Management : Delegation Quiz 1

You are working with a UAP to provide care for six patients. At the beginning of the shift, you carefully tell the UAP what patient interventions and tasks she is expected to perform. To be sure that your communication is appropriate, you refer to the "Four C's." List the four C's.

1. clear 2. concise 3. correct 4. complete

A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report? A. Repeated episodes of nausea and vomitting B. Reports of pain associated with exertion C. Failure to eat all the food on the breakfast tray D. Client hair loss during the morning bath

A

During assessment of a patient with fractures of the medial ulna and radius, you find all these data. Which assessment finding should you report to the health care provider immediately? A. The patient reports pressure and pain. B. The cast is in place and is dry and intact. C. The skin is pink and warm to the touch. D. The patient can move all the fingers and the thumb.

A

While admitting a client, you obtain this information about their cardiovascular risk factors: Her mother and two siblings had MIs, the client smokes and has a 20 pack year hx of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol for HTN and her BP has been 130/60-138/85 mmHg. Which interventions will be important to include in discharge plans? A. Referral to community programs that assist in smoking cessation B. Teaching about the impact of family hx of CV risk C. Education about the need for a change in antiHTN meds D. Assistance in reducing the stress associated with her CV risk E. Discussion of risks associated with having a sedentary lifestyle

A, B

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all) A. Reminding the client to avoid commercial mouth washes B. Encouraging mouth rinsing with warm saline C. Observing the lips, tongue, and mucous membranes D. Providing mouth care every 2 hours while the client is awake E. Seeking a dietary consult to increase fluids on meal trays

A, B, C, D

As charge nurse, you assign the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would you provide for the LPN/LVN? (Select all) A. Check the patient's VS q15 min in the first hour B. Check the dressing for drainage and tightness C. Elevate the patient's hand above the heart D. The patient will no longer need pain medication E. Check the neurovascular status of the fingers qhr

A, B, C, E

You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all) A. Wear a hip protector when ambulating B. Remove throw rugs and other obstacles at home C. Exercise to help build your strength D. Expect a few bumps and bruises when you go home E. Rest when you are tired

A, B, C, E

The client has an order for hydrochorothiazide (HCTZ, Mierozide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? (Select all) A. "Take this medication in the morning." B. "This medication should be taken in 2 divided doses when you get up and when you go to bed." C. "Eat foods with extra sodium every day." D. "Inform your prescriber if you notice weight gain or increased swelling." E. "You should expect your urine output to increase."

A, D, E

The HCP prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? A. Attaching cardiac monitor leads B. Giving heparin 5000 units IV push C. Administering morphine sulfate 4 mg IV D. Obtaining a 12-lead electrocardiogram (ECG) E. Asking the client about pertinent medical history F. Having the client chew and swallow aspirin

A, D, F

A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately? A. Respiratory rate of 8 to 10 breaths/min B. Decrease in pain level from 6 to 2 (on a scale of 10) C. Request by the client that the room door be closed D. Heart rate of 90 to 100 beats/min

A.

A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would you be sure to teach the patient? A. Pain and numbness will be experienced for several days to weeks B. Immediately after surgery, the patient will no longer need assistance. C. After surgery, the dressing will be large and there will be lots of drainage. D. The patient's pain and parathesia will no longer be present

A.

A patient with a right above the knee amputation asks you why he has phantom pain. What is your best response? A. "Phantom limb pain is not explained or predicted by any one theory." B. "Phantom limb pain occurs because your body thinks the limb is still there." C. "Phantom limb pain will not interfere with you activities of daily living." D. "Phantom limb pain is not real pain but is remembered pain."

A.

At 10 AM, a hospitalized client receives a new order for transesophageal echocardiography (TTE) as soon as possible. Which action will you take first? A. Put the client on "nothing by mouth" (NPO) status B. Teach the client about the procedure C. Insert an IV catheter in the client's forearm D. Attach the client to the cardiac monitor

A.

During the initial postop assessment of a client who has just been transferred to the PACU after repair of an abdominal aortic aneurysm, you obtain these data. Which finding has the most immediate implications for the client's care? A. Arterial line indicates a BP of 190/122 mmHg B. Cardiac monitor shows frequent premature atrial contractions C. There is no response verbal stimulation D. Urine output is 40 mL of amber urine

A.

The nursing diagnosis for a patient with a fracture of the right ankle is Impaired Physical Mobility. As charge nurse, you observe a newly-graduated RN perform all of these interventions. For which action should you intervene? A. Encouraging the patient to go from a lying to standing position B. Administering pain medication before the patient begins exercises C. Explaining the the patient and family the purpose of the exercise program D. Reminding the patient about the correct use of crutches

A.

When receiving discharge instructions, a patient with osteoporosis makes all these statements. Which statement indicates to you that the patient needs additional teaching? A. "I take my ibuprofen every morning as soon as I get up." B. "My daughter removed all of the throw rugs in my home." C. "My husbands helps me every afternoon with ROM exercises." D. "I rest in my reclining chair every day for at least an hour."

A.

A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first year student nurse whom you are supervising? A. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally B. Administer spironolactone (Aldactone) 25 mg orally. C. Assess the ECG strip for tall T waves D. Administer potassium 10 mEq orally

A. Administer sodium polysterene sulfonate (Kayexalate) 15 g orally.

The client also has the nursing diagnosis of Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? A. Flattened neck veins when the client is in the supine position B. Full and bounding pedal and post tibial pulses C. Pitting edema located in the feet, ankles and calfs D. Shallow respirations with crackles on auscultation

A. Flattened neck veins when the client is in the supine position - supine : laying flat, face up - they should be distended in this position

The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in the ventilator setting should you expect to correct this problem? A. Increase rate from 6 to 10 breaths/minute B. Decrease rate from 10 to 6 breaths/minute C. Increase oxygen concentration from 30% to 40% D. Decrease in oxygen concentration from 40% to 30%

A. Increase rate from 6 to 10 breaths/minute - hyperventilation - alkalosis

The charge assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to a UAP? A. Provide oral care every 3-4 hours B. Monitoring for indications of dehydration C. Administering 0.45% saline by IV line D. Assessing daily weights for trends

A. Providing oral care every 3 to 4 hours

The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel. Which medication is most important to clarify further with the HCP? A. Aspirin 162 mg daily B. Omeprazole 20 mg daily C. Metoprolol 50 mg daily D. Nitroglycerin patch 0.4 mg/hr

B - PPI's affects the metabolism of clopidogrel

A client is seen in the clinic with SOB and fatigue is being evaluated for a possible diagnosis of heart failure. Which lab result will be most useful to monitor? A. Serum potassium B. B type natiuretic peptide C. Blood urea nitrogen D. Hematocrit

B - increases in pt with decrease left ventricular function and HF

While working on the cardiac step down unit, you are serving as preceptor to newly graduated RN who has been in a 6 week orientation program. Which client will be best to assign to the new graduate? A. 19 year old with rheumatic fever who needs discharge teaching before going home with a roommate today B. 33 year old admitted a week ago with endocarditis who will be receiving ceftriaxone 2 g IV C. 50 year old with newly diagnosed stable angina who has many questions about medications and nursing care D. 75 year old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

B - to this point, the nurse should have learned how to properly manage IVs

Which action should you delegate to the UAP for the client with diabetic ketoacidosis (select all) A. Checking fingerstick glucose results every hour B. Recording intake and output every hour C. Measuring vital signs every every 15 minutes D. Assessing for indicators of fluid imbalance E. Notifying the provider of changes in glucose level

B, C

You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 bpm. In which order will you take the following actions? A. Call the client's physician B. Have the client sit down C. Check the client's BP D. Administer PRN oxygen by NC

B, D, C, A

A patient has a fractured femur. Which finding would you instruct the UAP to report immediately? A. The patient reports pain B. The patient appears confused C. The patients BP is 136/88 mmHg D. The patient voided using the bedpan

B.

As the charge nurse in a long term care facility that employs RNs, LPNs/LVNs, and UAPs, you have developed a plan for the ongoing assessment of all the residents with a diagnosis of heart failure. Which activity included in the plan in most appropriate to delegate to an LPN/LVN team member? A. Weighing all residents with heart failure each morning B. Listening to lung sounds and checking for edema each week C. Reviewing all heart failure medications with residents every month D. Updating activity plans for residents with heart failure every quarter

B.

The UAP reports to you that a client seems very anxious and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B.

The charge nurse is assigning the nursing care of a patient who had a left below the knee amputation 1 day ago to an experienced LPN/LVN, who will function under your supervision. What will you tell the LPN/LVN is your major focus for the patient's care today? A. To attain pain control over phantom pain B. To monitor signs of sufficient tissue perfusion C. To assist the patient to ambulate ASAP D. To elevate the residual limb when the patient is supine

B.

The client has a NG tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response? A. "It's common for client's with uncomfortable equipment such as NG tubes to have a lower rate of breathing." B. "The client may have metabolic alkalosis due to the NG suctioning, and the decreased RR is a compensatory mechanism." C. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." D. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

B.

You are preparing the client who had carpal tunnel release surgery for discharge. Which info is important to provide to this patient? A. The surgical procedure is a cure for CTS. B. Hand movements will be restricted for 4 to 6 weeks after surgery C. Frequent doses of pain medication will no longer be necessary D. The HCP should be notified immediately if there is any pain or discomfort

B.

You are preparing to implement teaching about a heart healthy diet and activity levels for a client who has had an MI and her husband. The client says "I don't see why I need any teaching. I dont think I need to change anything right now." Which response is most appropriate? A. "Do you think your family may want you to make some lifestyle changes?" B. "Can you tell me why you don't feel that you need to make any changes?" C. "You are still in the stage of denial, but you will want this information later on." D. "Even though you don't want to change, it's important that you have this teaching."

B.

You are the charge nurse for the coronary care step down unit. Which client is best to assign to a float RN who has come for the day from the general Med-Surg unit. A. Client requiring discharge teaching about coronary artery stenting before going home today B. Client receiving IV furosemide to treat acute left ventricular failure C. Client who just transferred in from the radiology department after a coronary angioplasty. D. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

B.

You have just received a change of shift report about these clients on a coronary step down unit. Which one will you assess first? A. 26 year old with heart failure caused by congenital mitral stenosis who is scheduled for ballon valvuloplasty later today B. 45 year old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change C. 56 year old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure D. 77 year old who was transferred from the ICU 2 days ago after coronary artery bypass grafting and has a temperature of 100.6 F

B.

Your assessment reveals all of these data when you are admitting a patient with Paget disease. Which finding should you notify the physician about first? A. There is a bowing of both legs and the knees are asymmetrical. B. The base of the skull is invaginated (platybasia) C. The patient is only 5 feet tall and weighs 120 lbs. D. The skull is soft, thick and larger than normal

B. - makes space for brainstem more narrow - threatens life

Which blood test result would you be sure to monitor for the client taking HCTZ? A. Sodium level B. Potassium level C. Chloride level D. Calcium level

B. - risk of hypokalemia

After you receive the change of shift report, which patient should you assess first? A. 42 year old with CTS who reports pain B. 64 year old with osteoporosis awaiting discharge C. 28 year old with a fracture who reports that the cast is tight D. 56 year old with a left leg amputation who reports phantom pain

C

You are caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should you delegate to the UAP? A. Initiating placement of a splint for immobilization during the day B. Assessing the patient's wrist and hand for discoloration and brittle nails C. Assisting the patient with daily self-care measures such as bathing and eating. D. Testing the patient for painful tingling in the four digits of the hand

C

You are developing a standardized care plan for the postop care of client undergoing cardiac surgery. Which nursing activity included in the care plan will need to be performed by RN staff members? A. Removing chest and leg dressings on the second postop day and cleaning the incisions with antibacterial swabs B. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake C. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes D. Administering oral analgesic medications as needed before helping the client out of bed on the first postop day

C

You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first? A. Insert an IV catheter B. Auscultate heart sounds C. Administer sublingual nitroglycerin D. Draw blood for a troponin 1 level

C

You observe a UAP performing all of these interventions for a patient with CTS. Which action requires that you intervene immediately? A. Arranging the patient's lunch tray and cutting his meat B. Providing warm water and assisting the patient with his bath C. Replacing the patient's splint in hyperextension position D. Reminding the patient not to lift very heavy objects

C

You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? A. Client admitted with heart failure who has atrial fibrillation with a rate of 88 bpm while at rest B. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 bpm C. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 bpm with frequent premature ventricular contractions D. Client who has recently started taking atenolol and has a first degree heart block, with a rate of 58 bpm

C - can easily lead to ventricular tachycardia and fibrillation

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? A. Lower the client's left foot below the heart level B. Administer oxygen at 4 L/min to the client C. Notify the client's physician about the change in status D. Reassure the client that embolization is common in endocarditis

C.

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would you instruct the UAP to report immediately? A. The patient wants to change position B. There is a small amount of clear fluid at the pin site C. The traction weights are resting on the floor D. The patient reports pain and muscle spasms

C.

An 80 year old client on the coronary step down unit tells you that he does not want to take the ordered docusate because he does not have constipation. Which action is most appropriate? A. Document the medication on the client's chart as "refused" B. Mix the medication with food and administer it to the client C. Explain that his decreased activity level may cause constipation D. Reinforce that the docusate has been prescribed for a good reason

C.

During a home visit to an 88 year old client who is taking digoxin 0.25 mg daily to treat heart failure and atrial fibrillation, you obtain this assessment information. Which finding is most important to communicate to the HCP? A. Apical pulse of 68 bpm and irregularly irregular B. Digoxin taken with meals C. Vision that is becoming "fuzzy" D. Lung crackles that clear after coughing

C.

Two weeks ago a 63 year old client with heart failure received a new prescription for carvedilol 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern? A. Reports of increased fatigue B. Weight increase of 0.5 kg over a 1 week period C. Sinus bradycardia at a rate of 48 bpm D. Traces of edema noted over both ankles

C.

You are caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which lab value will be most important to monitor? A. Sodium B. Blood urea nitrogen C. Potassium D. Alkaline phosphatase

C.

You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the HCP about a change in the drug therapy? A. Client reports frequent urination B. CLient's blood pressure is 138/86 mmHg C. Client coughs often during the visit D. Client says "I get dizzy sometimes."

C. - could lead to noncompliance

The charge nurse observes an LPN/LVN providing all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? A. Administering 600 mg of ibuprofen to the patient B. Encouraging the patient to perform PT recommended exercises C. Applying ice and gentle massage to the patient's lower extremities D. Reminding the patient to drink milk and and eat cottage cheese.

C. - need heat

The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? A. "The client's low phosphorus is probably due to malnutrition." B. "The client is just worn out form not getting enough rest." C. "The client's skeletal muscles are weak because of the low phosphorus." D. "The client will do more for himself when his phosphorus level is normal."

C. " The client's skeletal muscles are weak because of the low phosphorus." - all of the answers could be true; however, the only one that addresses the question is C.

A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia

C. Hyponatremia - SIADH causes excess fluid retention thus causing hypoNa by dilution

A 9:00 PM, you admit a 63 year old with a dx of acute MI. Which finding is most important to communicate to the HCP who is considering the use of fibrinolytic therapy with tissue plasminogen activator for the client? A. The client was treated with alteplase about 8 months ago B. The client takes famotidine for esophageal reflux C. The client has ST segment elevations on the 12 lead ECG D. The client has had continuous chest pain since 8:00 AM

D

You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to nursing diagnosis Risk of Falls. Which interventions should you delegate to the UAP? A. Identifying environmental factors that increase risk for falls B. Monitoring gait, balance, and fatigue level with ambulation C. Collaborating with the PT to provide the patient with a walker D. Assisting the pt with ambulation to the bathroom and in the halls

D

A resident in a long term facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for you to delegate to the UAP? A. Teaching family members the signs of infection B. Monitoring capillary perfusion once every 8 hours C. Evaluating foot sensation and movement each shift D. Assisting the client in cleaning around the Unna boot

D.

During morning care, a patient with a below the knee amputation asks the UAP about protheses. How will you instruct the UAP to respond? A. "You should get a protheses so that you can walk again." B. " Wait and ask your doctor that question the next time he comes in." C. "It's too soon to be worrying about getting a prothesis." D. "Ill ask the nurse to come in and discuss this with you."

D.

You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalance? A. Hx of MI B. Antacid use for occasional indigestion C. SOB with extreme exertion D. Chronic renal insuff

D.

You are monitoring a 53 year old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? A. Blood pressure of 152/88 mmHg B. HR of 134 bpm C. Oxygen saturation of 91% D.Chest pain level of 3 out of 10.

D.

You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? A. BP decrease from 114/65 to 106/58 B. RR drop from 18 to 12 breath/min C. Cardiac monitor indicating sinus rhythm at a rate of 96 bpm D. Persisting chest pain at level of 1

D.

You are preparing to administer the following medications to a client with multiple health problems who has been hospitalized with DVT. Which medication is most important to double check with another licensed nurse? A. Famotidie 20 mg IV B. Furosemide 40 mg IV C. Digoxin 0.25 mg PO D. Warfarin 2.5 mg PO

D. - anticoagulant is high alert

You assess a client who has just returned to the recovery area after undergoing surgery coronary arteriography. Which information is of most concern? A. BP is 144/78 mmHg B. Pedal pulses are palpable at 1+ C. Left groin has a 3 cm bruised area D. Apical pulse is 122 bpm and regular

D. - earliest indication of hemorrhage is increased HR

The RN is providing care for a patient diagnosed with dehydration and hypovolemic shock. Which order should the RN question? A. Blood pressure every 15 minutes B. Place two 18 guage IV lines C. Oxygen at 3 L via NC D. D5W to run at 250 mL/hr

D. - to fix this, they need isotonic fluids like NS or LR

You are preparing to discharge a client whose calcium level was low but is now just barely within the normal range. Which statement by the client indicates to you the need for additional teaching? A. "I will call my doctor if I experience muscle twitching or seizures." B. "I will make sure to take my Vitamin D with my calcium each day." C. "I will take my calcium citrate pill every morning before breakfast." D. "I will avoid dairy products, broccoli, and spinach when I eat."

D. "I will avoid dairy products, broccoli, and spinach when I eat."

The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? A. Weigh client every morning B. Maintain accurate intake and output records C. Restrict fluids to 1500 ml/day D. Administer furosemide (Lasix) 40 mg IV push

D. Administer furosemide 40 mg IV push

You are reviewing the client's morning laboratory results. Which of these results is of most concern to you? A. Serum potassium level of 5.2 mEq/L B. Serum sodium level of 134 mEq/L C. Serum calcium level of 10.6 mEq/L D. Serum magnesium level of 0.8 mEq/L

D. Serum magnesium level of 0.8 mEq/L

You are working in an outpatient client where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to an experienced LPN/LVN? A. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated B. Checking BP and HR every 10 minutes in a client who is undergoing exercise testing C. Obtaining info about allergies from a client who is scheduled for left leg contract venography D. Providing brief teaching for a client who will undergo a right subclavian vein Doppler study

A.

You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN? A. Administering nitroglycerin if chest discomfort occurs during client activities B. Monitoring pulse, BP, and O2 sat before and after patient ambulation C. Teaching the client energy conservation techniques to decrease myocardial oxygen demand D. Explaining the rationale for alternating rest periods with exercise to the client and family.

A.

You delegate the measurement of vital signs to an experienced UAP. Osteomyelitis has been diagnosed in a patient. Which vital sign value would you instruct the UAP to report immediately? A. Temperature of 101 B. BP 136/80 mmHg C. HR of 96 bpm D. RR of 24 breaths/min

A.

A patient who underwent a right above the knee amputation 4 days ago also has a diagnosis of depression. Which order would you clarify with the HCP? A. Give fluoxetine 40 mg once a day. B. Administer acetaminophen with codeine 1 or 2 tablets every 4 hours as needed. C. Assist the patient to the bedside chair every shift. D. Reinforce the dressing to the right residual limb as needed.

A. - any dose > 20 mg should be given in two divided doses

Ventricular fibrillation is identified in an unresponsive 50 year old client who has just arrived in the ED. Which action will you take first? A. Defibrillate at 200 J B. Start CPR C. Administer epinephrine D. Intubate and manually ventilate

A. - rapid defibrillation will increase the likelihood of success

As the charge nurse, you would assign which client to the step-down unit nurse floated to the ICU for the day? A. 68 year old on a ventilator with acute respiratory failure and respiratory acidosis B. 72 year old with COPD and normal blood gas values and who is ventilator dependent C. Newly-admitted 56 year old with diabetic ketoacidosis receiving an insulin drip D. 38 year old on a ventilator with narcotic overdose and respiratory alkalosis

B. 72 year old with COPD and normal blood gas values and who is ventilator dependent. - most stable out of all of the clients

You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which lab value should you check immediately? A. Sodium B. Potassium C. Magnesium D. Calcium

B. Potassium - hypokalemia

An experienced LPN/LVN reports to you that a client's BP and HR have decreased, and when his face is assessed, one side twitches. What action should you take at this time? A. Reassess the client's BP and HR B. Review the client's AM calcium level C. Request a neurologic consult today D. Check the client's pupillary reaction to light.

B. Review the client's AM calcium level - LPN/LVNs have been trained and are experienced enough to obtain proper VS, no need to reassess

You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which lab test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? A. Cretine kinase MB level B. Troponin 1 level C. Myoglobin level D. C-reactive protein level

B. Troponin level

As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the PACU for the day? A. 35 year old with osteomyelitis who needs teaching before hyperbaric oxygen therapy B. 62 year old with osteomalacia who is being discharged to a long term care facility C. 68 year old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed D. 72 year old with Paget disease who has just returned from surgery for total knee replacement

D

The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? a. Administering IV fluids as prescribed by the physician b. Providing straws and offering fluids between meals c. Developing a plan for added fluid intake over 24 hours d. Teaching family members to assist the client with fluid intake

b. providing straws and offering fluids between meals