg -before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterwards, pulse is 80/min and BP is 126/82 mm Hg -client with coronary artery disease on metoprolol; pulse is 62/min -elderly client with black stools; pulse is 112/min -neonate crying inconsolably at feeding time; pulse is 160/min

-before liver biopsy, pulse is 80/min and BP is 120/80 mm Hg; 1 hour afterwards, pulse is 112/min and BP is 90/60 mm Hg -elderly client with black stools; pulse is 112/min --The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. --The change in vital signs from preprocedure of lumbar puncture to post-procedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive

The nurse is managing assigned clients on the evening shift. Which client presentation is a priority? -blunt head trauma with projectile vomiting -hx of alzheimer disease with agitation -hx of carpal tunnel syndrome with hand numbness -hx of third cranial nerve pathology with double vision

-blunt head trauma with projectile vomiting --A client with a TBI from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. S/S are similar to those if increased ICP and include change in LOC, projectile vomiting, ataxia, ipsilateral pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated.

The nurse witnessed a signed inform consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? -add the secondary hernia to the consent form that the client signed before the procedure -call the client's medical power of attorney to provide consent for the additional procedure -document that an additional hernia was found and that it will require surgery at a later time -witness an additional consent after both procedures are complete and the client is awake

-call the client's medical power of attorney to provide consent for the additional procedure --the nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients unconscious or under the influence of mind-altering drugs cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent.

A nurse cares for a client on life-support who has been declared brain dead. Which intervention is appropriate at this time? -ask the family members about their plans for the funeral services -call the local organ procurement services representative -discontinue nursing care and provide postmortem care -remove life support as requested by the spouse and family

-call the local organ procurement services representative --local organ procurement services are notified for every client death, per hospital protocol. If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation. Cardiac support continue as organ donation is discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donated due to physiological reasons or the client/family does not consent.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer use in postoperative client. What is the best indicator that the client goal for this process has been met? -chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% -documentation shows that 100% of nurses attended an inservice seminar on the topic -nurses report an increased number of written reminders given to appropriate clients -surgeons who admit to the unit report increased satisfaction with current client IS use

-chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% --The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on personal opinion or staff activities.

A client with end-stage renal disease, oxygen-dependent COPD, and a DNR code status is admitted to the medical floor for COPD exacerbation. The nurse walks in to the room and finds that the client is not breathing. What should the nurse do first? -activate the code system -call the HCP stat -check the apical pulse -check the blood pressure

-check the apical pulse --the nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support.

The nurse practicing on a medical surgical unit cares for a client with type 1 diabetes mellitus. Which action should the nurse delegate to the experienced UAP? -assess the client for S/S of hypoglycemia -check the blood glucose before meals and report it to the primary nurse -teach the client to cut toenails straight across and file with rounded curves of the toes -update the care plan to include client's preference for nighttime diabetic snack

-check the blood glucose before meals and report it to the primary nurse

The nurse in the ED receives 4 clients. Which client should the nurse see first? -child who is confused and irritable and whose parent claims 2 glyburide pills are missing -child with an abscess on the buttock that is red, swollen, and warm to the touch -child with immune thrombocytopenia who fell off a bike and reports shoulder pain -child with low-grade fever, barking cough, and runny nose who has mild retractions

-child who is confused and irritable and whose parent claims 2 glyburide pills are missing --Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if ingested by a client who does not have diabetes, especially a child. Based on the symptoms the child is exhibiting, hypoglycemia is likely. This client requires immediate intervention as severe hypoglycemia can result in coma and/or death. --immune thrombocytopenia can be a serious condition due to the risk for bleeding. A client with this condition should be assessed for internal bleeding following an injury, especially to the head. Shoulder pain is not a symptom associated with life-threatening bleeding, thus the client is not a priority.

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? -clarify the skills/knowledge that the nurse is able/unable to perform -read the policy and procedure book for the unit before providing care -refuse to go due to concerns about client safety -tell the supervisor to send someone else instead

-clarify the skills/knowledge that the nurse is able/unable to perform --When a nurse is asked to care for clients in an unfamiliar population, the duties to be performed and the nurse's limitations in skills or knowledge of specialized care should be clarified. Refusing to go can result in disciplinary action, including termination

An RN, LPN, and UAP are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? SATA -cleaning the skin surrounding the gastrostomy tube stoma -crushing and administering metoprolol through the gastrostomy tube -programming the feeding pump to administer a prescribed bolus feeding -teaching the client about home enteral feeding and gastrostomy tube care -weighing the client using the bed scale

-cleaning the skin surrounding the gastrostomy tube stoma -crushing and administering metoprolol through the gastrostomy tube -programming the feeding pump to administer a prescribed bolus feeding

Which client does the nurse assess first after receiving morning report? -client 1 day postoperative with IV patient-controlled analgesia who reports burning at the IV site -client with a bowel obstruction prescribed continuous nasogastric suction who was admitted yesterday -client with atrial fibrillation and an irregular heart rate of 94/min -client with dementia and C diff who was incontinent of liquid stool

-client 1 day postoperative with IV patient-controlled analgesia who reports burning at the IV site --The nurse assesses the client who reports burning at the PCA IV site first. The analgesia runs through a special PCA administration set that is attached to the PCA pump. It is attached to a running IV line, which is on its own infusion pump, to flush the PCA drug through the IV line each time a dose is administered. If the IV line infiltrates the subcutaneous tissue or the catheter becomes occluded, the PCA drug can back up into the primary tubing each time a dose is administered, resulting in inadequate pain control. In addition, burning can indicate phlebitis, which causes vessel wall injury and can lead to thrombophlebitis.

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the LPN? -client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void -client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections -client who has just been admitted to the telemetry unit from the ED with a rule-out myocardial infarction -client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

-client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void --the charge nurse should assign the most stable and predictable client to the LPN. Clients who are less predictable and stable require clinical assessment and judgment and should be assigned to an RN.

The nurse has just received shift report. Which client should be seen first? -client 1 day post-op abdominal aortic aneurysm repair who has hypoactive bowel sounds in all 4 quadrants -client 2 days post-op BKA who reports same-leg foot pain rated as 7 -client with DVT who is up to use the bathroom for the second time -client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

-client 2 days post-op BKA who reports same-leg foot pain rated as 7 --The client with BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. --Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterwards

The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? -client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour -client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tinging of the hand and fingers -client 8 hours postoperative total knee arhtorplasty who has 2 closed wound suction drains and a total output of 200 mL sanguineous drainage -male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% and hemoglobin of 12.5 g/dL

-client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour --Compartment syndrome results from swelling and increased pressure within a confined space. It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset, irreversible nerve and muscle injury can occur.

The nurse has received report on the following clients. Which client should the nurse assess first? -client 4 hours postop colon resection who has a blood pressure of 90/74 mm Hg -client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea -client with anemia and hemoglobin level of 7 g/dL who has a pulse of 110/min after ambulation -client with diabetic keotacidosis who has rapid, deep respirations at a rate of 32/min

-client 4 hours postop colon resection who has a blood pressure of 90/74 mm Hg --Postop hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. changes in VS can indicate decreased cardiac output and altered tissue perfusion.

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? -client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain -client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing -client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg -client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

-client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg --Nurse should first assess the client showing symptoms of DVT. If a DVT is suspected, early diagnostic testing and treatment with anticoagulant therapy are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism.

The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? -client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching -client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness -client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up -client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

-client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness --The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances, and potential cardiac dysrhythmias. The client is exhibiting manifestation of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias. --a histamine-related reaction is an expected adverse effect associated with the administration of epidural morphine, so this client does not need to be assessed first.

The nurse has just received report. Which client should the nurse assess first? -client admitted from coronary angiography in the past hour with back pain -client with DVT on heparin drip at 1250 units/hr with an aPTT of 60 seconds -client with a head injury and GCS of 14 -postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale

-client admitted from coronary angiography in the past hour with back pain --Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics. The client should also be assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at incision site. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. --A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the HCP during the middle of the night? SATA -client develops right-sided upper and lower extremity drift -client found lying unconscious on the floor -client has order for heparin with surgery planned for the morning -client has serum sodium of 124 mEq/L -client refuses a prescribed, routine pain medication

-client develops right-sided upper and lower extremity drift -client found lying unconscious on the floor -client has order for heparin with surgery planned for the morning -client has serum sodium of 124 mEq/L --The nurse should notify the HCP, regardless of the time, for acute client deterioration, critical lab values, falls, or death. Other reasons include prescription clarification and the client leaving against medical advice or refusing a key treatment.

The nurse has received report on 4 clients at the start of the shift. which client should the nurse assess first? -client in body cast who reports abdominal pain and bloating -client post mastectomy who reports numbness at the surgical site -client post neck dissection who reports difficulty chewing -client receiving antibiotics who reports new-onset vaginal itching

-client in body cast who reports abdominal pain and bloating --clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome. Cast syndrome is a rare complication of an overly tight cast that involves a compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus. If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction. If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure. --antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which present with vaginal discharge and itching. A client reporting this needs to be assessed, but is not priority.

Which client does the nurse assess first after receiving the morning report? -client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now -client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago -client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving -client is 3 days postoperative total knee replacement; waiting to be discharged

-client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving --Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication. --the client trying to leave against medical advice is the second priority. --the nurse must follow-up 30 minutes after morphine is administered.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? -client who had a foot amputation today reporting left shoulder pain radiating down the arm -client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain -client who has multiple myeloma reporting deep pelvic pain after walking down the hall -client who has sickle cell disease reporting severe pain in the arms and upper back

-client who had a foot amputation today reporting left shoulder pain radiating down the arm --Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations other than chest pain during a MI.

The RN prepares to give out client care assignments. Which client is appropriate for the RN to assign to the LPN? -client admitted 3 hours ago with suspected acute pancreatitis -client who had a total right hip replacement 2 days ago -client who had a total thyroidectomy 2 hours ago -client with alcohol withdrawal syndrome

-client who had a total right hip replacement 2 days ago --The LPN should be assigned to clients who are medically stable and have expected outcomes. LPNS should not be assigned to clients who require complex care and clinical judgment and have potential negative outcomes. Teaching, assessment, clinical judgment, and evaluation of a client are the responsibility of the RN and should never be delegated to the LPN.

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? -client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain -client with is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath -client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago -client with a kidney stone who is requesting pain medication for severe flank pain

-client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain --The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for PE. Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. --Client 3-days postoperative right knee surgery likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE.

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? -1 day postoperative client with lower abdominal pain and no urine output for 6 hours -an elderly client with blood pressure 190/88 mm Hg who is asymptomatic -client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase values 4 times the normal value -client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

-client who underwent thyroidectomy yesterday and now has positive Trousseau's sign --Trousseau's sign indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. --Client 1 likely has postoperative urinary retention and needs to be evaluated as soon as possible, but is not life-threatening.

The nurse on the medical unit finishes receiving the change of shift repot at 7:30 AM. Which assigned client should the nurse see first? -client with GI bleed, who is receiving a unit of packed RBCs -client with an ulcerative colitis flare-up has temp of 101 F and abdominal cramping -client with A-fib, on telemetry, prescribed warfarin, with an INR of 3.2 -client with CKD scheduled for bedside hemodialysis at 8 AM, with a serum creatinine of 8.4 mg/dL

-client with GI bleed, who is receiving a unit of packed RBCs --The nurse should first check the client with the GI bleed to check the infusion device; flow rate; and IV site while also collecting baseline physical assessment data and assess for any complications --Secondly, the client with CKD to perform a baseline assessment before dialysis is initiated. The nurse should prepare the client by making sure the client eats breakfast and administer morning medications. --Thirdly, the nurse should assess the client with ulcerative colitis. -Finally, the nurse assesses the client with A-fib. The monitor tech will alert the nurse if there are any dysrhythmias. The goal INR is 2-3 for a-fib, but a 3.2 is expected when adjusting the warfarin dose

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client? -client with multiple myeloma who is being treated with corticosteroids -client with diabetes mellitus and osteomyelitis receiving IV antibiotics -client with a GI bleed who has an NG tube -client with influenza with a high fever who is receiving oseltamivir

-client with a GI bleed who has an NG tube --the most appropriate room assignment is with a client who is least susceptible to infection.

A nurse receives information in a change of shift report. Which client is the priority? -client prescribed levothyroxine to treat hypothyroidism who reports nervousness, sweating, and insomnia -client receives intravenous antibiotics for bacterial pneumonia who reports cough with blood-tinged sputum -client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites -client with chronic pancreatitis who reports upper abdominal pain and voluminous, foul-smelling, fatty stools

-client with a femoral external fixator who has a temperature of 100.9 F and redness and pain around the pin sites --External fixation stabilizes bone by inserting metal pins through skin into the bone and attaching them to a metal rod outside the skin. The nurse should assess this client first as any S/S of an infection warrant immediate evaluation and treatment. Localized pin tract infection can progress to osteomyelitis, a serious bone infection that requires long-term treatment with antibiotics. --the dose of levothyroxine may need to be adjusted as the client is now exhibiting manifestations of hyperthyroidism

The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first? -client with a hx of asthma who reports scoring a peak flow of 45% of personal best -client with a pneumothorax who reports scant, clear drainage from the Heimlich valve -client with active TB reporting dark red orange urine after starting rifampin -client with COPD with an oxygen saturation of 90%

-client with a hx of asthma who reports scoring a peak flow of 45% of personal best --Peak expiratory flow rate is the peak velocity of exhaled air during forced exhalation. Clients with asthma use a peak flow meter to monitor their PEFR and determine their level of asthma control. An optimal PEFR is determined by recording the client's personal best peak flow number during 2 weeks of well-controlled asthma symptoms. Guided by their personal best, clients are taught asthma self-care using peak flow "zones" Green is good and >80%. Yellow requires intervention is is 50-79%. Red zone is bad and requires emergency medical care. Red zone is deemed anything less than 50% of personal best

The nurse receives report on 4 clients. Which client should be seen first? -client with a hx of chronic HTN exhibiting epistaxis and blurred vision -client with a unilateral, pulsating HA reporting sensitivity to light -client with episodes of vomiting and abdominal cramps following a outdoor party -client with multiple sclerosis reporting blurred vision and right arm weakness

-client with a hx of chronic HTN exhibiting epistaxis and blurred vision --Hypertensive encephalopathy is a medical emergency caused by a sudden elevation in blood pressure creating cerebral edema and increased ICP. Triggers of HE include an acute exacerbation of pre-exisintg hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report severe HA, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma. HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a hx of chronic HTN and active signs of increased ICP requires immediate assessment and treatment. --The client with multiple sclerosis may have recurrent exacerbations, including symptoms of blurred vision, focal weakness, and/or sensory abnormalities.

Which client should the nurse assess first after receiving the hand-off morning report? -client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants -client with a peripherally inserted central catheter who has a 5-com increase in external catheter length since yesterday -client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line -client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%

-client with a peripherally inserted central catheter who has a 5-com increase in external catheter length since yesterday --A PICC is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the healthcare provider for x-ray evaluation of catheter tip placement. --after abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. The client with malabsorption syndrome is unable to digest and absorb nutrients by the GI tract. Peripheraly parenteral nutrition with 10% dextrose is expected treatment. Hemoglobin A1C level of 9% is above the recommended level and reflects inadequate glycemic control, which can be expected in a client with diabetes.

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? -client diagnosed with chronic anemia receiving iron via IV route -client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL -client undergoing ultrafiltration for congestive heart failure -client with a prescription for routine hemodialysis who has chronic renal failure

-client with a prescription for routine hemodialysis who has chronic renal failure

The nurse receives report on 4 clients. Which client should the nurse assess first? -client 1 day postoperative receiving PCA with morphine who reports itching and nausea -client receiving maintenance IV NS with labeled tubing indicating that tubing was changed 48 hours ago -client with a pulmonary embolus receiving continuous heparin infusion and warfarin who has an INR of 1.9 -client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

-client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site --Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs, catheter movement within the vein, or bacteria. If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection. --itching and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers and an antiemetic can provide relief. --EBP recommend changing a continuous IV peripheral tubing administration no earlier than every 72 hours unless it becomes contaminated. Intermittent infusion and hypertonic solutions require more frequent changes (4-24 hours). --parenteral and oral anticoagulant medications are administered concurrently until the INR reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued.

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first? -client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm/pink skin -client with a concussion from closed-head injury due to a fall, GCS score of 15, HA, and memory loss -client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light -client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr

-client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light --A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation. Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (HTN, bradycardia, and irregular respirations), ipsilateral pupil dilation, HA, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. --central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality. Treatment is necessary, but polyuria and hypernatremia due to dehydration are expected manifestations.

A nurse working in the office of a HCP receives 4 telephones messages. Which client call should the nurse return first? -client with acute sinusitis prescribed azithromycin 3 days ago now has hives -client with chronic low back pain requests an oxycodone medication prescription refill -client with fever of 100 F has aching and itching at site after getting a flu shot yesterday -client with newly diagnosed asthma has palpitations after using an albuterol rescue inhaler

-client with acute sinusitis prescribed azithromycin 3 days ago now has hives --The first phone call the nurse should return is to the client with acute sinusitis. Hives can be a manifestation of hypersensitivity to the macrolide antibiotic azithromycin. Anaphylaxis is a potential complication, and the drug should be discontinued immediately. Anaphylaxis poses the greatest threat to survival.

After making initial rounds on all the assigned clients by 8AM, which client should the nurse care for first? -client 1 day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago -client 1 day postoperative with pink-colored urine after transurethral resection of the prostate -client scheduled for discharge today who needs instruction on how to change a sterile dressing -client with adenocarcinoma scheduled for a lobectomy at 9 AM who was restless and awake all night

-client with adenocarcinoma scheduled for a lobectomy at 9 AM who was restless and awake all night --Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns, teach the client about what to expect following surgery, and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well. --Tramadol 50-100 mg orally every 4-6 hours is prescribed for moderate-to-severe postoperative pain. The client was medicated 1.5 hours ago. The drug onset is 1 hour, the peak is 2-3 hours, and the duration is 4-6 hours. Therefore, this client is most likely stable at this time and does not need care

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? -client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea -client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min -Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temp of 101 F -Client with dysphagia and a sore throat who has a NG tube to administer contrast media for an abdominal CT scan

-client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min --The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities, and esophageal varices that increase the risk for hemorrhage. Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. --A paralytic ileus is a non-mechanical intestinal obstruction that can occur following abdominal surgery. Expected manifestations include absent or hypoactive bowel sounds due to the lack of bowel motility and peristalsis, and abdominal distension and nausea due to the accumulation of gas and fluids in the bowel.

The nurse receives report on 4 clients. Which client should the nurse assess first? -client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea -client taking ibuprofen for ankylosing spondylitis who reports black-colored stools -client with altered mental status who is not following commands starts vomiting -client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

-client with altered mental status who is not following commands starts vomiting --This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? -client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 and refuses to take prescribed medications -client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain -client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage -client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

-client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting --An inguinal hernia is a protrusion of intraperitoneal contents through a weakened area in the abdominal wall. Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical.

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? -client on chemotherapy who started antibiotics today for cellulitis of the leg -client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours -client with diabetes who has nausea, abdominal pain, and vomiting -client with ulcerative colitis and diarrhea who has developed fever and vomiting

-client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours --a client with acute exacerbation may require treatment in the ER or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids. --clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy is required

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client 1 day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site -client with asthma who reports SOA following an albuterol nebulizer treatment 15 minutes ago -client with COPD exacerbation who is receiving bi-level positive airway pressure therapy and has a pulse oximetry reading of 90% -client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics

-client with asthma who reports SOA following an albuterol nebulizer treatment 15 minutes ago --Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization for one hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation. The nurse should assess the client for wheezing, decreased breath sounds, use of accessory muscles to breathe, capillary refill, respiratory rate, and pulse oximeter reading and pulse. --subcutaneous emphysema is air that leaks into the tissue surrounding the chest tube insertion site. The amount is usually small and reabsorbs spontaneously. The nurse should auscultate for lung sounds, assess for a popping sound, and palpate the site for a crackling sensation, but is not priority.

The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the nurse to report to the HCP? -client with atrial fibrillation receiving warfarin for 7 days with an INR of 1.3 -client with chronic bronchitis who has a hematocrit of 56% and hemoglobin of 10 g/dL -client with C. diff infection who has a white blood cell count of 15,000/mm3 -client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL

-client with atrial fibrillation receiving warfarin for 7 days with an INR of 1.3 --The client with A-fib is at increased risk for the development of atrial thrombi due to blood stasis, which can embolize and lead to an ischemic brain attack. The INR is a measurement used to assess and monitor coagulation status in clients receiving anticoagulation therapy. The therapeutic INR level for a client receiving warfarin to treat A-fib is 2-3. The subtherapeutic INR of 1.3 is the most important result to report as the client is at increased risk for a stroke and dose adjustment is needed.

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? -client with blood pressure of 90/70 mm Hg and deviated trachea -client with concussion who was unconscious for 5 minutes -client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg -client with pain at the thoracic spine and complete paralysis of both legs

-client with blood pressure of 90/70 mm Hg and deviated trachea --tension pneumothorax causes marked compression and shifting of mediastinal structures, including the heart and great vessels, resulting in reduced cardiac output and hypotension, resulting in a life-threatening emergency. The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures. --clients who have a head injury and lose consciousness are at high risk of intracranial injury (bled). This client would likely need a CT scan to assess for further damage, but is not the priority. A grossly swollen upper thigh likely represents a femur fracture with extensive bleeding. It requires intervention, especially IV fluids and surgical correction. However, this is second priority. Thoracic spine pain and leg paralysis likely represent injury to the spinal cord. Precautions such as a hard cervical collar and backboard should be used to prevent further injury. This client requires further testing and treatment, but is not priority.

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? -client with change in level of consciousness who fell in the nursing home -client with chronic headaches who is scheduled for an MRI at 9 AM -client with COPD and pulse oximeter reading of 90% -client with heart failure and 3+ pitting edema of the lower extremities

-client with change in level of consciousness who fell in the nursing home --Change in LOC is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment. This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased ICP.

Which ED client would be allowed to leave against medical advice after the risks are discussed with the primary HCP? -5 year old client with meningitis whose parent refuses antibiotics -client who tried to commit suicide by taking a handful of acetaminophen an hour ago -client with UTI who is disoriented to time and place -client with coffee-ground emesis from chronic use of high-dose aspirin

-client with coffee-ground emesis from chronic use of high-dose aspirin --to leave AMA, a client must have the risks explained and be able to understand them. Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Despite it not being within the client's best interest to leave with a GI bleed, they can. --Parents may not refuse life; limb; or organ saving treatment on behalf of their minor child for religious or personal reasons; they can make that decision only for themselves.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? -client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge -client with dementia and urinary incontinence wearing an external urine collection device -client with hx of splenectomy 15 years ago, now admitted for PE -client with lupus nephritis who is prescribed treatment with azathioprine

-client with dementia and urinary incontinence wearing an external urine collection device --The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to the other clients.

Multiple clients arrive at the ED. Which client should the triage nurse prioritize for the HCP to see first? -client at 24 weeks gestation, showing no signs of labor, with cough productive of yellow phlegm -client with dementia arriving with new-onset restlessness and confusion -client with epilepsy who had a seizure earlier but is now alert and oriented -client with newly deformed forearm with normal circulation and sensation, pain rated 8/10

-client with dementia arriving with new-onset restlessness and confusion --Clients with dementia are expected to be alert, with a gradual development of symptoms showing cognitive decline. The sudden onset of a new behavior may indicate delirium caused by infection or another serious etiology and is considered a priority. --The client who had a seizure earlier is now stable. The nurse can maintain a safe environment until the client is seen, but the client with dementia and behavior changes is the priority.

A nurse in the ED assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? -client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL -client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg, pCO2 38 mm Hg, and HCO3 30 mEq/L -client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% -client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL

-client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% --Carbon monoxide is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. when hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen. The diagnosis of CO poisoning is often missed in the ED because symptoms are nonspecifci. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client who had an appendectomy today and reports severe nausea and 8 out of 10 pain -client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL -client with fever of unknown origin whose arterial blood gas reveals PaCO3 30 mm Hg -client with persistent diarrhea who has continuous lactated Ringer solution IV infusing at 125 mL/hr

-client with fever of unknown origin whose arterial blood gas reveals PaCO3 30 mm Hg --systemic inflammatory response syndrome is a pathophysiologic response mediated by the release of large quanities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection, and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction. Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea. Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes as SIRS may be life-threatening. --a client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but signs of SIRS should be addressed first.

After the nurse receives the change-of-shift report, which client should the nurse assess first? -client with asthma who has SOA and high-pitched expiratory wheezing -client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage -client with heart failure who is SOA and coughing up pink frothy sputum -client with left pleural effusion and absent breath sounds in the left base

-client with heart failure who is SOA and coughing up pink frothy sputum --This client has developed acute pulmonary edema, a potentially life-threatening condition. This client's status has deteriorated from baseline and is potentially the most hemodynamically unstable.

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? -client with charred, leathery skin over entire back, chest, and legs -client with cool skin, shivering from sitting in water until rescued -client with diabetes who was unable to take prescribed insulin today -client with high-pitched, crowing inspiratory respirations

-client with high-pitched, crowing inspiratory respirations --during mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that categorizes them from highest medical priority to lowest. The client with stridor, which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client is classified as emergent. --Clients with wet clothing or cold water immersion are at risk for hypothermia, but can easily be self-managed by provision of warm, dry blankets; this client is nonemergent.

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the HCP? SATA -client with a malignancy prescribed filgrastim has neutropenia -client with acute osteomyelitis prescribed vancomycin has leukocytosis -client with acute pancreatitis prescribed hydromorphone has an elevated lipase level -client with hypertension prescribed candesartan has hyperkalemia -client with peritonitis prescribed tobramycin has an elevated creatinine level

-client with hypertension prescribed candesartan has hyperkalemia -client with peritonitis prescribed tobramycin has an elevated creatinine level --Potassium-sparing diuretics, ACE inhibitors, and angiotensin II receptor blockers cause hyperkalemia. Therefore, those should be held in clients with underlying hyperkalemia. Aminoglycosides are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level to the HCP as it is a major adverse effect that can indicate reversible nephrotoxicity. --Neutropenia increases a client's susceptibility to infection. Filgrastim is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemo. Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection, increased erythrocyte sedimentation rate, fever and involves long-term antibiotic therapy. Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids.

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the ICU? -client experiencing fever and pain with mastitis -client preparing for discharge after cesarean birth -client showing disinterest in caring for the newborn -client with hysterectomy after postpartum hemorrhage

-client with hysterectomy after postpartum hemorrhage --the client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from ICU would have the assessment skills needed to recognize any changes.

A major disaster involving hundreds of victims has occurred and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital? -client at 8 weeks gestation with spotting and pulse of 90/min -client with a compound femoral fracture and an oozing laceration -client with fixed and dilated pupils and no spontaneous respirations -client with paradoxical chest movement throughout respirations

-client with paradoxical chest movement throughout respirations --Disaster triage is based on the principle of providing the greatest good for the greatest number of people. The client with flail chest from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. In addition, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Therefore, this client would be classified as emergent due to airway compromise

A LPN is discussing assessment findings for several older adult clients with the RN. Which client is priority for the RN to assess? -client taking metoprolol who has a pulse of 54/min and blood pressure of 154/82 mm Hg -client who has chronic obstructive pulmonary disease with an oxygen saturation of 92% -client with 345 mL of gastric residual volume aspirate from a PEG tube before an enteral feed -client with pneumonia who is receiving IV fluids and has a new S3 heart sound

-client with pneumonia who is receiving IV fluids and has a new S3 heart sound --An S3 heart sound is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2. It may be present as a normal finding in young adults. However, a new S3 in older adults is a significant finding as it may indicate development of volume overload or heart failure. These conditions require prompt intervention as they may rapidly progress to life-threatening events. This client may be receiving excessive IV fluids that are causing volume overload. --Repeated high gastric residual volumes in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent N/V or abdominal distension

The L & D nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to this L&D nurse? -client with occluded arteriovenous fistula receiving IV heparin infusion -client with cirrhosis and ascites who requires bedside paracentesis -client with diabetes who is one day postoperative below-the-knee amputation -client with pyelonephritis who is febrile and receiving IV antibiotics

-client with pyelonephritis who is febrile and receiving IV antibiotics --A float nurse should be assigned to clients who require care similar to the nurse's usual client population. Clients requiring care from a nurse with specialized knowledge should not be assigned to a float nurse.

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? -client with anemia who began receiving a unit of packed red blood cells one hour ago -client with hemoglobin of 7 g/dL who needs to be started on IV iron therapy -client with seizure activity who received lorazepam 20 minutes ago -client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour

-client with seizure activity who received lorazepam 20 minutes ago --This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain baseline neurological vital signs against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions have been initiated. --hemoglobin of 7 g/dL is not life-threatening and many clients can tolerate this level.

The charge nurse on the medical-surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? -client with diabetes mellitus and CKD who is on hemodialysis and has a serum glucose level of 265 mg/dL -Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 -Client with cellulitis of the leg due to spider bite who has a white blood cell count of 13,000/mm3 -client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3

-client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 --This client does not place the immediate post-operative client at increased risk for infection. --A client with diabetes mellitus and advanced CKD may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia.

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? -client with alcohol withdrawal who needs IV lorazepam every 2 hours -client with emphysema and an oxygen saturation of 89% on room air -client with sickle cell crisis requiring IV morphine every 2 hours -client with type 2 diabetes mellitus who needs discharge teaching

-client with sickle cell crisis requiring IV morphine every 2 hours --The most appropriate assignment for the pediatric nurse is the client with sickle cell anemia requiring IV morphine every 2 hours. Sickle cell anemia is a common disorder in children and the pediatric nurse would be familiar with the assessment, plan of care, and treatment of clients with sickle cell crisis. --alcohol withdrawal is predominantly a disease of adults. A pediatric nurse would have little experience managing clients with delirium tremens. Emphysema is a COPD not commonly seen in pediatric clients since it occurs later in life due to long-term smoking. Type 2 diabetes mellitus is increasing in incidence in the pediatric population. However, discharge teaching would be performed better by a nurse from the adult medical surgical unit who has more experience with the disease and discharge paperwork.

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? -client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours -client with an indwelling urinary catheter who is 1 day postoperative prostatectomy reports severe bladder spasms -client with an urethral stent placed this morning after laser lithotripsy reports burning on urination and hematuria -client with spinal cord injury requiring intermittent catheterization reports a throbbing HA and nausea

-client with spinal cord injury requiring intermittent catheterization reports a throbbing HA and nausea --Autonomic dysreflexia can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing HA, nausea, and blurred vision; HTN and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention to remove the precipitating trigger.

4 clients comes to the ER and are assessed by the triage nurse. Which client should be prioritized for more definitive care? -client with HX of gout who has severe pain in the right foot -client with HX of migraines reporting HA and photophobia -client with severe epigastric pain radiating to the back after an alcohol binge -client with sudden onset of the "worst HA of my life"

-client with sudden onset of the "worst HA of my life" --This is a classic description of a subarachnoid hemorrhage and requires emergency evaluation due to high mortality.

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? -client 2 days postoperative abdominal surgery who is to receive enoxaprin for venous thromboembolism prophylaxis -client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine -client with suspected sepsis who has a temp of 102.3 F and is to receive an initial dose of IV ceftazidime -client with type 2 diabetes mellitus and blood sugar of 500 mg/dL who is to receive subcutaneous regular insulin and insulin glargine

-client with suspected sepsis who has a temp of 102.3 F and is to receive an initial dose of IV ceftazidime --Sepsis is a condition associated with a serious infection in the bloodstream. EBP guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock and multiorgan dysfunction syndrome. --The client with high blood pressure needs treatment, but the condition is not life-threatening

A client with AIDS treated for intractable seizures is transferred from the ICU to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? -client with C. Diff -Client with fever of unknown origin -client with bacterial pneumonia -client with upper GI bleed

-client with upper GI bleed --this client does not place the immunocompromised client with AIDS at increased risk for infection

Which situations would prompt the healthcare team to use the client's advance directive to make a decision regarding care? SATA -client diagnosed with lumbar spinal cord compression has paraplegia -client's Glasgow Coma Scale score is 3 -client is refusing a life-saving treatment due to religious beliefs -client with intracerebral hemorrhage has aphasia -oriented client has cancer and is on a ventilator

-client's Glasgow Coma Scale score is 3 -client with intracerebral hemorrhage has aphasia --Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing

Handoff report typically includes:

-clients name, location, age, gender, healthcare provider, and diagnoses -client's current baseline measurements, treatment plan, goals, and response to treatment -priority and outstanding tasks and changes from previous days

What is the scope of practice for an RN?

-clinical assessment -initial client education -discharge education -clinical judgment -initiating blood transfusion

Which of these tasks are appropriate for the RN to delegate to the UAP? SATA -assign lunch times to the other UAP on the unit -assist a client with a new ostomy with bathing and changing pouches -collect vital signs on a client 4 hours after laparoscopic appendectomy -pick up an intravenous antibiotic from the pharmacy -record intake and output for a client with metabolic alkalosis

-collect vital signs on a client 4 hours after laparoscopic appendectomy -pick up an intravenous antibiotic from the pharmacy -record intake and output for a client with metabolic alkalosis --Client care that involves any part of the nursing process can never be delegated to the LPN or UAP. The UAP can assist with basic care activities and collect data for stable clients. The RN is ultimately accountable for the care provided by the UAP.

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the RN delegate to the experienced UAP? SATA -assisting the client is completing a health history form -collecting a urine specimen for culture and sensitivity -instructing the client to strain urine when voiding -measuring and documenting urine output -monitoring the color and characteristics of urine output

-collecting a urine specimen for culture and sensitivity -measuring and documenting urine output

While receiving prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate? -adjust documentation to indicate that the client is a G1P0 -ask the client and partner about a previous miscarriage or abortion -confirm the obstetric history when the client is alone -explain the importance of accurate information to the client and partner

-confirm the obstetric history when the client is alone --The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview and the medical record, the information should be clarified when the client is alone to maintain confidentiality.

Describe stage 3 (severe) stage of Alzheimer disease

-decreased mobility -dependent on others for ADLs -no recognition of self or previously familiar people -fragmented memory

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? SATA -diagnosed with endocarditis on antibiotics with a PICC line -history of multiple sclerosis with ataxia and diplopia -one day postoperative form a hemicolectomy -reporting abdominal pain with coffee ground emesis -taking warfarin with PT/INR 2X control value

-diagnosed with endocarditis on antibiotics with a PICC line -history of multiple sclerosis with ataxia and diplopia -taking warfarin with PT/INR 2X control value --These clients are all stable and are experiencing typical symptoms. Large intestine peristalsis does not return for up to 3-5 days after hemicolectomy. This client cannot be discharged until they are able to tolerate oral intake with normal elimination. Coffee ground emesis indicates upper GI bleeding. Etiology and treatment need to be determine before the client is discharged.

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? SATA -do not continue the handoff report with the oncoming nurse -document the incident according to facility policy -notify the charge nurse -say nothing but watch for impaired behavior -tell the oncoming nurse that he/she is not fit for duty

-do not continue the handoff report with the oncoming nurse -document the incident according to facility policy -notify the charge nurse --an impaired nurse cannot safely give care regardless of the reason for impairment. If impairment is suspected, the nurse has a duty to take action that will both protect the client and ensure that the impaired individual receives assistance. The charge nurse should be notified, the incident documented, and the nurse not allowed to give care while impaired. Confronting the impaired nurse in a hostile manner does nothing to protect the client and offers no support to the nurse. Confrontation may be necessary if the client is in immediate danger.

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. Which tasks would be appropriate to delegate to the UAP? SATA -document output from the urinary collection bag -hold adipose tissue out of the way during catheter insertion -monitor color of the urine after the nurse has assessed it -reinforce education about the purpose of the urinary catheter -secure the catheter to the client's thigh with an anchor

-document output from the urinary collection bag -hold adipose tissue out of the way during catheter insertion -secure the catheter to the client's thigh with an anchor

The nurse caring for a client in the ICU reports a critical lab value of 120,000/mm3 platelets, decreased from 300,000/mm3 on admission. The HCP says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? -contact the appropriate certification and licensing board -document the exchange in the chart -report the incident to the hospital's legal team -report the incident to the state medical board.

-document the exchange in the chart --When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor.

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members do if they experience workplace violence? SATA -document the interactions with the bully -ignore the bully's comments, remarks, and allegations -observe interactions between the bully and other colleagues -report the violent incidents to the hospital administrator -tell the bully you will not tolerate the unprofessional behavior

-document the interactions with the bully -observe interactions between the bully and other colleagues -tell the bully you will not tolerate the unprofessional behavior --Lateral violence in the workplace should not be tolerated or ignored. Victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way, and seeking support. The chain of command should be followed when reporting of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? SATA -document this communication in the EMR -encourage the client to discuss this decision with the healthcare proxy -facilitate completion of an advance directive that reflects the client's decision -obtain a signed informed consent from the client -tell the HCP that the client needs a DNR order

-document this communication in the EMR -encourage the client to discuss this decision with the healthcare proxy -facilitate completion of an advance directive that reflects the client's decision --An advanced directive is used to communicate a client's wishes when the client is not able to communicate them him/herself. The nurse can advocate for the client by ensuring that expressed wishes are communicated in the advance directive and medical record and by encouraging the client to share this information with the appointed health care proxy.

The nurse is assigned to care for clients with assistance from UAP. Which of the following tasks are appropriate for the nurse to assign to UAP? SATA -emptying a urinary drainage bag and recording output volume -emptying and verifying the patency of an accordion drain -escorting a disgruntled family member off the unit -providing perineal care around an indwelling urinary catheter -reapply bilateral sequential compression devices

-emptying a urinary drainage bag and recording output volume -providing perineal care around an indwelling urinary catheter -reapply bilateral sequential compression devices

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? SATA -facilitating communication between HCP -obtaining health information from the client's nursing home -reconciliation of home medications -referral for home health after discharge -visiting the client daily while hospitalized

-facilitating communication between HCP -obtaining health information from the client's nursing home -referral for home health after discharge --Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases framentation of care, helps to coordinate care and communication between HCPs, makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge.

Which are correct understandings of applying nursing ethical principles? SATA -autonomy is requiring the client to have an advance directive -beneficence is withholding prognosis from a client due to family wishes -fidelity is administering medication as prescribed to the client -justice is telling the client the truth that the biopsy is positive -nonmaleficence is refusing to give report to a nurse who is impaired

-fidelity is administering medication as prescribed to the client -nonmaleficence is refusing to give report to a nurse who is impaired --Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability. Nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition and from a nurse who is impaired.

A client with terminal cancer arrives in the ED unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? -ask the spouse about the client's wishes -get directions about care from the client's sister -prepare for emergency intubation -request that the sister provide a living will

-get directions about care from the client's sister --Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent. The most common forms are living will and medical power of attorney. A living will declares the client's wishes related to specific situations. A medical POA allows the client to designated a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances. --A client's spouse is typically the primary decision maker. However, clients have the right to declare any specific individual who they trust as their agent with medical POA, and the agent becomes the final decision maker.

An elderly client visits the clinic for an annual examination, which includes updating the client's advance care plan. When assessing the client's advance care planning needs, which topics should the nurse discuss? SATA -financial power of attorney -health care proxy -life insurance beneficiary -living will -safe deposit box

-health care proxy -living will --financial power of attorney form can help clients having difficulty managing financial affairs and needing someone to help, but is not part of the advance care planning process.

The nurse is working in a busy ED and is assigned 4 clients. Which client should the nurse see first? -client receiving cyclophosphamide reporting bloody urine -client who reports severe N/V after chemotherapy -client with an elbow abrasion and a lip laceration possibly requiring sutures -homeless client who appears drowsy with a temperature of 95 F

-homeless client who appears drowsy with a temperature of 95 F --The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Sins of hypothermia include a core temperature less than 95 F, mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma. Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental factors, while addressing this client's hypothermia. --hemorrhagic cystitis is a well-known complication of cyclophosphamide. The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures. Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.

The RN delegates to the UAP the ambulation of a client. The RN observes the UAP place the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. what action should the RN take initially? -discuss the need for UAP inservice education with the nurse manager -give praise to the UAP for encouraging the client to walk the entire hallway -immediately lower the bag and speak privately to the UAP -let the UAP complete assigned tasks and speak to the UAP at the end of the shift

-immediately lower the bag and speak privately to the UAP --The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client.

What are some atypical presentations of MI in women, older adults, or clients with diabetes?

-indigestion -jaw/shoulder pain -dyspnea -diaphoresis -N/V

A visiting family member of a hospitalized client reports sudden onset of a HA and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. what is the most appropriate response by the nurse? -encourage the visitor to lie down and see if symptoms change -initiate protocol to assist the visitor to the ED -proceed to take the visitor's blood pressure -suggest that the visitor call the HCP

-initiate protocol to assist the visitor to the ED --Providing care establishes a legal caregiver obligation/relationship between the nurse and the visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish this relationship and instead implement facility protocol to help get the visitor promptly to the ED.

An ED nurse is assigned to triage. Which client should the nurse assess first? -five year old with a superficial leg laceration -lethargic 3 month old with diarrhea for the past 12 hours -seven year old with a elevated temp of 101 F and hematuria -17 year old with severe, acute abdominal pain

-lethargic 3 month old with diarrhea for the past 12 hours --Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "first, second, and third" priority level framework, the priority needs progress from the most immediate (first) to the least (third) level of risk. The include: ABCs and IV (first); mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal lab values, and risk (second); longer-term issues such as health education, rest, and coping (third)

What are some examples requiring unit quality improvement?

-medications prescribed STAT not being available in a timely manner -catheter-associated bacterial infections are increasing within the unit

The RN, LPN, and UAP are assigned a client who is being transferred from the PACU. Which tasks are the most appropriate to delegate to the LPN? SATA -assess the client on admission -measure vital signs and pulse oximetry -monitor pain level and administer pain medications -receive verbal report from the PACU nurse -reposition client every 2 hours -titrate oxygen based on unit protocols

-monitor pain level and administer pain medications -titrate oxygen based on unit protocols

A client is hospitalized for a broken leg. The client has a hx of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? SATA -nurse floated from another medical-surgical floor -nurse who is 24 weeks pregnant -nurse with erythematous rash and honey-color crusts on the hands -UAP who just received yearly injectable flu vaccination -UAP with a cold

-nurse floated from another medical-surgical floor -nurse who is 24 weeks pregnant -UAP who just received yearly injectable flu vaccination --clients who are immunosuppressed from chemotherapy should not be cared for by a HCP who is infectious

The UAP notifies the charge nurse that the client told the UAP that the client is feeling short of breath. What should the charge nurse do first? -activate a rapid response team -ask the UAP to take vital signs and report back -notify the client's assigned LPN to assess the client -personally go and auscultate the client's lung

-personally go and auscultate the client's lung --when an RN receives a report of a client complaint that is potentially ominous from a staff member of lesser qualifications, the RN should personally assess the client. This is the primary nursing assessment that will be use to decide if an urgent need exists and a change in the nursing plan of care is needed.

What are examples of when an incident report would be required?

-physical, verbal, or sexual assault occurs in the health facility -clients falls, with or without occurring injuries -staff or visitor falls, regardless of acceptance/refusal of treatment -failure to obtain/intervene upon results of diagnostic procedures -inadequate/delayed diagnosis and monitoring -delay, omission, or incorrect performance/administration of prescribed therapies/medications -hospital equipment failure

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the RN to delegate to the UAP to promote client safety? SATA -orient the client to the bedside unit and explain the call bell system on admission -place the bedside commode as close to the bed as possible -remind the client to change position slowly -report observations of changes in client's condition immediately -report whether client is using correct gait and balance while ambulating with walker

-place the bedside commode as close to the bed as possible -remind the client to change position slowly -report observations of changes in client's condition immediately

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced UAP? SATA -notifying the family of the client's death -placing dentures in the client's mouth -positioning a pillow beneath the client's head -transporting the client to the morgue -washing the client's body

-placing dentures in the client's mouth -positioning a pillow beneath the client's head -transporting the client to the morgue -washing the client's body

The RN is caring for a client with TB who is on airborne isolation precautions. The RN can delegate which tasks to the experienced UAP? SATA -alert the x-ray department about maintaining airborne isolation precautions -explain to the client why the client must wear a mask during transport to another department -post signs for airborne isolation precautions on the client's door and stock necessary equipment -remind visitors to wear a respirator mask and keep the door closed while in the client's room -talk with the family about the reasons for airborne isolation precautions in the client

-post signs for airborne isolation precautions on the client's door and stock necessary equipment -remind visitors to wear a respirator mask and keep the door closed while in the client's room --The RN is responsible for appropriate communication with other departments and providing instruction to clients and their families, but can delegate a UAP to post signs on the door pertaining to isolation precautions as well as stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room.

What should be performed by the nurse when using an interpreter?

-provide a same-sex interpreter, who is NOT a family member, but a trained professional -speak slowly and directly to the client, providing direct eye contact with the client -provider information in the sequence it will occur -obtain feedback of comprehension beyond merely nodding

UAP reports 4 situations to the RN. Which situation warrants the nurse's intervention first? -client on a 24hour urine collection had a specimen discarded by mistake -client and family request clergy to administer last rites -puncture-resistant sharps disposal container on the wall is full -client with diabetes mellitus has an 8AM fingerstick glucose of 80 mg/dL

-puncture-resistant sharps disposal container on the wall is full --healthcare workers are required to abide by OSHA standards and regulations to reduce work-related injuries and exposure to bloodborne pathogens. A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. --if any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but no immediate interaction required. --the nurse will arrange for a visit from clergy to administer the last rites, a religious ceremony for roman Catholic clients who are extremely ill, but this does not require prompt intervention --a fingerstick glucose of 80 mg/dL is normal and requires no intervention unless the client received insulin and refuses or is unable to eat.

At 8 AM, medications are prescribed for assigned clients. Which medication should the nurse administer first? -acetylsalicylic acid for a client with a hx of coronary artery disease and ischemic stroke -metformin for a client with serum glucose of 285 mg/dL who is scheduled for a CT scan with contrast -morphine sulfate for a client with terminal lung cancer who has chronic bone pain -pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing

-pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallowing --Myasthenia gravis is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles. Pyridostigmine is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk.

Describe stage 2 (moderate) stage of Alzheimer disease

-reduced ability to perform ADLs -behavioral changes (argues easily, anxious, depressed) -paces and wanders -needs close supervision

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? -ask about liver disease and give acetaminophen from the nurse's personal supply -assess the employee's blood pressure -check for allergies to drugs before giving acetaminophen from hospital stock -refer employee to the employee health provider

-refer employee to the employee health provider --although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment and a legal caregiving relationship will be established by administering the medication.

A client was treated in the ED 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? -call the prescription into the client's pharmacy -document the spouse's statement in the client's chart -notify the ED physician -request that the spouse tell the client to call back

-request that the spouse tell the client to call back --the spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and then sending the police to contact the client.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the HCP? -CD4+ cell count of 500/mm3 in a client with oral candidiasis and HIV who is receiving fluconazole orally -hemoglobin A1c of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin -platelet count of 148,000/mm3 in a client with a venous thrombosis who is receiving a continuous heparin infusion -serum glucose of 68 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition

-serum glucose of 68 mg/dL in a client with radiation enteritis who is receiving total parenteral nutrition --The target range for glucose in clients receiving nutritional support is 140-180 mg/dL. Hypoglycemia can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition than hyperglycemia does, hypoglycemia can lead to life-threatening complications. Therefore, the serum glucose of 68 mg/dL is the laboratory finding of highest priority for the nurse to report to the HCP.

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the healthcare provider? -gram-negative infection and positive blood cultures in a client prescribed tobramycin -serum B-type natriuretic peptide 650 pg/mL in a client prescribed furosemide -serum potassium 5.7 mEq/L in a client prescribed spironolactone -serum sodium 132 mEq/L in a client prescribed IV normal saline solution at 175 mL/hr

-serum potassium 5.7 mEq/L in a client prescribed spironolactone --This client who was prescribed spironolactone, a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium. The continuation of this medication puts this client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority.

A nurse reviews the most current serum lab results for assigned clients. Which result is the highest priority to report to the HCP? -albumin of 3.0 g/dL in a client with chronic hepatitis -B-type natriuretic peptide of 400 pg/mL in a client with heart failure -magnesium of 1.7 mEq/L in a client with alcohol withdrawal -sodium of 120 mEq/L in a client with small lung cancer

-sodium of 120 mEq/L in a client with small lung cancer --Malignant lung tumors are a common cause of SIADH. When serum sodium drops below 120 mEq/L, immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH. --clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits.

Examples of potassium-sparing diuretics

-spironolactone -triamterene -eplerenone

A HCP is screaming, "Why didn't you get surgery scheduled sooner!?", at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? -firmly indicate that the HCP cannot speak to the nurse in that manner -immediately apologize and attempt to fix the situation -say nothing and let the HCP vent frustrations -state that the conversation needs to take place in private and walk to a room

-state that the conversation needs to take place in private and walk to a room --when there is inter-staff disagreement, it is important to not have a public "show". The first action should be to take the conflict "off stage". Rather than suggest and wait, the nurse should immediately lead and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concern and work to resolve the issue.

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? -student who feels well but is concerned about possible exposure to viral meningitis at an off-campus party 2 weeks ago -student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain -student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain -student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a STI

-student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain --Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained healthcare provider to identify and treat injuries.

The nurse has received report on the following pediatric clients. Which action should the nurse perform first? -administer water enema to the 2 year old with intussusception who has severe abdominal pain -call the HCP about the 4 year old with leukemia who has a low-grade fever -measure head circumference of the 3 month old with ventriculoperitonal shunt placement -suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding

-suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding --bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. --Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously as it can result in lethal sepsis. The client needs cultures and empiric antibiotics, but is not priority over the client with bronchiolitis.

During the shift report, the night shift nurse tells the day charge nurse that the night UAP is totally incompetent. What is the best response for the day charge nurse to give? -encourage the night nurse to provide the UAP with additional training -indicate that it is the night nurse's job to deal with staff problems -remind the night nurse that the UAP is doing the best job the UAP can -suggest that the night nurse discuss concerns with the nurse manager

-suggest that the night nurse discuss concerns with the nurse manager --Incompetency is a concern for client safety and quality care. The nurse manager is responsible for hiring/firing and setting up additional training times or experiences for staff. The situation should be discussed with the person who has 24/7 responsibility for the unit so that an appropriate response can be given to the night nurse's perceptions

A charge nurse suspects that the UAP is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? -ask a client if the UAP has performed the test -discuss the importance of task completion and accurate documentation in a staff meeting -give the UAP a verbal warning not to falsify data -take a client's capillary glucose personally and compare it to the recorded result

-take a client's capillary glucose personally and compare it to the recorded result --When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

After talking to the client, the HCP tells the RN that the client's signature is needed on the consent form that has been filled out. While the nurse is obtaining the signature, the client states "I'm not clear on what is included in the low-fat diet that I'll be on after the cholecystectomy" What action should the nurse take first? -call the HCP to come and talk to the client -refuse to witness the signature on the consent form -teach the client about a low-fat diet -tell the client that the HCP will explain it later

-teach the client about a low-fat diet --the HCP performing the surgery should explain the risks, benefits, and alternatives of the specific procedure to the client. However, the nurse can witness the client's signing of the consent form; this differs from "obtaining consent." If the client had a question about the procedure, or the risks, alternatives, or outcomes, then the HCP should be contacted to provide additional teaching to the client. However, an ordinary question about general care or health care teaching can be answered by the nurse as this is part of the nurse;s role.

A nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance? -the client will demonstrate proper organization of medications in a weekly pill box by the end of the teaching session -the client will identify and attend a support group meeting for clients with dementia by the end of the month -the client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session -the client will verbalize 3 examples of easy, nutritious meals that can be prepared independently by the end of the clinic visit

-the client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session --anticipatory guidance prepares the client and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to diseases processes/ This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to this client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future.

The nurse has just received report on the telemetry unit. Which client should be seen first? -the client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases -the client 4 hours post permanent pacemaker insertion that is 100% paced -the client with DVT who has a dose of enoxaparin due -the client with coronary artery disease and atrial fibrillation who has a dose of warfarin due

-the client with DVT who has a dose of enoxaparin due --This client has a current clot and is at risk for development of PE if the clot mobilizes. Enoxaparin is a low-molecular-weight heparin given as an anticoagulant and should not be delayed. The nurse should monitor the client for S/S of bleeding and clinical manifestations of a PE (dyspnea, chest pain, or hypoxemia) --atelectasis is a common complication after heart surgery and the nurse should assess the client and encourage coughing, deep breathing, and use of the incentive spirometer. The client with a-fib is at risk of forming left atrial clots, which can embolize and cause stroke. Warfarin and other anticoagulants are given for prevention of clot formation, which is important but not a critical as DVT.

Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with spurting blood. The nurse giving reasonable assistance could be held liable despite Good Samaritan laws in which situations? SATA -the nurse accepts money from the victim -the nurse does not accompany the victim on the ambulance -the nurse does not apply direct pressure to the artery -the nurse knows the victim from college -the victim dies after reaching the hospital

-the nurse accepts money from the victim -the nurse does not apply direct pressure to the artery --Good Samaritan laws prevent civil action against nurses who stop of their own accord to help injured individuals after an accident. The nurse cannot receive payment for any care given. It is essential for the nurse to perform in the same manner as any reasonable and prudent medical professional would in the same or similar circumstances. A reasonable, prudent nurse would apply pressure to help control an arterial bleed. --although this nurse is not legally obligated to offer assistance, it can be argued that there is an ethical responsibility. Once the nurse starts to render care, the nurse is responsible to continue until the care can be handed off to an appropriate caregiver, such as a paramedic. The nurse is not obligated to accompany the client to the hospital.

Which of the following are examples of medical battery? SATA -a child is placed in a papoose restraint for suturing of a facial laceration with the parent present -application of soft wrist restraints to the arms of a confused, adult client with a NG tube -the nurse administers 3 mg of morphine PRN to a difficult, alert client but tells the client it is saline -the nurse inserts a needed urinary catheter even though a competent client refuses -the nurse threatens to put a client in restraints if the client does not stay in bed

-the nurse administers 3 mg of morphine PRN to a difficult, alert client but tells the client it is saline -the nurse inserts a needed urinary catheter even though a competent client refuses

The nurse is caring for a 5 year old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? -the parent cannot stay the hospital due to potential job loss from absence -the parent is in the process of a divorce and will soon be a single parent -the parent is witnessed stealing food and drinks from the cafeteria -the parent leaves the client's younger sibling to care for the client's newborn sibling

-the parent leaves the client's younger sibling to care for the client's newborn sibling --supervisory neglect is a type of child neglect and represents an immediate risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to social services.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? -room where client is in skeletal traction following a fracture of the femur, who has erythema at the pin sites -the room with a client with cellulitis and osteomyelitis following blunt trauma of the tibia -the room with a client with compartment syndrome following a crush injury, who is 1 day post fasciotomy -the room with a client with a long leg cast following open reduction of a fractured tibia

-the room with a client with a long leg cast following open reduction of a fractured tibia --This client has the lowest potential risk for infection. --erythema can be a sign of infection. The client with the fasciotomy wound is also a potential source of infection due to usually keeping the wound open for several days to relieve the pressure in the myofascial compartment.

The emergency department nurse is obligated to make a report for which symptoms? SATA -to a client's employer that the client had a car crash while intoxicated -to the authorities that an elderly client has suspicious bruising but denies caregiver abuse -to the medical examiner of a death following trauma, even if the family refuses autopsy -to the spouse of a client that the client has a reportable STI -to the supervisor that an oncoming healthcare provider has the smell of alcohol on the breath

-to the authorities that an elderly client has suspicious bruising but denies caregiver abuse -to the medical examiner of a death following trauma, even if the family refuses autopsy -to the supervisor that an oncoming healthcare provider has the smell of alcohol on the breath

4 clients come to the ED. Which client should the triage RN assign as highest priority for definitive diagnosis and treatment? -client with COPD with yellow expectoration and oxygen saturation of 91% -healthy child with new-onset fiery-red rash on cheeks and the "flu" -middle-aged client with vaginal itching and white, curdlike discharge -unconscious elderly client who smells of alcohol and has fresh vomit on the face

-unconscious elderly client who smells of alcohol and has fresh vomit on the face --Vomit and decreased LOC places this client at risk for airway obstruction.

To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines:

-use a gait/transfer belt to transfer a partially weight-bearing client to a chair -use 2 or more caregivers to reposition clients who are uncooperative or unable to assist - use a full-body sling lift to move/transfer clients weighing less than 200 lb -use 3 or more caregivers to move cooperative clients weighing more than 200 lbs

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit appear busy. What is the most appropriate action by the nurse? -ask UAP to witness the wasting of the medication -document that another nurse was not available to waste the medication -wait until another nurse is available and then witness the waste together -waste the morphine alone and then show the empty cartridge to the charge nurse

-wait until another nurse is available and then witness the waste together --waste of controlled substances must be witnessed by two licensed nurses to comply with facility policy and government regulations.

What is a normal respiratory rate for an infant?

30-60/min

Define autonomy

allowing clients to choose the direction of their care --accomplished with advanced directives along with informed consent and choices regarding proposed treatments

define assault

an act that threatens the client and causes the client to fear harm, but without the client being touched

What is intussusception?

an intestinal obstruction that results when a part of the intestine folds into a section next to it. --it is a medical emergency and can be fatal if left untreated

What legal term is this an example of? "Threatening to adminsiter a benzodiazepine if the client does not comply" --assault; battery; false imprisonment; informed consent; invasion of privacy

assault

How are descending aortic dissections typically described?

associated with back pain and abdominal pain --abrupt in onset --described as "worst ever", "tearing", or "ripping" pain

define false imprisonment

confinement of a client against the client's will or without legal justification

define invasion of privacy

disclosing medical information to others without client consent. Under HIPPA, a client's information regarding medical treatment is private and cannot be released without the client's permission

Define Battery

involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses.

What is the most common form of childhood cancer?

leukemia

What does veracity refer to?

the duty to tell the truth

Which type of precautions are all patients placed on?

universal

S/S of increased ICP

-irritability -fever -high-pitched cry (infant) -pupillary reactions -sunset eyes -dilated scalp veins -poor feeding (infants) -vomiting -bulging fontanelles (infants)

The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? -fell, twisting the right knee; heard a "pop" -history of glomerulonephritis; has "iced-tea" colored urine -pain 10/10 in reddened eye; wears contact lens -took a handful of amitriptlyine tablets after a fight with spouse

-took a handful of amitriptyline tablets after a fight with spouse --Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline is lethal if taken in overdose, especially if consumed with alcohol. Death typically results due to serious cardiac arrhythmias.

What is required for a client to be able to leave against medical advice?

the client must be legally competent to make an educated decision to stop treatment. --disqualifications for legal competency include altered consciousness, mental illness, and being under chemical influence.

When a client is unable to make decision, who is legally able to make the decisions for the client?

the healthcare proxy.

What drug classification is amitriptyline?

tricyclic antidepressant --AKA Elavil

Define paternalism

type of beneficence whereby clients are treated as children.

After receiving the shift report, the nurse should assess which infant first? -an infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min -an infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL -an infant with bilateral crackles who was delivered vaginally 30 minutes ago -an infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F

-an infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL --a normal blood glucose range for an infant is 40-60 mg/dL within the first 24 hours after delivery. A blood glucose level <40 indicates hypoglycemia. Symptoms include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures.

When caring for a client with pneumonia, which nursing activities are most appropriate for the RN to delegate to the LPN working under RN supervision? SATA -administering metered-dose inhaled medications -monitoring lung sounds -evaluating use of the incentive spirometer -nasotracheal suctioning to collect a sputum specimen -teaching the importance of fluid intake

-administering metered-dose inhaled medications -monitoring lung sounds -nasotracheal suctioning to collect a sputum specimen

S/S of PE

-dyspnea -hypoxemia -tachypnea -cough -chest pain -hemoptysis -tachycardia -syncope -hemodynamic instability

Describe stage 1 (mild) stage of Alzheimer disease

-immediate recall affected, distant memories preserved -gets lost easily -trouble remembering words and common objects -difficulty finding words, repetitive -cognitive impairment with progressive decline

An admitted ED client is waiting for an ICU bed to be available for transfer to the inpatient unit. The Ed is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? -call the telemetry unit manager -notify the nursing supervisor -send the client to ICU to "hold: the client in the hallway -wait until the resident has time to request the transfer

-notify the nursing supervisor --it is important to move the client to the ICU and for the ED to continue to care for incoming clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve interdepartmental issues when it is necessary for a higher authority to intervene and expedite processes.

The nurse is caring for a 4 year old child in the ER who has a 104 F temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? -assisting the parents in signing AMA papers -discharging the child if parents have power of attorney papers -notifying the hospital administration about the situation -reassuring the parents that their decision will be respected under the principle of autonomy

-notifying the hospital administration about the situation --A competent adult has the right to make any decisions regarding the client's health care, even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in LOC, nuchal rigidity, and meningeal signs. Ethical principle of autonomy is deciding for oneself. In this case, the child's best interest is priority and the legal authority takes precedent

What is a normal blood glucose range for an infant within the first 24 hours after delivery?

40-60 mg/dL

The night nurse receives a call at 4 AM from the lab regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? -call the answering service and speak to the HCP now -document the results of the culture in the client's medical record -leave a message on the HCP phone -speak to the HCP on rounds in the morning

-call the answering service and speak to the HCP now --Critical lab results require immediate communication with HCP

Which emergency department clients cannot be allowed to sign out against medical advice? SATA -client in sickle cell crisis receiving oxygen via face mask -client who drank a 1 L bottle of vodka 2 hours ago -client who hears voice commands to kill a coworker -client with mania who has not eaten in 5 days -client with ST elevation on ECG monitoring

-client who drank a 1 L bottle of vodka 2 hours ago -client who hears voice commands to kill a coworker -client with mania who has not eaten in 5 days

which client should the nurse assess first? -client with A-fib with a new prescription for warfarin -client with COPD with an oxygen saturation of 91% -client with postoperative pain rated 8 out of 10 -client with 3rd degree heart block with a pulse of 42/min

-client with 3rd degree heart block with a pulse of 42/min

What information is included in SBAR?

-Situation (what prompted the communication) -Background (pertinent information, admission time frame, when change of condition occurred, current diagnosis, relevant history, vital signs) -Assessment (the nurse's assessment of the situation) -Recommendation (request for prescription or action from the HCP)

Which of the following tasks would the charge nurse on a surgical unit assign to the UAP? -assisting a client in ambulating to the bathroom for the first time following surgery? -explaining why using the incentive spirometer is important to a client with postoperative pneumonia -feeding a client with dementia who has a blood sugar of 70 mg/dL -taking vital signs every 15 minutes on a client who was just transferred from the post-anesthesia recovery unit

-feeding a client with dementia who has a blood sugar of 70 mg/dL

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? -2 year old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy -5 year old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus - 9 year old client with parvovirus B-19 infection admitted for observation after a febrile seizure -14 year old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

- 9 year old client with parvovirus B-19 infection admitted for observation after a febrile seizure --Parvovirus B-19 is a common childhood infection known as "fifth disease". Infected clients display a characteristic "slapped cheek" rah on the face. Symptoms range in severity; however, most children do no require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies. It is recognized as a TORCH infection,a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. Extreme caution should be taken while handling cytotoxic medication; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse,

The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? -"I will get this notarized as soon as I can" -"I will give a copy of this to my daughter, who is listed as my healthcare proxy" -"I'll put this on my fridge, so no one will give me CPR" -"You and my daughter can witness this for me"

-"I will give a copy of this to my daughter, who is listed as my healthcare proxy" --An advance directive is placed in the client's medical record and copies are given to healthcare proxies. Two witnesses are required for completion of the advance directive, but they should not be the healthcare proxies listed in the document.

What is the scope of practice for an LPN/LVN?

-monitoring findings of RN -reinforcing education -routine procedures -most medication administrations -ostomy care -tube patency and enteral feeding -specific assessments ( lung sounds, bowel sounds, neurovascular checks)

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? -autonomy -nonmaleficence -paternalism -veracity

-nonmaleficence --Nonmaleficence is the ethical principle of doing no harm

Which of the following are violations of protected clinical health information? SATA -client overhears the nurse give report on the client's roommate through the room curtain -nurse calls a client by the first and last name in the public waiting room -nurse gives a pregnancy result to the client's partner without the client's permission -nurse tells the transporting tech that the client has breast cancer -UAP tells a discharged client, "You take care now"

-nurse gives a pregnancy result to the client's partner without the client's permission -nurse tells the transporting tech that the client has breast cancer --The HIPAA and PIPEDA requirements related to protected health information include not giving results to a spouse without permission or telling a client diagnosis to an employee who does not need to know it. It is not a violation to call clients by their names, have information overheard inadvertently, or indicate well wishes. A client overhearing report through a privacy curtain is inadvertent communication and is not considered a violation

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? SATA -"Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation" -"Client reports that IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Healthcare provider notified" -"Heparin infusion running at 15 units/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, a PTT 65 sec. HCP notified; will draw labs again at 1:20 PM" -"IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour" -"Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings"

-"Heparin infusion running at 15 units/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, a PTT 65 sec. HCP notified; will draw labs again at 1:20 PM" -"IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour"

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? -4 year old girl in Buck traction and 5 year old boy post laparoscopic appendectomy -6 year old girl with varicella and 7 year old girl with measles -9 month old boy with rotavirus infection and 8 month old boy with salmonella infection -14 year old girl with sickle cell anemia and 13 year old girl with periorbital cellulitis.

-4 year old girl in Buck traction and 5 year old boy post laparoscopic appendectomy --Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. A client with sickle cell anemia is at risk for infection due to spleen dysfunction and a client with periorbital cellulitis has an infection-therefore they should not share a room.

Four clients with different skin alterations comes to the ER. Which client should the nurse advise that the HCP see first? -8 year old client who uses corticosteroid inhaler who has white patches on the tongue -50 year old client who developed a smooth, red, pinpoint rash after taking sulfa -60 year old client with pain and crusted blisters along the back -70 year old client who has erythema with a small pustule at the hair follicle

-50 year old client who developed a smooth, red, pinpoint rash after taking sulfa --Petechiae and purpura can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation.

The nurse triaging clients in the emergency department. Which client needs to be seen first? -18 year old female with fever, suprapubic pain, and dysuria -21 year old male with diffuse abdominal pain and a rigid abdomen -64 year old male with a pulsatile mass in the perumbilical area and back pain -75 year old with nausea, fever, and left lower quadrant pain

-64 year old male with a pulsatile mass in the perumbilical area and back pain --Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites r nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. Fever, suprapubic pain, and dysuria in a young female client indicate a UTI. Diffuse pain and a rigid abdomen indicate peritonitis, which is not life-threatening. Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? -7 day old fussy infant with a rectal temperature of 100.6 F and 6 wet diapers today -client receiving radiation therapy who has 6 in arm laceration that is not actively bleeding -client with purulent drainage and crusting of the eyelid with vision unaffected -new parent who is crying and overwhelmed, and denies suicidal ideation

-7 day old fussy infant with a rectal temperature of 100.6 F and 6 wet diapers today --Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age, although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. pink eye is highly contagious, but is not emergent.

Several clients check into the emergency department at the same time. Which client should be seen first? -8 month old with persistent vomiting and diarrhea for several days -5 year old who has a foreign body in the right naris -7 year old who is restless after tonsillectomy surgery 3 days ago -9 year old with a second-degree burn to the arm who is crying inconsolably

-7 year old who is restless after tonsillectomy surgery 3 days ago --A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. The client who had a tonsillectomy 3 days ago has signs of hemorrhage should be seen first. Signs and symptoms of hemorrhage after tonsillectomy and adenoidectomy include restlessness, frequent swallowing or throat-clearing, vomiting of blood, and pallor. Persistent vomiting and diarrhea in an 8-month old would warrant concern for dehydration. IV fluid resuscitation may be required. This client, with potential circulatory compromise, should be seen second. A second-degree burn is not full thickness and is not considered life threatening. This client needs treatment for pain and infection prevention and should be seen third.

The charge nurse on a med-surg step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? -65 year old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse -66 year old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision -75 year old client with an ischemic stroke transferred from the ICU 1 hour ago; unresponsive with right-sided paralysis -78 year old with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

-78 year old with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage --The RN makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care

The charge nurse in the ER assigns a client to a new nurse who has been off orientation for a week. which client assignment is most appropriate? -3 year old with a temperature of 102.4 who had a seizure at home 30 minutes ago and is very irritable -8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale -32 year old with asthma who has an upper respiratory tract infection and a peak expiratory flow rate that is 45% of personal best -72 year old prescribed antibiotics 3 days ago to treat acute sinusitis who reports shortness of breath and has a rash

-8 year old with a closed fracture of the clavicle following a fall who is talkative and rates pain as a "2" on the 0-10 FACES pain scale --A fractured clavicle is not uncommon in children <10 years and is usually treated conservatively. A new nurse should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury. A client who has a severely reduced peak expiratory flow rate needs emergency intervention and is not an appropriate assignment

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? -8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness -11 year old with viral meningitis requesting pain medication for headache -male child scheduled for surgery for intussusceptio who has reddish mucoid stool -male child with hemophilia who has hemarthrosis and is receiving desmopressin

-8 year old with sickle cell crisis who has sudden-onset unilateral arm weakness --Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemicstroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to assess it.

The charge RN on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? -a LPN assigned to a client receiving blood transfusions -a student nurse assigned to a client who requires frequent IV pain medication -an LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today -An RN assigned to a client 1 day postoperative repair of a compound fracture

-An RN assigned to a client 1 day postoperative repair of a compound fracture --An RN is appropriately assigned to the client who is the most unstable. The postoperative client requires thorough education and evaluation prior to discharge, which requires the skill of an RN due to being out of LPN scope of practice.

The charge nurse on a medical unit makes assignments for the nursing team composed of a RN, 2 LPNs, and a SN. Which assignment is most appropriate? -LPN assigned to a client with a GI bleed and hypotension who is receiving blood and requires VS monitoring every hour -LPN assigned to a newly admitted client with a bowel obstruction who is experiencing severe abdominal pain -RN assigned to a client with change in mental status who is being transferred to ICU -SN assigned to a client with MS and dysphagia who requires multiple oral and IV meds

-RN assigned to a client with change in mental status who is being transferred to ICU

The nurse enters a client's room just as the UAP is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? -UAP applies the anti-embolism stockings while maintaining the client in supine position -UAP carefully smooths out any wrinkles over the length of the stockings -UAP checks that the toe opening of the stockings is located on the plantar side of the foot -UAP rolls down and folds over the excess material at the top of the stockings

-UAP rolls down and folds over the excess material at the top of the stockings --Stockings should not be rolled down, folded down, cut, or altered in any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? -a 3 year old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling -a 7 year old has had a high fever, cough, and sore throat for the past 2 days -a 14 year old with asthma controlled with a corticosteroid inhaler developed oral white patches -a 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain

-a 16 year old diagnosed with mononucleosis 10 days ago reports abdominal pain --Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16 year old client should be taken to ER for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. Skin peeling is expected in the subacute stage of Kawasaki disease. Corticosteroid inhalers can cause oral thrush.

The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action? -a 3-month-old with fever, vomiting, high-pitched cry, and irritability -a 9-month old with diarrhea who is refusing fluids and cries without tears -an 11-month old with cold symptoms and an abdominal breathing pattern -an 18-month old who cries with the caregiver leaves

-a 3-month-old with fever, vomiting, high-pitched cry, and irritability --infants with underlying infection and increased intracranial pressure will be very irritable and have a fever and high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3 month old needs to be seen first due to the potential for bacterial meningitis. The absence of tears when crying indicates moderate dehydration.

The pediatric nurse receives reports on 4 clients. Which client should the nurse see first? -a 2 month old awaiting evaluation for possible hip dislocation; parents are at the bedside -a 6 year old just returned from a bronchoscopy; a parent is at the bedside -a 7 year old just returned from a noncontrast abdominal CT scan; no parents are at the bedside -an 11 year old scheduled for ear surgery today; no parents are at the bedside

-a 6 year old just returned from a bronchoscopy; a parent is at the bedside --When deciding which client to see first, the nurse should apply the ABC's (airway, breathing, circulation) guideline to problems that clients may have or could develop

The clinical coordinator RN on a surgical unit makes assignments for the staff of RN, LPN, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? -a 36 year old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning -a 56 year old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery -a 68 year old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning -an 80 year old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

-a 68 year old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning --When assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member. The more experienced RN is assigned to the client with the more complex physiologic and psychologic needs, who requires a more advanced level of nursing skill. The new graduate nurse is assigned to the client who less complex needs, who requires basic nursing skills, such as measurement of vital signs and basic physical assessment.

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? -a client post cholecystectomy reporting increased nausea -a client post myomectomy with mild oozing of blood from the surgical site -a client post spinal surgery requesting additional pain medication -a client post transurethral resection of the prostate with reddish-pink drainage

-a client post cholecystectomy reporting increased nausea --Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered LOC. These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications. Mild oozing of blood from the surgical site is normal during the postoperative period. Pain control after surgery is important for client recovery- see this client second. After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected.

Which of the these clients should the nurse assess first? -A client who has SOB from moderate pleural effusion and is waiting for thoracentesis -a client who just had a long leg cast applied and has severe pain despite a dose of morphine -a client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness -a sickle cell crisis client who has severe bone pain despite a dose of morphine

-a client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness --First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. Anaphylactic reactions are potentially fatal medical emergencies that must be treated immediately. Compartment syndrome prevents perfusion and can cause tissue death and limb loss. Stable clients awaiting procedures are assessed last.

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? -a client recovering from a ruptured appendix -a client with cystic fibrosis -a client with minimal change nephrotic syndrome -a client with rheumatic fever

-a client with minimal change nephrotic syndrome --MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia

The RN and practical nurse are caring for a client who was admitted to the medical unit last night with a moderate asthma exacerbation and an upper respiratory infection. Which tasks are appropriate for the RN to delegate to the PN? SATA -administering albuterol metered dose inhaler medication -auscultating lung sounds to determine the response to a bronchodilator -checking oxygen saturation with the pulse oximeter -measuring morning peak expiratory flow with the client's peak flow meter -teaching the client about a newly prescribed inhaled corticosteroid

-administering albuterol metered dose inhaler medication -checking oxygen saturation with the pulse oximeter -measuring morning peak expiratory flow with the client's peak flow meter

The RN is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? SATA -administering enoxaparin subcutaneously to a client in skeletal traction -applying sequential compression devices to a client with limited mobility -evaluating partial thromboplastin time in a client receiving heparin -measuring a client with chronic heart failure for compression stockings -teaching a client with a new prescription for warfarin about bleeding precautions

-administering enoxaparin subcutaneously to a client in skeletal traction -applying sequential compression devices to a client with limited mobility -measuring a client with chronic heart failure for compression stockings

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the ICU. What client care tasks can the nurse safely delegate to the UAP? SATA -applying moisturizing solution to the oral mucosa and lips -cleaning the area around tracheostomy stoma with normal saline -educating the family to maintain the head of the bed at least 30 degrees -obtaining and documenting respiratory rate and pulse oximetry readings -performing passive and active range-of-motion exercises

-applying moisturizing solution to the oral mucosa and lips -obtaining and documenting respiratory rate and pulse oximetry readings -performing passive and active range-of-motion exercises --when caring for a ventilated client, nurses may consider delegating the following tasks to UAP: vital sign measurement, oral care, personal hygiene, blood glucose testing, passive/active range-of-motion exercises, and measurement of urine/drainage output

During the charge nurse's morning rounds, a client says, "I hope you will take better care of me than the nurse I had last night." What should be the charge nurse's initial response? -apologize for the previous nurse's treatment -ask the client to describe what happened last night -explain that the night nurse was probably busy -reassure the client that things will be better today

-ask the client to describe what happened last night -the first step in management issues is assessment. The charge nurse must first determine what happened before deciding the next course of action. The client could have misperceived certain actions.

Which tasks can the registered nurse appropriate delegate to the UAP? SATA -assist the RN with ambulating a client 1-day post chest tube placement -measure wound drainage from a bulb drain and document it on the output flow sheet -monitor for redness and swelling at the IV insertion site and report back to the nurse -return an unused unit of packed red blood cells to the blood bank -take family members to the waiting room after a client goes into surgery

-assist the RN with ambulating a client 1-day post chest tube placement -measure wound drainage from a bulb drain and document it on the output flow sheet -return an unused unit of packed red blood cells to the blood bank -take family members to the waiting room after a client goes into surgery --UAP may perform clerical and clinical tasks related to the care of stable clients under the direction of the RN.

The RN and LPN are caring for a client with an established colostomy. Which nursing actions may the RN delegate to the LPN? SATA -assess perfusion of the stoma tissue -assist the client in changing the ostomy pouch -auscultate the client's bowel sounds -develop a plan of care to prevent skin breakdown -monitor the color of ostomy drainage

-assist the client in changing the ostomy pouch -auscultate the client's bowel sounds -monitor the color of the ostomy drainage --Tasks requiring initial assessment, initial or discharge education, care planning, or care of an unstable client require the clinical judgment of the RN and may not be delegated. The LPN may perform basic care activities of the client with an established ostomy, perform specific assessments, monitor RN findings, and reinforce education.

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? -assess skin to determine severity of burns and wounds -assign client to a cot with other similarly triaged clients -assist the client to the designated showering area -prepare supplies to establish IV access

-assist the client to the designated showering area --Decontamination is a priority nursing action for clients who have been exposed to a chemical or radioactive agent. During a mass casualty disaster, the nurse should assist clients with complete decontamination before providing care. Decontamination limits further client injury and prevents exposure to other clients and staff.

While caring for a client in skeletal traction, which tasks can the RN delegate to experienced unlicensed assistive personnel to help prevent immobility hazards? SATA -assist with active and passive range of motion exercises -change bed linens while logrolling the client from side to side -check the color and temperature of the affected extremity -remind the client to use the incentive spirometer -reapply pneumatic compression device after bathing the client

-assist with active and passive range of motion exercises -remind the client to use the incentive spirometer -reapply pneumatic compression device after bathing the client --Logrolling this client would require multiple staff members and would not be recommended. Clients in traction are instructed to lift themselves using the overhead trapeze.

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? SATA -acute head injury with GCS of 12 -admitted with cirrhosis of liver with oozing esophageal varices -asthma exacerbation with peak flow at 85% of personal best -DVT on IV heparin with platelets 40,000/mm3 -myasthenia gravis with ptosis in the evening

-asthma exacerbation with peak flow at 85% of personal best -myasthenia gravis with ptosis in the evening --normal GCS is 15; score of 12 indicates impairment requiring further care; the varices oozing blood are at risk for rupture and/or increasing ammonia; normal platelet count is 150,000-400,000. A potential complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical thrombosis and rarely bleeding.

Which actions are appropriate for the RN to delegate to an experienced LPN? SATA -administer heparin continuous infusion to a client with a venous thromboembolism -auscultate bowel sounds 2 days after repair of an inguinal hernia -discuss concerns about last shift's care with an irate family member -monitor flow rate and drainage in a client receiving bladder irrigation -teach kegel exercises after a client has a catheter removed

-auscultate bowel sounds 2 days after repair of an inguinal hernia -monitor flow rate and drainage in a client receiving bladder irrigation --Under the direction of the RN, the LPN can perform higher-level skills within the scope of practice defined by the state. Appropriate tasks include administering routine medications for expected needs, monitoring RN findings, and performing focused assessments.

A nurse receives the following change-of-shift morning report for the assigned clients/ Which client should the nurse assess first? -client 1 day postop with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning -client 1 day postop with serosanguineous drainage on the abdominal surgical dressing and temp of 100.4 F -client 2 days postop receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale -client 2 days postop receiving fluids infusing at 125 mL/hr, with a foley catheter and urine output of 100 mL during the last 8 hours

-client 2 days postop receiving fluids infusing at 125 mL/hr, with a foley catheter and urine output of 100 mL during the last 8 hours --This client is becoming oliguric. The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distention and foley catheter patency before notifying the HCP. Auscultating fine crackles in the base of the lungs is common 1 day postop and is usually related to ateletctatsis caused by hypoventilation.

The nurse receives report on 4 clients. Which client should the nurse see first? -client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood -client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off -client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site -client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

-client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood --Serosanguineous drainage is expected after a surgical procedure, but a dressing saturated with sanguineous drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the healthcare provider for evaluation. Treatment with a pressure dressing to provide hemostasis, cauterization of a bleeding vessel, or fluid replacement may be necessary. Dialysis grafts are prone to infection and is not an immediate life-threatening condition.

The nurse receivees report on 4 clients. Which client should the nurse see first? -client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone -client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently -client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement -client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change

-client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently --Although it is not a STAT order, an extra dose of furosemide was precribed for the client with congestive heart failure. The SOB is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. Even though the client is experiencing asthma exacerbation, steroids do not show their effects immediately. These drugs control underlying inflammation, but take several hours/days to take effect. Drugs that provide immediate relief to a patient with asthma exacerbation includes albuterol or ipratropium.

The nurse is reviewing new laboratory values. Which client would be the priority to report to the HCP? -client 2 days after a hip arthroplasty with a WBC count of 12,000 -client admitted for cocaine overdose with a creatine kinase of 30,000 U/L -client admitted for end-stage renal disease with a creatine of 3.6 mg/dL -client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL

-client admitted for cocaine overdose with a creatine kinase of 30,000 U/L --Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction, heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically > 15,000 U/L are observed with severe muscle damage and can be a precursor to kidney injury. Forced saline diuresis with IV fluids is necessary to prevent permanent kidney damage.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? -client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea -client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine -client with a demand pacemaker set a 70/min who has ventricular rate of 65/min -client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

-client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine --a hypertensive crisis is an elevation in blood pressure >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage. The goal of treatment is to slowly lower BP using IV antihypertensive medications to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication and has the knowledge and skill to assess vital signs. Unstable angina is a medical emergency that requires specialist-level monitoring and intervention.

The nurse has received report on 4 clients. Which client should the nurse see first? -client admitted this morning with acute pyelonephritis whose IV line is infiltrated -client scheduled for surgery in 2 hours who has questions about the procedure -client who had a colostomy yesterday and now has a leaking colostomy bag -client with total hip replacement 3 days ago who reports no bowel movement in 2 days.

-client admitted this morning with acute pyelonephritis whose IV line is infiltrated --Acute pyelonephritis is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the kidney and can be life-threatening. Initial treatment includes vigorous parenteral IV fluids and IV antibiotics. This client's needs are the priority as treatment is dependent on patent IV access.

A nurse on the medical surgical unit has just received report. Which client should be seen first? -client 1 day post femoral-popliteal bypass grafting who has an IV antibiotic due now -client diagnosed with DVT yesterday who reports some chest discomfort and cough -client with HTN and BP 180/92 mm Hg who reports a HA -client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately

-client diagnosed with DVT yesterday who reports some chest discomfort and cough --This client is showing potential S/S of PE, a life-threatening condition. The nurse should elevate the HOB, administer oxygen, and assess the client.

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment? -client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg -client who is 1 day post bowel resection with absent bowel sounds -client with a pulse of 100/min who has hx of atrial fibrillation -client with pancreatitis whose total parenteral nutrition is almost finished

-client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg --A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. HTN may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. It can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia.

The charge nurse in an intensive care unit is rounding and reviewing hemodynamic data for clients in the unit. Which client requires immediate intervention? -client who is septic due to pneumonia with central venous pressure of 6 mm Hg -client who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min -client with GI bleed and mean arterial pressure of 58 mm Hg -client with an adrenal gland tumor and blood pressure of 168/95 mm Hg

-client with GI bleed and mean arterial pressure of 58 mm Hg --MAP of at least 60 mm Hg is required to adequately perfuse vital organs; however, MAP >70 mm Hg is optimal. Without intervention, MAP <60 mm Hg may progress to tissue ischemia, organ damage, and death. CVP of 6 mm Hg and CO of 5 L/min are within normal limits. Blood pressure of 168/95 is an elevated reading requiring further assessment. However, low MAP is the highest priority due to the risk for tissue ischemia

The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first? -client who has a migraine is reporting 10/10 pain and nausea -client who is postictal after a seizure is drowsy and confused -client with ALS experiencing dysarthria -client with a GCS score of 9 is no longer responding when called

-client with a GCS score of 9 is no longer responding when called --Declining neurological status threatens the airway and breathing; therefore, the client with the GCS of 9 is the highest priority. A GCS score of 8 or lower is classified as a coma. Dysarthria is a typical symptom of ALS.

Which client assignment is most appropriate for the nruse on an orthopedic unit to assign to a float nurse from a general medical unit? -client 1 day postop with external fixators to stabilize a complex fracture of the wrist -client 3 days post knee replacement surgery awaiting discharge -client who is scheduled for an above-the-knee amputation today -client with a long leg cast applied yesterday morning to treat a fractured ankle

-client with a long leg cast applied yesterday morning to treat a fractured ankle --This client is the most stable and appropriate assignment for the float nurse. This client requires the nurse to perform basic pain, peripheral vascular and peripheral neurologic assessments, which should be familiar to a nurse who works on a general medical unit. The client scheduled for an amputation requires preoperative teaching and psychological support specific to this type of surgery. Therefore, this client should be assigned to a nurse who is familiar with preparing clients for orthopedic surgery.

The nurse receives morning report on 4 clients who were admitted 2 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? -client with a fracture pelvis who has a large area of ecchymosis and bruising over the pelvic region -client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes -client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain -client with pneumothorax and a chest tube who has intermittent in the water-seal chamber

-client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain --A lung contusion caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the HCP as immediate interventions to decrease the WOB and improve gas exchange may be necessary.

A nurse working in the office of a healthcare provider must respond to client telephone messages. The nurse should return which call first? -client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone -client with a right leg cast applied yesterday for a fractured ankle, reports tinging in the right foot -client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting -client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

-client with a right leg cast applied yesterday for a fractured ankle, reports tinging in the right foot --The nurse should first call the client with tingling in the right foot. Musculoskeletal injuries and immbolization devices can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia is an early sign of neurovascular impairment. It would be important for the client to report to the HCP for immediate evaluation. Clients with diabetes are usually able to take the prescribed insulin dose when ill, and some clients may need a higher dose. Illness is a physiologic stressor and can increase blood glucose level. On the other hand, if the oral intake is low, blood sugars can be low and insulin may need to be reduced. While it is important to instruct the client to check glucose levels and repeat every 4 hours, reporting glucose levels above or below target range to the HCP, it is not the most important call.

The nurse receives report on 4 clients. Which client should be seen first? -client with amyotrophic lateral sclerosis experiencing increased dysarthria -client with COPD reporting increasing leg edema -client with strep throat and fever of 102 on antibiotics for 12 hours -client with urolithiasis reporting wavelike flank pain and nausea

-client with amyotrophic lateral sclerosis experiencing increased dysarthria --ALS is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALC focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis. The client with COPD and peripheral edema may have cor pulmonale, or right-sided heart failure, from vasoconstriction of the pulmonary vessels.

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first? -client with a head injury and fixed, dilated pupils -client with an open right femur fracture and palpable pedal pulses -client with full-thickness burns covering 85% total body surface area -client with shallow lacerations over legs and arms

-client with an open right femur fracture and palpable pedal pulses

Which client should the charge nurse assign to the room closest to the nurses' station? -client with a Salem sump tube to continuous suction who is deaf -client with gastroenteritis and dementia who wanders -client with herpes zoster under airborne isolation precautions -client with sickle cell crisis who requires frequent intravenous opioids.

-client with gastroenteritis and dementia who wanders --When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety.

Which client is most appropriate for the charge nurse on a cardiac step-down unit to assign to the float registered nurse from a med-surg unit? -client who just returned to the unit after coronary angioplasty and placement of stent -client with a-fib scheduled for electrical cardioversion this afternoon -client with heart block scheduled for pacemaker placement this afternoon -client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

-client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? -client with acute cholecystitis who reports right shoulder pain -client with gastroparesis who reports persistent nausea and vomiting -client with intractable lower back pain who reports new urinary incontinence -client with Meniere disease who reports increasing tinnitus

-client with intractable lower back pain who reports new urinary incontinence --Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia, and bowel/bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome; therefore, this client is of the most priority.

The emergency department nurse is assigned to triage. Which client should the nurse assess first? -client who smokes who has intermittent leg pain that is worse with walking and eases with rest -client with diabetes mellitus who has temperature of 100.7 -client with leg swelling and calf pain who was on a 15-hour flight 2 days ago -client with pain, edema, and redness in the leg following a dog bite 1 hour ago

-client with leg swelling and calf pain who was on a 15-hour flight 2 days ago --Life-threatening physiological problems are the highest priority followed by less threatening problems. Unilateral edema and calf pain could be signs of a VT, a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications. Prolonged immobilization increases the risk for DVT. A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of peripheral artery disease.

The nurse receives handoff report on 4 clients. Which client should the nurse assess first? -client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth -client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up -client with major depressive disorder taking phenelzine and pseudoephedrine who has a HA -client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea

-client with major depressive disorder taking phenelzine and pseudoephedrine who has a HA --MAOIs are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs.

The nurse receives report on 4 clients. Which client should the nurse assess first? -client with cellulitis of the right foot, medicated with hydromorphone IV 1 hour ago, reports pain as 6 on a scale of 0-10 -client with chronic kidney disease with hemoglobin 8 g/dL and hematocrit 24% reports shortness of breath with activity -client with heart failure exacerbation and a large pleural effusion with serum sodium of 132 mEq/L reports HA -client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing

-client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing --The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first. Clients with symptomatic asthma will receive inhaled beta agonists; however, even after medication, it is a priority to assess this client's lung sounds, work of breathing, and LOC to determine respiratory status. A sudden decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial constriction. Dilutional hyponatremia is expected in a client with heart failure due to excess fluid and cause fatigue and HA. Change in LOC and seizures can occur with sodium <120 mEq/L, but a borderline low level does not require immediate attention.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit the medical unit? -client newly admitted for an evolving ischemic stroke -client newly diagnosed with diabetes mellitus who needs insulin administration teaching -client with exacerbation of chronic obstructive pulmonary disease with a new tracheostomy -client with sickle cell crisis who requires frequent IV opioid medication for pain

-client with sickle cell crisis who requires frequent IV opioid medication for pain --The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility.

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? -client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg -client with pneumonia and temperature of 101.8 F who is unable to receive antibiotics due to an occluded IV catheter -client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour -client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL

-client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour --when caring for clients with sickle cell disease, it is important to observe for indicators of sickle cell crisis. Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage and death

The nurse is providing handoff-of care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report? - chest x-ray showed lung infiltrates; WBC count is 14,000/mm3 -client's spouse was acting rudely toward the nurse earlier -current respirations are 24/min; pulse oximetry is 93% on 2 L/min -intravenous line is infusing with no signs of infiltration

-current respirations are 24/min; pulse oximetry is 93% on 2 L/min --Handoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record so that the oncoming nurse can prioritize care.

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? -ask if the client can go without the oxygen for 2 hours -delay discharge until the oxygen is delivered -notify the HCP to see what action should be taken -send a hospital oxygen tank home with the client

-delay discharge until the oxygen is delivered --a client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge.

The nurse is caring for a client newly diagnosed with mild Alzheimer disease. Which action should the nurse prioritize at this time when teaching the client and family? -demonstrate behavioral management techniques to caregivers -encourage the client to make an advance directive before cognitive decline worsens -inform the client that mentally stimulating activities can slow disease progression -provide information about local adult daycare programs

-encourage the client to make an advance directive before cognitive decline worsens --due to the progressive course of AD, it is important to discuss advance directives while the client can make informed decisions.

The nurse is assisting the healthcare provider with a lumbar puncture in the client's room. The unit secretary calls over the room intercom and tells the nurse that the lab is on the phone with a critical value report for one of the nurse's other clients. What action should the nurse take? -Ask the unit secretary to write down a message from the lab personnel -instruct the unit secretary to have the charge nurse receive the report -leave the room to talk to the lab on the phone and then return immediately -tell the unit secretary to have lab personnel send a written result

-instruct the unit secretary to have the charge nurse receive the report --A critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. The nurse should delegate the task to the charge nurse so appropriate interventions can be initiated while the nurse finishes the sterile procedure. This is the option with the least client risk. Timely reporting of critical results is part of the international patient safety goals. A written report may never be received or the nurse may forget to look for it.