Focus on Delegating Prioritizing Triage Disaster

A client is complaining of chest pain, and the nurse notes that the client's skin is cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the pulse oximetry reading is 84%. Which action should the nurse take first?

Increasing the oxygen to 3 L/min Rationale: Pulse oximetry identifies hemoglobin saturation. A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur. Ideal pulse oximetry values range from 90% to 100%. A range of 85% to 89% is acceptable in certain chronic disease conditions. When the value is below 85%, the body's tissues have a difficult time becoming oxygenated. Therefore the nurse would increase the oxygen to 3 L/min. Although the client is complaining of chest pain, there is no information to indicate that the client is experiencing chest pain that is cardiac in origin, so administering nitroglycerin as the first action is incorrect. Taking the client's vital signs and obtaining an ABG specimen will provide additional data, but in this situation an intervention is needed first.

A woman is brought to the emergency department (ED) in a severe state of anxiety after witnessing a child's drowning. The nurse assigned to care for the client would first:

Take the client to a quiet room with minimal stimulation Rationale: If a client with severe anxiety is left alone, he or she may feel abandoned and become overwhelmed. Placing the client in a quiet room where there is minimal stimulation is a priority intervention, but the nurse must stay with the client. It is not possible to teach the client relaxation techniques until her anxiety has decreased. The client should not be asked to describe the events of the accident until her anxiety has decreased. Although providing the client with a gross motor activity to drain some tension may be an appropriate intervention, it is not the first action.

An emergency department (ED) nurse receives a telephone call and is informed that several victims from a train accident will be brought to the ED. The nurse who received the telephone call must first:

Activate the agency disaster plan Rationale: In an external disaster, many people may be brought to an ED for treatment. Calling the ICU and asking the nurses to assist with the victims, making room for the arriving victims, and ensuring that making sure the triage rooms are supplied may all be components of preparing for the casualties, but activation of the disaster plan must be the initial action. Ideally the nurse would notify the nursing supervisor, who would then ensure that the ED is adequately staffed.

A labor nurse is caring for a client with a known history of sickle cell anemia. Which action does the nurse implement as a priority to help prevent sickle cell crisis?

Administering intravenous (IV) fluids as prescribed Rationale: Nursing care is focused on preventing sickle cell crisis. Oxygen is administered continuously, and IV fluids are administered to prevent dehydration because hypoxemia, dehydration, exertion, infection, and acidosis all stimulate the sickling effect. Providing support to the client and maintaining strict asepsis are appropriate interventions during labor but are not specific measures to prevent sickle cell crisis.

A client arrives in the emergency department complaining of feeling "something in my eye" and reports that some dust blew into the eye. The nurse would first:

Assess the client's vision Rationale: If the client complains of the presence of a foreign body in the eye, the nurse would first assess the client's vision. The nurse would examine the eye with fluorescein if a corneal abrasion is suspected, then perform gentle ocular irrigation with sterile normal saline to remove any particles. Once the foreign body has been removed, an eye patch may be applied.

A nurse monitoring a client who has just undergone cardiac catheterization notes the presence of a hematoma at the catheter insertion site. The nurse immediately:

Checks the peripheral pulse in the affected extremity Rationale: If a hematoma forms at the site of catheter insertion, the nurse must immediately check the peripheral pulse in the affected extremity, then contact the health care provider immediately so interventions may be initiated promptly. Placing ice on the catheter insertion site and applying a pressure dressing to the site are both inappropriate. Although the nurse may check the client's blood pressure and pulse, this is not the immediate priority.

A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye. The nurse must immediately:

Notify the surgeon Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the surgeon immediately. The client is not positioned supine because of the risk of increasing the intraocular pressure from swelling. Although pain medication may be prescribed, the client's symptoms indicate a serious complication requiring health care provider notification. Severe eye pain often indicates that the position of the iris has been disrupted, causing an acute increase in the intraocular pressure that may require surgical correction to preserve the client's vision.

A man calls a nurse in the emergency department (ED) and tells the nurse that his wife "just got a bloody nose." The man then asks the nurse what to do to stop the bleeding. The nurse tells the man immediately to:

Place the spouse in a sitting position, leaning forward with the head tipped downward Rationale: Initial care of the client with epistaxis consists of having the client sit up and lean forward with the head tipped downward to prevent the swallowing or aspiration of blood. The fingers are used to compress the soft tissues of the nose against the septum, with pressure maintained for at least 5 minutes. Ice or a cold compress is applied to the nose, not the back of the neck, to constrict the blood vessels. The health care provider is notified if bleeding does not stop with these interventions. In the hospital, if bleeding does not stop with direct pressure, a cotton ball soaked in a topical vasoconstrictor is placed in the nose and pressure is applied.

A mother brings her child to the emergency department because an insect has flown into the child's ear and the child is complaining of a buzzing sound. The nurse uses a flashlight in an attempt to coax the insect out of the ear, but this intervention is unsuccessful. Which action should the nurse take next?

Placing diluted alcohol in the ear Rationale: An insect that makes its way into an ear can often be coaxed out with the use of a flashlight or a humming noise. If this is unsuccessful, the insect must be killed before being removed. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed with ear forceps. The use of sterile water is avoided, because its use may cause swelling of foreign objects within the ear. Placing cotton in the ear to stop the buzzing and using an otoscope and ear forceps to remove the insect are both incorrect.

A home health nurse is assigned to three client visits today. One client requires twice-daily irrigation of an abdominal wound. Another client was discharged from the hospital yesterday after cardiac catheterization and will require an admission assessment and assistance with the scheduling of medications. The last client has diabetes mellitus and requires a blood specimen for serum glucose testing to be drawn. The nurse will schedule the assignment by visiting:

The client with diabetes mellitus first, the client with the wound irrigation second, and the client requiring admission last Rationale: The client with diabetes mellitus must remain on nothing-by-mouth (NPO) status until the blood specimen is drawn and so should be seen first. Because the client requiring wound irrigations will need to be visited twice, that client should be seen next. The client requiring admission would be visited third, after which the nurse would make the second visit to the client requiring wound irrigation.

A nurse is caring for a client who had a tracheostomy tube inserted 24 hours ago. The client begins to cough vigorously, accidentally decannulating (dislodging) the tube. The nurse immediately:

Ventilates the client with the use of a manual resuscitation bag and face mask Rationale: Tube dislodgement in the 72 hours after surgery is a medical emergency because the tracheostomy tract has not matured and tissue planes are not well defined. Attempts at replacement of a tube may result in cannulation of subcutaneous tissue planes instead of the trachea itself. Therefore the nurse would ventilate the client with the use of a manual-resuscitation bag and face mask while another nurse calls the resuscitation team for help.

A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client's respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first:

Discontinues the magnesium sulfate Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity. Other signs include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the client's vital signs and contact the health care provider health care providerThe most recent serum magnesium level may be checked; however, a current serum level would provide more useful data.

A client who sustained serious rib fractures in a motor vehicle accident is exhibiting signs of flail chest. With which immediate treatment measure does the nurse prepare to assist?

Endotracheal intubation with mechanical ventilation Rationale: Treatment for flail chest involves nasal or endotracheal intubation and mechanical ventilation with positive end-expiratory pressure (PEEP). Administering an opioid analgesic for pain, splinting the ribs with a rib strap, and inserting a chest tube are not interventions for the treatment of flail chest.

A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. The nurse immediately assesses the fetal heart rate, then:

Checks the character of the amniotic fluid Rationale: When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Next the nurse checks the character of the amniotic fluid, checks the maternal vital signs, and documents the findings. There is no information in this question to indicate that preparing the client for immediate delivery is necessary at this time.

A nurse monitoring a client undergoing peritoneal dialysis notes that the client is experiencing problems with inflow of the dialysate. The nurse first:

Asks the client about recent problems with constipation Rationale: Constipation is the primary cause of problems with inflow and outflow of peritoneal dialysate. Therefore the nurse would first question the client about recent problems with constipation. The nurse would next check the dialysis tubing for kinks and change the client's position. Placing the client in a supine low Fowler position minimizes intraabdominal pressure and promotes adequate inflow and outflow of dialysate. Milking of the peritoneal dialysis tube could dislodge a fibrin clot obstructing the tubing.

A nurse teaches a client with urolithiasis about the signs of urinary obstruction and the interventions to be taken if obstruction is suspected. The nurse tells the client that if signs of urinary obstruction occur, the client should immediately:

Call the health care provider Rationale: If signs of urinary obstruction occur, the client should immediately contact the health care provider. Obstruction is a medical emergency, requiring prompt treatment to preserve kidney function. Telling the client to drink 1500 mL of water is incorrect. Additionally, if an obstruction is present, increasing fluids could cause hydronephrosis. Checking the pH of the urine is not related to relieving an obstruction. Self-catheterization is inappropriate and may cause injury to the urethra.

A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed and the pulse and respiratory rate are increased from the client's baseline. The nurse would first:

Check the client's capillary blood glucose Rationale: The client's signs and symptoms are consistent with hyperglycemia. The nurse must first obtain a blood glucose reading to verify this interpretation, which would then be reported to the health care provider for subsequent prescriptions. Giving the client a glass of orange juice and administering a bolus dose of 50% dextrose would be implemented as needed in the treatment of hypoglycemia. Insulin therapy is guided by blood glucose measurements.

A client who has been bitten on the right arm by a snake arrives at the emergency department. The nurse immediately:

Immobilizes the affected arm at heart level Rationale: Treatment of snakebite is focused on preventing the spread of venom. Rings, watches, and restrictive clothing should be removed, after which the affected limb should be immobilized at the level of the heart. Ice and tourniquets are not recommended. Tetanus prophylaxis is administered, but this is not the action to be taken first.

A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first:

Place a tourniquet proximal to the site of the insect sting Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated, and start an IV line.

A client undergoing mechanical ventilation pulls out the endotracheal tube. The nurse would immediately:

Prepare for re-intubation Rationale: If unexpected extubation occurs, the nurse must first assess the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance, and prepare for re-intubation. There is no information in the question to indicate that a code needs to be called or that the client needs to be suctioned. A chest x-ray might be performed after re-intubation but would not be the immediate action in this situation.

An emergency department nurse is conducting an assessment of a client who has sustained a circumferential burn to the right arm. What should the nurse assess first?

Radial pulse Rationale: The client who sustains circumferential burns to an extremity is at risk for altered peripheral circulation. The priority assessment is to check for the presence of the peripheral pulse to ensure that circulation is adequate. Although the temperature, heart rate, and BP would also be assessed, the priority with a circumferential burn is assessment for the presence of a peripheral pulse.

A nurse is caring for a client with a closed chest tube drainage system. When the client is repositioned, the chest tube is disconnected. The nurse immediately:

Submerges the end of the tube in a bottle of sterile water Rationale: If the tube becomes disconnected, it is best to immediately submerge the end in a bottle of sterile water or saline to re-establish a water seal. In most situations, clamping of a chest tube is contraindicated. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax, because the air has no escape route. The health care provider may need to be notified, but this is not the immediate action. The client would not be instructed to perform a Valsalva maneuver.

A client calls the nurse at the emergency department (ED), says that he thinks that he came in contact with poison ivy while working in his yard, and asks the nurse for advice. The nurse tells the client immediately to:

Take a shower Rationale: If contact with poison ivy is suspected, symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before it can penetrate the skin. It is not necessary for the client to be seen immediately in the ED. Oatmeal baths are useful in soothing dry or itchy skin. The nurse would not advise the client to apply hydrocortisone cream. Medications should be recommended by the health care provider, and this intervention would probably not be recommended unless a pruritic poison ivy rash actually developed.

A ventilator's high-pressure alarm sounds. The nurse rushes to the client's room and assesses the client but is unable to determine the cause of the alarm. The nurse immediately:

Ventilates the client manually with the use of a resuscitation bag Rationale: Mechanical ventilators have alarm systems that warn the nurse of problems with the client or ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with the use of a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or the health care provider. Inserting an oral airway is not an immediate intervention, although one may be inserted in a client who is biting on the endotracheal tube.

A nurse on the day shift (7 a.m.-3 p.m.) is assigned to care for four clients. In planning care, which client does the nurse assess first?

A client with emphysema who is receiving oxygen at a rate of 2 L/min Rationale: Airway is always the priority, so the nurse would first attend to the client who has emphysema and is receiving oxygen. The client scheduled for a barium enema today, the client requiring the daily dressing change on an amputation stump, and a client who has undergone angioplasty and is preparing for discharge are all intermediate priorities.

A home care nurse is assigned to visit a client who lives alone. The client was recently discharged from the hospital after cardiac catheterization and placement of two stents in the right main coronary artery. The client tells the nurse that she has been experiencing chest pain and has taken 3 sublingual nitroglycerin tablets, with no relief. What immediate action should the nurse take?

Call an ambulance to take the client to the ED Rationale: Chest pain that is unrelieved by rest and nitroglycerin may not be typical anginal pain; instead, it may signal myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. The nurse would call an ambulance to transport the client to the ED. The nurse would not drive the client, because the client should not exert energy or increase the workload of the heart. Additionally, the nurse would not be able to provide adequate care if an emergency were to arise during transport to the hospital. Although the nurse would contact a family member and inform the home healthcare agency of the situation, these are not the immediate interventions.

A nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lowering the head of bed slowly until the dizziness passes Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. This is most likely a result of orthostatic hypotension. When this occurs, the nurse relieves the feeling by lowering the head of the bed slowly until the dizziness eases. The nurse then checks the pulse and blood pressure. There is no reason to contact the health care provider at this time. It may be appropriate to obtain assistance in getting the client out of bed, but this is not the first nursing action.

A client with a spinal cord injury suddenly experiences a severe headache and nasal stuffiness. The client is also diaphoretic, hypertensive, and bradycardic. The nurse determines that the client is experiencing autonomic dysreflexia and immediately:

Raises the head of the bed to a high Fowler position Rationale: Autonomic dysreflexia is an emergency that occurs in people who have sustained spinal injuries as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distension or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a high Fowler position to lower the blood pressure. The health care provider is then notified of the emergency. Finally the nurse performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately with the use of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or other compromise.

A registered nurse (RN) is planning the client assignments for the day. To which nurse does the RN appropriately assign care of a woman undergoing brachytherapy with a sealed radiation source for cervical cancer?

A nurse who has worked with clients undergoing brachytherapy in the past Rationale: Brachytherapy involves the use of radioactive isotopes in solid form or within body fluids. Because the radiation source is within the client, the client emits radiation for some time and may pose a hazard to others. A pregnant nurse should not care for a client undergoing brachytherapy. The time any nurse is exposed to such radiation sources should be limited to 30 minutes of direct care per 8-hour shift, so a nurse should not be assigned to care for more than one client undergoing brachytherapy. It is most appropriate to assign a nurse who is familiar with the care of a client with brachytherapy rather than to assign a nurse who is not.

A client is admitted to the emergency department with a complaint of severe crushing chest pain that radiate down both arms. The client is dyspneic, and the nurse immediately places a cannula on the client to deliver oxygen at 4 L/min and inserts an intravenous (IV) catheter. The health care provider orders an immediate troponin determination, a chest x-ray, a 12-lead electrocardiogram (ECG), and morphine sulfate 2 mg IV. What will the nurse do first?

Administer the IV morphine sulfate Rationale: Pain control is a priority, because the chest pain indicates cardiac ischemia. Pain also stimulates the autonomic nervous system and increases preload, resulting in increased myocardial demand and further cardiac damage. The nurse would administer oxygen to the client and administer morphine sulfate. Once the morphine sulfate has been administered, the nurse can obtain the ECG, which may provide evidence of cardiac damage and the location of myocardial ischemia. Although an evaluation of the client's troponin level may be of use in the choice of treatment, this is an assessment, and the situation requires action. Although the chest x-ray might show cardiac enlargement, having the chest x-ray would not influence immediate treatment, so is not the priority.

A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply.

-A client who has been fitted with skeletal traction of the right leg after an open reduction measures -A client with a nasogastric tube who underwent bowel resection 2 days ago Rationale: When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant.

A registered nurse is planning client assignments for the day. Which clients should the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply.

-A client with diarrhea who requires assistance with hygiene care -A client on strict bed rest who requires range-of-motion exercises every 2 hours Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the nurse practice act and the job description of the employing agency. A client scheduled for colonoscopy has physiological needs and requires nursing assessments, as well as psychosocial support. A client who underwent mastectomy 2 days earlier will require both physiological and psychosocial care. A client scheduled for discharge after cardiac catheterization will require reinforcement of medication information and home care management. The nursing assistant may care for the client requiring hygiene care for diarrhea. The UAP has been trained to care for a client on bed rest and in the procedure for performing range-of-motion exercises. The nurse would provide instructions to the UAP regarding these tasks, but the tasks required for this client are within the role description of a UAP.

A registered nurse (RN) on the 7 a.m.-3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all that apply.

-A client with type 1 diabetes mellitus who has a foot ulcer -A client who had a mastectomy 2 days ago -A client with left-side weakness who will need assistance with personal care Rationale: When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN.

A nurse is delegating tasks to the nursing staff. Which tasks are appropriate for the unlicensed assistive personnel (UAP)? Select all that apply.

-Accompanying a man being discharged home to his transportation at the hospital entrance -Obtaining frequent oral temperatures from a client who is receiving a blood transfusion -Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency Rationale: The nurse must determine the most appropriate assignments on the basis of the skills of the staff member and the needs of the client. Although assisting clients with feeding is often within the scope of practice of a UAP, a newly admitted client who has had a stroke and is experiencing dysphagia should be cared for by the RN so that an assessment of the client's risk for aspiration may be completed and appropriate recommendations for safe feeding made. Neither would it be appropriate to assign a UAP to obtain a 24-hour dietary recall from a client with anorexia nervosa. This assessment is most appropriately conducted by a registered nurse, who would assess the quantity of food consumed by the client. The tasks identified in the remaining three options include no data to indicate that they carry any major risks.

A registered nurse (RN) on the day shift has been assigned to care for four clients. Once the nurse has made initial rounds and checked all of the assigned clients, which client will the RN care for first? *A client with metastatic carcinoma who has just received pain medication *A client who is scheduled for occupational therapy at 10 a.m. *A client scheduled for an ultrasound at 11 a.m. who is on nothing-by-mouth (NPO) status *A client who is scheduled for surgery at 1 p.m.

A client who is scheduled for surgery at 1 p.m. Rationale: The RN would care for the client who is scheduled for surgery at 1 p.m. first. Several issues, including client preparation (physical and emotional) and health care provider prescriptions, must be addressed before the surgery, and this preparation takes time. Additionally, the operating often makes late changes in the schedule, depending on room and health care provider availability, and may request an earlier surgery time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client in pain. The client scheduled for an ultrasound and the client scheduled for occupational therapy later in the morning do not have priority needs.

A client returns from the operating room after the application of skeletal traction to treat a fractured femur. Which action would the nurse implement first in the care of the client?

Assessing the neurovascular status of the affected extremity Rationale: The neurovascular status of the injured extremity must be assessed every 2 hours during the 24 hours following the procedure. Asking the client about pain is appropriate, but pain medication would be administered after the extremity assessment; client alertness is needed to answer questions about sensation. The vital signs are also assessed, but the client's neurovascular status is the priority. Instructing the client in the use of the trapeze is not the priority.

A registered nurse (RN) must determine how best to assign an RN and a licensed practical nurse (LPN) to provide care to a group of clients. Which is the appropriate assignment?

Assigning the RN to care for a woman with newly diagnosed metastatic carcinoma who has two school-aged children Rationale: For an accurate determination of what may or may not be delegated to a co-worker, several factors must be considered. The nurse must carefully consider the level of care each client requires, immediately and potentially in the future; the competencies possessed by the co-workers; and the legal limitations on the practice of those co-workers. The woman with newly diagnosed metastatic carcinoma who has two school-aged children is likely to be in need of the skills of an RN, in terms of both physiological needs and psychosocial needs, making this the correct option and an appropriate assignment. The client who was transferred from the ICU this morning has undergone a neurosurgical procedure (craniotomy) in which the risk of increased intracranial pressure is present and therefore requires frequent neurological assessments. This, in addition to the fact that the client was transferred from the ICU this morning, makes this an inappropriate assignment for an LPN. The LPN should not provide initial discharge teaching on medications to a client. Teaching is a professional responsibility that the RN may not delegate to anyone but another RN, making this option incorrect. Although under some circumstances the RN might care for a client being discharged after chest pain, the question tells you that an LPN is available. The RN would be best used to care for the clients with more critical or complicated needs. Therefore this option is incorrect.

A nurse is monitoring a client with an oral endotracheal tube inserted that is attached to mechanical ventilation. The nurse assesses the client and notes that the client has unequal breath sounds. On the basis of this assessment finding, the nurse would first:

Check the depth marking at the client's lips Rationale: If it is determined that breath sounds in the client with an endotracheal tube attached to mechanical ventilation are unequal, the nurse would first check the depth marking at the client's lips to evaluate the endotracheal tube for proper depth. If the tube is deeper or shallower than it should be, repositioning of the tube will be necessary. The nurse would then notify the health care provider, who may prescribe a chest x-ray to verify placement and then reposition the tube as needed. If the tube is displaced, suctioning the client would not remedy the problem. Humidified oxygen should already be in place for a client receiving mechanical ventilation.

A nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse first:

Checks the client's white blood cell (WBC) count Rationale: When the dialysis drainage becomes cloudy, peritonitis is suspected, and the nurse must first check the client's WBC count. A culture and sensitivity are obtained, and broad-spectrum antibiotics are added to the dialysate solution pending culture and sensitivity results as prescribed. The dialysate solution may also be heparinized (per health care provider prescription) to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or recurrent, but the nurse would not make this decision. The peritoneal dialysis flow is not increased.

A nurse notes that a client who has just been given a diagnosis of AIDS appears anxious and is reluctant to ask questions. Which initial action by the nurse is the best way to deal with the observation?

Identifying common fears and questions expressed by other clients with the same diagnosis Rationale: Identifying common fears and questions expressed by other clients often encourages the client to ask questions that he or she has thought of but not verbalized. The nurse should plan to spend additional time with the client. Requesting that a family member be present could reduce the client's anxiety and may be tried after the nurse has talked to the client. However, communication with the client is needed to determine the source of the anxiety. Asking the client direct questions is initially a nontherapeutic communication technique. The client may not be able to explain or discuss his or her feelings about having the disease.

A nurse conducting a postpartum assessment notes that the client's uterus is not firmly contracted. The nurse would first:

Massage the uterine fundus Rationale: If the uterus is not firmly contracted, the nurse must first massage the uterine fundus until it is firm; this will also help express clots that may have accumulated in the uterus. If the uterus does not contract, the nurse must contact the health care provider. A rapid intravenous infusion of dilute oxytocin may be prescribed to increase uterine tone and decrease bleeding if uterine massage is not effective. The nurse would check the client's vital signs, but this would not be the first action.

A nurse determines that a client with type 1 diabetes mellitus is having a mild hypoglycemic reaction. The nurse immediately gives the client:

1 tablespoon of honey Rationale: Mild hypoglycemia is immediately treated with 10 to 15 g of carbohydrate. Sources of carbohydrate include ½ cup (120 ml) of fruit juice, ½ cup (120 ml) of a regular (nondiet) soft drink, 8 oz (240 ml) of skim milk, 6 to 10 hard candies, four cubes or 4 teaspoons of sugar, six saltines, three graham crackers, and 1 tablespoon of honey or syrup. Eating a full-size candy bar is not an appropriate treatment for hypoglycemia, because the bar contains an inappropriate amount of carbohydrates. Graham crackers and peanut butter may be indicated for a moderate reaction or if the client continues to experience hypoglycemia despite treatment with the initial 10 to 15 g of carbohydrates.

A nurse is assigned to care for four clients. Which client would the nurse would assess first during initial rounds?

A client with pneumonia Rationale: Airway is always a high priority, and the nurse would assess the client with pneumonia first. Clients in Buck's traction and those with chronic renal failure or cirrhosis have intermediate needs.

A client who has sustained a severe burn injury is brought to the emergency department (ED). Which action does the ED nurse implement immediately?

Administering 100% oxygen by way of face mask Rationale: When a victim who sustains a burn injury arrives at the ED, breathing is assessed and a patent airway established immediately. The client is also immediately given 100% oxygen by face mask to prevent tissue hypoxia, which may occur as a result of the high carboxyhemoglobin level involved in a burn. If the victim has severe respiratory distress or airway edema, endotracheal intubation may be necessary. Once oxygen has been started, fluid resuscitation is implemented. Body temperature is maintained and the client is covered with sterile sheets or blankets. Care of the burn wound is delayed until all live-saving measures have been initiated. Tetanus prophylaxis may be necessary, but this is not a priority intervention.

A nurse who is caring for a client with a tracheostomy tube notes heavy bleeding from the stoma and sees that the tracheostomy tube pulsates with the client's heartbeat. Suspecting that a trachea-innominate artery fistula has developed, the nurse immediately removes the tracheotomy tube. The next nursing action is:

Applying direct pressure to the innominate artery at the stoma site Rationale: With a trachea-innominate artery fistula, malpositioning occurs when the tube's distal tip pushes against the lateral wall of the tracheostomy. Continued pressure from the tracheostomy tube causes necrosis and erosion of the innominate artery. This situation is a life-threatening complication. The tracheostomy tube is immediately removed. Direct pressure is then applied to the innominate artery at the stoma site and the client is prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action. The nurse would not insert a smaller tracheostomy tube.

A nurse is changing a client's central intravenous (IV) catheter dressing. During the procedure, the unit secretary calls the nurse over the handheld radio and says that a health care provider has telephoned and is asking to speak to the nurse. The nurse should:

Ask the unit secretary to inform the health care provider that the call will be returned after the dressing change has been completed Rationale: Because the dressing change is a sterile procedure and a risk for infection exists, it is appropriate to ask the unit secretary to obtain a telephone number from the health care provider so that the call may be returned. It is not appropriate to ask a health care provider to wait while a procedure is being completed. Having the unit secretary transfer the call to the nurse's handheld radio is a potential HIPAA violation, because the health care provider may wish to speak to the nurse regarding another client, and the client with whom the nurse is working would hear the conversation.

A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. On the basis of these assessment findings, the nurse first:

Contacts the health care provider Rationale: The client with early acute compartment syndrome typically complains of severe, diffuse pain that is unrelieved by pain medication. The client also complains that pain during passive motion is greater than that during active motion. The nurse notifies the health care provider immediately. Checking to see whether it is time for more pain medication and continuing to assess the pain level are both incorrect and delay necessary interventions. The fractured extremity should already have been elevated.

A mother rushes into the emergency department with her child and tells the nurse that the child has drunk bleach from a bottle that the mother was using to clean bathrooms. The nurse notes that child is alert but sees areas of irritation around his mouth. Which intervention does the nurse immediately begin preparing for?

Dilution of the corrosive substance with water or milk Rationale: Household bleach is a corrosive agent. Treatment includes diluting the corrosive agent with water or milk (usually no more than 120 mL). Inducing emesis is contraindicated because vomiting will damage the mucosa. Neutralization is not performed in this type of poisoning because it may result in a hypothermic reaction, which produces heat, causing a worsening of symptoms or producing a thermal burn in addition to a chemical burn. There is no useful purpose for inserting a nasogastric tube in this type of poisoning.

A nurse on the surgical nursing unit is assessing a postoperative client who is experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg and the pulse rate is 100 beats/min. The client is receiving oxygen at 2 L/min by way of nasal cannula, and the pulse oximetry reading is 92%. Once it has been determined that the airway is patent, what should the nurse do next?

Elevate the client's feet and legs above heart level Rationale: The client is exhibiting signs of shock and requires emergency intervention. When shock is suspected, the nurse immediately takes steps to ensure a patent airway and administers oxygen. In this case, the client is already receiving oxygen and the nurse has determined that the airway is patent. The nurse would next elevate the client's feet and legs, keeping his or her head flat or elevated 30 degrees. The nurse should assess the dressing for any bleeding and, if bleeding is noted, apply direct pressure. The surgeon would be notified. The surgeon may prescribe an increase in intravenous fluids or a blood transfusion; however, preparing a transfusion administration set at this time is not indicated.

A client arrives at the emergency department after experiencing a traumatic blow to the eye, and a hyphema is diagnosed. The nurse should first:

Ensure that the client is placed in a semi-Fowler position Rationale: Hyphema is the presence of blood in the anterior chamber of the eye. It occurs when force is applied to the eye, breaking the blood vessels. The client is immediately placed on bed rest in a semi-Fowler position to allow gravity to help keep the hyphema away from the optical center of the cornea. Minimal or no sudden eye movements are permitted for 3 to 5 days to decrease the risk of rebleeding. Cycloplegic eye drops may be prescribed to place the eye at rest, and the eye is protected by a patch and shield. Watching television and reading are usually restricted. Hyphema usually resolves in 5 to 7 days.

The mother of a 6-year-old calls a nurse who lives in the neighborhood and reports that her child has accidentally splashed alcohol into her eyes. The nurse tells the mother immediately to:

Hold the child's head with the eyes under running lukewarm tap water for 20 minutes Rationale: In the event of a chemical injury, the eyes should be copiously irrigated with tap water for 20 minutes. The child's head is held with the eyes under running lukewarm tap water, and the upper eyelids are everted to flush the eyes thoroughly. The child is then taken to the emergency department. After treatment at the emergency department, the child should rest with the eyes closed in a darkened room. Wiping the eyes with a wet towel is incorrect and would increase the pain and burning.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. Which health care provider's prescriptions does the nurse implement first?

Obtaining a pulse oximetry reading Rationale: The child is attached to a pulse oximeter, which provides ongoing information regarding the child's oxygen level, as a means of determining whether oxygen intake is sufficient. The child is also immediately attached to a cardio-respiratory monitor to facilitate early identification of apnea and bradycardia. The nurse would then conduct an assessment, including taking the child's temperature and weight and asking the parents about the child. Although administering the prescribed antibiotic, encouraging the intake of oral fluids, and administering pertussis immune globulin are all appropriate interventions, none is a priority among the options provided.

A client arrives in the nursing unit after internal maxillary fixation (IMF) surgery. The nurse immediately:

Positions the client on one side with the head slightly elevated Rationale: Immediately after IMF surgery, the client is positioned on one side with the head slightly elevated. The nurse then connects the NG tube to low intermittent suction to remove fluids and gas from the stomach to help prevent aspiration. Antiemetic medications are administered to prevent vomiting, but this is not the immediate action. Wire cutters and suction equipment should already have been placed at the bedside.

A client arrives at the emergency department with an episode of status asthmaticus. The nurse first:

Places the client in a high Fowler position Rationale: The first nursing action is to place the client in a position that aids respiration —sitting bolt upright or in a high Fowler position. Other nursing actions include monitoring vital signs and administering bronchodilators and oxygen at levels of 2 to 5 L/min or 24% to 28% by way of Venti mask. Insertion of an IV line and ongoing monitoring of respiratory status are also indicated.

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is red and inflamed and feels hard on palpation. On the basis of this assessment, the nurse should first:

Remove the IV catheter Rationale: Phlebitis at an IV site may be signaled by client discomfort at the site, as well as by redness, warmth, hardness, and swelling proximal to the catheter. The IV catheter should be removed and a new IV catheter inserted at a different site. Recognizing that slowing the infusion will not resolve the client's symptoms will help you eliminate this option. The health care provider would be notified if phlebitis occurred, but this is not the first action for the nurse. Warm compresses are applied to the site to relieve pain and discomfort, but the IV catheter would be removed first.

A client who has just undergone surgery is receiving continuous intravenous (IV) morphine sulfate for pain control. On assessment of the client, what does the nurse check first?

Respiration Rationale: Morphine sulfate depresses respiration, so the nurse monitors the client's respiratory status closely. The nurse also monitors the client's blood pressure closely because of the risk for orthostatic hypotension. Although the temperature, urine output, and surgical incision are all assessed, respiration is the priority nursing action.

A nurse is assigned to care for a client in the fourth stage of labor. What does the nurse plan to do first?

Assess the uterine fundus Rationale: The fourth stage of labor is the stage of physical recovery for the mother and infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. One potential complication after delivery is hemorrhage, and the most significant source of bleeding is the site where the placenta is attached. Therefore the nurse should first assess the client's uterine fundus to ensure that it is firm. The nurse must also check the client's vital signs. Once these interventions have been performed, the nurse checks lochial flow, assesses the episiotomy site, places ice on the perineal area to promote comfort, and provides the mother with oral fluids. Once physiological needs have been met, the nurse may allow visitors to see the mother and newborn.

A nurse reviews the laboratory values of a client with bipolar disorder who is taking lithium carbonate (Lithobod) and notes that the serum lithium level is 2.0 mEq/L (2.0 mmol/L). On the basis of this laboratory value, the nurse first:

Calls the health care provider Rationale: A serum lithium level of 2.0 mEq/L (2.0 mmol/L) indicates toxicity, and the health care provider must be notified. The nurse would assess the client for signs of toxicity, which include coarse hand tremors, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, and incoordination. Administering the prescribed dose of lithium carbonate is incorrect, because the lithium level indicates toxicity. Placing the client in the seclusion room is also inappropriate. Although the laboratory report will be documented in the client's record, this is not the priority action.

A nurse is preparing to care for a client who is undergoing cardioversion. Once the procedure is complete, the nurse ensures that the client has a patent airway and administers oxygen to the client, then:

Checks the client's vital signs Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, administration of oxygen, assessment of vital signs and level of consciousness, and detection of dysrhythmia. All of the options are interventions performed after cardioversion, but checking the client's vital signs is the priority.

A health care provider places an intestinal tube in a client. After insertion, the nurse immediately:

Positions the client on the right side Rationale: The intestinal tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a health care provider's responsibility. The tube, which has a weighted tungsten tip, is advanced either by gravity or manually. Advancement of the tube may be monitored by measuring the tube and by with the use of x-rays. The tube is not secured to the client's face until the desired location is reached. After insertion, the client is positioned on the right side to facilitate passage of the tube via the natural mobility of the gastrointestinal tract. The nurse documents the insertion and the client's tolerance of the procedure in the client's record, but this is not the immediate action.

A nurse is preparing to care for a child being admitted to the hospital with infectious gastroenteritis. The priority nursing intervention is:

Starting an intravenous (IV) line as prescribed Rationale: Infectious gastroenteritis is caused by a variety of communicable viruses, bacteria, and parasites capable of causing serious diarrhea, massive fluid and electrolyte loss, sepsis, and death. The priority therapy in a child with infectious gastroenteritis is the replacement of water and correction of acid-base or fluid and electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement preparations. A stool culture and antimicrobial drugs may be prescribed, but these are not the priority interventions. Instructions to the parents may be necessary but are not the priority on admission of the child to the hospital.

A cardiac monitor alarm sounds, and the nurse notes an erratic rhythm on the screen. The immediate nursing action is to:

Assess the client Rationale: If a monitor alarm sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. If the clinical status of the client is stable, the nurse must next check the cardiac electrodes attached to the client. A rhythm strip is obtained if the client is experiencing a dysrhythmia. A code is called if the client requires cardiopulmonary resuscitation. On the basis of the information in the question and the options provided, calling a code, checking the cardiac electrodes attached to the client and obtaining a rhythm strip for evaluation are not the immediate actions.

A nurse is caring for a client who is receiving intermittent feedings by way of a nasogastric tube. Before feeding the client, the nurse checks tube placement and determines correct placement, then:

Checks the residual volume Rationale: Before starting the feeding, the nurse checks the placement of the nasogastric tube by aspirating gastric contents and measuring the pH. The residual volume is checked, and the feeding is held if the residual volume is greater than 100 to 150 mL (depending on agency policy and procedures) to help prevent aspiration. In another intervention designed to help prevent aspiration while a tube feeding is being administered, the nurse places the client in an upright sitting position or elevates the head of the bed at least 30 degrees. Formulas are administered at room temperature. The nasogastric tube may be irrigated just before a feeding, but the residual volume is checked first.

A client who experienced ventricular fibrillation has undergone defibrillation three times, without success. The nurse would next:

Continue cardiopulmonary resuscitation (CPR) Rationale: After defibrillation, the nurse immediately assesses the client's cardiac rhythm and pulse. These assessments will provide the information needed to determine whether the defibrillation was successful. If the first countershock is unsuccessful, immediate defibrillation is performed at a higher energy level. Defibrillation may be applied three times, if needed, for persistent ventricular fibrillation or pulseless ventricular fibrillation. CPR should be continued if the three defibrillations are unsuccessful. Assessing the client's level of consciousness is not the priority if defibrillation is unsuccessful. Defibrillating one last time is incorrect protocol, and increasing the IV flow rate is not done without a prescription to do so.

A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately:

Place the client in a semi-Fowler position Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed chest injury is suspected, the nurse must immediately place the client in a semi-Fowler position. Because this is a medical emergency, the nurse then notifies the health care provider. A chest x-ray, computed tomography, or ultrasonography would be used to confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and placement of a chest drainage system, the nurse then prepares a thoracentesis tray and chest drainage equipment.

A nurse assesses a client at the beginning of the shift and notes an intravenous (IV) infusion is running at 100 mL/hr and that 800 mL of fluid remains in the IV bag. Thirty minutes later, the client calls the nurse and complains of shortness of breath. The nurse sees that 400 mL of IV solution remains in the IV bag. The nurse immediately:

Stops the rate of the IV infusion Rationale: The client is most likely experiencing circulatory overload. The nurse may identify the condition by noting that 400 mL has infused over the course of 30 minutes. The first action on the part of the nurse is to stop the rate of the IV infusion but ensure that IV patency is maintained so that any prescribed medications can be administered. Other actions may follow in rapid sequence: The nurse raises the client to an upright position to aid the client's breathing, notifies the health care provider, monitors the client's vital signs, and administers oxygen as prescribed.

A registered nurse (RN) is planning assignments for six clients on a nursing unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) on the nursing team. Which clients should the nurse assign to the RN? Select all that apply

-A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L) -A client with newly diagnosed type 1 diabetes mellitus -A client who was admitted during the night after an acute asthma attack Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The client with newly diagnosed type 1 diabetes mellitus will require significant education, which should be provided by the RN. The client with gastrointestinal bleeding and a low hemoglobin level will likely require a blood transfusion, which must be performed by the RN. The client who was admitted to the hospital during the night after an acute asthma attack would most appropriately be assigned to the RN, because frequent respiratory assessments will be required. The UAP can most appropriately assist with personal care. The LPN can perform dressing changes and administer enemas.

Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle crash. During an assessment, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client exhibits signs of hypoxia. The nurse immediately:

Cuts the mouth wires Rationale: IMF is a common means of securing a mandibular fracture. The bones are realigned and then wired in place with the bite closed. After surgery, the client is at risk for aspiration if he or she vomits because of the impossibility of opening the jaws to allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the client at all times in readiness for this emergency. Antiemetics may be prescribed to prevent nausea and subsequent vomiting; however, this is not the immediate action if the client is vomiting. Placing the client in a supine position increases the risk of aspiration. The client is placed in an upright position and turned to the side. There is no helpful reason to contact the anesthesiologist.

A nurse is performing closed suctioning through a tracheostomy for a ventilator-dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately:

Oxygenates the client manually with 100% oxygen Rationale: Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client's problem in this situation. An increase in PEEP is not indicated at this time.

A nurse responds to a disaster call in which a building collapsed and several victims were seriously injured. Which victim will the nurse attend to first?

A victim with an amputated arm Rationale: A triage system identifies and categorizes victims so that those with the most critical but treatable injuries or illnesses are treated first. In one common system, red denotes priority I, yellow is priority II, green is priority III, and black is priority 0. Priority I includes life-threatening problems that need immediate attention such as trauma, chest pain, respiratory distress, chemicals in the eyes, arm or leg amputation, and shock. Priority II includes victims in need of treatment within 20 minutes to 2 hours — for example, a victim with a simple fracture. Priority III is assigned to victims who can wait for treatment, such as people who have sustained sprains or minor lacerations. Priority 0 denotes a victim who is dying or dead, who has sustained massive head trauma, or who is in cardiopulmonary arrest.

A nurse notes that a client who is attached to a cardiac monitor has suddenly began exhibiting the following rhythm. (A fib onset) After contacting the health care provider, which intervention does the nurse prepare the client for?

Administration of adenosine Rationale: The client's ECG shows the onset of atrial fibrillation with a rapid ventricular response rate. The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses, and the medication usually prescribed is adenosine Other medications used to control this dysrhythmia in emergency situations include amiodarone,diltiazem, and verapamil. In atrial fibrillation, thrombi may form in the stagnant blood in the atria and become emboli, which may lodge in the pulmonary or peripheral blood vessels. Therefore, although an intravenous infusion of heparin sodium may be prescribed, this is not the initial treatment. Anticoagulation therapy, which may be continued for at least 4 weeks after the client is converted to a normal sinus rhythm, may include warfarin sodium or aspirin. TEE is performed to determine the presence of atrial thrombi. A permanent pacemaker may play a role in the management of atrial fibrillation but would not be the initial intervention.

A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first:

Assess the client's intake and output Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client's intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client's weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention during physical assessment.

A nurse in charge of an emergency department (ED) arrives at work at 11 p.m. and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services has just called to report that several victims of a fire will be brought to the ED. The nurse in charge immediately:

Calls the nursing supervisor to discuss activation of the disaster plan Rationale: External disasters are a fact of life in a community, and victims are often brought to the ED for care. In this situation, the nurse in charge would first contact the nursing supervisor to explain the need for additional staffing and discuss activation of the disaster plan. The nurse in charge should ask, not demand, that nurses from the evening shift stay until all of the victims have been treated. The nurse in charge would not ask emergency medical services to take the victims to another hospital or close the ED temporarily to incoming clients. These decisions are made by hospital administration.

A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour is 20 mL. On the basis of this finding, the nurse should first:

Check the client's overall intake and output record Rationale: Clients are at risk for hypovolemia after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Increasing the rate of the IV infusion and administering a 250-mL bolus of normal saline (0.9%) would not be implemented without a prescription from the health care provider. The health care provider is called once the nurse has gathered all necessary assessment data, including the overall fluid status, and vital signs.

A client arrives in the emergency department and reports that an acid solution was splashed into his eye. The nurse immediately:

Irrigates the eye with copious amounts of sterile normal saline solution Rationale: Emergency care after a chemical injury to the eye includes irrigating the eye immediately with water, sterile normal saline, or ocular irrigating solution. The irrigation should be maintained for at least 15 minutes before the client is further evaluated and treated. Irrigating the eye immediately may preserve eye function. After this emergency treatment, visual acuity is assessed. A litmus paper may be applied to the conjunctiva to determine the pH if the substance that splashed into the eye is unknown. Further treatment may include topical antibiotics or corticosteroids.

A nurse assessing a client with a closed chest tube drainage system notes constant bubbling in the water seal chamber. The nurse assesses the system for air leaks but is unable to locate a visible leak. Based on this finding, the nurse next:

Replaces the drainage system Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an air leak if constant bubbling were noted in this chamber. If an air leak cannot be located, the nurse next replaces the drainage system. If continuous bubbling in the water seal chamber continues, the health care provider is notified, because an air leak may be present in the pleural space, and leakage and trapping of air in the pleural space may result in a tension pneumothorax. Reducing the degree of suction being delivered will not affect the bubbling in the water seal chamber and could be a harmful. Clamping and milking the chest tube are both incorrect. Additionally, a chest tube is not clamped or milked unless specifically prescribed and the procedure is an approved intervention as stated in the agency's policies and procedures.

A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125 mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of dependent edema and puffiness around the client's eyes. The nurse suspects circulatory overload and immediately:

Slows the IV rate Rationale: Signs of circulatory overload include shortness of breath, cough, increased blood pressure, puffiness around the eyes, and edema in dependent areas. The client's neck veins may be engorged, and the nurse may hear moist breath sounds on auscultation of the lungs. If circulatory overload occurs, the nurse must immediately slow the IV rate and then notify the health care provider. The client would be placed in an upright position. The nurse would monitor the client's vital signs and administer oxygen and diuretics as prescribed.

A nurse is planning client assignments for the shift. Which clients would the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply.

-A client with incontinence who requires a bladder scan after each void -A client who needs to be ambulated with a walker twice a day Rationale: Assignment of tasks must be implemented on the basis of the job description of the UAP, the UAPs level of clinical competence, and state law. A client who is receiving blood transfusions, one in a bowel-management program who requires a rectal suppository daily, and one with diabetes mellitus who requires blood glucose monitoring all require the skill of a licensed nurse, because these are invasive procedures. A client receiving blood must be monitored closely for transfusion reactions. A rectal suppository must be administered by a licensed nurse. Blood glucose monitoring needs to be performed by a licensed nurse. A client with incontinence requiring a bladder scan after each void and a client who needs to be ambulated with a walker twice a day are the most appropriate assignments for the UAP.

A client comes to the emergency department after being hit in the eye with a hockey puck. Which action does the nurse, seeing that the client has periorbital ecchymosis, implement immediately?

Applying ice to the affected eye Rationale: Treatment for a contusion, which is ideally begun at the time of injury, includes the application of ice to the site. The client should also undergo a thorough eye examination to rule out the presence of other eye injuries. A pressure dressing is not of use in treating this type of injury. Irrigation of the eye with cool water may be implemented for injuries that involve a splash of an irritant into the eye.

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions in the catheter. The nurse should immediately:

Check the degree of suction pressure being applied Rationale: Bloody secretions are an unexpected outcome of suctioning. If they are noted, the nurse first assesses the client and then checks the degree of suction pressure being applied. The degree of suction pressure may need to be decreased. The nurse must also ensure that intermittent suction and catheter rotation are being performed during suctioning. Continuing with the suctioning or suctioning more vigorously will cause increased trauma and therefore increased bleeding. Suctioning is normally performed in clients who are unable to expectorate secretions. Therefore it is unlikely that the client would be able to cough out the bloody secretions. The health care provider may need to be notified, but this is not the first action.

A client who has sustained an open pneumothorax as a result of a gunshot wound is brought to the emergency department (ED) with an occlusive dressing, placed by a paramedic, over the wound. The ED nurse assesses the client and notes extreme respiratory distress and distended jugular neck veins. On the basis of these assessment findings, the nurse should first:

Remove the occlusive dressing Rationale: Placement of a dressing over a sucking chest wound could convert an open pneumothorax to a closed (tension) pneumothorax, resulting in a sudden decline in respiratory status, mediastinal shift, twisting of the great vessels, and circulatory compromise. If this occurs, the nurse removes the dressing immediately, allowing air to escape. Checking the client's blood pressure and pulse oximetry readings and contacting the health care provider would all be implemented, but none is the first action to be taken.

A nurse in a postanesthesia care unit (PACU) receives a client who is being transferred from the operating room after abdominal surgery. The PACU nurse ensures that the client has a patent airway and that the respiratory pattern is adequate. Which interventions should the PACU nurse perform next?

Checking the client's pulse oximetry readings Rationale: After a client is transferred from the operating room, the PACU nurse conducts an assessment. The ABCs — airway, breathing, and circulation — must be assessed first. Because the nurse has ensured that the client has a patent airway (airway) and that the respiratory pattern is adequate (breathing), the nurse would next assess circulatory status. The nurse would accomplish this by assessing the client's pulse, blood pressure, skin color, pulse oximetry, and electrocardiogram status (if the client is attached to a monitor), then evaluating wound status and dressings. Urine output and orientation to the surroundings may also be assessed, but these are not the priority actions.

A client who has just undergone abdominal surgery calls the nurse and states, "I feel as if I just split open." The nurse checks the abdominal incision and finds wound evisceration. The nurse immediately:

Contacts the health care provider Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of the internal organs or viscera through the open wound. When evisceration occurs, the nurse immediately calls for help and has the health care provider notified. The nurse stays with the client and positions the client with the hips and knees bent. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline solution. The nurse would then take the client's vital signs and document the occurrence. Since this is a surgical emergency, the operating room would be notified but this would not be done until directed to do so by the surgeon.

A client complains of pain at the site of an intravenous (IV) catheter. On assessment, the nurse notes that the site appears bruised and concludes that the client has a hematoma. The nurse first:

Removes the IV catheter Rationale: A hematoma at an IV site is a result of leakage of blood into surrounding tissue. It may occur when the back of the vein is pierced during insertion of the catheter. It results in a discolored area of bruising around the IV site and swelling, and the client may complain of pain at the site. The nurse would first remove the IV catheter, then apply pressure. If the hematoma is recent, ice may prevent further seepage into the surrounding tissues. If it did not occur recently, warm, moist compresses will speed reabsorption of the fluid. The nurse should notify the health care provider, but this is not the initial action.

A nurse is monitoring a client in the active stage of labor who is receiving oxytocin . The nurse checks the fetal monitor and sees this: (Late Decelerations) The nurse immediately places an oxygen cannula on the mother and then:

Stops the oxytocin infusion Rationale: The mother is experiencing late decelerations and the oxytocin infusion should be stopped. Late decelerations are a result of uteroplacental insufficiency that occurs because of decreased blood flow and oxygen transfer to the fetus through the intervillous space during uterine contractions. Continuing the oxytocin would cause further hypoxemia, because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Because late decelerations are associated with hypoxemia, maternal oxygen administration is necessary. Although late decelerations are considered an ominous sign, their presence does not necessarily require immediate birth of the baby, so transporting the client to the delivery room is not the priority. Although the finding must be documented, documentation is not the immediate action in this situation. The supine position is avoided because of the risk of uteroplacental insufficiency.

A nurse assesses the closed chest tube drainage system of a client who underwent pulmonary wedge resection 12 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first:

Checks for obstructions or kinks in the chest drainage system Rationale: If it is noted that a chest tube is not draining, the nurse first checks for a kink or clot in the chest tube drainage system. The nurse also observes the client for respiratory distress or mediastinal shift; if this is detected, the health care provider is notified. Stripping the chest tube greatly increases intrapleural pressure, which could damage the pleural tissue. Stripping the chest tube is a practice that has been discontinued in many institutions, and the institutional policy concerning this procedure should be checked before a tube is stripped. Assessing the heart rate is not directly related to the lack of chest tube drainage. An air leak is suspected if continuous bubbling in the water seal chamber is noted.

A registered nurse is in charge of the emergency department on the night shift when a client is brought for treatment after being sexually assaulted. The nurse has never cared for anyone after a sexual assault. To determine the interventions that the client requires, the nurse would first:

Check unit policy regarding the protocol for care to clients who have been sexually assaulted Rationale: A policy is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online in the institution's computer network. Specific unit policies are sometimes referred to as protocols. The policy or protocol for dealing with a client who has been sexually assaulted will identify which authorities (e.g., the police) should be notified and the interventions required in the care of the client. It is inappropriate to call the nurse in charge of the day shift. If additional information was needed after a review of the policy or protocol, the nurse would contact the nursing supervisor for the night shift.

A nurse is caring for a client with a central venous catheter. The client suddenly complains of chest pain and dyspnea. During assessment of the client, the nurse notes hypotension, tachycardia, and a loud churning sound over the pericardium on auscultation. The nurse suspects an air embolism and immediately:

Clamps the central line catheter Rationale: An air embolism occurs when air enters the central venous system. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety, tachycardia, hypotension, and a loud churning sound over the pericardium on auscultation. Air may be introduced into the central venous system during insertion of the catheter, tubing changes, or breakage of the catheter. The nurse immediately clamps the catheter, places the client in a lateral Trendelenburg position on the left side to trap the air in the right atrium, and contacts the health care provider. The health care provider may order an electrocardiogram, chest x-ray, and arterial blood gas determinations. Placing the client in a high Fowler position and connecting a syringe to the line and aspirating as much fluid as possible are both incorrect.

A client who is receiving a blood transfusion suddenly experiences chills, a high fever, vomiting, and diarrhea and complains of abdominal cramping. The nurse, noting that the client's blood pressure has dropped significantly, suspects that the client is experiencing a bacterial sepsis reaction to the transfusion. The nurse immediately stops the blood transfusion, hangs an intravenous (IV) bag of normal saline solution to be infused at a keep-vein-open rate, and contacts the health care provider, who prescribes several interventions. Which prescription will the nurse implement first?

Obtaining blood for cultures Rationale: If bacterial sepsis from a blood transfusion is suspected, the transfusion is stopped and IV access is maintained by infusing normal saline pending further health care provider orders. The nurse would continue to monitor the client's vital signs. Samples for blood culture and Gram staining must be obtained before the administration of medications, particularly the antibiotic. The blood bank is notified, but this is not the first action.

A nurse assessing a peripheral intravenous (IV) site notes blanching, coolness, and edema at the site. What should the nurse do first?

Remove the IV catheter Rationale: Blanching, coolness, and edema of the IV site are all classic signs of infiltration. Because infiltration may result in damage to the surrounding tissues, the nurse must first remove the IV catheter to prevent any further damage. The nurse should not depend solely on blood return for assurance that the catheter is in the vein, because blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. The area of infiltration should be measured after the IV has been removed so that further tissue damage may be assessed and monitored.

A nurse is suctioning an adult client undergoing mechanical ventilation through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation on pulse oximetry has dropped to 89%. The nurse would:

Stop and oxygenate the client with 100% oxygen Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. A drop in pulse oximetry to 89% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the suctioning procedure. The client is reoxygenated with the use of a 100% oxygen delivery system until baseline parameters are achieved. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia. In adults, the standard catheter size is 12F to 14F and should not exceed half the diameter of the artificial airway. There is no indication in the question that these parameters are being exceeded. Additionally, increasing the suction pressure could be harmful. It is inappropriate to call respiratory therapy to check the pulse oximeter.

A nurse is caring for a client who sustained a serious burn injury 24 hours ago. On assessment, the nurse finds that the client's urine output is 0.3 mL/kg/hr, blood pressure is 88/60 mm Hg, and heart rate is 110 beats/min. The nurse would immediately:

Notify the health care provider Rationale: The nurse notifies the health care provider immediately if a burned client exhibits decreased urine output or blood pressure or an increased pulse rate. Because of the rapid fluid shifts that occur in burn shock, fluid deficit must be detected early so that hypovolemic shock may be prevented. A nurse does not increase an IV rate without a specific prescription to do so. Reassessing the client in 30 minutes will delay necessary interventions to prevent the development of hypovolemic shock. A warm environment is maintained, but this is not the immediate action. Urine output should be maintained between 0.5 and 1.0 mL/kg/hr.