Chapter 11- prioritization, delegation, & assignment questions

When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching? 1. "I take my ibuprofen every morning as soon as I get up." 2. "My daughter removed all of the throw rugs in my home." 3. "My husband helps me every afternoon with range-of-motion exercises." 4. "I rest in my reclining chair every day for at least an hour.

1. "I take my ibuprofen every morning as soon as I get up."

A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain. What is the nurse's best response? 1. "Phantom limb pain is not explained or predicted by any one theory." 2. "Phantom limb pain occurs because your body thinks your leg is still present." 3. "Phantom limb pain will not interfere with your activities of daily living." 4. "Phantom limb pain is not real pain but is remembered pain."

1. "Phantom limb pain is not explained or predicted by any one theory."

The nurse is caring for a patient who had a dual-energy x-ray absorptiometry (DEXA) scan and is now prescribed calcium with vitamin D twice a day. The patient asks the nurse the purpose of this drug. What is the nurse's best response? Select all that apply. 1. "When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." 2. "When your vitamin D level is high, your bones release calcium to keep your blood calcium level in the normal range." 3. "When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." 4. "When blood calcium is normal, long bones are formed increasing a person's height." 5. "The extra calcium and vitamin D will help protect your bones from damage such as fractures." 6. "You can also get extra vitamin D by increasing your intake of beef and pork sources."

1. "When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." 3. "When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." 5. "The extra calcium and vitamin D will help protect your bones from damage such as fractures."

The nurse delegates the measurement of vital signs to an experienced unlicensed assistive personnel (UAP). Osteomyelitis has been diagnosed in a patient. Which vital sign value would the nurse instruct the UAP to report immediately for this patient? 1. Temperature of 101°F (38.3°C) 2. Blood pressure of 136/80 mm Hg 3. Heart rate of 96 beats/min 4. Respiratory rate of 24 breaths/min

1. Temperature of 101°F (38.3°C)

The nurse is preparing a discussion of musculoskeletal health maintenance for a group of older adults. Which key points would the nurse be sure to include? Select all that apply. 1. Be aware of and consume foods rich in calcium and vitamin D. 2. Wear hats and long sleeves to avoid sun exposure at all times. 3. Consider exercise with low impact to avoid risk for injury. 4. If you smoke, consider a smoking cessation program. 5. Excessive alcohol intake can interfere with vitamins and nutrients for bone growth. 6. Weight-bearing activities decrease the risk for osteoporosis.

1. Be aware of and consume foods rich in calcium and vitamin D. 3. Consider exercise with low impact to avoid risk for injury. 4. If you smoke, consider a smoking cessation program. 5. Excessive alcohol intake can interfere with vitamins and nutrients for bone growth. 6. Weight-bearing activities decrease the risk for osteoporosis.

The charge nurse assigns the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would the RN provide for the LPN/LVN? Select all that apply. 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour. 6. Instruct the patient to perform range of motion on the affected wrist.

1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 5. Check the neurovascular status of the fingers every hour.

The nurse is working with unlicensed assistive personnel (UAP) to provide care for six patients. At the beginning of the shift, the nurse carefully tells the UAP what patient interventions and tasks he or she is expected to perform. Which "Four Cs" guide the nurse's communication with the UAP? Select all that apply. 1. Clear 2. Comprehensive 3. Concise 4. Credible 5. Correct 6. Complete

1. Clear 3. Concise 5. Correct 6. Complete

A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would the nurse be sure to teach the patient? 1. Pain and numbness are expected to be experienced for several days to weeks. 2. Immediately after surgery, the patient will no longer need assistance. 3. After surgery, the dressing will be large, and there will be lots of drainage. 4. The patient's pain and paresthesia will no longer be present.

1. Pain and numbness are expected to be experienced for several days to weeks.

The nurse is supervising a new graduate RN caring for a patient with a fracture of the right ankle who is at risk for complications of immobility. For which action should the supervising nurse intervene? 1. Encouraging the patient to go from a lying to a standing position 2. Administering pain medication before the patient begins exercises 3. Explaining to the patient and family the purpose of the exercise program 4. Reminding the patient about the correct use of crutches

1. Encouraging the patient to go from a lying to a standing position

A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would the nurse clarify with the health care provider? 1. Give fluoxetine 40 mg once a day. 2. Administer acetaminophen with codeine 1 or 2 tablets every 4 hours as needed. 3. Assist the patient to the bedside chair every shift. 4. Reinforce the dressing to the right residual limb as needed.

1. Give fluoxetine 40 mg once a day.

During assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider immediately? 1. The patient reports pressure and pain. 2. The cast is in place and is dry and intact. 3. The skin is pink and warm to the touch. 4. The patient can move all the fingers and the thumb.

1. The patient reports pressure and pain.

The nurse is preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points should the nurse be sure to include? Select all that apply. 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired. 6. Avoid consuming three or more alcoholic drinks per day.

1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 5. Rest when you are tired.

The emergency department nurse receives a call about a patient with a traumatic finger amputation. What instructions does the nurse provide to the patient's wife? Select all that apply. 1. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. 2. Put the finger in a watertight, sealed plastic bag. 3. Place the bag directly on ice. 4. Elevate the affected extremity above the patient's heart. 5. Examine the amputation site and apply direct pressure with layers of dry gauze. 6. After performing these steps, call 911 and check the patient for breathing.

1. Wrap the completely severed finger in dry sterile gauze (if available) or a clean cloth. 2. Put the finger in a watertight, sealed plastic bag. 4. Elevate the affected extremity above the patient's heart. 5. Examine the amputation site and apply direct pressure with layers of dry gauze.

The nurse's assessment reveals all of these data when a patient with Paget disease is admitted to the acute care unit. Which finding should the nurse notify the health care provider about first? 1. There is a bowing of both legs, and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.

2. The base of the skull is invaginated (platybasia).

The nurse is preparing a patient who had carpal tunnel release surgery for discharge. Which information is important to provide for this patient? 1. The surgical procedure is a cure for carpal tunnel syndrome. 2. Do not lift any heavy objects. 3. Frequent doses of pain medication will no longer be necessary. 4. The health care provider should be notified immediately if there is any pain or discomfort.

2. Do not lift any heavy objects.

The ER nurse should question which health care provider order when providing care for an older adult with a fracture of the left ulna? 1. Get x-rays of left forearm. 2. Give meperidine IM for pain. 3. Monitor vital signs every hour. 4. Elevate left arm on pillows

2. Give meperidine IM for pain.

A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.

2. The patient appears confused.

The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the major focus for the patient's care today? 1. To attain pain control over phantom pain 2. To monitor for signs of sufficient tissue perfusion 3. To assist the patient to ambulate as soon as possible 4. To elevate the residual limb when the patient is supine

2. To monitor for signs of sufficient tissue perfusion

The nurse is caring for a postop patient with a hip replacement. Which patient care actions can be delegated to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Inspect heels and other bony prominences every 8 hours. 2. Turn and reposition the patient every 2 hours. 3. Assure that the patient's heels are elevated off the bed. 4. Assess the patient's calf regions for redness and swelling. 5. Check vital signs and oxygen saturation via pulse oximetry. 6. Assess for pain and administer pain medication

2. Turn and reposition the patient every 2 hours. 3. Assure that the patient's heels are elevated off the bed. 5. Check vital signs and oxygen saturation via pulse oximetry.

After the nurse receives change-of-shift report, which patient should be assessed first? 1. A 42-year-old patient with carpal tunnel syndrome who reports pain 2. A 64-year-old patient with osteoporosis awaiting discharge 3. A 28-year-old patient with a fracture who reports that the cast is tight 4. A 56-year-old patient with a left leg amputation who reports phantom pain

3. A 28-year-old patient with a fracture who reports that the cast is tight

The charge nurse observes an LPN/LVN assigned to provide all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen to the patient 2. Encouraging the patient to perform exercises recommended by a physical therapist 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

3. Applying ice and gentle massage to the patient's lower extremities

The nurse is caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should be delegated to the unlicensed assistive personnel (UAP)? 1. Initiating placement of a splint for immobilization during the day 2. Assessing the patient's wrist and hand for discoloration and brittle nails 3. Assisting the patient with daily self-care measures such as bathing and eating 4. Testing the patient for painful tingling in the four digits of the hand

3. Assisting the patient with daily self-care measures such as bathing and eating

The nurse is providing care for a patient with a rotator cuff tear. What treatment does the nurse expect the health care provider will prescribe first for this patient? 1. Arthroscopic repair of the rotator cuff tear 2. Elimination of movements in the affected shoulder 3. Conservative therapies such as nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy 4. Pendulum exercises that start slow and progress over 2 weeks

3. Conservative therapies such as nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy

The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish the patient's bone strength and determine if osteoporosis is present? 1. CT scan 2. MRI scan 3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan 4. Joint x-rays

3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan

The nurse observes the unlicensed assistive personnel (UAP) performing all of these interventions for a patient with carpal tunnel syndrome (CTS). Which action requires that the nurse intervene immediately? 1. Arranging the patient's lunch tray and cutting his meat 2. Providing warm water and assisting the patient with his bath 3. Replacing the patient's splint in hyperextension position 4. Reminding the patient not to lift very heavy objects

3. Replacing the patient's splint in hyperextension position

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient wants to change position in bed. 2. There is a small amount of clear fluid at the pin sites. 3. The traction weights are resting on the floor. 4. The patient reports pain and muscle spasm

3. The traction weights are resting on the floor.

During morning care, a patient with a below-the-knee amputation asks the unlicensed assistive personnel (UAP) about prostheses. How will the nurse instruct the UAP to respond? 1. "You should get a prosthesis so that you can walk again." 2. "Wait and ask your doctor that question the next time he comes in." 3. "It's too soon to be worrying about getting a prosthesis." 4. "I'll ask the nurse to come in and discuss this with you."

4. "I'll ask the nurse to come in and discuss this with you."

The charge nurse is making assignments for the day shift. Which patient should be assigned to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. A 35-year-old patient with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility 3. A 68-year-old patient with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement

4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement

The nurse is caring for a patient with osteoporosis who is at increased risk for falls. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls

4. Assisting the patient with ambulation to the bathroom and in the halls

The nurse is preparing a patient for MRI. Which action can the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Teach the patient what to expect during the test. 2. Instruct the patient to remove metal objects including zippers. 3. Witness that the patient has signed the consent form. 4. Check and record preprocedural vital signs.

4. Check and record preprocedural vital signs.

The RN is mentoring a student nurse who is caring for a patient with carpal tunnel syndrome of the right hand with neurovascular check ordered every 2 hours. For which action by the student nurse must the RN intervene? 1. Student nurse checks the patient's radial pulse every 2 hours. 2. Student nurse checks for sensation in the patient's right hand. 3. Student nurse assesses color, temperature, and pain in right wrist and hand. 4. Student nurse instructs the patient to avoid movement because of the pain.

4. Student nurse instructs the patient to avoid movement because of the pain.