Jones

A client's family member comes to the nurse's station and says, "He needs more pain medicine. He is still having a lot of pain." What is the nurse's best response? 1. "The health care provider (HCP) ordered the medicine to be given every 4 hours." 2. "If medication is given too frequently, there are ill effects." 3. "Please tell him that I will be right there to check on him." 4. "Let's wait about 40 minutes. If there he still hurts, I'll call the HCP."

"Please tell him that I will be right there to check on him." Responding to the client and family in a timely fashion is important. Next, directly ask the client about the pain and perform a complete pain assessment. This information will determine which action to take next.

The client described in question 3 is also at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

1 Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of excess fluid volume.

The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a prescription to discontinue the morphine via patient-controlled analgesia and to start oral pain medication. The client begs, "Please don't stop the morphine. My pain is really a lot worse today than it was yesterday." What is the best response? 1. "Let me stop the pump, and we can try oral pain medication to see if it relieves the pain." 2. "I realize that you are scared of the pain, but we must try to wean you off the pump." 3. "Show me where your pain is and describe how it feels compared with yesterday." 4. "Let's take your vital signs; then I will discuss your concerns with the health care provider."

"Show me where your pain is and describe how it feels compared with yesterday." Assessing the pain is the priority in this acute care setting because there is a risk of infection or hemorrhage. The other options might be appropriate based on the assessment findings.

The nurse is interviewing a patient who was treated several months ago for breast cancer. The patient reports taking nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain. Which patient comment is cause for greatest concern? 1. "The NSAIDs are really not relieving the back pain." 2. "The NSAID tablets are too large, and they are hard to swallow." 3. "I gained weight because I eat a lot before taking NSAIDs." 4. "The NSAIDs are upsetting my stomach in the morning."

1 Primary cancers (lung, prostate, breast, and colon) may metastasize to the spine. In spinal cord compression, back pain is a common early symptom. Later symptoms include weakness, loss of sensation, urinary retention or incontinence, and constipation.

A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1 Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of UAPs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses.

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1 Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will the nurse advocate for first? 1. Gabapentin 2. Corticosteroids 3. Hydromorphone 4. Lorazepam

1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be prescribed as an adjuvant medication.

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1 Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN.

The nurse is providing end-of-life-care for a patient with terminal liver cancer. The patient is weak and restless. Her skin is cool and mottled. Dyspnea develops, and the patient appears anxious and frightened. What should the nurse do first? 1. Administer an as needed (PRN) dose of morphine elixir. 2. Alert the Rapid Response Team and call the health care provider. 3. Deliver breaths at 20 breaths/min with a bag-valve mask and prepare for intubation. 4. Sit quietly with the patient and offer emotional support and comfort.

1 Morphine elixir is the therapy of choice because it is thought to reduce anxiety and the subjective sensation of air hunger. It also increases venous capacitance. End-of-life care should not include aggressive measures such as intubation or resuscitation. Support and comfort are always welcome, but in this case, there is an option that would offer some physical relief for the patient.

A patient in the allergy clinic who has a rash has received diphenhydramine 50 mg PO. Which patient information is most indicative of a need for action by the nurse? 1. The patient is preparing to drive home. 2. The patient reports itching at the site of the rash. 3. The patient has a history of constipation. 4. The patient states, "My mouth feels so very dry!"

1 Sedation is a common effect of the first-generation antihistamines, and patients should be cautioned against driving when taking medications such as diphenhydramine. Itching of the rash is expected with an allergic reaction. The patient should be taught about how to manage common antihistamine side effects such as constipation and oral dryness, but these side effects are not safety concerns.

Which task could be appropriately delegated to the unlicensed assistive personnel (UAP) working with the nurse at the obstetric clinic? 1. Checking the blood pressure of a patient who is 36 weeks' pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient who may be experiencing domestic violence 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

1 The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning and should be performed by the RN. Provision of accurate and supportive education about breast feeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed.

In caring for a patient who is admitted to a medical surgical unit for treatment of anorexia nervosa, which task can be delegated to unlicensed assistive personnel (UAP)? 1. Sitting with the patient during meals and for 1 to 1½ hours after meals 2. Observing for and reporting ritualistic behaviors related to food 3. Obtaining special food for the patient when she requests it 4. Weighing the patient daily and reinforcing that she is underweight

1 The UAP should be instructed to observe the amount of food eaten and ensure that the patient is not throwing out the food. After meals, observation is necessary to ensure that the patient does not induce vomiting. Ritualistic behaviors can be subtle or difficult to define. Observation for these behaviors cannot be delegated. Requests for special foods could be delaying tactics or attempts to manipulate the staff. The UAP should not be responsible for deciding if food requests are appropriate. Daily weights may not be ordered, because this could increase the patient's emotional focus on weight. In addition, repeatedly telling the patient that she is underweight is counterproductive because she does not believe she is underweight.

In the care of a client with acute viral hepatitis, which task should be delegated to unlicensed assistive personnel (UAP)? 1. Emptying the bedpan while wearing gloves 2. Playing games or engaging the client in diversional activities 3. Monitoring dietary preferences 4. Reporting signs and symptoms of jaundice

1 The UAP should use infection control precautions for the protection of self, employees, and other clients. Monitoring is an RN responsibility. UAPs can report valuable information; however, they are not responsible for detecting signs and symptoms that can be subtle or hard to detect, such as skin changes. Although playing games with the client may be ideal, it is rarely possible on a medical-surgical unit.

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which patient care actions should the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply. 1. Monitor and record strict intake and output. 2. Provide the patient with ice chips when requested. 3. Remind the patient about his or her fluid restriction. 4. Weigh the patient every morning using the same scale. 5. Report a weight gain of 2.2 lb (1 kg) to the nurse. 6. Provide mouth care allowing the patient to swallow the rinses.

1,3,4,5 Fluid restriction is essential because fluid intake further dilutes plasma sodium levels. In some cases, fluid intake may be kept as low as 500 to 1000 mL over 24 hours. All oral fluids count, including ice chips and mouth rinses, and strict intake and output is required. Measure intake, output, and daily weights to assess the degree of fluid restriction needed. A weight gain of 2.2 lb (1 kg) or more per day or a gradual increase over several days is cause for concern. A 2.2-lb (1 kg) weight increase is equal to a 1000-mL fluid retention (1 kg = 1 L). Keep the mouth moist by offering frequent oral rinsing (warn patients not to swallow the rinses).

A 26-year-old gravida 1, para 1 patient who underwent cesarean section 24 hours ago tells the nurse that she is having some trouble breast feeding. Which tasks could be appropriately delegated to the unlicensed assistive personnel (UAP) on the postpartum floor? Select all that apply. 1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast feeding 3. Taking the mother's vital signs 4. Checking the amount of lochia present 5. Assisting the mother with ambulation

1,3,5 The UAP could provide an abdominal binder, measure the vital signs of the patient, and assist her to ambulate. The RN would be responsible for evaluating the normality of the vital sign values. The UAP should be given parameter limits for vital signs and told to report values outside these limits to the RN. Assisting in breast feeding for a first-time mother is a very important nursing function because the RN needs to give consistent, evidence-based advice to enhance success at breast feeding. A common complaint of postpartum patients is inconsistent help with and advice on breast feeding. The RN should also be the one to check the amount of lochia because the evaluation requires nursing judgment. The use of the professionally educated RN to provide evidence-based and consistent information and assistance with breast feeding supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only.

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

1,3,5,6 Clear, concise, correct, complete are the "Four Cs" of communication. Implementing the four Cs of communication helps the nurse ensure that the UAP understands what is being said; that the UAP does not confuse the nurse's directions; that the directions comply with policies, procedures, job descriptions, and the law; and that the UAP has all the information necessary to complete the tasks assigned.

According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical clients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies 5. Long-acting oral opioids, especially in the immediate postoperative period, for continuous around-the-clock relief 6. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, or ketamine is recommended for postoperative pain

1234 The American Pain Society in collaboration with the American Society of Anesthesiologists recommendations for postoperative clients include: acetaminophen and/or NSAIDs if there are no contraindications; surgical site-specific peripheral regional anesthetic for procedures; neuraxial analgesia (also known as epidural) for major thoracic and abdominal procedures, if client has risk for cardiac complications or prolonged ileus; and multimodal therapy, which includes use of different types of medications and other therapies. Long-acting oral opioids are not recommended in the postoperative period. Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine is not recommended.

The nurse is working with a patient who has a new diagnosis of human immunodeficiency virus (HIV) and who reports current use of injectable heroin and methamphetamine. Which actions by the nurse are appropriate? Select all that apply. 1. Refer the patient to a substance abuse treatment program. 2. Plan for the patient to participate in a needle exchange program. 3. Coordinate the patient's schedule for directly observed antiretroviral drug treatment. 4. Instruct the patient that ongoing injectable drug use is a contraindication for antiretroviral therapy. 5. Provide patient education about the risk of transmitting HIV to others when sharing needles.

1235 Current guidelines indicate that antiretroviral therapy for HIV should be initiated as soon as possible after HIV diagnosis. Although ongoing substance abuse is a risk factor for poor adherence, antiretroviral therapy can be initiated when strategies to improve adherence are used. Strategies include directly observing patients taking medications, needle exchange programs, and referring patients for substance abuse treatment.

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

126 The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to assign to an LPN/LVN? 1. Develop a "quit plan" 2. Explain how to apply a nicotine patch 3. Discuss strategies to avoid relapse 4. Suggest ways to deal with urges for tobacco

2 An LPN/LVN is versed in medication administration and able to teach patients standardized information. The other options require more in-depth assessment, planning, and teaching, which should be performed by the RN. Helping patients with smoking cessation is a Core Measure.

The nurse assesses the patient and determines that the patient is having frequent breakthrough cancer pain. Which member of the health care team is the nurse most likely to contact first? 1. Physical therapist to reevaluate physical therapy routines 2. Health care provider to review medication, dosage, and frequency 3. Unlicensed assistive personnel to provide more assistance with activities of daily living 4. Psychiatric clinical nurse specialist to evaluate psychogenic pain

2 Breakthrough pain is defined as rapid onset, short duration, and moderate to severe; a temporary exacerbation related to poorly controlled around-the-clock dosing of background pain. Frequent breakthrough pain suggests that the around-the-clock dosing needs reevaluation, so the nurse would contact the health care provider and advocate for a change of medication or dose or frequency.

An older patient with type 2 diabetes has cardiovascular autonomic neuropathy (CAN). Which instruction would the nurse provide for the unlicensed assistive personnel (UAP) assisting the patient with morning care? 1. Provide a complete bed bath for this patient. 2. Sit the patient up slowly on the side of the bed before standing. 3. Only let the patient wash his or her face and brush his or her teeth. 4. Be sure to provide rest periods between activities.

2 CAN affects sympathetic and parasympathetic nerves of the heart and blood vessels. It may lead to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing) caused by failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. The nurse should be sure to instruct the UAP to have the patient change positions slowly when moving from lying to sitting and standing.

The nurse is caring for a young client with type 1 diabetes who has sustained injuries when she tried to commit suicide by crashing her car. Her blood glucose (BG) level is 550 mg/dL (30.5 mmol/L), but she refuses insulin; however, she wants the pain medication. What is the best action? 1. Notify the charge nurse and make arrangements to transfer to intensive care. 2. Explain significance of BG and insulin and then call the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.

2 Explain that insulin is a priority because life-threatening ketoacidosis may already be in progress. If she is already aware of the dangers of an elevated BG level, then her refusal suggests ongoing suicidal intent and the provider should be notified so that steps can be taken to override her refusal (potentially a court order). A BG level of over 600 mg/dL (33.3 mmol/L) is typically a criterion for transfer to intensive care, but making arrangements for transfer is time consuming, and treatment of the elevated BG should begin as soon as possible. Withholding pain medication is unethical, and merely documenting refusal of insulin is inappropriate because of elevated BG and possible ongoing suicidal intent.

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.

2 If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.

2 If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

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

2 Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial because it may promote knee flexion contracture.

The nurse is assessing a client who has been receiving opioid medication via patient-controlled analgesia. What is an early sign that alerts the nurse to a possible adverse opioid reaction? 1. Client reports shortness of breath. 2. Client is more difficult to arouse. 3. Client is more anxious and nervous. 4. Client reports pain is worsening.

2 Most adverse opioid events are preceded by an increased level of sedation.

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

2 Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.

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

2,3,5 The UAP's scope of practice includes repositioning patients and checking vital signs, and an experienced UAP would know how to check pulse oximetry and elevate the patient's heels off the bed. Assessing and inspecting patients is more appropriate to the educational level of the professional nurse.

When the nurse is developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will be delegated to the home health aide? Select all that apply. 1. Monitoring the client for symptoms of urinary tract infection 2. Helping the client to connect the catheter to the leg bag 3. Checking the client's incision for appropriate wound healing 4. Assisting the client in ambulating for increasing distances 5. Helping the client shower at least every other day

2,4,5 Assisting with catheter care, ambulation, and hygiene are included in home health aide education and would be expected activities for this staff member. Client assessments are the responsibility of RN members of the home health care team.

Which actions can the school nurse delegate to an experienced unlicensed assistive personnel (UAP) who is working with a 7-year-old child with type 1 diabetes in an elementary school? Select all that apply. 1. Obtaining information about the child's usual insulin use from the parents 2. Administering oral glucose tablets when blood glucose level falls below 60 mg/dL (3.3 mmol/L) 3. Teaching the child about what foods have high carbohydrate levels 4. Obtaining blood glucose readings using the child's blood glucose monitor 5. Reminding the child to have a snack after the physical education class 6. Assessing the child's knowledge level about his or her type 1 diabetes

2,4,5 National guidelines published by the American Diabetes Association (ADA) indicate that administration of emergency treatment for hypoglycemia (e.g., glucose tablets), obtaining blood glucose readings, and reminding children about content they have already been taught by licensed caregivers are appropriate tasks for non-health care professional personnel such as teachers, paraprofessionals, and UAP. Assessments and education require more specialized education and scope of practice and should be done by the school nurse.

In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to unlicensed assistive personnel (UAP)? Select all that apply. 1. Counseling the client to express grief or loss 2. Assisting the client with ambulating in the hall 3. Orienting the client to the surroundings 4. Encouraging independence 5. Obtaining supplies for hygienic care 6. Storing personal items to reduce clutter

2,5 Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and encouraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearranging furniture are inappropriate actions because the client needs be able to consistently locate objects in the immediate environment.

A patient diagnosed with hypertension has received the first dose of lisinopril. Which interventions will the RN delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Restrict the patient to bed rest for at least 12 hours. 2. Recheck the patient's vital signs every 4 to 8 hours. 3. Ensure that the patient's call light is within easy reach. 4. Keep the patient's bed in a supine position with all side rails up. 5. Remind the patient to rise slowly from the bed and sit before standing. 6. Assist the patient to get out of bed and use the bathroom. 7. Assess the patient for signs of dizziness.

2356 After the first dose of most antihypertensive drugs, dizziness is a common side effect. The patient should call for help when getting out of bed, and the call light should be within easy reach. The patient should rise slowly, sitting on the side of the bed before standing, and then can be assisted to the bathroom. The UAP's scope of practice includes these actions. Patients are not restricted to bed rest or kept in a supine (flat) position, and side rails are not all kept up for safety of the patient. Assessment is not within the scope of practice for a UAP. However, the RN could instruct the UAP to ask the patient about dizziness before and during ambulation and then report any dizziness immediately to the RN.

** Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump 2. Client with a leg cast who needs neuro-circ checks and as needed (PRN) hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

236 The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.

245 Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? Select all that apply. 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent as needed (PRN) pain medication

256 The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions.

Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually subsides after ambulation begins.=

In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals

3 Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing client concerns.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3 The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

The nurse is caring for a client who was admitted to the medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to unlicensed assistive personnel (UAP)? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check urometer every hour and observe for red- or pink-tinged urine. 3. Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

3 The UAP can take vital signs and report all of the values to the RN. In this case, all of the values are needed to detect trends. In other cases, the nurse may decide to give parameters for reporting. The RN should assess skin temperature and pain and closely monitor the urine because quantity is an indicator of perfusion and fluid status. Red or pink urine can signal damage to the urinary system, transfusion reaction, or rhabdomyolysis.

For which of these clients is IV morphine the first-line choice for pain management? 1. A 33-year-old intrapartum client needs pain relief for labor contractions. 2. A 24-year-old client reports severe headache related to being hit in the head. 3. A 56-year-old client reports breakthrough bone pain related to multiple myeloma. 4. A 73-year-old client reports chronic pain associated with hip replacement surgery.

3 The client with cancer needs morphine for symptom relief. For obstetric clients, morphine can suppress fetal respiration and uterine contractions, so regional or epidural methods are preferred. For head injuries, morphine could make evaluation of mental status more difficult. In addition, if respirations are depressed, intracranial pressure could increase. Opioids are usually not the first-line choice for chronic pain, and opioids must be used with caution in older adult clients because of changes related to aging, such as renal clearance. In addition, use of opioids increases risk for falls and contributes to constipation.

An athletic young man was recently diagnosed with Ewing sarcoma. He has pain, low-grade fever, and anemia. The surgeon recommends amputation of the right lower leg for an operable tumor. The patient tells the nurse that he is leaving the hospital to go on a long hiking trip. What is the priority nursing concept to consider at this time? 1. Pain 2. Cellular regulation 3. Coping 4. Adherence

3 The patient is not coping with the recent diagnosis of cancer and prospect of losing his leg. His decision to go hiking may be a form of denial or possibly a veiled suicide threat. It is also possible that he has decided not to have any treatment; however, the nurse needs to make additional assessment about his decision and actions and help him to discuss alternatives and consequences. This situation is complex, but if he leaves the hospital, there may be no chance to address any other issues.

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

3 UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

3' Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.

The home health nurse is reviewing the cancer patient's medication list and sees that a bisphosphonate medication has been prescribed. Which question is the nurse most likely to ask to evaluate the efficacy of the medication? 1. "Has the medication helped relieve the discomfort in your mouth?" 2. "Have you noticed any increase or changes in your energy level?" 3. "Has the medication helped to stop the nausea and vomiting?" 4. "Has the medication relieved the bone pain that you were having?"

4 Bisphosphonate medications are used for patients with cancer help to relieve bone pain associated with primary bone cancer or metastasis and to reduce the risk of fractures. They also lower the calcium level in the blood.

The patient describes a burning sensation in the leg. The health care provider tells the nurse that a medication will be prescribed for neuropathic pain secondary to chemotherapy. The nurse is most likely to question the prescription of which drug? 1. Imipramine 2. Carbamazepine 3. Gabapentin 4. Morphine

4 Morphine is usually not prescribed for neuropathic pain because pain relief response is poor. Other medications, some antidepressants (e.g., imipramine) and some anticonvulsants (e.g., carbamazepine and gabapentin), provide better relief.

A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should the nurse delegate to the unlicensed assistive personnel (UAP) caring for the patient? 1. Checking the skin for signs of redness or peeling 2. Assisting the patient in choosing appropriate clothing 3. Explaining good skin care to the patient and family 4. Cleaning the skin over the area daily with a mild soap

4 Skin care is included in UAP education and job description. Assessment and patient teaching are more complex tasks that should be delegated to RNs. Because the patient's clothes need to be carefully chosen to prevent irritation or damage to the skin, the RN should assist the patient with this.

** The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy.

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4 The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses.

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the staff nurses to assess their care of this client.

4 The charge nurse must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.

The unlicensed assistive personnel (UAP) reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the nondominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.

4 The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The client may need additional fluids (IV or oral) after the cause of the low urine output is determined. Elevating the head of the bed will not help with urine output. Notifying the health care provider is the first priority in this case.

What is the best way to schedule medication for a client with constant pain? 1. As needed (PRN) at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around-the-clock

4. Around-the-clock

When an unexpected death occurs in the emergency department, which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Escorting the family to a place of privacy 2. Accompanying organ donor specialist to talk to family 3. Assisting with postmortem care 4. Helping the family to collect belongings

Assisting with postmortem care Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.

The nurse is caring for a patient with uterine cancer who is being treated with intracavitary radiation therapy. Unlicensed assistive personnel (UAP) reports that the patient insisted on ambulating to the bathroom and now "something feels like it is coming out." What is the priority action? 1. Assess the UAP's knowledge; explain the rationale for strict bed rest. 2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. 3. Assess the patient's knowledge of the treatment plan and her willingness to participate. 4. Notify the health care provider about dislodgment of the radiation implant.

Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. If the radiation implant has obviously been expelled (e.g., is on the bed linens), use a pair of forceps to place the radiation source in a lead container. The other options would be appropriate after safety of the patient and personnel are ensured.

A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should the nurse delegate to unlicensed assistive personnel (UAP) working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing

Scheduling a follow-up appointment for the client in 2 days Scheduling a follow-up appointment for the client is within the legal scope of practice and training for the UAP role. Client teaching, assessment for positive skin reactions to the test, and monitoring for serious allergic reactions are appropriate to the education and practice role of licensed nursing staff.

The nurse is supervising a student nurse who is caring for a patient with human immunodeficiency virus (HIV). The patient has severe esophagitis caused by Candida albicans. Which action by the student requires the most rapid intervention by the nurse? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the prescribed oral nystatin suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

Giving the patient a glass of water after administering the prescribed oral nystatin suspension Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet or contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

Hyponatremia SIADH results in a relative sodium deficit caused by excessive retention of water.

A patient in a long-term care facility who has anemia reports chronic fatigue and dizziness with minimal activity. Which nursing activity will the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluating the patient's response to normal activities of daily living 2. Obtaining the patient's blood pressure and pulse with position changes 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength

Obtaining the patient's blood pressure and pulse with position changes UAP education covers routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of patient abilities, and nutrition planning are activities appropriate to RN practice.