l and m quiz 3

The results of laboratory tests that were performed when Ms. A arrived in the ED are faxed to the RN. Complete blood count results are as follows: Hematocrit 42% (0.42) Hemoglobin level 12.6 g/dL (126 g/L) Platelet count 200,000/mm 3 (200 × 10 9 /L) White blood cell count 7500/mm 3 (7.5 × 10 9 /L) The metabolic profile shows the following: Blood urea nitrogen level 13 mg/dL (4.64 mmol/L) Chloride level 102 mEq/L (102 mmol/L) Creatinine level 0.7 mg/dL (61.88 µmol/L) Glucose level 144 mg/dL (7.99 mmol/L) Magnesium level 1.7 mEq/L (0.85 mmol/L) Potassium level 4.1 mEq/L (4.1 mmol/L) Sodium level 133 mEq/L (133 mmol/L) Arterial blood gas results are as follows: Arterial partial pressure of carbon dioxide (Paco2 ) 56 mm Hg (7.45 kPa) Arterial partial pressure of oxygen (Pao2) 65 mm Hg (8.64 kPa) Bicarbonate ( ) 22 mEq/L (22 mmol/L) O2 saturation 88% (0.88) pH 7.3 Based on the laboratory values, which collaborative intervention will the 594 nurse anticipate next? 1. Type and cross-match for 3 units of packed red blood cells. 2. Administer magnesium sulfate 1 g IV over the next 3 hours. 3. Give insulin aspart dose based on the standard sliding scale. 4. Obtain an endotracheal intubation tray and assist with intubation.

Ans: 4 Ms. A's ABG results indicate uncompensated respiratory acidosis and hypoxemia. Because her respiratory drive is suppressed, she will need rapid intubation and ventilation using a mechanical positive-pressure ventilator. She may need surgery, in which case it would be appropriate to have blood available in the blood bank. Although ongoing monitoring of the magnesium level is indicated, the magnesium level is in the low-normal range, so administration of magnesium is not a priority at this time. Insulin would not typically be administered for a small glucose elevation such as this in a nonfasting client. Focus: Prioritization.

Which additional assessment information is most important to obtain at this time? 1. Temperature 2. Breath sounds 3. Pedal pulses 4. Oxygen saturation

Ans: 4 National guidelines for the emergency management of traumatic brain injury indicate that the assessment of airway and breathing is the priority action for this client. Ms. A's slow and irregular respiratory rate is a risk factor for hypoxemia, which would decrease oxygen delivery to the brain as well as other vital organs and tissues. The other assessment information should also be obtained quickly because Ms. A is at risk for hypothermia, blood loss associated with a possible left leg fracture, and aspiration. Focus: Prioritization.

Ms. H's (acute cholecystitis) HIDA scan shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are the key signs and symptoms that the nurse will watch for? 1. Rebound tenderness and a sausage-shaped mass in the right upper quadrant 2. Flatulence, dyspepsia, and eructation after eating or drinking 3. Right upper quadrant abdominal pain that radiates to the right shoulder or scapula 4. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

Ans: 4 Severe pain with tachycardia, pallor, diaphoresis, and prostration (exhaustion) are signs and symptoms of severe biliary colic. This is a medical emergency. Keep the client flat and notify the Rapid Response Team because of the potential for shock. Rebound tenderness and a sausage-shaped mass in the right upper quadrant suggest peritoneal inflammation. Flatulence (gas), dyspepsia (indigestion), and eructation (belching) after eating are commonly reported by clients when they first seek help for gallbladder problems. Right upper quadrant pain that radiates to the right shoulder or scapula is reported by some clients in their descriptions of pain patterns. Focus: Prioritization

Ms. T is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "I'm being kept alive with tubes." Which explanation will encourage Ms. T to continue with the TPN therapy? 1. "It will help you regain your weight." 2. "It will create a positive nitrogen balance." 3. "Your health care provider has ordered this important therapy for you." 4. "Your bowel can rest, and the diarrhea will decrease."

Ans: 4 Stopping the diarrhea is a priority for Ms. T. Chronic, frequent diarrhea is demoralizing, and fluid and electrolyte losses cause weakness. If the bowel is allowed to rest, the cramping will stop. The other options also provide accurate information, but the potential resolution of the most disturbing symptom will encourage her to continue. Focus: Prioritization

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

Ans: 4 Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger, and an oxygen saturation of 93% is low normal. Focus: Prioritization.

Because of Ms. T's (ulcerative colitis) severe diarrhea, the nurse is reviewing the laboratory results. Which laboratory results are cause for greatest concern? 1. The WBC count is slightly increased. 2. The hemoglobin and hematocrit are slightly decreased. 3. The erythrocyte sedimentation (ESR) rate is increased. 4. The serum sodium and potassium levels are decreased.

Ans: 4 The low potassium level is the greatest concern because of the potential for cardiac dysthymias. Sodium is also lost during diarrhea episodes. The WBC count, C-reactive protein, and ESR rate are likely to be increased because of the inflammatory process of the disease. Low hemoglobin and hematocrit can occur because of ulceration and irritation of the intestinal mucosa. Focus: Prioritization

After change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. A 57-year-old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics 4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

Ans: 4 The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In patients with COPD, pulse oximetry oxygen saturations of more than 90% are acceptable. Focus: Prioritization.

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio2 ) and call the health care provider to discuss the patient's status.

Ans: 4 The patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. Focus: Prioritization.

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates correct understanding of this patient's curve shift? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen." 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

Ans: 4 When the need for oxygen is greater in the tissues, there is a curve shift to the right. This means that oxygen is dissociated from hemoglobin faster. Conditions that shift the curve to the right include increased body temperature, increased carbon dioxide concentration, and decreased pH or acidosis. This means that hemoglobin unloads oxygen to the tissues because they need it to support the higher metabolism, and this is a tissue protection that increases oxygen delivery to the tissues that need it the most.

The night shift nurse has just finished giving the RN team leader a report on the six clients. Which client has the highest acuity level and is at greatest risk for shock during the shift? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG-tube) 6. Mr. R (acute pancreatitis)

Ans: 6 Mr. R has several prognostic factors that increase the risk for death: age older than 50 years and increased WBC count and an elevated blood glucose level. Shock can occur secondary to bleeding; release of kinins, which causes vasodilation; or release of enzymes into the circulation. He is also at risk for infection and sepsis. Respiratory complications of pancreatitis include pneumonia, atelectasis, pleural effusions, and acute respiratory distress syndrome. Focus: Prioritization; Test Taking Tip: This question simulates the information filtering and subsequent decision making that nurses use while listening to the hand-off report. Use the airway, breathing, circulation (ABCs) and determine which clients are at risk for respiratory distress or hemorrhage.

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

. Ans: 1 When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

In the care of Mr. K (PEG tube), which health care team members are demonstrating the roles and responsibilities that support interprofessional collaboration? Select all that apply. 1. The UAP tells Mr. K's family that she will be in at 10:00 am to assist Mr. K with hygiene. 2. The RN gives the UAP specific instructions about how to clean around Mr. K's PEG tube. 3. The RN acknowledges that the UAP has the best working relationship with Mr. K's daughter. 4. The enterostomal therapist performs care for Mr. K, but staff and family are unsure about follow-up. 5. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities. 6. The surgeon does mini-grand rounds with nursing student to explain the purpose of Mr. K's PEG tube.

. Ans: 1, 2, 3, 5, 6 The UAP informs the family. The RN gives specific instructions. The RN acknowledges strengths of a team member. Nursing student recognizes her own limitations. The surgeon enhances the student's learning. These team members have filled their roles and responsibilities toward interprofessional collaboration. The enterostomal therapist performs a task but fails to communicate to other team members what is needed for follow-up care. Focus: Supervision, Knowledge.

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." 2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

. Ans: 2 Teach the UAP that compared with light-skinned adults, adults with dark skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status. None of the other responses are correct.

The nurse is supervising an RN who floated from the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply. 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

. Ans: 2, 3, 4, 5, 6 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed.

Mr. R (acute pancreatitis) demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a lowgrade fever. Which potential complication does the nurse suspect? 1. Hypovolemic shock 2. Pleural effusion 3. Paralytic ileus 4. Acute respiratory distress syndrome

ans: 2 A dry cough, left-sided chest pain when breathing deeply, shortness of breath, and low-grade fever are signs and symptoms of pleural effusion. Clients with acute pancreatitis can develop many complications: pancreatic infection that can lead to septic shock, hemorrhage secondary to necrotizing hemorrhagic pancreatitis, acute kidney failure, paralytic ileus, hypovolemic shock, pleural effusion, acute respiratory distress syndrome, atelectasis, pneumonia, multiorgan system failure, disseminated intravascular coagulation, and type 2 diabetes mellitus. Focus: Prioritization.

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

ans: 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. Focus: Delegation, Supervision

Ms. A is transported to the operating room, where the epidural hematoma is evacuated and an open reduction and internal fixation of her left leg fracture is completed. After surgery, Ms. A is transferred to the intensive care unit. She is attached to a cardiac monitor and has an arterial line in place. She is making no spontaneous respiratory ef ort but is being mechanically ventilated. Ms. A's indwelling urinary catheter is draining large amounts of clear, pale yellow urine. An intracranial monitor is in place. Her vital sign values and intracranial pressure (ICP) are as follows: Blood pressure 112/64 mm Hg (mean arterial pressure [MAP], 80 mm Hg) Heart rate 50 to 56 beats/min (sinus bradycardia) ICP 22 mm Hg (reference range, 5-15 mm Hg) O2 saturation 93% (0.93) Respiratory rate 20 breaths/min (ventilator controlled) Temperature 97.4°F (36.3°C) (tympanic) Which of the assessment data listed above requires the most immediate nursing action? 1. Cardiac rhythm 595 2. Blood pressure 3. O2 saturation 4. ICP

. Ans: 4 Normal ICP is 0 to 15 mm Hg, and CPP should be at least 60 mm Hg or higher. CPP is calculated using the formula MAP − ICP = CPP. Ms. A's CPP is 58 mm Hg (80 − 22 = 58); interventions should be implemented immediately to decrease her ICP and improve CPP. The other data indicate a need for ongoing monitoring but do not require immediate intervention. Focus: Prioritization

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest

Ans: 1 A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Focus: Prioritization.

. 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

Ans: 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. Focus: Delegation, Supervision

Psychosocial assessment reveals that Mr. A (appendectomy) faces several financial and personal problems. Which finding has the most impact on discharge teaching for wound care and other follow-up issues? 1. He is homeless and has no family in the city. 2. He has no money for the prescribed medications. 3. He has no transportation to the follow-up appointment. 4. He cannot read or write very well.

Ans: 1 Because Mr. A is homeless, he will need instructions for adapting the dressing change procedures because of inconsistent access to hot water, soap, and adequate bathroom facilities. The social worker can be contacted for assistance with financial issues related to medication or transportation. Simplify written material and verbally reinforce it or instruct Mr. A to have a friend read the information to him. Focus: Prioritization

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

Ans: 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. Focus: Delegation, Supervision.

The nurse is reviewing the medication administration record for Ms. T (ulcerative colitis). Which situation needs immediate investigation? 1. Two tablets of senna were given yesterday morning. 2. One dose of atropine sulfate was given yesterday morning. 3. IV infusion of infliximab 5 mg/kg was given last evening. 4. IV hydrocortisone 100 mg was given last evening

Ans: 1 Generally, laxatives should not be given to clients with ulcerative colitis. In Ms. T's situation, controlling her diarrhea is one of the main treatment goals. Senna is a stimulant laxative and will increase peristalsis and cramping. Atropine sulfate is an antidiarrheal medication. Antidiarrheal medication can be used for symptomatic relief, but caution is necessary because of the potential for colon dilation or toxic megacolon. Infliximab and hydrocortisone (and sulfasalazine) can be used for clients with ulcerative colitis to reduce the inflammation. Focus: Prioritization.

Arterial blood gas values are as follows: Paco2 25 mm Hg (3.33 kPa) Pao2 90 mm Hg (11.97 kPa) 20 mEq/L (20 mmol/L) O2 saturation 96% (0.96) pH 7.54 Which parameter indicates a need for an immediate change in the ventilator settings? 1. Paco2 2. O2 saturation 3. HCO3 4. Pao2

Ans: 1 Lower-than-normal Paco2 levels cause cerebral vasoconstriction and result in further cerebral hypoxia. The RN should notify the HCP and anticipate a decrease in the ventilator rate. The oxygen percentage being delivered by the ventilator should be evaluated because a lower fraction of inspired oxygen (Fio2 ) may be adequate. However, the current Pao2 will not have any adverse effect on cerebral perfusion. The decrease in reflects a compensatory mechanism for the client's respiratory alkalosis and will resolve spontaneously when the Pao2 level rises. Focus: Prioritization; Test Taking Tip: When analyzing ABGs, always consider both oxygenation (using Pao2 and oxygen saturation) and acid-base balance (using pH, Paco2 , and ). Even if the client's oxygenation is adequate, disorders in acidbase balance may lead to poor outcomes.

. The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

Ans: 1 Older patients, especially those who have smoked or who have chronic lung problems such as COPD, are at risk for ventilator dependence and failure to wean. Age-related changes, such as chest wall stiffness, reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. Younger patients without respiratory illnesses are likely to wean from the ventilator without difficulty. Focus: Prioritization

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

Ans: 1 Patients who have recently experienced trauma are at risk for deep 146 vein thrombosis (DVT) and pulmonary embolus (PE). None of the other findings are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short. Focus: Prioritization.

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? 1. Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3. Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.

Ans: 1 Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, highprotein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals. Focus: Delegation, Supervision

When the nurse assesses Ms. A at 2:00 pm, her left leg is pale, swollen, and very firm to palpation. The left leg pulses are only faintly audible using a Doppler pulse monitor. Which action is most appropriate at this time? 1. Call the orthopedic surgeon to communicate the assessment. 2. Elevate the left leg on two pillows to decrease the swelling. 3. Continue to monitor the left leg's appearance and pedal pulses. 4. Assess the client for indications of pain, such as restlessness

Ans: 1 The assessment data suggest the development of compartment syndrome, an emergency that can lead to permanent neuromuscular damage within 4 to 6 hours without rapid treatment. Elevation of the leg will further reduce blood flow to the leg. Continuing to monitor the leg without correcting the compartment syndrome will allow the ischemia to persist. Although restlessness may indicate pain in clients with intact neurologic function, Ms. A's neurologic status is severely compromised, and monitoring for restlessness will not be helpful in assessing for ischemic leg pain. Focus: Prioritization.

After being intubated and placed on mechanical ventilation, Ms. A is transported to the radiology department. The CT scans indicate that she has a large epidural hematoma. In addition, chest and left leg radiographs show that she has a left femur fracture and evidence of aspiration pneumonia. When the nurse reassesses Ms. A, she is flaccid and has no response to verbal or painful stimulation. Her pupils are dilated and nonreactive to light. Vital sign values are: Blood pressure 190/40 mm Hg Heart rate 40 beats/min (sinus bradycardia) O2 saturation 92% (0.92) Respiratory rate 14 breaths/min (ventilator controlled) Temperature 96°F (35.6°C) (tympanic) Which complication is the nurse most concerned about at present? 1. Brainstem herniation 2. Respiratory acidosis 3. Hemorrhage 4. Hypothermia

Ans: 1 The client's fixed and dilated pupils, widened pulse pressure, and bradycardia are caused by increasing pressure on the brainstem and indicate that she is at risk for brainstem herniation, which would result in brain death. Immediate surgical intervention is needed to prevent this complication. She is at risk for the other complications, but they are not as life threatening. Focus: Prioritization; Test Taking Tip: Although pupil dilation is associated with increases in ICP, remember that this is usually a late sign. You will want to monitor carefully for earlier signs of increased ICP, such as subtle changes in memory, orientation, and responsiveness, and communicate these changes quickly to the HCP

Ms. A suddenly begins to vomit. Which action should the nurse take first? 1. Use the backboard to log-roll Ms. A to her side. 2. Suction Ms. A's airway with a Yankauer suction device. 3. Hyperoxygenate Ms. A with a bag-valve mask system. 4. Insert a nasogastric tube and connect to low suction.

Ans: 1 The most important goal for an unconscious client who is vomiting is to prevent aspiration. Turning Ms. A to her side (while maintaining cervical spine stability through the use of the backboard and cervical collar) is the best method to ensure that she does not aspirate. Suctioning would also be utilized but does not clear the airway as well as having the client positioned on her side. Hyperoxygenation may also be required for this client but will not protect the airway while she is vomiting. A nasogastric tube is usually not inserted in clients with possible facial fractures. Insertion of an orogastric tube may be indicated but would not protect from aspiration at the present time. Focus: Prioritization; Test Taking Tip: Remember that maintenance of the airway and prevention of aspiration will be a priority for any client who has a decreased level of consciousnes

What information regarding Mr. R (acute pancreatitis) is appropriate to report to the HCP? Select all that apply. 1. Hematocrit is decreased by more than 10%. 2. Calcium level is less than 9 mg/dL (2.25 mmol/L). 3. Partial oxygen pressure (Po2 ) is less than 60 mm Hg. 4. Pain is unrelieved by medication. 5. Blood type is O positive. 6. NG tube and IV line are intact.

Ans: 1, 2, 3, 4 The low calcium level and the falling hematocrit and Po2 , in combination with the elevated WBC count and his age, are indicators of a high mortality risk. High level of pain is not a prognostic factor, but severe unrelieved pain should always be reported. Blood type will not affect the HCP's decisions about therapy. Reporting on the NG tube and IV line would be appropriate for hand-over report, but information about equipment is not reported to the HCP unless there is a specific problem that requires an order or a change of therapy. Focus: Prioritization.

Which tasks can be delegated to the UAP? Select all that apply. 1. Assisting Ms. T with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for Mr. R 3. Transporting Ms. H off the unit for a procedure 4. Gently cleansing the nares around Ms. D's NG tube 5. Removing Mr. A's dressing 6. Helping Mr. K to brush his teeth

Ans: 1, 2, 3, 4, 6 Measuring vital signs, performing hygienic care, and transporting (stable clients) are within the scope of the UAP's duties. The UAP should not remove the dressing. If the dressing needs to be removed, the nurse should remove it, conduct the wound assessment, clean the area, and redress as needed. Focus: Delegation

. A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

Ans: 1, 2, 3, 5 While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practice for professional nurses. All of the other instructions are appropriate for the UAP when caring for a patient receiving anticoagulants. Focus: Delegation, Supervision

The RN is observing the nursing student perform an abdominal assessment on Ms. D, who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? Select all that apply. 1. Palpating for abdominal distention with the index fingertip 2. Auscultating for bowel sounds with the NG tube attached to low wall suction 3. Performing the physical assessment before asking about pain 4. Checking the NG collection canister for quantity and quality of drainage 5. Inspecting for visible signs of peristaltic waves or abdominal distention 6. Checking for skin turgor over the lower abdominal area

Ans: 1, 2, 3, 6 The flat palmar surface of the hand is better than the fingertips when palpating for distention. If the wall suction is activated, it will interfere with auscultating for bowel sounds. Asking about pain first will guide the physical assessment steps. The skin on the anterior chest under the clavicle is a better place to check for turgor than the lower abdomen, especially if abdominal distention is present. Checking the drainage and inspecting for peristaltic waves or distention are correct actions. Focus: Supervision.

Which clients would be best to assign to the new RN? Select all that apply. 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG-tube) 6. Mr. R (acute pancreatitis)

Ans: 1, 2, 4 Ms. H, Ms. D, and Mr. A are in the most stable condition and represent the least complex cases according to the shift report. Mr. R's confusion and belligerence will make pain management especially difficult. Laboratory results and potential complications must be closely monitored. Ms. T is at risk for electrolyte imbalances, especially hypokalemia. She needs repetitive perineal hygiene and skin assessment. TPN and central line management require additional skills. Mr. K is in stable condition, but because of the family dynamics, his care should be handled by an experienced nurse. Focus: Assignment.

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

Ans: 1, 2, 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply. 135 1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 3. Wash all bedding in cold water to reduce and destroy dust mites. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

Ans: 1, 2, 4, 5, 6 Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma. Focus: Prioritization.

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply. 1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 3. Eat three large meals every day focusing on calories and protein. 4. Organize your work area so that what you use most is easy to reach. 5. Get all of your activities accomplished then take a nap. 6. Don't hold your breath while performing any activities

Ans: 1, 2, 4, 6 Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to pace activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller more frequent meals may be less tiring. Teach the patient to avoid breath-holding while performing any activity because this interferes with gas exchange. Focus: Prioritization

Available staffing in the emergency department includes an experienced unlicensed assistive personnel (UAP). Which actions should the nurse delegate to the UAP? Select all that apply. 1. Measuring vital signs every 15 minutes 2. Attaching the patient to a cardiac monitor 3. Documenting a head-to-toe assessment 4. Checking orientation and alertness 5. Inserting an IV line 6. Monitoring urine output hourly

Ans: 1, 2, 6 Checking vital signs and urine output is included in UAP education. Experienced UAPs will know which patient information to report immediately to the supervising RN. UAPs working in the ED would also have been trained and know how to establish cardiac monitoring, although dysrhythmia analysis and treatment are the responsibility of the RN. Obtaining and documenting assessments and starting an IV line should be done by the RN. Focus: Delegation

To provide good continuity of care for Mr. A (appendectomy), who is homeless, which members of the interdisciplinary team should routinely have access to Mr. A's medical records? Select all that apply. 1. Hospital social worker who is helping Mr. A to locate resources 2. Surgeon who performed Mr. A's appendectomy 3. An epidemiologist who is collecting data on the homeless 4. All of the UAPs who work in the medical-surgical area 5. Administrator of the shelter where Mr. A frequently stays 6. Nurse who works at the shelter where Mr. A frequently stays

Ans: 1, 2, 6 Health care staff who provide direct care for the client have routine access to a client's medical records. An epidemiologist could access records to gather data at the aggregate level, but this would require special permission. Only the UAPs who assist in the care of the client would have access to records, and UAP access may be restricted to flow sheets, for recording vital signs, intake and output, and so on. Administrator of the shelter might be advised, about a client's condition, but the information is likely to come from the nurse or HCP who oversees client care at the shelter. Focus: Prioritization, Knowledge

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

Ans: 1, 2, 6 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.

The nurse is the team leader RN working with a student nurse. The student nurse is to teach a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in correct order the steps that the student nurse should teach the patient. 1. Remove the inhaler cap and shake the inhaler. 2. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away. 3. Breathe out completely. 4. Hold your breath for at least 10 seconds. 5. Press down firmly on the canister and breathe deeply through your mouth. 6. Wait at least 1 minute between puffs. _____, _____, _____, _____, _____, ____

Ans: 1, 3, 2, 5, 4, 6 Before each use, the cap is removed, and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler. Focus: Prioritization.

Because of Mr. K's (PEG tube) advanced age, which complications of enteral feedings may occur? Select all that apply. 1. Hyperglycemia 2. Hypotension 3. Aspiration 4. Diarrhea 5. Fluid overload 6. Weight loss

Ans: 1, 3, 4, 5 Older adult clients are especially at risk for hyperglycemia, aspiration, diarrhea, and fluid overload. Hypotension and weight loss should not occur because of enteral feedings. Focus: Prioritization, Knowledge.

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove. 2. The student nurse applies suction while inserting the catheter. 3. The student nurse applies suction during catheter removal. 4. The student nurses uses a twirling motion when withdrawing the catheter. 5. The student nurse uses a no. 12 French catheter. 6. The student nurse applies suction for at least 20 seconds.

Ans: 1, 3, 4, 5 The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning. Focus: Prioritization

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply. 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or outside? 6. Do you have a difficult time not smoking in places where it is not allowed?

Ans: 1, 3, 4, 6 When a patient expresses interest in smoking cessation, this is an important teaching moment for the nurse. However, it is essential to determine the patient's level of nicotine dependence by asking questions such as questions 1, 3, 4, and 6, which will give clues to this important information. While it is important to know about other family smokers and whether the patient smokes inside or outside, this information does not necessarily help with determining nicotine dependence.

The postcraniotomy care plan for the first postoperative day includes these nursing actions. Which actions can the nurse assign to an experienced LPN/LVN working in the intensive care unit? Select all that apply. 1. Checking the gastric pH every 4 hours 2. Performing a neurologic status examination every 2 hours 3. Assessing breath sounds every 4 hours 4. Turning the client side to side every 2 hours 5. Monitoring intake and output hourly 6. Sending a urine specimen to check specific gravity daily

Ans: 1, 5, 6 Checking gastric pH, monitoring intake and output, and obtaining urine specimens are included in LPN/LVN education and scope of practice. An experienced LPN/LVN would be expected to report any changes in client status to the supervising RN. Usually repositioning a client would also be included in the LPN/LVN role; however, this client is at risk for increased ICP during positioning and should be monitored by the RN during and after repositioning. Assessments of breath sounds and neurologic status in critically ill clients should be accomplished by an experienced RN. Focus: Assignment.

Which of these interventions will be used to meet the goal of maintaining Ms. A's cerebral perfusion pressure (CPP) at 60 mm Hg or more? Select all that apply. 1. Keep the head of the bed elevated 30 degrees. 2. Check pupil reaction to light every hour. 3. Reposition the client at least every 2 hours. 4. Perform endotracheal suctioning as necessary. 5. Check Glasgow Coma Scale score hourly. 6. Administer mannitol 100 mg IV if ICP is above 20 mm Hg. 7. Titrate norepinephrine drip to maintain MAP above 80 mm Hg.

Ans: 1, 6, 7 Evidence-based guidelines recommend the use of mannitol in clients who have traumatic brain injury with increased ICP to reduce ICP and improve CPP. In hypotensive clients, cerebral perfusion may also be improved by administering vasopressors to raise arterial pressure. Positioning the head of the bed at 30 degrees also reduces cerebral edema by promoting venous drainage from the cerebral circulation. Although neurologic assessments such as checking the Glasgow Coma Scale score and observing pupil reaction to light are necessary, the stimulation caused by these interventions can increase ICP. Suctioning and repositioning also cause transient increases in ICP. It is important to monitor intracranial and arterial pressures during these procedures and modify care to avoid unnecessary increases in ICP. Focus: Prioritization

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? 1. Nasal cannula 2. Nonrebreather mask 3. Venturi mask 4. Simple face mask

Ans: 2 A nonrebreather mask can provide a fraction of inspired oxygen (Fio2 ) of close to 100%, which will be needed for this severely hypoxemic patient. Nasal cannulas deliver a maximum Fio2 of 44%, simple face masks deliver an Fio2 of up to 60%, and Venturi masks provide a maximum Fio2 of 55%. Focus: Prioritization; Test Taking Tip: Since administration of oxygen is a common nursing action, you will need to know which type of oxygen administration equipment is needed to achieve a variety of Fio2 percentages

About 20 minutes after Ms. A is positioned on her right side, her ICP has increased to 30 mm Hg. Which action should the nurse take next? 1. Administer the as needed (PRN) mannitol 100 mg IV. 2. Assess the alignment of Ms. A's head and neck. 3. Elevate the head of the bed to 45 degrees. 4. Check Ms. A's pupil size and response to light.

Ans: 2 Because the client has just been repositioned, it is likely that the elevated ICP is caused by poor positioning. The head and neck should be maintained in good alignment because neck flexion can cause venous obstruction and an increase in ICP. Administration of mannitol and further elevation of the head of the bed may be needed if repositioning Ms. A's head and neck is ineffective. However, these measures should be used only if her MAP is high enough to maintain a CPP of 60 mm Hg. Checking Ms. A's pupils would not offer any additional information, and the stimulation may increase the ICP. Focus: Prioritization.

The RN is teaching the nursing student about enteral feedings for clients such as Mr. K, who has a PEG tube. In the postoperative period, when can enteral feedings be started? 1. Within 6 to 8 hours after the procedure 2. When bowel sounds occur, usually within 24 hours 3. When the client reports feeling hungry 4. On a schedule determined by the pharmacy

Ans: 2 Bowel sounds should resume in 24 hours; this signals GI system readiness. The client's subjective reports of hunger (or lack of hunger) should not dictate initiation of feedings. The pharmacy may label the formula according to the HCP prescription but will not determine the feeding schedule. Focus: Prioritization

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

Ans: 2 Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not 145 changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak. Focus: Delegation, Supervision.

The UAP asks, "Why can't Ms. T (ulcerative colitis) get out of bed and do things for herself? She's only 29 years old." What is the team leader's best response? 1. "The HCP ordered bed rest for a few days." 2. "Decreasing activity helps to decrease the diarrhea." 3. "I see you're frustrated; just do your best to help." 4. "She is too depressed to get out of bed."

Ans: 2 Explaining the physiologic reason helps the UAP to understand that rest is part of the therapy. Following the HCP's orders is important, but it is an inadequate explanation. Acknowledging frustration is appropriate, but a generalized platitude, such as "do your best," does not help the UAP understand the goals of therapy. Depression is not an indication for bed rest. Focus: Supervision.

Mr. K (PEG tube) needs 1200 kcal/day. The enteral feeding formula provides 1 kcal/mL. Yesterday's formula feedings were 100 mL at 7:00 am, 50 mL at 11:00 am, 200 mL at 3:00 pm, and 100 mL at 7:00 pm. What should the nurse do first? 1. Give additional feedings to catch up on nutritional needs. 2. Look at the original prescription to determine frequency and amount. 3. Look at weight trends to see if client is losing or maintaining weight. 4. Call the nurse who cared for Mr. K yesterday and asked what happened

Ans: 2 First the nurse would look at the original prescription. If the prescribed amount seems insufficient, the nurse could contact the HCP and the nutritionist to have the feeding changed. If the prescribed orders were not followed, the charge nurse should be notified to follow up with all nurses who are caring for Mr. K to prevent reoccurrence. Looking at weight trends is part of the routine assessment for clients with feeding tubes and those at risk for nutritional problems. Mr. K only received 450 kcal yesterday, but trying to catch up by overfeeding may cause distention, vomiting, fluid overload, or electrolyte imbalances. Focus: Prioritization.

What instructions will the nurse give to the UAP about how to reposition Mr. R to relieve discomfort related to acute pancreatitis? 1. Place him in a high Fowler position. 2. Help him to lie in a side-lying "fetal" position. 3. Lay the bed flat and put the client's legs on a pillow. 4. Help him to sit on edge of bed and dangle his legs

Ans: 2 For clients with pancreatitis, the fetal position or sitting up and holding the knees to the chest will open the retroperitoneal space, which helps to decrease discomfort. For Mr. R, having him lie down is preferable to having him sit because of his mental status and condition. Focus: Supervision, Delegation.

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

Ans: 2 For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If the nurse does not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization; Test Taking Tip: Immediate or priority concerns are issues that can threaten life or limb. In this case, the nurse should remember the normal drive to breathe and recognize that this patient's drive is different. With a respiratory rate so low, the patient is at risk for a respiratory arrest.

Ms. A's mother, who has been staying at the bedside, asks the nurse why her daughter is receiving omeprazole, stating that her daughter has no history of peptic ulcers. Which answer is best? 1. "Omeprazole will lower the chance that she will aspirate." 2. "Omeprazole decreases the incidence of gastric stress ulcers." 3. "Omeprazole will reduce the risk for gastroesophageal reflux." 4. "Omeprazole prevents gastric irritation caused by the orogastric tube."

Ans: 2 Gastric stress ulcers are a common complication of head injury unless histamine2 (H2 ) blockers (e.g., famotidine) or proton pump inhibitors (e.g., omeprazole) are administered prophylactically. Administration of omeprazole may decrease the risk of pneumonitis if aspiration occurs, minimize the effects of gastroesophageal reflux, and decrease stomach irritation, but none of the other responses addresses the use of proton pump inhibitors in clients with head injury. Focus: Prioritization.

. The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

Ans: 2 Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips. Elevating the head of the bed may help with oxygenation but will not help with hoarseness. Responses 3 and 4 are important but do not speak directly to the patient's concern. Focus: Prioritization.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2 ) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

Ans: 2 Manual ventilation of the patient will allow the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia. Focus: Prioritization.

The health care provider (HCP) prescribes these actions. Which action will the nurse take first? 1. Notify family members of Ms. A's admission. 2. Obtain computed tomography (CT) scan of head. 3. Clean the occipital laceration and apply a dressing. 4. Infuse famotidine 20 mg IV every 12 hours

Ans: 2 National advanced trauma life support guidelines indicate that a CT scan should be done as soon as possible after a closed head injury to determine the extent and types of injury and guide interventions, such as surgery. The other actions are also appropriate for the client but do not need implementation as rapidly. Focus: Prioritization.

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. "Everyone in my family needs to go and see the doctor for TB testing." 2. "I will continue to take my isoniazid until I am feeling completely well." 3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." 4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

Ans: 2 Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing and placing tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB. Focus: Prioritization.

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)

Ans: 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. Focus: Delegation, Supervision.

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

Ans: 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. Focus: Delegation, Supervision.

. The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

Ans: 2 The UAP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN's scope of practice. Focus: Delegation, Supervision.

Based on the initial history and assessment, which action prescribed by the health care provider (HCP) will the nurse implement first? 1. Insert a Foley catheter and monitor urine output hourly. 2. Start oxygen and maintain oxygen saturation at 90% or higher. 3. Place the patient on a cardiac monitor. 4. Check the blood glucose level.

Ans: 2 The oxygen saturation indicates that the patient is severely hypoxemic (despite an increased respiratory rate). Because this hypoxia will affect all other body systems, it should be treated immediately. The other orders also should be rapidly implemented, but they do not require action as urgently as the low oxygen saturation. Focus: Prioritization; Test Taking Tip: When patients are in critical distress, the ABCs (airway, breathing, and circulation) are usually the best guide to the priority actions, no matter what the patient diagnosis is.

As the shift ends, the nurse is preparing Ms. A for transfer to surgery for an emergency fasciotomy. What is the best option for obtaining informed consent for the fasciotomy? 1. Informed consent is not needed for emergency surgery. 2. Permission for surgery can be given by Ms. A's mother. 3. Consent for surgery is not required for unconscious clients. 4. Authorization can be given by the nursing supervisor.

Ans: 2 When a client is unable to provide informed consent for a procedure, a close family member (who is likely to be most knowledgeable about the client's wishes) is able to give permission. Emergency procedures can take place without written consent for an unconscious or incompetent client when no family or legal representative is available to give permission. The nursing supervisor does not have the authority to consent to surgery for an unconscious client. Focus: Prioritization.

The night nurse gives a brief and incomplete report. Which question should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H who was admitted for acute cholecystitis? 1. "What are her vital signs?" 2. "Is she going to surgery or radiology this morning?" 3. "Is she still having pain?" 4. "Does she need any morning medications?"

Ans: 2 When the shift report is incomplete, the nurse can ask for any type of additional information. However, morning surgery or procedures impact the immediate plan of care for the individual client and the organization of care for other assigned clients. HCPs frequently communicate verbally to the nursing staff, but the written notes may be pending, especially if it is an emergency admission or if the HCP is trying to complete rounds or do procedures. Vital sign values and the need for medications can be obtained from the records if the off-going nurse neglects to give that information. A current pain report can and should be obtained directly from the client. Focus: Prioritization.

Based on Ms. A's history, vital signs, and assessment data, the client is most at risk for which types of shock? Select all that apply. 1. Cardiogenic 2. Hypovolemic 3. Neurogenic 4. Septic 5. Anaphylactic

Ans: 2, 3 Ms. A's bradycardia and hypotension suggest that she is experiencing neurogenic shock in response to her head injury. It is also important to remember that with any traumatic injury, hypovolemic shock caused by hemorrhage should be considered. In this case, Ms. A should be assessed for blood loss associated with her leg injury and for internal bleeding caused by blunt trauma to her chest and abdomen. There are no indications in the client's history that she is at risk for cardiac, septic, or anaphylactic shock. Focus: Prioritization.

The HCP has been paged and is en route to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. His pulse rate is 140 beats/min, and his blood pressure is 140/60 mm Hg. List the following steps, in order of priority, in caring for Mr. R with 1 being the first and 6 being the last. 1. Restart the IV line. 2. Stay with the client and call for assistance. 3. Replace the nasal cannula for supplemental oxygen. 4. Have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask. 5. Check the blood glucose level. 6. Delegate UAP to take vital signs every 15 minutes. ____, ____, ____, ____, ____, ____, ___

Ans: 2, 3, 4, 1, 5, 6 Stay with the client, but call for assistance; reestablish oxygen per nasal cannula, and have a colleague gather equipment. (Note: Check oxygen saturation with nasal cannula in place and replace with nonrebreather mask as needed.) Restart the IV infusion so that emergency fluids or drugs can be given. Check the blood glucose level to rule out a hypoglycemic reaction. Continuously monitor vital signs. If at all possible, reinsert the NG tube; however, this is not a lifesaving priority. Focus: Prioritization.

Using the SBAR (situation, background, assessment, recommendations) format, in which order will the nurse communicate this information about the client to the HCP? 1. "I am concerned that Ms. A may develop worsening cerebral hypoxia caused by cerebral vasoconstriction and I would like to decrease the respiratory rate setting on the ventilator." 2. "This is the nurse caring for Ms. A. The client's most recent arterial blood gases (ABGs) indicate that her Paco2 is too low, possibly worsening her cerebral perfusion." 3. "Her current ventilator respiratory rate is set at 20, and ABGs show the Paco2 is 25 mm Hg (3.33 kPa), with a pH of 7.54. O2 saturation is 96% (0.96) with Pao2 of 90 mm Hg (11.97 kPa)." 4. "Ms. A is a 20-year-old woman who had evacuation of an epidural hematoma and has been nonresponsive and ventilator dependent since surgery."

Ans: 2, 4, 3, 1 Using the SBAR format, the nurse first describes the primary concern (situation) and then provides background information about the client. Next, the nurse discusses pertinent assessment data. Finally, recommendations for needed changes in the treatment plan are communicated. Focus: Prioritization.

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.

Ans: 2, 4, 5 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

Mr. A (appendectomy) will be discharged with prescriptions for pain medication and an antibiotic. What is the most important point that the nurse will emphasize about the medications? 1. "Take the pain medication before the pain becomes severe." 2. "The pain medication may make you feel drowsy or sleepy." 3. "All of the antibiotics should be taken, even if you feel good." 4. "The antibiotics should not be shared with any other person."

Ans: 3 All of the teaching points are important; however, Mr. A had a ruptured appendicitis, and it is essential that he complete the antibiotic prescription so that the infection will completely resolve. Recurrent infections can be more difficult to treat because the organisms will develop a resistance. Focus: Prioritization; Test Taking Tip: To prevent the development of drugresistant strains of microbes, clients should always be instructed to complete a prescription of antibiotics.

The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.

Ans: 3 Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the health care provider needs to be called. Focus: Prioritization.

The nurse notes that Ms. A has abnormal movement when pressure is applied to her nail beds, as shown in the illustration (hands out). What is the best way to document this finding? 1. Extensor rigidity 2. Decorticate posturing 3. Decerebrate posturing 4. Traumatic brain injury

Ans: 3 Decerbrate posturing includes stiff extension of the arms and legs, plantar flexion of the feet, and arm pronation and usually indicates brainstem dysfunction. Documenting extensor rigidity alone would be an incomplete description of the client's assessment. Decorticate posturing involves flexion and internal rotation of the arms. The client clearly does have a traumatic brain injury, but a clear description of the baseline assessment by the nurse is needed. Focus: Prioritization

The nurse notes that Mr. R (acute pancreatitis) has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? 1. Remove the IV line and restart it at different site. 2. Remind the UAP to handle Mr. R very gently. 3. Assess for other signs of obvious or occult bleeding. 4. Obtain an order for coagulation studies

Ans: 3 First, the nurse would assess for additional evidence of bleeding. Findings would be immediately reported to the HCP, because clients with acute pancreatitis have an increased risk for coagulation disorders, such as disseminated intravascular coagulation. Restarting the IV line at a different site will not alleviate the problem. If there is a coagulation disorder, the new insertion site will also bleed. It would be appropriate to initiate interventions for bleeding precautions, such as gentle handling. The nurse anticipates that the HCP will want coagulation studies after assessment findings are reported. Focus: Prioritization.

. The health care provider (HCP) told Ms. H (acute cholecystitis) that she would probably need a laparoscopic cholecystectomy; however, the hepatobiliary iminodiacetic acid (HIDA) scan and laboratory results are still 529 pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? 1. Describe the surgical procedure. 2. Call the HCP to come and speak with her. 3. Provide some written material about gallbladder disease and options. 4. Explain general postoperative care, such as coughing and deep breathing exercises

Ans: 3 Giving written information about gallbladder disease and options will help Ms. H to prepare any questions she might have for the HCP. If diagnostic results are pending, calling the HCP is premature. Describing the surgical procedure is inappropriate because there is more than one type of procedure, and the one to be used is still undetermined. Explaining postoperative care would be appropriate after the need for cholecystectomy has been verified by the HCP. Focus: Prioritization

The new RN asks the team leader if it is okay to give Ms. D (bowel obstruction) a dose of psyllium using the HCP's standing orders. Ms. D says, "She feels constipated and takes psyllium on a regular basis at home." What is team leader's best response? 1. "Call the HCP to see if the standing orders apply to Ms. D" 2. "Give the psyllium according to the standing orders." 3. "Laxatives can cause perforation if there is a bowel obstruction." 4. "The client can't be constipated because she is NPO."

Ans: 3 Laxatives should not be used for clients with bowel obstructions or fecal impactions because increased peristaltic action can cause rupture and perforation. Assessment for return of bowel function (e.g., passing flatus, hearing bowel sounds) should be performed, and evidence of function should be pointed out to the client. The client should be told that being nothing by mouth will decrease fecal mass and that eventual return of function and normalization of bowel pattern are the therapeutic goals. Focus: Supervision.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

Ans: 3 Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses. Focus: Assignment.

The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status (refer to questions 28 and 31), the team leader would advocate for which intervention? 1. Perform additional laboratory tests and continue monitoring. 2. Prepare Mr. R for emergency surgery. 3. Prepare Mr. R for transfer to the intensive care unit (ICU). 4. Reestablish NG suction and apply restraints or use one-on-one observation.

Ans: 3 Mr. R has severe life-threatening problems that warrant intensive care. The HCP is responsible for the decision to transfer Mr. R; however, the nurse must recognize and advocate for clients who are decompensating. Ordering laboratory and other diagnostic testing may be needed, and restraints or one-on-one observation could be suggested to prevent dislodging equipment, but ultimately, the client should be transferred to the ICU. Surgery is unlikely until aggressive medical management measures are exhausted. Focus: Prioritization

The LPN/LVN reports that Ms. A's output for the past hour was 1200 mL and that her urine is very pale yellow. Which action is best for the nurse to take at this time? 1. Instruct the LPN/LVN to continue to monitor the urine output hourly. 2. Send a urine specimen to the laboratory to check specific gravity. 3. Notify the neurosurgeon and anticipate an increase in the IV rate. 4. Assess the client's neurologic status for signs of increased irritability.

Ans: 3 Ms. A's high urine output suggests that she has developed diabetes insipidus, a common complication of intracranial surgery. Because diabetes insipidus can rapidly lead to dehydration in a client who is unable to take in oral fluids, the priority action needed is to increase the IV rate. Continuing to monitor the output and checking the specific gravity would also be needed but would not correct the risk for hypovolemia and hypotension. Because Ms. A's neurologic status is so poor, it is unlikely that changes in her neurologic status would be helpful in determining the effects of fluid and electrolyte imbalance. Focus: Prioritization.

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

Ans: 3 Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure. Focus: Prioritization.

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

Ans: 3 Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP. Focus: Prioritization; Test Taking Tip: Prevention of VAP has been a subject of research; as a result, a ventilator bundle order set has been developed to apply to patients placed on ventilators with the goal of prevention of VAP.

Ms. T is receiving an oral dose of sulfasalazine 500 mg every 6 hours for treatment of ulcerative colitis. Which assessment finding is cause for greatest concern? 1. Decreased appetite 2. Nausea and vomiting 3. Decreased urine output 4. Headache

Ans: 3 Sulfasalazine is potentially nephrotoxic. The other adverse effects are also possible but are less serious. Focus: Prioritization.

What is the best approach by the nurse when communicating concerns about the medical resident's decision making? 1. Call the medical resident's supervisor about the concerns. 2. Ask the nursing supervisor to discuss appropriate care with the medical resident. 3. Tell the medical resident that lumbar puncture may cause brainstem herniation. 4. Explain that lumbar puncture is not within the medical resident's scope of practice.

Ans: 3 The Core Competencies for Interprofessional Collaborative Practice indicate that professionals should clearly express knowledge and opinions about client care in order to ensure common understanding of information, treatment, and care decisions. In this situation, the nurse needs to rapidly and clearly communicate with the resident to prevent injury to the client. Calling the resident's supervisor or asking the nursing supervisor to intervene may also be appropriate, but a more direct approach is best in the current situation. The resident will be familiar with medical scope of practice. Focus: Prioritization.

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

Ans: 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. Focus: Delegation, Supervision, Prioritization

Which is the best way to clearly document Ms. A's level of consciousness? 1. Client is comatose. 2. Client is unresponsive. 3. Client's Glasgow Coma Scale score is 4. 4. Client has a decreased level of consciousness

Ans: 3 The Glasgow Coma Scale offers a standardized and objective way to assess and document neurologic status. Although the other responses also accurately describe the client's level of consciousness, they do not provide objective data that can be readily used to determine changes in the client's neurologic status. Focus: Prioritization.

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness

Ans: 3 The UAP can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can administer or assign medication administration to an LPN/LVN.

Which staff member will be best to assign to take primary responsibility for 593 Ms. A's ongoing care? 1. RN from a temporary agency with extensive previous emergency experience who has been working in this ED for 3 days 2. LPN/LVN with 10 years of experience in the ED who is in the last semester of an RN program 3. RN who has worked in the ED for the past 5 years after transferring from the mother and baby unit 4. RN who has 12 years of intensive care unit experience and has floated to the ED today

Ans: 3 The initial care of clients with traumatic injuries requires the expertise of an RN with extensive ED experience. Neither the agency RN nor the float RN will be familiar with the location of equipment and with the organization of care in the ED. Although the LPN has experience, the LPN/LVN scope of practice does not include the complex assessments and interventions that will be needed in caring for this client. (The LPN could be assigned to assist the RN caring for Ms. A.) Focus: Assignment.

While the nurse is teaching Mr. A about dressing changes for his appendectomy wound, he says, "When you live on the street, you can't do everything the way you nurses do in the hospital." What is the most important thing to emphasize in helping him to accomplish self-care? 1. "Change the dressing in the am and the pm." 2. "Use the gauze package to make a sterile field." 3. "Wash your hands before a dressing change." 4. "Discard any opened packages of unused gauze."

Ans: 3 Washing the hands is the first basic step for dressing change. Helping Mr. A identify other ways to maintain asepsis would be more useful than stressing strict sterile technique. Changing the dressing in the morning and the evening maybe ideal, but this type of dressing change can be done at any time. Focus: Prioritization; Test Taking Tip: From fundamentals, recall that hand hygiene is the single most important action to prevent infection.

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

Ans: 3 When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

Ms. D (bowel obstruction) reports feeling weak. She seems more confused compared with her baseline. The NG drainage container has a large amount of watery bile-colored fluid. Which laboratory values should be checked first? 1. Blood urea nitrogen and creatinine levels 2. Platelet count and WBC count 3. Sodium level, potassium level, and pH of blood 4. Bilirubin level, hematocrit, and hemoglobin level

Ans: 3 With continuous NG suction, there is a loss of sodium and potassium. Also, the loss of acid via suctioning will result in an increase in blood pH or metabolic alkalosis. Full assessment of laboratory data is always important when a change in status is noted, but the other values are less relevant to this client's NG therapy. Focus: Prioritization.

Which reporting tasks are appropriate to delegate to the UAP? Select all that apply. 1. Reporting on the condition of Ms. T's perineal area after application of ointment 2. Reporting the quality and color of NG drainage for Ms. D 3. Reporting whether Mr. R's blood pressure is below 100/60 mm Hg 4. Reporting if any of the clients indicate pain 5. Reporting if Mr. A is seen leaving the unit to smoke a cigarette 6. Reporting that Mr. K's family has questions

Ans: 3, 4, 5, 6 The UAP can report on changes in vital sign values; giving parameters for notification is better than asking for general reports on any changes. The UAP can report that a client is having pain but is not expected to assess that pain. The UAP can report that the family has questions but should not be expected to answer questions about the client's care. All staff should be aware of when registered clients come and go on the unit and should keep each other advised. (Note: Clients should also be encouraged to tell someone if they are going off the unit.) Judging response to treatment and evaluating drainage are responsibilities of the RN. Focus: Delegation

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)

Ans: 4 A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern. Focus: Prioritization, Delegation, Supervision.

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

Ans: 4 An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN. Focus: Assignment, Supervision

Toward the end of the shift, the team leader finds the new RN in the bathroom crying. The new nurse says, "I'm a terrible nurse. I'm so disorganized, and I'm so far behind. I'm going to quit. I hate this job." What is the best thing to do? 1. Have her take a short break off the unit. 2. Offer to take one of her clients. 3. Ask the UAP to help her. 4. Calm her down and help her prioritize.

Ans: 4 Helping her to prioritize will build skill and confidence. She feels upset, but she has not made any errors that have compromised client care (the team leader would point this out to her). Sending her off the unit further delays care, leaves her without support, and hinders opportunities to problem solve. Asking the UAP to help her or helping her with select tasks is the second-best choice because it demonstrates team support. Taking over one of her clients is not necessary unless care and safety are compromised. Focus: Supervision.

All of these clients must receive their routine morning medications. Which client should receive his or her medication last? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. K (PEG-tube

Ans: 4 In the provision of routine care and when all clients are stable, clients who need extra time should be left until last so that care for others is not delayed. Mr. K will require more time and assistance because of age and weakness. Also, his medications must be crushed and administered via PEG tube, which is more time consuming. Dealing with Mr. K's family is also more time consuming. Older adult clients and their families typically benefit from and appreciate caregivers who do not act rushed or hurried. Focus: Prioritization.

For Mr. K (PEG tube), several new medications and a change in the enteral feeding solution are included in the discharge plan. Which team member is the nurse most likely to consult before teaching the client and family about these new medications and enteral solution? 1. Nutritionist to verify that the calories and other nutrients are sufficient 2. Home health nurse to verify that follow-up teaching will be performed 3. Social worker to verify that medications and formula are covered by insurance 4. Pharmacist to verify that medications are compatible with the feeding solution

Ans: 4 In this circumstance, the nurse is most likely to consult the pharmacist to see if there are any incompatibilities. The nurse is less likely to consult the other team members at this time unless there are specific issues related to insufficient nutrition, a problem with home health care, or inadequate insurance coverage. Focus: Prioritization.

A new medical resident is working in the ED today. Which action by the resident indicates a need for immediate intervention by the nurse? 1. Assessing for the Babinski sign 2. Increasing the IV infusion rate to 200 mL/hr 3. Ordering an electrocardiogram (ECG) 4. Preparing to perform a lumbar puncture

Ans: 4 Lumbar puncture is contraindicated in a client who may have increased ICP because it increases the risk for herniation of the brainstem through the foramen magnum at the base of the skull. Checking for a positive Babinski sign and obtaining an ECG are not priorities for this client but would not place the client at any increased risk. Increasing the IV rate is appropriate based on the client's blood pressure. Focus: Prioritization

. The RN is supervising the nursing student in administering Ms. D's (bowel obstruction) medications through the NG tube. When would the nurse intervene? 1. The student compares medication administration record with the original prescription. 2. The student draws up 30 mL of sterile water for flush in a large-bore syringe. 3. The student performs three checks of the medication names and dosages. 4. The student crushes tablets and puts all medications in the same cup.

Ans: 4 Medications should be given separately because of increased risk for physical and chemical incompatibilities, increased chance of clogging the tube, and altered therapeutic response. The other actions are correct. Focus: Supervision

An RN is the leader of a team caring for clients with gastrointestinal (GI) disorders on a medical-surgical unit. The team includes a newly graduated RN who has recently completed hospital orientation, an experienced unlicensed assistive personnel (UAP), and a nursing student. The following information about the six assigned clients is included in the hand-of report. (Note to student: Use the information from the handof report to make brief notes about these six clients and refer to the notes as you work through the case study. This gives you practice in identifying important information and simulates how you would use the notes to remember and keep track of six clients over the course of a shift.) • Ms. H, a 42-year-old woman, has right upper quadrant pain that radiates to the right shoulder. She has a history of gallstones. She was admitted through the emergency department last night with acute cholecystitis. The night shift nurse reports, "She had a good night." • Ms. D, a 60-year-old woman, was admitted with vomiting and pain in the midabdomen related to a bowel obstruction. She reports abdominal pain that has gradually improved since the insertion of a nasogastric (NG) tube. She is receiving IV fluids and is currently to have nothing by mouth (NPO). • Ms. T, a 29-year-old woman, was admitted for an acute exacerbation of ulcerative colitis. She appears wasted and malnourished. She has severe diarrhea and reports predefecation abdominal pain and generalized tenderness to palpation. She is receiving total parenteral nutrition (TPN) through a central line. • Mr. A, a 26-year-old man, will be discharged in the afternoon. He is homeless and frequently sleeps in a nearby shelter. He had discharge teaching from the enterostomal therapist yesterday regarding his infected wound secondary to a ruptured appendix; he wants a review of the wound care instructions before he leaves. • Mr. K, an 85-year-old man, is frail but alert and oriented × 2. He was transferred from an extended-care facility to receive a percutaneous endoscopic gastrostomy (PEG) tube that was placed 5 days ago. He has a large family. They ask a lot of questions and argue continuously among themselves and with the staf . His vital signs are stable. • Mr. R, a 57-year-old man, has periumbilical pain. The pain is very severe, despite medication, and radiates to the back. Mr. R was admitted with acute pancreatitis. He is nothing by mouth and has an NG tube and IV line. He is belligerent and confused. The white blood cell (WBC) count and blood glucose level are increased.

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Ms. A, a 20-year-old college student who had been drinking at a fraternity party before she fell from a second-floor balcony, has just arrived in the emergency department (ED). A fellow college student who accompanies Ms. A tells the triage nurse, "She was completely knocked out right after the fall. But then she woke up a little, so we thought she was okay—until she stopped moving again." When the nurse assesses Ms. A, there is no response to commands or to having her name called. Her eyes are shut, and she does not open them even when the nurse applies nail bed pressure. Her pupils are unequal, with the right pupil larger than the left. Ms. A's blood pressure is 70/30 mm Hg, she is in a sinus bradycardia with a rate of 40 beats/min, and her respiratory rate is 6 breaths/min. Her respirations are irregular, and she has 20-second periods of apnea. She has a large occipital laceration, and her left leg is misaligned. The paramedics have a cervical collar and backboard in place. A 16-gauge catheter has been inserted at the left antecubital area, and lactated Ringer's solution is infusing at 150 mL/hr.

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Ms. D, a 54-year-old patient, is brought to the emergency department by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although usually Ms. D is very alert and oriented, today she has been increasingly lethargic. Her medical history includes hypertension, atrial fibrillation, and diabetes mellitus type 2. The initial vital sign values are as follows: Blood pressure 102/38 mm Hg Heart rate 102 beats/min O2 saturation 76% (0.76) Respiratory rate 30 breaths/min Temperature 102.4°F (39.1°C)

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