Leadership & Management - UWorld

The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? 1. Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour 2. Client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tingling of the hand and fingers 3. Client 8 hours postoperative total knee arthroplasty who has 2 closed-wound suction drains and a total output of 200 mL sanguineous drainage 4. Male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L)

1 Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast removal), irreversible nerve and muscle injury can occur. (Option 2) Immobilization of the extremity in a sling can lead to venous pooling and edema of the hands and fingers if the sling is not applied properly. The nurse should evaluate the elbow and hand positions and perform a neurovascular assessment, but this is not the priority. (Option 3) Sanguineous (red) wound drainage at 25 mL/hr is expected 1 day postoperative knee replacement. Drains are usually removed in 24 hours unless drainage is excessive (eg, >1500 mL/24 hr). (Option 4) Anticoagulant therapy (eg, unfractionated heparin, enoxaparin, fondaparinux) is standard following total hip replacement. Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50% [0.39-.50], 13.2-17.3 g/dL [132-173 g/L], respectively) are expected due to intra- and postoperative blood loss. Educational objective: Compartment syndrome is a medical emergency that requires decompression within 4-6 hours of onset (eg, fasciotomy, cast removal) to prevent irreversible nerve and muscle injury.

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? 1. A 36-year-old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning 2. A 56-year-old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing surgery 3. A 68-year-old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning 4. An 80-year-old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

3 To prepare a client for a bronchoscopy, the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain nothing-by-mouth status; prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure. Because these are skills a graduate nurse possesses, this is an appropriate assignment. (Option 1) Initiating a heparin infusion according to institution protocol involves collecting baseline serum specimens (eg, partial thromboplastin time [aPTT], International Normalized Ratio [INR], prothrombin time, platelets, hemoglobin, hematocrit), calculating weight-based dosages, (eg, bolus dose, infusion rate in units/hr), and calculating intravenous infusion pump hourly rate. Serum aPTT and INR levels are monitored every 6 hours or according to protocol. Frequent changes in rate or dose based on these levels may be necessary to maintain a therapeutic level of heparin. For these reasons, this is not an appropriate assignment for a new graduate nurse. (Option 2) A client with newly diagnosed cancer who is refusing radical surgery that will result in the loss of speech and inability to communicate normally is demonstrating fear and anxiety. This client needs preoperative teaching about the surgical procedure, what to expect immediately after surgery, methods for speech restoration, and general preoperative teaching (eg, deep breathing, suctioning, pain management). Emotional support, education, and advanced therapeutic communication skills are necessary to help allay fear and anxiety. For these reasons, this is not an appropriate assignment for a new graduate nurse. (Option 4) The elderly client with new-onset confusion is at risk for developing hospital-induced delirium related to advanced age, surgery, hypoxia, fluid and electrolyte disturbances, immobility, pain, and/or drugs. The nurse must perform neurological assessments to determine the cause and intervene appropriately. For these reasons, it is not an appropriate assignment for a new graduate nurse. Educational objective: When assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member. The more experienced RN is assigned to the client with the more complex physiologic and psychologic needs, who requires a more advanced level of nursing skill. The new graduate nurse is assigned to the client with less complex needs, who requires basic nursing skills, such as measurement of vital signs and basic physical assessment.

The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate? 1. Contact the appropriate certification and licensing board 2. Document the exchange in the chart 3. Report the incident to the hospital's legal team 4. Report the incident to the state medical board

2 There are 2 forms of heparin-induced thrombocytopenia. The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation. When in doubt of a clinician's judgment, the nurse should document these objections and report to the nursing supervisor. (Options 1, 3, and 4) It is important to first refer up the nursing hierarchy. Educational objective: The nurse should document and then report objections about a clinician's judgment to the nursing supervisor.

Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit? 1. Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist 2. Client 3-days post knee replacement surgery awaiting discharge 3. Client who is scheduled for an above-the-knee amputation today 4. Client with a long leg cast applied yesterday morning to treat a fractured ankle

4 The client with the cast applied 24-hours ago is stable and is the most appropriate assignment for the float nurse. This client requires the nurse to perform basic pain, peripheral vascular (eg, color, temperature, capillary refill, peripheral pulses, edema), and peripheral neurologic (eg, sensation and motor function) assessments, which should be familiar to a nurse who works on a general medical unit. (Option 1) This client is unstable and requires frequent assessments to identify signs and symptoms of infection and changes in neurovascular status (for compartment syndrome). Pin care is needed as well. (Option 2) The client waiting to be discharged requires extensive discharge teaching about using a continuous passive motion device, weight-bearing restrictions and assistive devices, anticoagulation prophylaxis, and rehabilitation. (Option 3) The client scheduled for an amputation requires preoperative teaching and psychological support specific to this type of surgery (eg, phantom pain, change in body image). Therefore, this client should be assigned to a nurse who is familiar with preparing clients for orthopedic surgery. Educational objective: The nurse on the orthopedic unit, who is giving client assignments to a float nurse, must consider how to best meet the needs of the clients safely. The most appropriate assignment is a stable client, who requires basic pain, peripheral, and neurovascular assessments, which should be familiar to a float nurse from a general medical unit.

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1, 4 Everyone on the health care team contributes to the client's pain management. The registered nurse (RN) is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain (ie, P - provocation/palliation, Q - quality, R - region/radiation, S - severity, T - timing); performing initial client and caregiver teaching, including discharge instructions; and evaluating the effectiveness of the care plan (Options 2 and 5). The nurse should always consider the 5 rights of delegation prior to delegating a task. In this case, the RN may delegate the following tasks to the licensed practical nurse (LPN): - Administering oral pain medication; individual practice region and facility policy will determine which of the various routes of medication the LPN is permitted to use (Option 1) - Monitoring current objective pain level (numeric scale) (Option 4) (Option 3) The RN should delegate vital sign measurement to the unlicensed assistive personnel (UAP). Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources. The RN should provide instructions regarding timing of vital sign measurement and is responsible for evaluating the client's vital signs. Educational objective: The registered nurse is responsible for assessing pain characteristics, developing the care plan, and providing initial and discharge teaching. A licensed practical nurse may monitor pain level and administer pain medication. The nurse should consider the 5 rights of delegation and effective use of resources when delegating tasks.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

1 The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation, movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality (Option 1). (Option 2) The dressing on an infected foot ulcer is usually removed before the foot is placed in a whirlpool bath (hydrotherapy). The nurse can apply a new dressing or cover and wrap the foot using a sterile towel or gauze bandage to protect it from microorganisms. This client is not the priority. (Option 3) Dialysis grafts are prone to infection. This client needs to be assessed for erythema, graft tenderness, fever, and tachycardia. These are not immediately life-threatening conditions. (Option 4) Infection can cause delirium (altered mental status). This client needs one-to-one observation and repeated reorientation while antibiotics take effect. However, this client is not a priority over a client who is actively bleeding. Educational objective: Serosanguineous (pink) drainage is expected after a surgical procedure, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. Treatment with a pressure dressing to provide hemostasis, cauterization of a bleeding vessel, or fluid replacement may be necessary.

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is most appropriate for the charge nurse to assign to the L&D nurse? 1. Client with an occluded arteriovenous fistula receiving IV heparin infusion 2. Client with cirrhosis and ascites who requires bedside paracentesis 3. Client with diabetes who is one day postoperative below-the-knee amputation 4. Client with pyelonephritis who is febrile and receiving IV antibiotics

4 Nurses must sometimes "float" to a nursing unit outside of their normal area of practice based on staffing needs. A nurse who floats to an unfamiliar practice area should be assigned clients who do not require specialized knowledge and can be safely managed with similar skills as with their usual client population. It is the responsibility of the floated nurse to inform the supervisor of any lack of experience with the client population and to request orientation to the unit. Labor and delivery (L&D) nurses possess focused knowledge and training to care for the obstetric population but are able to generalize many skills to other client populations. L&D nurses frequently care for pregnant women with urinary tract infections and would be familiar with the management of a client with pyelonephritis. The administration of IV antibiotics is a general nursing skill with which all nurses should be familiar (Option 4). (Option 1) The L&D nurse is likely unfamiliar with IV heparin administration, which requires close monitoring and specific knowledge of infusion titration. (Option 2) The L&D nurse likely lacks the specific knowledge required to assist with bedside paracentesis and monitor for potential post-procedure complications. (Option 3) A client who undergoes an amputation has unique educational and care needs, with which the L&D nurse is likely unfamiliar. Educational objective: A float nurse should be assigned clients who require care similar to the nurse's usual client population. Clients requiring care from a nurse with specialized knowledge should not be assigned to a float nurse.

Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%

2 A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement. (Option 1) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. (Option 3) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract. Peripheral parenteral nutrition with 10% dextrose is an expected treatment. (Option 4) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control, which can be expected in a client with diabetes mellitus. Educational objective: A change in the length of the external portion of a peripherally inserted central catheter (PICC) can indicate migration of the catheter from its original position. If migration is suspected, the nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider immediately for evaluation and x-ray verification of placement of the catheter tip.

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment? 1. Adult protective services 2. Physical therapist 3. Physician 4. Social worker

4 An important part of the nursing role is to advocate for the health and safety of the client. This client has fallen and lost weight when living in the child's home, prompting the nurse to advocate for the client by bringing in other members of the interdisciplinary team to assess the home situation. When a nurse is concerned about the client's living situation, the social worker is the most appropriate team member to consult with first. The role of the social worker includes assessing the client's living situation and arranging for an alternate living situation or support services as needed. (Option 1) Adult protective services would be notified when abuse or neglect is suspected. In the hospital setting, a social worker should be contacted to do a detailed assessment of the situation before adult protective services is notified. (Option 2) The physical therapist should be consulted when there is concern about the client's ability to function safely in the home environment. (Option 3) The physician would not be the most appropriate person to appoint when a detailed assessment of the home living situation needs to be conducted. However, the physician should be notified if a social worker is assigned to assess the home living situation. Educational objective: Nursing advocacy for the safety of the client includes the appropriate use of interdisciplinary team members, such as the social worker. Advocacy is especially important in younger and elderly clients and those who are cognitively challenged or have mental health concerns.

Which client in the emergency department should the nurse see first? 1. 2-year-old with fever and sore throat who is restless and drooling 2. 7-year-old with appendicitis who has right lower quadrant pain and vomiting 3. 9-year-old with immune thrombocytopenia who has generalized petechiae 4. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum

1 Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus influenzae type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency. Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia. The nurse should prepare to assist with emergent endotracheal intubation. (Option 2) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately. (Option 3) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of ITP. Acute ITP usually resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids, IV immunoglobulin). (Option 4) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated but is not a priority. Educational objective: Acute epiglottitis is a life-threatening emergency due to possible airway obstruction from severe swelling of the epiglottis. Symptoms include fever, sore throat, stridor, drooling, restlessness, and tripod positioning. The nurse should prepare to assist with emergent endotracheal intubation.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? 1. Client who had a foot amputation today reporting left shoulder pain radiating down the arm 2. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain 3. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall 4. Client who has sickle cell disease reporting severe pain in the arms and upper back

1 Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, shoulder pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia. Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction (Option 1). (Option 2) In clients with pancreatitis, autodigestion of the pancreas by pancreatic enzymes causes severe, continuous, piercing, or penetrating abdominal pain. (Option 3) Multiple myeloma is a cancer of the bone marrow that causes bone degeneration and skeletal pain. Clients commonly report spinal, pelvic, and rib pain with physical activity. (Option 4) Clients with sickle cell disease experience acute painful episodes (sickle cell crisis) from exacerbation of red blood cell sickling and vasoocclusion. Vasoocclusion can cause severe pain, most often in the upper back, arms, or legs. Educational objective: Women, older adults, or clients with diabetes may have atypical presentations (eg, indigestion, jaw/shoulder pain, dyspnea, diaphoresis, nausea/vomiting) other than chest pain during a myocardial infarction.

After morning report, the nurse must perform which action first when caring for assigned clients? 1. Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea 2. Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) 3. Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump 4. Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr

1 Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea. (Option 2) The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but this is not as urgent as improving gas exchange in the lungs. (Option 3) The patient-controlled analgesia tubing is connected to a running IV that is attached to an IV pump, so the IV line should remain patent even if the opioid syringe is empty. A short delay in receiving analgesia does not pose a threat to the client's survival, so this is not the priority action. (Option 4) An electronic IV pump is used to administer a heparin infusion. A new IV container is replaced when 50 mL is remaining to ensure the bag does not run dry. At the current rate of 50 mL/hr with 100 mL remaining, the new bag should be hung in about 1 hour, so this is not the priority action. Educational objective: Bumetanide (Bumex) is prescribed for clients with heart failure to promote diuresis and mobilize excess fluid in the systemic circulation and the lungs, which results in increased cardiac output and improved gas exchange.

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same-day appointment to the client 4. Tell the spouse to have the client call the nurse

1 The first step in the nursing process is assessment. In this situation, additional information is needed before the nurse can determine the next course of action (Option 1). (Option 2) The United States' Health Insurance Portability and Accountability Act (HIPAA) and Canada's Personal Information Protection and Electronic Documents Act (PIPEDA) prevent release of private, privileged health care information to people who do not need to know it for a client's care. In this case, the nurse is not releasing any information and is obtaining further information to assess the client's condition. In addition, there is no privacy violation in obtaining information that the spouse would know. (Option 3) Additional information is required before knowing whether the client needs to be seen in the clinic. The client may need instruction to instead call 911 and go to the emergency department. (Option 4) The nurse can ask the client to call, but the client may be unable (eg, seizure, unconscious) or unwilling to do so. In addition, the client may not be aware of signs (eg, acute-onset confusion) that are concerning to the spouse. The situation is unclear (eg, the client may have trouble speaking [ie, stroke symptom]) but may be clarified after the nurse receives additional information from the spouse. Educational objective: The nurse should further assess the situation and gather more information when a spouse calls reporting troublesome symptoms in a client. It is not a violation to obtain information about a client from a knowledgeable source.

The nurse is delegating client care tasks to a licensed practical nurse (LPN) and unlicensed assistive personnel. Which of the following assignments are most appropriate to assign to the LPN? Select all that apply. 1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy 4. Reinforce teaching on self-administration of insulin to a client with diabetes mellitus 5. Tally the shift's intake and outputs for the entire unit

1, 2, 4 Nurses preparing to delegate client care to a licensed practical nurse (LPN) and/or unlicensed assistive personnel (UAP) should consider the 5 rights of delegation. The LPN can monitor and care for stable clients who have been initially evaluated by a registered nurse (RN). Interventions LPNs may perform include: - Administering oral and parenteral medications, but excluding administering IV medications, which vary by state legislation (Options 1 and 2) - Reinforcing teaching and skills that have been initially taught by the RN (Option 4) - Focused assessments (eg, bowel sounds) after the RN's initial assessment (Option 3) Performing admission or initial assessments is outside the scope of the LPN and UAP. The RN must perform initial assessments in order to analyze the findings and formulate the client's plan of care before delegating tasks. (Option 5) The LPN is capable of performing routine care (eg, calculating daily intake and output, toileting). However, the UAP may also perform these tasks, which frees the LPN to perform more complex duties. Therefore, the most appropriate staff member to assign the task of calculating intake and output to is the UAP. Educational objective: Nurses preparing to delegate client care should consider the 5 rights of delegation. Appropriate tasks to delegate to a licensed practical nurse include administration of oral and parenteral medications, excluding IV route, and reinforcement of teaching previously provided by the registered nurse.

The registered nurse is working with a licensed practical nurse and unlicensed assistive personnel. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the registered nurse to assign to the licensed practical nurse? Select all that apply. 1. Administer oral pain medication for the client's chronic lower back pain 2. Assist the client with the use of a urinal post-procedure 3. Monitor for bleeding at the catheter insertion site every 15 minutes 4. Perform the initial post-procedure vital sign measurements 5. Review the ECG monitor for dysrhythmias

1, 3 After performing the initial assessment of the client post-procedure and comparing it to the pre-procedure baseline, the registered nurse (RN) may assign the following tasks to the licensed practical nurse (LPN): - Administer medications (Option 1) - Monitor neurovascular status of involved extremity - Monitor for bleeding at catheter site every 15 minutes for the first hour, then according to facility policy (Option 3) - Report any changes in neurovascular status or bleeding to the RN (Option 2) Unlicensed assistive personnel (UAP) possess appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be performed safely by an LPN, underutilizing UAP would be an ineffective use of resources. (Options 4 and 5) The RN should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs. If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements to the UAP. Educational objective: In the client who has had a percutaneous coronary intervention, after initial assessment and comparison to pre-procedure baseline, the RN may assign the tasks of medication administration, monitoring of neurovascular status of the involved extremity, and checking for bleeding at the catheter insertion site to the LPN.

The nurse prepares to teach an in-service on legal issues related to nursing. Which legal terms are followed by an appropriate example? Select all that apply. 1. Assault: Threatening to administer a benzodiazepine if the client does not comply 2. Battery: Misinforming a client that a painful injection will not create discomfort 3. False imprisonment: Storing a competent client's clothes to prevent the client from leaving prior to a prescribed treatment 4. Informed consent: Calling the parent of an emancipated minor for approval prior to providing care 5. Invasion of privacy: Posting a medical update on the social media page of a client who is a friend

1, 3, 5 Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched (Option 1). False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is not a threat to self or others) (Option 3). Invasion of privacy includes disclosing medical information to others without client consent. Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and cannot be released without the client's permission (Option 5). (Option 2) Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful. (Option 4) An emancipated minor is an individual under the age of legal responsibility who has been legally freed from parental control through a court order (eg, due to enlistment in the military, marriage, pregnancy). The parent in this situation would not need to be called. Clients have the right to be informed of risks and benefits of procedures prior to care and to give informed consent. Educational objective: Clients have the right to privacy and to give informed consent prior to medical care. Assault is an act that threatens the client, causing the client to fear harm without the client being touched. Battery is physical contact against a client's will or without legal justification. False imprisonment includes restraining a competent client without the client's permission.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change

1, 3, 5 In this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. (Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. (Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care. Educational objective: During a weather-related emergency, home care visits are classified as: > High priority - unstable clients who need care and are at risk for hospitalization if not seen. > Moderate priority - clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients. > Low priority - clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care.

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply. 1. Before liver biopsy, pulse is 80/min and blood pressure (BP) is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg 2. Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg 3. Client with coronary artery disease on metoprolol; pulse is 62/min 4. Elderly client with black stools; pulse is 112/min 5. Neonate crying inconsolably at feeding time; pulse is 160/min

1, 4 The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment. (Option 2) This change in vital signs from preprocedure to postprocedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it would compress the spinal cord, causing paralysis in the lower extremities. (Option 3) This client has a pulse of 62/min (normal 60-100/min), which indicates a therapeutic effect of metoprolol. The nurse should monitor for bradycardia, which is a common and expected finding following administration of a beta-adrenergic blocker. Bradycardia would require nursing intervention only if the client became symptomatic (eg, hypotension, dizziness, nausea). (Option 5) A neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a temporary rise. Vital signs are concerning if they rise when a client is at rest. Educational objective: Vital sign changes that are early signs of concern for hypovolemic shock are tachypnea, tachycardia, and agitation; hypotension is a late finding.

The registered nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). Which tasks are most appropriate to assign to the LPN? Select all that apply. 1. Administering a scheduled analgesic to a client with chronic back pain currently rated 8/10 2. Assessing fluid volume status of a client with heart failure who is scheduled for discharge 3. Assisting with bathing, feeding, and dressing a client with multiple sclerosis 4. Performing wound care and sterile dressing change for a client with a stasis ulcer 5. Providing incontinence care and linen change for a client with diarrhea

1, 4 Wound care and routine medication administration are the most appropriate tasks to assign to the LPN. The LPN can perform sterile procedures and cleanse and dress wounds for which there is an established prescription plan (Option 4). Pain rated at 8/10 is an expected finding in a client with chronic back pain, and the oral analgesic may be administered as scheduled by the LPN (Option 1). If this client were experiencing new-onset, unexplained pain requiring intravenous analgesic administration, the client would need assessment by the RN. (Option 2) The LPN may perform specific assessments, but evaluating the fluid volume status of a heart failure client is a comprehensive assessment involving multiple body systems (eg, heart and lung sounds, peripheral edema, adequacy of urine output). This client will also require discharge education on home management of heart failure, which is the responsibility of the RN. (Options 3 and 5) UAP have the appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be safely carried out by an LPN, underutilizing UAP would be an ineffective use of resources. Educational objective: LPNs may safely perform sterile procedures and routine medication administration. The RN is responsible for discharge planning and performing comprehensive clinical assessments. The nurse should also consider appropriate use of resources when making assignments or delegating tasks.

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

2 In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings. (Option 1) The time frame in this option should be more specific. In addition, there is no communication about what the RN expects as follow-up. (Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The expectation from the RN is not clear and the UAP needs more direction. (Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to communicate the method needed to accomplish the task. Educational objective: The RN should communicate directions to the delegate that include any unique client requirements and characteristics as well as clear expectations on what to do, what to report, and when to ask for assistance.

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication

2 Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department. (Option 1) Urinary tract infections can recur in sexually active women. This client needs antibiotics but is not a priority. (Option 3) This client may have some degree of prostatic hyperplasia given his age. Decongestants (eg, pseudoephedrine) or antihistamines (eg, diphenhydramine) should be used with caution as they can lead to difficulty voiding and acute urinary retention. The client needs to be assessed, but this is not the most emergent call. (Option 4) The client with prostate cancer may need increasing pain medication as clients develop tolerance to opioids. However, this is not a priority. Educational objective: Priapism is a prolonged, painful erection not necessarily related to sexual arousal. It requires urgent treatment in the emergency department as it can lead to erectile tissue ischemia and necrosis.

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation

2 Registered nurses (RNs) are able to delegate tasks to LPNs. The nurse delegating a task remains legally responsible for the client's total care during the shift, and may be held liable for delegating inappropriately. Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care. (Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching. Educational objective: The charge nurse should assign the most stable clients to the LPN. Tasks exclusive to the RN includes assessment of an unstable client and intravenous medication administration.

The nurse assesses 4 clients in the emergency department. Which client should the nurse prioritize first? 1. 12-year-old with right lower quadrant abdominal pain that started in the periumbilical region 2. 14-year-old with severe scrotal pain; right testis is tender, swollen, and more elevated than the left 3. 16-year-old with sickle cell disease who has excruciating generalized body pain 4. 34-year-old with sudden-onset, right-sided flank pain radiating to the right groin

2 Testicular torsion is an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority. (Option 1) Right lower quadrant pain referred from the periumbilical area is a classic sign of appendicitis. If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. Surgery is usually required within 24 hours. This client should receive prompt attention but is not a priority over the client with testicular torsion. (Option 3) Clients with sickle cell disease have episodes of sickle cell crisis, in which the sickle-shaped cells occlude the blood vessels. This decreased blood flow is responsible for the generalized body pain. This client should be treated emergently with pain medications and IV fluids but is not a priority over the client with testicular torsion. (Option 4) Sudden-onset, right-sided flank pain radiating to the groin is classic for renal stones. Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow. This client is not a priority over the client with testicular torsion. Educational objective: Testicular torsion can result in testicular ischemia and necrosis from inadequate blood supply. There is a short time frame (4-6 hours) in which testicular torsion can be treated to prevent death of the testicle, and the client will most likely require emergency surgery.

The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

2 The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics. (Option 1) Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterward. (Option 3) Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse should see this client second to assess the affected limb. (Option 4) Raynaud's phenomenon is usually triggered by cold exposure. During a typical episode, digital arteries (most often in the fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel numb and cold. As blood flow returns to the affected digits, the skin turns red and a throbbing or tingling sensation is often felt. This is an expected finding; episodes usually resolve in 15-20 minutes once the trigger has been removed (eg, rewarming of the fingers). Educational objective: Phantom limb pain should be prioritized and treated just as any other client report of pain. It is typically treated with opioids early in the post-surgical period. Chronic phantom limb pain may be treated with antidepressants, anticonvulsants, or therapies such as nerve stimulation, mirror therapy, or acupuncture.

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? 1. Ask if the client can go without the oxygen for 2 hours 2. Delay discharge until the oxygen is delivered 3. Notify the health care provider (HCP) to see what action should be taken 4. Send a hospital oxygen tank home with the client

2 The nurse (with the case manager) needs to assure that the client has the essential equipment/supplies for a smooth discharge into the home environment. The safest option is to delay discharge until that can be accomplished. (Option 1) It is not appropriate to ask the client to go without the oxygen as it would mean not following the client's prescription. The client could arrive home and then require oxygen due to additional exertion. (Option 3) The issue is not the client's need or the prescription but the logistics of implementation. There is no need to involve the HCP as the solution is within the nurse's abilities and control. (Option 4) If the nurse sends the hospital oxygen tank home with the client, the question of how it will be returned remains. It is safer and more reasonable to delay the discharge. Educational objective: A client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge.

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse? 1. "Would you mind answering the lights anyway?" 2. "I need you to answer the lights because we want to provide good client care." 3. Say nothing and answer the lights, but write up a disciplinary action 4. Tell the UAP that this is unacceptable and speak to the nurse manager

2 The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action. (Option 1) The request should not be given as an option as there is a legitimate need the UAP can meet. The nurse needs to be directive and assertive when indicating what needs to be done. (Option 3) This is an avoidance action and does not resolve the bigger issue. The nurse should attempt to rectify the issue first rather than focus on discipline. Discipline measures are appropriate if there is insubordination (the UAP refuses) or a pattern of behavior (on every shift the UAP does not answer lights despite being told). (Option 4) The nurse should give the UAP a chance to change behavior first. Speaking to the manager in the future does not resolve the current issue. The nurse can take this step if there is insubordination or a pattern of behavior. Educational objective: The nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats (aggression) and should not avoid the issue by just performing the action itself (avoidance).

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply. 1. 2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection 2. 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 3. A client in sickle cell disease crisis and a client with streptococcal pneumonia 4. A client who had abdominal surgery today and a client with universal precautions 5. A young client in Buck's traction with an elderly client with Parkinson's disease

2, 4, 5 When clients must be housed together in less than ideal circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly). Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious (even if this is not socially acceptable). (Option 1) Though both clients are on contact isolation, they are infected with different organisms and this places them at risk for cross-infection. (Option 3) By around age 4, clients with sickle cell disease have some level of immunosuppression as their spleens are dysfunctional due to infarctions from the sickling episodes. The spleen then fails to carry out protective phagocytosis, especially to encapsulated bacteria (eg, streptococcus pneumoniae). Educational objective: Clients infected with different organisms cannot be placed together in the same room (due to risk of cross-infection). An infectious client should not be housed with an immunocompromised one.

Which of these clients should the nurse assess first? 1. A client who has shortness of breath from moderate pleural effusion and is waiting for thoracentesis 2. A client who just had a long leg cast applied and has severe pain despite a dose of morphine 3. A client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness 4. A sickle cell crisis client who has severe bone pain despite a dose of morphine

3 First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. A client receiving the first dose of an antibiotic is at risk for allergic reactions, including anaphylaxis. Signs and symptoms of anaphylaxis include itching, flushing, hives, wheezing, bronchospasm, swelling of the oral mucosa, and hypotension. This is a potentially fatal complication that requires immediate intervention (Option 3). (Option 1) This client with a moderate pleural effusion awaiting the corrective procedure would be the last client to be assessed by the nurse. Shortness of breath is an expected symptom of pleural effusion. If signs or symptoms of respiratory distress or hypoxemia occur, this client will increase in priority. (Option 2) This client with a new cast experiencing severe pain would be the second client to be assessed. This client is at risk for compartment syndrome and limb loss. Increasing fluid (eg, bleeding) in a confined space or decreasing compartmental capacity (eg, casting) causes neurovascular compromise as the vessels are compressed and unable to deliver oxygen to the tissues. Long bone fractures account for most cases of acute compartment syndrome. (Option 4) This client with sickle cell pain would be evaluated third. Although in crisis, the client is not at risk for loss of life or limb. Educational objective: First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. Anaphylactic reactions are potentially fatal medical emergencies that must be treated immediately. Compartment syndrome prevents perfusion and can cause tissue death and limb loss. Stable clients awaiting procedures are assessed last.

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever

3 Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production. It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia. (Option 1) Appendicitis is a result of viral or infectious processes and can lead to rupture of the appendix. A client recovering from a ruptured appendix poses a threat of infection to the child who has leukemia. (Option 2) A client with cystic fibrosis has pulmonary complications due to thick mucus that traps bacteria. The tracheobronchial tree is colonized with bacteria and respiratory infections are a lifelong problem. This client poses a threat of infection to the child with leukemia. (Option 4) Rheumatic fever occurs following pharyngitis caused by group A β-hemolytic Streptococcus. A client with this condition poses a threat of infection to the child with leukemia. Educational objective: Leukemia is a cancer of the blood and organs involved in hematologic function. Due to myelosuppression, clients are at risk for problems related to infection, anemia, and bleeding.

The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 32-year-old woman with a temperature of 100.4 F (38 C) who reports feeling achy following a flu shot yesterday 2. 50-year-old man who reports right shoulder pain and difficulty raising the arm above the head after playing baseball 2 days ago 3. 68-year-old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday 4. 72-year-old woman with urge incontinence who started taking solifenacin 2 days ago and reports constipation and very dry mouth

3 Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing, substernal type of chest pain. These symptoms include atypical pain (jaw or arm), shortness of breath, indigestion, nausea, dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to gather more information. The symptoms can indicate a cardiac medical emergency (myocardial ischemia or acute myocardial infarction) that requires immediate evaluation and intervention. (Option 1) Minor expected adverse effects can occur 1-2 days after influenza vaccination. Symptoms include flulike symptoms (eg, fever, aching, itching at the injection site); analgesia with ibuprofen or acetaminophen can help provide relief. (Option 2) The client's symptoms began following a specific event and can indicate a rotator cuff injury. Imaging, treatment with nonsteroidal anti-inflammatory drugs, and physical therapy may be indicated. Although further evaluation is necessary, this is not a medical emergency. (Option 4) Solifenacin (VESicare) is a cholinergic antagonist prescribed to treat symptoms associated with an overactive bladder (eg, urge incontinence, frequency). Common expected adverse effects include dry mouth and constipation. The nurse should caution the client about safety when performing activities until the response to the medication is determined, as it can also cause dizziness and blurred vision. This is not a medical emergency. Educational objective: Women with myocardial ischemia and acute myocardial infarction (AMI) often have atypical pain and nonspecific symptoms. Evaluation and treatment for a suspected AMI are critical as it can be life-threatening.

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action? 1. Ask the UAP to take the postoperative client's vital signs and report back immediately 2. Direct the UAP to ask the client to rate the pain on a scale of 0-10 and report back immediately 3. Direct the UAP to tell the client that you will be there shortly, and complete the sterile dressing change 4. Interrupt the dressing change to medicate the postoperative client

3 The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option 3). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option 4). (Option 1) Although taking vital signs when a client reports pain is appropriate, evidence indicates that vital signs are unreliable physiologic indicators for pain. (Option 2) The UAP is instructed to ask the client if they are having pain and then report back to the nurse. However, the registered nurse is responsible for pain assessment and should not delegate this task to the UAP. Educational objective: A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait.

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? 1. Activate the code system 2. Call the health care provider (HCP) stat 3. Check the apical pulse 4. Check the blood pressure

3 The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support. (Option 1) Activating the code system is not appropriate as this client has an order to withhold resuscitation. (Option 2) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR. (Option 4) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central pulse would be appropriate after noticing that the client is not breathing. Educational objective: A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.

The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation? 1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives 2. Tape-record a report and leave a cell phone number to call if there are any questions 3. Tell the charge nurse of the impending need to leave and that client coverage is required 4. Write out a report about the clients for the incoming nurse prior to leaving

3 The off-going nurse must ensure that there is another registered nurse responsible for the care of the clients, if this is not done then abandonment has occurred. A deliberate report must be given using standardized format for continuity of care. During the hand-off, objective data should be provided about the clients' current status and response to treatment to enable planning care. The off-going nurse should let the charge nurse know as this individual is responsible for the staffing of the unit and would have the authority to try different options, such as asking another nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit. In addition, there is no established time frame for the incoming nurse's actual arrival; a significant amount of time could pass before this inadequate staffing issue is resolved. (Option 1) This general vague oversight is an inadequate report and transfer of responsibility to the other nurse. (Option 2) Tape recording a report is a legitimate method of communication as long as there is an opportunity to ask questions. However, this does not resolve the issue of procuring a nurse to take over responsibility for the clients' care. (Option 4) Although this would help transmit essential information, it does not accomplish procurement of another nurse to be responsible for the clients' current care. Educational objective: In a facility with 24-hour care, prior to leaving, an off-going nurse must have another nurse take over the responsibility for the clients' care and give an appropriate report for these clients. Leaving clients without these elements can be deemed to be an act of abandonment.

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence 2. The parent is in the process of a divorce and will soon be a single parent 3. The parent is witnessed stealing food and drinks from the cafeteria 4. The parent leaves the client's younger sibling to care for the client's newborn sibling

4 Child neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to fulfill the basic needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving children without adequate guardianship to ensure safety, is one form of child neglect (Option 4). Children age <12 lack formal operational reasoning and cannot anticipate safety risks or respond appropriately to emergencies, and should therefore not be left to supervise other children. It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social services, should report the situation to an appropriate government child protective service and/or law enforcement. (Option 1) Potential job loss indicates that the parent may be overwhelmed. The nurse should alert a social worker about the situation at a later time to discuss potential assistance. (Option 2) Transitioning to the role of a single parent can present mental and financial stressors, possibly requiring assistance from a social worker. However, this does not require immediate intervention. (Option 3) A parent stealing food may warrant calling the police or security, but the children's safety is a priority requiring immediate action. Educational objective: Supervisory neglect (eg, leaving a young child to supervise other children) is a type of child neglect and represents an immediate risk to the safety of younger children. The nurse should ensure that the children are safe and report the child neglect incident to social services, the appropriate child protective service, and/or law enforcement.

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first? 1. A client with an ileostomy bag that has leaked stool all over 2. A client with chronic obstructive pulmonary disease, diminished breath sounds, and SpO2 of 91% 3. A client with deep venous thrombosis who missed the last warfarin dose 4. A client with sepsis who is developing petechiae

4 Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death. (Option 1) Stool leaking from an ileostomy bag is not a priority. (Option 2) It is common for clients with chronic obstructive pulmonary disease to have diminished breath sounds; the goal SpO2 level in this population is generally ≥90%. (Option 3) Although missing warfarin can increase the risk of clotting, most clients will usually have a therapeutic INR for 1-2 days. This is not a priority over the DIC client. Educational objective: Disseminated intravascular coagulation (DIC) results from abnormal activation of clotting cascade followed by consumption of clotting factors and platelets; this quickly leads to life-threatening external and internal bleeding. Any signs of DIC should be assessed immediately as emergent replacement of clotting factors, blood, and platelets is needed to save the client.

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggests the transfer of which client to the health care provider? 1. 52-year-old with unstable angina and chest pain at rest who has had 3 normal serum troponin I levels 2. 60-year-old with new-onset atrial fibrillation of 140/min who is receiving a continual IV infusion of diltiazem 3. 65-year-old admitted last night for third-degree heart block who is awaiting permanent pacemaker placement 4. 78-year-old with end-stage heart failure and ejection fraction of 15% whose family is requesting palliative care

4 Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any health care setting. (Option 1) Cardiac troponins are proteins released into the blood by damaged cardiac muscle (ie, myocardial infarction). Serial troponin I levels are normal (<0.5 ng/mL [0.5 mcg/L]) in clients with unstable angina as there is no muscle injury; however, cardiac ischemia is present. This client requires continual cardiac monitoring and interventions to restore blood flow to the heart. (Option 2) Atrial fibrillation involves the rapid firing of irritable foci in the atria and an irregular, sometimes rapid, ventricular response. To slow the heart rate (goal <100/min), an IV infusion of the calcium channel blocker diltiazem (Cardizem) is prescribed; this requires continual cardiac monitoring. (Option 3) Complete heart block is life-threatening and requires a pacemaker. This client should not be transferred. Educational objective: Clients with unstable angina experiencing chest pain and clients newly admitted with complete heart block or atrial fibrillation with a rapid ventricular response are unstable and require continual monitoring in an intensive care unit.

The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first? 1. Client receiving cyclophosphamide reporting bloody urine 2. Client who reports severe nausea and vomiting after chemotherapy 3. Client with an elbow abrasion and a lip laceration possibly requiring sutures 4. Homeless client who appears drowsy with a temperature of 95 F (35 C)

4 The client with a low body temperature and drowsiness needs immediate intervention to prevent and/or reverse physiologic compromise. Signs of hypothermia include a core temperature (eg, rectal) less than 95 F (35 C), mental status changes, shivering, and impaired coordination. Alterations in acid-base balance, coagulation values, and cardiac function may also occur. Hypothermia can lead to cardiac and respiratory failure and coma (Option 4). Homeless clients are at higher risk for hypothermia from exposure to the elements, infections, and poorly managed chronic health conditions. The nurse should anticipate a workup for sepsis and various types of shock, in addition to environmental factors, while addressing this client's hypothermia. (Option 1) Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent). The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy). Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening. (Option 2) Nausea and vomiting are expected side effects after chemotherapy. This client needs IV access established (if the chemotherapy port cannot be accessed) to address the nausea and prevent dehydration. However, this client would not take priority. (Option 3) This client needs to have all wounds cleaned and irrigated prior to suturing, but would not take priority. Educational objective: Hypothermia is a medical emergency that requires immediate intervention, including monitoring, rewarming, and supportive care. Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide.

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy 2. Document the spouse's statement in the client's chart 3. Notify the emergency department physician 4. Request that the spouse tell the client to call back

4 The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client. (Option 1) The prescription can be called into the pharmacy, but there is no guarantee that the client will pick it up and take it in light of the spouse's response. Speaking to the client is the priority. (Option 2) The statement and attempts for contact should be documented, but the first priority is client care. (Option 3) The emergency department physician should be notified of the conversation, but the priority is to speak to the client and explain the importance of the new follow-up treatment. If the client has a primary care provider, the nurse could also communicate with that office to aid follow-up. Educational objective: A competent adult with decision-making capacity can refuse essential treatment; the client's spouse does not have that legal authority. Treatment refusal must include awareness of the risks and benefits.

A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the nurse in the hallway. People in the hallway are staring. What is the best initial reaction by the nurse? 1. Firmly indicate that the HCP cannot speak to the nurse in that manner 2. Immediately apologize and attempt to fix the situation 3. Say nothing and let the HCP vent frustrations 4. State that the conversation needs to take place in private and walk to a room

4 When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference (eg, HCP/nurse). Rather than suggest and wait, the nurse should immediately leave and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concerns and work to resolve the issue (Option 4). (Option 1) Confrontation and aggressive response usually do not resolve or diffuse the situation and will still involve an audience. (Option 2) The nurse should first take the conversation private as the HCP is not likely to calm down soon. The nurse can offer a blameless apology (eg, "I'm sorry there has been a problem") and then focus on the solution. This should occur out of the public eye. (Option 3) This response involves avoidance rather than working to resolve the situation. It does not benefit staff or clients to see providers having a public disagreement. Educational objective: The first response to public displays of disruptive behavior is to take action to make the conversation private.

The registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply. 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 3. Evaluating partial thromboplastin time in a client receiving heparin 4. Measuring a client with chronic heart failure for compression stockings 5. Teaching a client with a new prescription for warfarin about bleeding precautions

1, 2, 4 When caring for a client at risk for venous thromboembolism (VTE), the registered nurse (RN) is responsible for assessing the client, including risk factors present, current medications and supplements that affect coagulation (eg, ginger, gingko biloba), and development of complications (eg, pulmonary embolism). The RN must also develop and implement the plan of care, provide client teaching, and evaluate the outcome of interventions. The RN may delegate care to licensed practical nurses (LPNs) and unlicensed assistive personnel using the five rights of delegation. It is within the scope of practice of the LPN to administer most anticoagulant medications and measure and apply compression devices (Options 1, 2, and 4). (Option 3) The LPN can collect and report data (eg, vital signs, results from complete blood count and coagulation studies), but analysis and evaluation of the data require the RN's expertise. (Option 5) The RN must provide initial education about VTE prevention (eg, medications, preventive measures, bleeding precautions). The LPN may then reinforce teaching to clients as necessary. Educational objective: The registered nurse (RN) is responsible for assessing the client at risk for venous thromboembolism, developing and implementing the plan of care, teaching, and evaluating interventions. The RN may delegate anticoagulant administration, measurement and application of compression devices, and teaching reinforcement to the licensed practical nurse.

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply. 1. "A continuous IV heparin infusion was initiated at 18 units/kg/hr at 0800, and the infusion bag will need to be replaced at 2100." 2. "I gave acetaminophen 500 mg PO to the client for a headache, with good relief." 3. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 4. "The client's sisters visited today and were very rude, but they did bring the client's medication list." 5. "The radiology department called to say that an ultrasound will be performed at 2100."

1, 3, 5 A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: - Provide identifying information (eg, client's name and room number). - Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option 1). - Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3). - Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5). - Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation). (Option 2) Report statements should include exact information (ie, time medication is administered, measurable outcome using a pain scale). "Good relief" is a vague term. (Option 4) Handoff should not include biased information or personal opinions (eg, "rude") and should include visitor information only if the visitor is involved in client care and/or teaching. It is appropriate to include information about a client's medication list. Educational objective: Nurse-to-nurse handoff of care reports should clearly communicate identifying information; care priorities and upcoming or outstanding tasks; exact, pertinent information; multidisciplinary plans; and significant client changes.

The nurse is assisting the health care provider with a lumbar puncture in the client's room. The unit secretary calls over the room intercom and tells the nurse that the laboratory is on the phone with a critical value report for one of the nurse's other clients. What action should the nurse take? 1. Ask the unit secretary to write down a message from the laboratory personnel 2. Instruct the unit secretary to have the charge nurse receive the report 3. Leave the room to talk to the laboratory on the phone and then return immediately 4. Tell the unit secretary to have laboratory personnel send a written result

2 A critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. An example is a potassium level of 7 mEq/L (7 mmol/L). The nurse should delegate the task to the charge nurse so appropriate interventions can be initiated while the nurse finishes the sterile procedure (Option 2). This is the option with the least client risk. Timely reporting of critical results is part of the International Patient Safety Goals. (Option 1) The unit secretary does not have the background, training, experience, and education to understand the implications of the critical value or know the next step. A registered nurse or other licensed practitioner must take the report. (Option 3) The nurse cannot "abandon" the client in the middle of a sterile procedure to take the report. (Option 4) The typical policy calls for the laboratory to verbally communicate critical results and document which nurse took the report. A written report may never be received or the nurse may forget to look for it. The best response is to have another nurse take the report. Educational objective: Registered nurses must learn to delegate tasks appropriately when busy. A critical value must be reported in a timely manner so interventions can be put in place to enhance patient safety.

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes 2. Get directions about care from the client's sister 3. Prepare for emergency intubation 4. Request that the sister provide a living will

2 Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent (eg, end of life, dementia, brain injury). The most common forms are living will and medical power of attorney (POA) (ie, health care surrogate/proxy). A living will declares the client's wishes related to specific situations (eg, do not intubate). A medical POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances (Option 2). (Option 1) A client's spouse is typically the primary decision maker. However, clients have the right to declare any specific individual who they trust as their agent with medical POA, and the agent becomes the final decision maker. (Option 3) The client should receive treatment immediately if there are no advance directives or family members present, but in this case, the agent authorized with medical POA is present and should approve the treatment plan before interventions are initiated. (Option 4) If the client's medical POA agent is present, treatment should not be delayed by requesting a living will as the agent will advocate for the client's wishes and has final decision-making authority. Educational objective: Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who advocates on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual becomes the final decision maker.

Which client should the charge nurse assign to the room closest to the nurses' station? 1. Client with a Salem sump tube to continuous suction who is deaf 2. Client with gastroenteritis and dementia who wanders 3. Client with herpes zoster under airborne isolation precautions 4. Client with sickle cell crisis who requires frequent intravenous opioids

2 The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room closest to the nurses' station as a confused client requires frequent checks and this allows the staff to respond quickly if necessary. (Option 1) The nurse will instruct the client who is deaf on the proper use of the call system. Staff should be instructed to answer this client's call light immediately. Notes to communicate that there was an immediate response to this client's call should be posted at the nurses' station as well. (Option 3) Meeting the needs of a client in airborne isolation safely is not dependent on proximity of the client's room to the nurse's station. The staff should assess the client with the same frequency even if the client is in the room furthest from the nurses' station. (Option 4) The client requiring frequent intravenous pain medication can rest best in a quiet location that is further away from the nurse's station. Proximity to the nurses' station does not affect the frequency of pain assessment, administration, and assessment of response to analgesia. Educational objective: When assigning rooms, the nurse should consider infection control, physical location, acuity level, and individual client safety needs. Cognitive impairment and fluid and electrolyte disturbances pose the greatest risks to a client's safety.

The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing Against Medical Advice (AMA) papers 2. Discharging the child if parents have power of attorney papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy

3 A competent adult has the right to make any decision regarding the client's health care even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential. (Option 1) The parents will not be allowed to take this child out of the hospital against medical advice as it will endanger the child's life. It does not matter that it is a religious reason for the desired AMA. (Option 2) Durable power of attorney for health care (health care proxy) is something a competent adult establishes when that adult can no longer self-advocate. Parents are automatically the legal guardians and decision makers for their minor children as long as the decisions do not put any of their children in danger. (Option 4) The ethical principle of autonomy is deciding for oneself. In this case, the child's best interest is priority and the legal authority takes precedent. Educational objective: Hospital administration will obtain legal protective custody of a minor child if the parents are deciding against life-saving measures for their child or when there is child abuse/neglect.

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent is required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

4 "Mature minors" are adolescents who are age 14-18 and are deemed able to understand treatment risks. They are legally allowed to give independent consent to receive/refuse treatment for some limited conditions. Classically, these conditions include testing and treatment for STIs, family planning, drug and alcohol abuse, blood donation, and mental health care. A minor who is a parent, pregnant, or an emancipated minor can also give consent. An emancipated minor is a self-supporting adolescent under age 18 who is married, on active duty in the military, granted emancipation by the court, or not living at home. (Option 1) This information could be requested if a professional relationship with assessment is established. It would be beneficial to reinforce the concept of safer sex regardless. However, that is not the essential need as STIs can be transmitted even when protection is used. (Option 2) Minor children ordinarily need parental consent unless specific conditions are met. In this case, the nature of the request allows the care to be given. (Option 3) STIs do not always have obvious signs/symptoms that would allow the client's needs to be determined accurately. Educational objective: Mature minors are adolescents between age 14-18 who can give independent consent for limited conditions such as STIs, family planning, drug and alcohol abuse, blood donation, and/or mental health care.

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the health care provider immediately? 1. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 100.9 F (38.3 C) and white blood cell count of 6,000/mm3 (6.0 × 109/L) 2. Client with acute cholecystitis scheduled for laparoscopic surgery who has a fever of 102 F (38.9 C) and white blood cell count of 13,000/mm3 (13.0 × 109/L) 3. Client with Clostridium difficile infection receiving metronidazole who has a fever of 101 F (38.3 C) and white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)

4 A common adverse effect of chemotherapy is bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression. A decreased neutrophil (type of white blood cell) count, termed neutropenia, increases the client's susceptibility to infection. A fever can signal an infection and, in the presence of neutropenia (ie, neutropenic fever), can rapidly develop into life-threatening sepsis. Even a low-grade fever should be taken seriously in these clients. (Option 1) Hodgkin lymphoma is a malignant cancer of the lymphatic system. Expected early manifestations include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. The client's white blood cell count is within normal limits (4,000-11,000 mm3 [4.0-11.0 × 109/L]). (Option 2) Acute cholecystitis involves inflammation of the gallbladder. Expected manifestations include right upper quadrant pain that can radiate to the right shoulder, nausea, vomiting, fever, and leukocytosis (white blood cells count >11,000/mm3 [11.0 × 109/L]). The client is scheduled for surgery and is likely on antibiotics. Even if the client is not on antibiotics, neutropenia is a priority over acute cholecystitis. (Option 3) Clostridium difficile is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. Expected manifestations include diarrhea, fever, and leukocytosis. First-line pharmacologic treatment includes metronidazole (Flagyl) and oral vancomycin. Educational objective: Common adverse effects of chemotherapy are bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression. Even a low-grade fever should be taken seriously in clients who are immunosuppressed or have neutropenia.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 2. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

4 An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. (Option 1) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary. (Option 2) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia). Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel. (Option 3) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are expected in a client with an infected venous leg ulcer. Educational objective: Intestinal obstruction and strangulated bowel are life-threatening complications associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention.

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center

4 Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: - Clients may not know where or how to seek help - Clients may be afraid or unable to leave their homes - Telephone services and other lines of communication may be disrupted - Potential clients may leave their homes and go to shelters or alternate housing - Transportation may be severely limited It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments. (Option 1) Contacting other social service agencies may be part of an effort to coordinate services once the team has reported in to the local command center. (Option 2) This is an appropriate outreach strategy after the mobile crisis team has checked in at the local command center and has received the assignments. (Option 3) Putting up flyers may not be a particularly effective way to provide outreach to those affected by a disaster as clients may be afraid to leave their homes or they may be unable to get to where the services are being provided. Educational objective: Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts.

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Alert the x-ray department about maintaining airborne isolation precautions 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room 5. Talk with the family about the reasons for airborne isolation precautions in the client

4, 5 The RN can delegate the following tasks to the experienced UAP: > Post signs for airborne isolation precautions on the client's door and stock necessary equipment: The UAP has the knowledge and skill to implement isolation precautions when caring for clients on contact, droplet, or airborne transmission-based precautions (Option 3). > Remind visitors to wear a respirator mask and keep the door closed while in the client's room: The UAP can reinforce the procedures and principles of infection control regarding airborne isolation precautions (eg, respirator masks, negative airflow room). However, the nurse should provide the initial instructions and is responsible for visitor compliance (Option 4). (Option 1) The RN is responsible for calling the x-ray or other departments to communicate pertinent information about the client, including the need to maintain airborne isolation precautions before and while transporting the client for diagnostic tests. (Option 2) The RN is responsible for explaining to the client that wearing a mask during transport to another department prevents transmission of airborne microorganisms from the client to others. This is client teaching and must be done by the RN. The UAP can implement the task of applying the mask before transport. (Option 5) The RN is responsible for talking with the family about the reasons the client is on airborne isolation precautions and teaching them about preventing the spread of the disease by wearing protective equipment upon entering the client's room. Educational objective: Experienced UAP can post signs on the client's door that display airborne isolation precautions, stock necessary equipment, and remind visitors to wear a respirator mask when entering the client's room. The RN is responsible for appropriate communication with other departments and providing instruction to clients and their families.