Hurst11
After receiving report from the previous shift nurse, Which client should the nurse assess first? 1. Client diagnosed with an ischemic stroke who is exhibiting increased restlessness. 2. Client diagnosed with dementia who needs assistance with ambulating. 3. Client with a halo device requesting to be transferred to the bedside chair. 4. Client diagnosed with a traumatic brain injury who cannot recall portions of the accident.
1. Correct: The client diagnosed with an ischemic stroke needs to be assessed first to be evaluated for signs of increased intracranial pressure (ICP). A neurological assessment should be initiated. Increased restlessness is an early sign of increased ICP. 2. Incorrect: Client safety should be evaluated. The client does require assistance with ambulating. But the client with potential increased ICP requires an immediate neurological assessment. 3. Incorrect: A client with a halo traction may require assistance to transfer to the chair. The nurse identifies that a neurological assessment on another client has priority. 4. Incorrect: The client with the traumatic head injury cannot recall portions of the accident, but is not presenting with any life-threatening symptoms.
A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.
1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. 2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice. An experienced registered nurse or primary healthcare provider must be specifically trained to perform this procedure. 3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of fetal well being and not within the LPN scope of practice.
The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.
1. Correct: The surgeon is responsible for informing the client about the surgical procedure, the options available,and the benefits and risks of each treatment modality. So, if the client has concerns the surgeon should be told and requested to see the client again prior to surgery. Surgery should be delayed until the client is sure of decision.2. Incorrect: The consent form signature is important; however, the client has the right to have questions answered and to change his mind.3. Incorrect: The client should not be encouraged to have the surgery if he still has questions about other options. The consent must be informed, so the client must have all questions answered. The surgery can be delayed until the client's concerns are addressed.4. Incorrect: The surgeon may have explained the options, however; it is obvious that the client did not understand the options. The client's concerns must be addressed prior to surgery.
The nurse is caring for a client with increased intracranial pressure (ICP). Which situation could increase the client's ICP? 1. Being in restraints 2. Elevating head 3. Performing Valsalva 4. Blowing nose 5. Keeping client supine 6. Suctioning
1., 3., 4., 5 & 6. Correct: All of these actions can cause increased pressure in the cerebral vascular system due to the vagal response that occurs through the valsalva, blowing nose, and suctioning. Restraints can result in the client fighting against restraints to cause an increase in pressure in the cerebral vascular system. With the client lying supine, more fluid is in the cerebral spinal space due to decreased drainage. 2. Incorrect: HOB should be raised at least 30 degrees. This decreases ICP.
A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases? 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine
1., 4. & 5. Correct: Yes. These medications typically decrease the respiratory rate, causing respiratory acidosis. 2. Incorrect: No. Diuretics do not affect breathing patterns. 3. Incorrect: No. Steroids do not affect breathing patterns. 6. Incorrect: No. Histamine 2 blockers do not affect breathing patterns.
Which client would be appropriate for the charge nurse to assign to the LPN? 1. The client with a leg cast who needs neurovascular checks. 2. The client diagnosed with arthritis who needs pain medication and heat application. 3. The client reporting abdominal pain and rebound tenderness after a bicycle accident. 4. The client with anorexia nervosa experiencing muscle weakness and decreased urinary output. 5. The client experiencing nausea and vomiting after receiving chemotherapy.
2. & 5. Correct: These are uncomplicated, stable clients. The LPN can provide pain medication and heat application to the arthritis client and can care for a client experiencing nausea and vomiting after chemotherapy. 1. Incorrect: The LPN can not do a neurovascular assessment independent of the RN. 3. Incorrect: This is a complicated client who has abdominal pain and rebound tenderness. This client is at risk for bleeding and peritonitis and needs further assessment by the RN. 4. Incorrect: This client has muscle weakness which is a symptom of hypokalemia. Also a decreased urinary output which could be due to FVD which could lead to shock. This client would be considered unstable or complicated and would not need to be assigned to the LPN.
The nurse is instructing a client newly diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed omeprazole. What comment by the client indicates to the nurse that the teaching was successful? 1. "I should lay down after eating a big meal." 2. "Spicy food and caffeine might cause me pain." 3. "If the pain gets worse, I should take two pills." 4. "I will take the omeprazole whenever I have pain."
2. CORRECT: There are many foods and drinks that might cause discomfort for the client, particularly in the early stages of treatment. Although specific foods can vary among individuals, usually spicy foods, caffeine, and even alcohol can contribute to the burning sensation reported by clients with GERD. This statement by the client is accurate. 1. INCORRECT: Lying down after a large meal often contributes to reflux because the pressure of food permits stomach contents and acid to flow back up the esophagus, leading to heartburn and possibly regurgitation. Clients should remain upright for a period of time after eating, which allows gravity to keep acid below the level of the esophagus. 3. INCORRECT: Omeprazole is a proton-pump inhibitor which decreases stomach acid and works to heal existing ulcers. This medication is taken once daily at the same time, and should never be doubled unless ordered to do so by the primary healthcare provider. Any increase in discomfort while taking this medication should be immediately reported. 4. INCORRECT: A proton-pump inhibitor is taken once daily, usually in the morning prior to breakfast. This medication is not administered only in the presence of pain. Taking this medication consistently over time will decrease stomach acid and help heal any damaged stomach tissue.
At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? 1. Ask clients' families which activities they would like to have available. 2. Research professional articles for guidelines to activities in long-term care. 3. Have clients peruse a variety of games and select what interests them. 4. Contact other facilities to inquire what types of programs they provide.
2. Correct: Research based criteria generally have a high rate of success because the testing has been completed under controlled circumstances and are practice based. 1. Incorrect: Although it would be acceptable to speak with the clients' families, this would not provide the most complete data for the project. Families would not likely understand pertinent considerations such as cost of supplies, number of staff required to assist, or clients' ability to participate. 3. Incorrect: While encouraging client input does allow for some independence, multiple choices can be overwhelming for elderly clients. There would also be an unnecessary expense in purchasing and providing multiple choices for the clients. 4. Incorrect: Most facilities individualize activities based on clientele, funding, and even location. Activities that work in one long term care facilities may not be appropriate for another facility.
Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? 1. Onset of nausea and vomiting 2. Contraction every 90 seconds lasting 70 seconds 3. Maternal blood pressure 140/90 4. Early decelerations in the fetal heart rate
2. Correct: These contractions are too long and too often. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome. 4. Incorrect: Early decels are generally not harmful and happen as baby is descending through the birth canal during the later stages of labor. These are not related to the oxytocin infusion.
What should a nurse include when preparing to educate a female client on how to prevent recurrent cystitis? 1. Drink at least eight, 4 ounce glasses of water per day. 2. Urinate as soon as the urge occurs. 3. Avoid irritating perineum with harsh soap. 4. Empty your bladder post coitus. 5. Avoid use of a diaphragm.
2., 3., 4. & 5. Correct: The client should void as soon as the urge occurs and completely empty the bladder. The client should not use excessive soap or harsh soap to minimize irritation of the urethra. Women should void immediately after sexual intercourse. This helps prevent bacteria from moving into the urethra. Pressure on the urethra may cause irritation and urinary tract infections in women who use diaphragms. 1. Incorrect: A client with normal renal function and who does not have heart or kidney disease needs to drink 2200 to 2700 mL of fluid daily. Increasing fluid intake helps flush out solutes or particles that collect in the urinary system.
Which statements made by a client diagnosed with Addison's disease indicates to the nurse that the client understands fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "I will limit my sodium intake to 200 mg per day." 4. "My medication dose will change based on my daily weight." 5. "I may need more medication if I feel weak or dizzy."
2., 4., & 5. Correct: Medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms, so more medication can be given to the client. 1. Incorrect: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 3. Incorrect: This client needs a high sodium diet as they are losing sodium and retaining potassium.
A home care nurse is assessing a client with a forearm cast recently applied for a displaced radial fracture. What client comment should the nurse consider the priority concern? 1. "The cast feels tight on my arm." 2. "There is an odd smell inside my cast." 3. "I can't open up my fingers this morning." 4. "The pain medicine is not relieving my pain."
3. CORRECT. All the reported problems have the potential to be serious and must be investigated; however, one problem has already occurred and could permanently impair the client's mobility. The inability to extend fingers, particularly in a casted extremity, is a contracture resulting from prolonged ischemia of muscle tissues. Swelling inside the cast causes muscles to shorten and scar, leading to deformities or contractures called Volkmann contractures. Mild cases may be treated with splinting and exercise but severe cases need surgical intervention and possible even transplanted tissues with no guarantee of restored dexterity or mobility. 1. INCORRECT. Obviously a 'really tight' sensation of the arm is of great concern, since swelling could be an early indication of compartment syndrome. However, the nurse should seek further clarification from the client regarding the "tightness" and its exact location. Another problem is of even greater concern. 2. INCORRECT. Many odors could emanate from casting material, from skin breakdown to the odor of drying cast material. The client may even have put something down inside the cast so the smell should definitely be investigated. However, the nurse has greater priority at the moment. 4. INCORRECT. There are many reasons pain medication may not relieve discomfort, including too low a dose or patient noncompliance with medication regime. On-going pain should certainly be investigated as a potential sign of greater problems but this is not the nurse's priority at this time.
A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?
3. Correct: According to the Client's Bill of Rights, the client has the right to view medical records pertaining to the client's care and to have those records explained if necessary. 1. Incorrect: The client may contact medical records and does not need to first contact the primary healthcare provider. 2. Incorrect: The electronic health record can be made available to the client when requested. 4. Incorrect: This is an open ended question, but the client may view this as challenging their desire to view the medical records.
The charge nurse on the postpartum unit is making assignments. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which nurse should be assigned to care for this client? 1. The RN with 8 years' experience in the Intensive Care Unit. 2. The RN with 10 years' experience pulled from the ER. 3. The RN with 5 years' experience in the Labor and Delivery unit. 4. The RN with 2 weeks' experience on the post-partum unit.
3. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client needs careful monitoring and specialized care. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. 1. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. Therefore, this would not be the most appropriate nurse to assign to this client. 4. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client.
The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.
3. Correct: Phenytoin is an anticonvulsant. It works by slowing down impulses in the brain that cause seizures. A major side effect is gingival hyperplasia. Oral hygiene is important for decreasing this complication while the client is on phenytoin. 1. Incorrect: Weight gain or loss are not typically a concern with phenytoin. 2. Incorrect: The apical pulse is checked with digoxin, not phenytoin.4. Incorrect: The medication often causes gastric distress and may need to be taken with a meal, not before.
The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication? 1. Occasional cough 2. Sore throat reported 3. Abdominal pain rated 8/10 4. Drowsy
3. Correct: The client should not have severe pain after the ERCP. Severe pain along with a distended abdomen is suspicious and should be of concern to the nurse. 1. Incorrect: A continuous cough would be indicative of a problem, such as perforation of the esophagus. An occasional cough is not of concern. 2. Incorrect: It is not abnormal for the client to experience a sore throat for 1-2 days post procedure as the instrument is passed through the mouth and esophagus to view the bile and pancreatic ducts. 4. Incorrect: It is normal for the client to be drowsy for several hours after the procedure as conscious sedation is used during the ERCP procedure.
A newly hired unlicensed assistive personnel (UAP) at a long-term care facility is being instructed on the proper method of feeding a stroke client with dysphagia. The nurse knows teaching was successful when the UAP makes what statement? 1. "Feeding the client in semi-fowlers position is easier." 2. "I should not allow the client to do any self-feeding." 3. "Thickened liquids are safer for the client to swallow." 4. "I am offering the client a drink after each bite to help digestion."
3. Correct: Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration. The client should be sitting upright and fed small amounts of food slowly, allowing time for chewing and swallowing. This statement indicates the UAP understands proper feeding protocols. 1. Incorrect: Semi-fowlers is a "semi-reclining" position, which would greatly increase the risk of aspiration during meals. This comment indicates the UAP would need further instruction. 2. Incorrect: It is crucial to encourage a stroke client to participate as much as possible in self-care, including feeding and bathing. If this client is capable of using utensils, such as modified silverware, it is important to allow as much participation in activities of daily living (ADL) as possible. If the UAP made this comment, further teaching is indicated. 4. Incorrect: Liquids after every bite would quickly fill up the client, decreasing the amount of food intake. Feeding slowly and allowing the client time to swallow after each bite is sufficient for digestion. Such a statement from the UAP means further instruction is needed.
A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? 1. Administer tap water enemas until clear at 6 AM. 2. Nothing by mouth (NPO). 3. IV of D5 ½ NS at 75 mL/hour with a 20 gauge catheter. 4. Give magnesium citrate 296 mL at 3 PM today.
4. Correct: Did you notice the hint? Complete blockage of the large intestine. If you give the magnesium citrate, which is a laxative, what will happen? Nothing will get passed the complete blockage. The client would develop severe cramping. This could cause a medical emergency. 1. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. 2. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. This is an appropriate prescription. 3. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO.
The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.
4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.
In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority. Client's tracheostomy needs to be suctioned. The water seal chamber is empty in a client's closed chest drainage unit. UAP reports a heart rate of 40/min in a client. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. Client reporting urinary frequency and dysuria.
The client with the highest need is the client who has a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented.
