Final

A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to the UAP? (SATA)

Apply water-soluble lip balm to the patients lips Reminding the patient to cough and deep breathe often

A patient is receiving O2 at 4L nasal cannula. What comfort measure may the nurse delegate to the UAP?

Apply water-soluble ointment to nares and lips

An ED charge nurse notes an increase in sick calls and bickering among the staff after a week of multiple trauma incident what is the best action for the nurse to take

Arrange for critical incident stress debriefing

The nurse is assessing a patient with suspected serum sickness. Which symptoms are consistent with serum sickness? (SATA)

Arthralgia Lymphadenopathy Malaise

The ED team is performing CPR on a client when the client's spouse arrives at the ED. Which action should the nurse take first?

Ask the spouse if he wishes to be present during the resuscitation

A patient with HIV has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?

Assess the patient for adherence to the drug regimen

A nurse is assessing an older patient for the presence of infection. The patients temperature is 97.6F. What response by the nurse is best?

Assess the patient for more specific sign

An older adult patient is admitted with an infection. On assessment, the nurse finds the patient slightly confused. Vitals: 99.2F, BP 100/60, HR-100, RR-20. Which action by the nurse is most appropriate?

Assess the patient for other signs of infection

A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the patients face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the patients O2 saturation (may have subcutaneous emphysema)

A patient with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases, and no wheezes. What's the nurses best action?

Assess the patients oxygen saturation

A nurse assesses a patient who is admitted with an acid-base imbalance. The patients ABG: pH-7.32, PaO2-85, PaCO2-34, HCO3-16. What action should the nurse take next?

Assess the patients rate, rhythm, and depth of respiration

The nurse is caring for an older adult who reports experiencing frequent asthma attacks and severe arthritic pain. What action by the nurse is most appropriate?

Assess use of medications for arthritis (NSAIDs can trigger asthma in some people)

A clinic nurse is working with an older patient. What assessment i most important for preventing infections in this patient?

Assessing vaccination records for booster shot needs

A nurse is teaching a female patient with RA about taking methotrexate (Rheumatrex) for disease control. What information does the nurse include? (SATA)

Avoid acetaminophen in OTC meds It may take several weeks to become effective on pain Stay away from large crowds and people who are ill You may find that folic acid, a B vitamin, reduces side effects

A nurse cares for a patient who has a heart rate averaging 56bpm with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?

Avoid straining while having a bowel movement

A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (SATA)

Increased pulse rate Distended neck veins Skeletal muscle weakness

A nurse assesses a patient with diabetes mellitus who is admitted with an acid-base imbalance. Patient's ABG values: pH-7.36, PaO2-98, PaCO2-33, HCO3-18. Which manifestation should the nurse identify as an example of the patients compensation mechanism?

Increased rate and depth of respirations

The nurse evaluates the following ABG and vital sign results for a patient with COPD: ph-7.32, PaCO2-62, PaO2-46, HCO3-28, HR-110bpm, RR-12, BP-145/65, O2 saturation-76%. Which action shuld the nurse take first?

Initiate O2 therapy to increase saturation to 92%

A nurse is assessing a patient who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?

Kussmaul respirations

A patient is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the patient needs more education regarding this medication?

Large chefs salad and muffin (Warfarin inhibits synthesis of vitamin K dependent clotting factors)

A nurse is triaging patients in the ED. Which patient complaint would the triage nurse classify as nonurgent?

Left arm fracture with palpable radial pulses

A patient has been injured in a stabbing incident. BP 80/60, HR 140, RR 35, bleeding from the stab wound, lethargic. Which trauma center is appropriate?

Level I

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II - located within community hospitals and provides care to most injured patients

A telemetry nurse assesses a patient with 3rd degree heart block who has wide QRS complexes and a heart rate of 35 bpm on the cardiac monitor. Which assessment should the nurse complete next?

Level of consciousness

The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patients pain?

Massaging non burned areas

A nurse assesses a patient who is prescribed Lasix for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

Metabolic alkalosis

A client with terminal pancreatic cancer is near death and reports increasing SOB with associated anxiety. Which hospice protocol order does the nurse implement first?

Morphine sulfate (Roxanol) 5-10mg as needed

A nurse is field triaging patients after an industrial accident. Which patient condition should the nurse triage with a red tag?

Multiple fractured ribs and SOB

The nurse is triaging patients in the ED. Which is true about the presentation of patient symptoms?

Older adults frequently have symptoms that are vague or less specific

The nurse is assessing a patient who has a chest tube. Which assessment finding requires intervention by the nurse?

Pain at the insertion site

EMS brings a large number of patients to the ED after a mass casualty incident. The nurse identifies the patients with which injuries with yellow tags? (SATA)

Partial thickness burns covering both legs Neck injury & numbness of both legs Small pieces of shrapnel embedded in both eyes Bruising & pain in the right lower abdomen

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?

You are free to express your feelings; whatever is said here stays here

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?

The patient is encouraged to cough and do deep breathing exercises frequently

The nurse is caring for 4 patients with asthma. Which patient does the nurse assess first?

The patient who heart rate is 120bpm

A patient has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (SATA)

Tracheal deviation Sudden onset of SOB Drainage greater than 70ml/hr Disconnection at Y site

A patient has RA that especially effects the hands. The patient wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?

Try a paraffin wax dip 20 mins before you quilt

The nurse working in the rheumatology clinic is seeing patients with RA. What assessment would be most important for the patients whose chart contains the diagnosis of Sjogren's syndrome?

Visual acuity

A patient with a new PE is anxious. What nursing actions are mot appropriate? (SATA)

Acknowledge the frightening nature of the illness Delegate a back rub to the UAP Give simple explanations of what is happening Stay with the patient and speak in a quiet, calm voice

A client with terminal lung cancer is receiving hospice care at home. Which action does the RN manager ask the LPN/LVN to do?

Administer prescribed medications to relieve the patients pain, SOB, and nausea

A nurse cares for a patient with burn injuries. Which intervention should the nurse implement to appropriately reduce the patients pain?

Administer the prescribed IV morphine sulfate

A patient is being admitted with suspected TB. What actions by the nurse are best? (SATA)

Admit the patient to a negative airflow room Order specialized masks/respirators for caregiving

A patient has been diagnosed with a very large PE and has a dropping BP. What medication should the nurse anticipate the patient will need as the priority?

Alteplase (Activase)

Which statement by a patient with a laryngectomy indicates a need for further discharge teaching?

"I cant put anything over my stoma to cover it"

A nurse has educated a patient on an epipen. What statement by the patient indicates additional instruction is needed?

"I dont need to go to the hospital after using it"

After providing discharge teaching, a nurse assesses the patients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the patient needs additional teaching?

"I take sodium bicarbonate after every meal to prevent heartburn"

A patient is scheduled for a total laryngectomy. Which statement by the patient indicates the need for further teaching about the procedure?

"I will have to take special care not to aspirate while eating"

What statement indicates that a patient needs further teaching regarding therapy with salmeterol (Serevent)?

"I will use the drug when I have an asthma attack." (Prevents attacks; doesn't relieve or reverse symptoms)

A patient has a chest tube. What assessment findings require immediate intervention from the nurse? (SATA)

"Silent chest" in the patient with a pneumothorax Tracheal deviation Constant bubbling in the water seal chamber in a patient post chest surgery

An emergency room nurse is triaging victims of a multi-casualty event. Which patient should receive care first?

26 yr old who has pale, cool, clammy skin

A nurse is assessing patients for fluid & electrolyte imbalances. Which patient should the nurse assess first for potential hyponatremia?

34 yr old on NPO status who is receiving IV DSW

A nurse triages patients arriving at the hospital after a mass casualty. Which patients are classified correctly? (SATA)

35 yr old female with severe chest pain - red tag 60 yr old male with an open fracture & distal pulses - yellow tag

A nurse is triaging patients in the ED. Which patient should the nurse prioritize to receive care first?

45 yr old reporting chest pain and diaphoresis

A nurse is triaging patients in the ED. Which patient should be considered urgent?

75 yr old female with a cough and temperature of 102f

A nurse teaches patients at a community center about risks for dehydration. Which patient is at greatest risk for dehydration?

76 yr old who is cognitively impaired

A nurse is assessing patients on a med-surg unit. Which patient should the nurse identify as being at greatest risk for atrial fibrillation?

A 50 yr old who is post coronary artery bypass graft surgery

A pulmonary nurse cares for patients who have COPD. Which patient should the nurse assess first?

A 52 yr old in a tripod position using accessory musles

A nurse is triaging patients in the ED. Which patient should the nurse classify as nonurgent?

A 62 yr old with a simple fracture of the left arm

The nurse assesses a patients chest tube and finds continuous bubbling is the water seal chamber. When the nurse clamps the chest tube close to the patients dressing, the bubbling stops. How does the nurse interpret this finding?

An air leak is present at the chest tube insertion site or in the thoracic cavity.

A patient has developed serum sickness. What is the most likely cause?

Antibiotic therapy

A nurse evaluates the following ABG: pH-7.48, PaO2-98, PaCO2-28, HCO3-22. Which condition should the nurse correlate with these results?

Anxiety-induced hyperventilation

A nurse is assessing patients on a med-surg unit. Which adult patient should the nurse identify as being at greatest risk for insensible water loss?

Anxious patient who has tachypnea

A patient is considering ART for HIV. What is the most important consideration about the patient when the primary health care provider is making a treatment choice?

Ability to adhere to therapy

A nurse is caring for a patient who has the following ABG: pH-7.12, PaO2-56, PaCO2-65, HCO3-22. Which clinical situation should the nurse correlate with these values?

Bronchial obstruction related to aspiration of a hotdog

A nurse in the oncology clinic is providing pre-op education to a patient just diagnosed with cancer. The patient has been scheduled for surgery in 3 days. What action by the nurse is best?

Call the patient at home the next day to review teaching

A nurse assesses a patient who is experiencing an acid-base imbalance. Patients ABG: pH-7.34, PaO2-88, PaCO2-38, HCO3-19. Which assessment should the nurse perform first?

Cardiac rate and rhythm

A student nurse is preparing to administer enoxaparin (Lovenox) to a patient. What action by the student requires immediate intervention by the supervising nurse?

Choosing an 18 gauge 2 inch needle

A nurse works on a unit that has admitted its first patient with AIDS. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the patient contracted the disease. What action by the nurse is best?

Confront the staff members about unethical behavior

A patients chest tube is accidentally dislodged. What action by the nurse is best?

Cover the insertion site with a sterile gauze and tape 3 sides

A nurse suspects a patient has serum sickness. What lab result would the nurse correlate with this condition?

Creatinine 3.2mg/dL (high, indicating serum sickness nephritis)

A patient with cancer is admitted to a short-term rehab facility. The nurse prepares to administer the patients oral chemotherapy meds. What action by the nurse is most appropriate?

Wear personal protective equipment when handling meds

A patient with AIDS is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?

Disposing of soiled dressings properly

A nurse prepares to defibrillate a patient who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this patient?

Ensure that everyone is clear of contact with the patient and the bed

A patient is diagnosed with mycobacterium TB. Which nursing intervention does the nurse implement for this patient?

Ensure the patient has a private room with negative airflow

A nurse is preparing to admit a patient on mechanical ventilation from the ED. What action by the nurse takes priority?

Ensuring there is a bag-valve-mask in the room

A patient hospitalized for chemotherapy has a hemoglobin of 6.1mg/dL. What medication should the nurse prepare to administer?

Epoetin alfa (Epogen)

The standard laryngectomy plan of care for a patient with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?

Establish a means for communicating during the immediate post-op period, such as a Magic Slate or an alphabet board.

The nurse is reviewing a medical record for an older adult patient recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the patient is receiving which medication?

Furosemide (Lasix)

A nurse receives new prescriptions for a patient with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The patients urine output continues to range from 0.2-0.25 ml/kg/hr. Which prescription should the nurse question?

Furosemide (Lasix) 40 mg IV push

To prevent the complications of Curling's ulcer, what does the nurse anticipate the provider will order?

H2 histamine blockers

A patient with Sjogrens Syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?

Home humidifier

After teaching a patient who was malnourished and is being discharged, a nurse assesses the patients understanding. Which statement indicates the patient correctly understood teaching to decrease risk for the development of metabolic acidosis?

I will eat 3 well-balanced meals and a snack daily

A patient with RA has an acutely swollen, red, and painful joint. What nonpharmacological treatment does the nurse apply?

Ice packs

A nurse cares for patients during a community-wide disaster drill. One of the patients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond?

In a disaster, extensive resources aren't used for one person at the expense of many others

A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do?

Place the patient in a side-lying position so secretions can drain

A patient is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?

Place the patient on Airborne precautions (manifestations of smallpox)

A nurse assesses a patient who is receiving TPN. For which adverse effects related to an acid-base imbalance should the nurse assess? (SATA)

Positive Chvostek's sign Anxiety and irritability

The ED nurse is assigned to triage patients. What is the purpose of triage?

Prioritize patients based on illness severity

A patient is on a ventilator and is sedated. What care may the nurse delegate to the UAP?

Provide frequent oral care per protocol

The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include

Reddish-purple skin lesions

A nurse assesses a patient who is experiencing an acid-base imbalance. ABG: pH-7.32, PaO2-94, PaCO2-34, HCO3-18. For which clinical manifestations should the nurse assess? (SATA)

Reduced deep tendon reflexes Drowsiness Increased respiratory rate

A nurse administers prescribed adenosine (Adenocard) to a patient. Which response should the nurse assess for as the expected therapeutic response

Short period of asystole

A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client?

Short, light massage

The lab report of a 38 yr old woman complaining of dry eyes, nose, mouth, and vaginal dryness shows elevated IgM levels, general antinuclear antibodies, and anti-SSA antibodies. Which condition does the nurse suspect?

Sjogrens Syndrome

While assessing a patient, the nurse notes that the patients vagina and buccal and nasal mucous membranes are dry. The lab reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome?

Sjogrens Syndrome

The nurse is caring for multiple patients in a temporary hospital after severe flooding in the area. Several patients have high fever, headache, and a papular rash over the face and extremities, including the palms of the hands. Some of the skin lesions are vesicular and pustular. What does the nurse suspect?

Smallpox

A nurse assesses a patient with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?

Speech alterations (Evidence of embolic events)

A nurse is teaching a patient about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self management?

Strict vegetarian

A patient is admitted with a pulmonary embolism. The patient is young, healthy, and active and has no known risk factors for PE. What action by the nurse is mot appropriate?

Teach the patient about factor V Leiden testing

A nurse is caring or a patient who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

Teach the patient fall prevention measures

Which activity performed by the community health nurse best reflects primary prevention of cancer?

Teaching a class on cancer prevention