Management: Quiz 2

When providing care for a patient with Addison disease, the nurse should be alert for which laboratory value change? 1. Decreased hematocrit 2. Increased sodium level 3. Decreased potassium level 4. Decreased calcium level

1 A patient with Addison disease is at risk for anemia. The nurse should expect this patient's sodium level to decrease and potassium and calcium levels to increase. Focus: Prioritization.

The RN is orienting a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must the RN intervene? 1. "To prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs." 2. "To correctly inject the insulin, lightly grasp a fold of skin and inject at a 90- degree angle." 3. "Always draw your regular insulin into the syringe first before your NPH (neutral protamine Hagedorn) insulin." 4. "Avoid injecting the insulin into scarred sites because those areas slow the absorption rate of insulin."

1 Although it is important to rotate injection sites for insulin, it is preferred that the injection sites be rotated within one anatomic site (e.g., the abdomen) to prevent day-to-day changes in the absorption rate of the insulin. All of the other teaching points are appropriate. Focus: Supervision, Prioritization.

A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the\ priority nursing concern at this time? 1. Fatigue 2. Inability to perform activities of daily living (ADLs) 3. Decreased mobility 4. Muscular weakness

1 At this time, based on the client's statement, the priority is inability to perform ADLs most likely related to being tired (fatigue) after physical therapy. The other three nursing concerns are appropriate to a client with MS but are not related to the client's statement.

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? 1. Instructing the client to sit up straight and the client responds with a puzzled expression 2. Moving the client's food tray to the right side of his over-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

1 Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? 1. "I will avoid exercise because the pain gets worse." 2. "I will use heat or ice to help control the pain." 3. "I will not wear high-heeled shoes at home or work." 4. "I will purchase a firm mattress to replace my old one."

1 Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times. Focus: Prioritization.

The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs/LVNs and delegating and supervising care given by unlicensed assistive personnel (UAP). Which activity is best to assign to the LPN/LVN team leaders? 1. Checking for improvement in resident memory after medication therapy is initiated 2. Using the Mini-Mental State Examination to assess residents every 6 months 3. Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence 4. Developing individualized activity plans after consulting with residents and family

1 LPN/LVN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility.

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1. Entering the room without putting on a protective mask and gown 2. Instructing the family that visits are restricted to 10 minutes 3. Giving the client a warm blanket when he says he feels cold 4. Checking the client's pupil response to light every 30 minutes

1 Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.

The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover? 1. Short-term memory impairment 2. Rapid mood swings 3. Physical aggressiveness 4. Increased confusion at night

1 One of the first symptoms of AD is short-term memory impairment. Behavioral changes that occur late in the disease progression include rapid mood swings, tendency toward physical and verbal aggressiveness, and increased confusion at night (when light is inadequate) or when the client is excessively fatigued.

A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should the nurse delegate to unlicensed assistive personnel (UAP)? 1. Reminding the patient to change positions slowly 2. Assessing the patient for muscle weakness 3. Teaching the patient how to collect a 24-hour urine sample 4. Revising the patient's nursing plan of care

1 Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. After a patient has been so instructed, it is appropriate for the UAP to remind the patient of the instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, Supervision.

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? 1. Position the client sitting up in bed before he or she is fed. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly because there are three more clients to feed. 4. Suction the client's secretions between bites of food.

1 Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.

A patient with adrenal insufficiency is to be discharged and will take prednisone 10 mg orally each day. Which instruction would the nurse be sure to teach the patient? 1. Excessive weight gain or swelling should be reported to the health care provider. 2. Changing positions rapidly may cause hypotension and dizziness. 3. A diet with foods low in sodium may be beneficial to prevent side effects. 4. Signs of hypoglycemia may occur while taking this drug.

1 Rapid weight gain and edema are signs of excessive drug therapy, and the dosage of the drug would need to be adjusted. Hypertension, hyponatremia, hyperkalemia, and hyperglycemia are common in patients with adrenal hypofunction. Focus: Prioritization.

A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which nursing assessment finding supports this diagnosis? 1. Patchy areas of pigment loss over the face 2. Decreased muscle strength 3. Greatly increased urine output 4. Scalp alopecia

1 Vitiligo, or patchy areas of pigment loss with increased pigmentation at the edges, is seen with primary hypofunction of the adrenal glands and is caused by autoimmune destruction of melanocytes in the skin. The other findings are signs of pituitary hypofunction. Focus: Prioritization.

The plan of care for a patient with diabetes includes all of these interventions. Which intervention should the nurse delegate to unlicensed assistive personnel (UAP)? 1. Reminding the patient to put on well-fitting shoes before ambulating 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe

1 Reminding the patient to put on well-fitting shoes (after the nurse has taught the patient about the importance of this action) is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. It is a safety measure that can prevent injury. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation.

Which change in vital signs would the nurse instruct the unlicensed assistive personnel to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure 3. Increased respiratory rate 4. Decreased oral temperature

1 The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition. Focus: Delegation, Supervision.

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/dL (13 mmol/L). 3. The client reports a continuing headache. 4. The daily weight has increased 2.2 lb (1 kg).

1 The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies.

The nurse is caring for a patient with diabetes who is developing diabetic ketoacidosis (DKA). Which task delegation or assignment is most appropriate? 1. Ask the unit clerk to page the health care provider to come to the unit. 2. Ask the LPN/LVN to administer IV push insulin according to a sliding scale. 3. Ask the unlicensed assistive personnel (UAP) to hang a new bag of normal saline. 4. Ask the UAP to get the patient a cup (236 mL) of orange juice.

1 The nurse should not leave the patient. The scope of the unit clerk's job includes calling and paging physicians. LPNs/LVNs generally do not administer IV push medication, although in some states with additional training, this may be done. (Be sure to check the Scope of Practice in your specific state.) IV fluid administration is not within the scope of practice of UAPs. Patients with DKA already have a high glucose level and do not need orange juice. Focus: Delegation, Supervision.

An LPN/LVN is assigned to administer rapid-acting insulin, lispro, to a patient with type 1 diabetes. What essential information would the RN be sure to tell the LPN/LVN? 1. Give this insulin when the food tray has been delivered and the patient is ready to eat. 2. Only give this insulin for fingerstick glucose reading is above 200 mg/dL (11.1 mmol/L). 3. This insulin mimics the basal glucose control of the pancreas. 4. Rapid-acting insulin is the only insulin that can be given subcutaneously or IV.

1 The onset of action for rapid-acting insulin is within minutes, so it should be given only when the patient has food and is ready to eat. Because of this, rapid-acting insulin is sometimes called "see food" insulin. Options 2, 3, and 4 are incorrect with regard to rapid-acting insulin. Option 2 is incorrect with regard to all forms of insulin. Long-acting insulins mimic the action of the pancreas. Regular insulin is the only insulin that can be given IV. Focus: Assignment, Supervision.

The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse? 1. Calcium level 2. Sodium level 3. Potassium level 4. White blood cell count

1 The parathyroid glands are located on the back of the thyroid gland. The parathyroids are important in maintaining calcium and phosphorus balance. The nurse should be attentive to all patient laboratory values, but calcium and phosphorus levels are especially important to monitor after thyroidectomy because abnormal values could be the result of removal of the parathyroid glands during the procedure. Focus: Prioritization.

The nurse is caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention? 1. Presence of glucose in the nasal drainage 2. Presence of nasal packing in the nares 3. Urine output of 40 to 50 mL/hr 4. Patient reports of thirst

1 The presence of glucose in nasal drainage indicates that the fluid is cerebrospinal fluid (CSF) and suggests a CSF leak. Packing is normally inserted in the nares after the surgical incision is closed. Urine output of 40 to 50 mL/hr is adequate, and patients may experience thirst postoperatively. When patients are thirsty, nursing staff should encourage fluid intake. Focus: Prioritization.

Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

1 The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.

What is the priority nursing concern for a client experiencing a migraine headache? 1. Pain 2. Anxiety 3. Hopelessness 4. Risk for brain injury

1 The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization.

The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider immediately? 1. Temperature elevation to 100.2°F (37.9°C) 2. Heart rate increase from 64 to 76 beats/min 3. Respiratory rate decrease from 26 to 16 breaths/min 4. Pulse oximetry reading of 92%

1 When caring for a patient with hyperthyroidism, even after a partial thyroidectomy, a temperature elevation of 1°F must be reported immediately because it may indicate an impending thyroid crisis. The other changes should be monitored, but none is urgent. Focus: Prioritization.

The nurse is caring for an older patient with type 1 diabetes and diabetic retinopathy. What is the nurse's priority concern for assessing this patient? 1. Assess ability to measure and inject insulin and to monitor blood glucose levels. 2. Assess for damage to motor fibers, which can result in muscle weakness. 3. Assess which modifiable risk factors can be reduced. 4. Assess for albuminuria, which may indicate kidney disease.

1 The older patient with diabetic retinopathy also has general age-related vision changes, and the ability to perform self-care may be seriously affected. He or she may have blurred vision, distorted central vision, fluctuating vision, loss of color perception, and mobility problems resulting from loss of depth perception. When a patient has visual changes, it is especially important to assess his or her ability to measure and inject insulin and to monitor blood glucose levels to determine if adaptive devices are needed to assist in self-management. The other options are important but are not specific to diabetic retinopathy. Focus: Prioritization.

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply. 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by the client's health care provider.

1, 2, 3, 4, 5 Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan. Focus: Prioritization.

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range-of-motion (ROM) exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair

1, 2, 3, 5, 6 An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed. Assessing for redness and swelling (signs of deep vein thrombosis) requires additional education and skill, appropriate to the professional nurse.

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 4. Monitor for cardiac dysrhythmias. 5. Administer oral prednisone 10 mg every morning. 6. Record intake and output.

1, 2, 3, 6 Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring. The nurse should make sure that the UAP has mastered this skill and then instruct the UAP to record and inform him or her about the results. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses. Focus: Delegation.

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle 6. Reminding the client to void in a urinal every hour while awake

1, 2, 4, 5 All of the strategies except straight catheterization may stimulate voiding in clients with a spinal cord injury (SCI). Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. To use a urinal, the client must have bladder control, which is often absent after SCI. In addition, every hour while awake would be too often and ignore the bladder filling at night. Focus: Prioritization.

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism? Select all that apply. 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 3. Creating an individualized nursing care plan for the patient 4. Administering sedation medications every 6 hours 5. Checking blood pressure, heart rate, and respirations every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

1, 2, 5, 6 Assessment, auscultation, and reminding patients about information that has been taught to them are within the scope of practice of the LPN/LVN. The LPN/LVN could be assigned to check the patient's vital signs, and this is certainly within the scope of practice. Checking vital signs could also be delegated to the unlicensed assistive personnel. Creating nursing care plans falls within the scope of practice of the RN. The use of sedation is discouraged for patients with hypothyroidism because it may make respiratory problems more difficult. If sedation is used, the dosage is reduced, and it is not given around the clock. Focus: Assignment, Supervision.

A patient with newly diagnosed diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? Select all that apply. 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 3. "Nylon socks are best to prevent friction on your toes from shoes." 4. "Only a podiatrist should trim your toenails." 5. "Report any nonhealing skin breaks to your health care provider (HCP)." 6. "Use a thermometer to check the temperature of water before taking a bath."

1, 2, 5, 6 Sensory alterations are the major cause of foot complications in patient with diabetes, and patients should be taught to examine their feet on a daily basis. Properly fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Using a bath thermometer can prevent burn injuries. Patients, family, or HCPs may trim toenails. Focus: Prioritization; Test Taking Tip: When caring for patients with diabetes, the nurse must be knowledgeable about safety issues with the potential for injuries to these patients. A key nursing role is patient teaching regarding these concerns so patients can perform protective interventions in the home to prevent injuries.

A 58-year-old patient with type 2 diabetes was admitted to the acute care unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. When the RN prepares a care plan for this patient, what would he or she be sure to include? Select all that apply. 1. Fingerstick blood glucose checks before meals and at bedtime 2. Sliding-scale insulin dosing as prescribed 3. Bed rest until the COPD exacerbation is resolved 4. Teaching about the Atkins diet for weight loss 5. Demonstration of the components of foot care 6. Discussing the relationship between illness and glucose levels

1, 2, 5, 6 When a patient with diabetes is ill, glucose levels become elevated, and administration of insulin may be necessary. Administration of sliding-scale insulin is guided by fingerstick blood glucose checks. Teaching or reviewing the components of proper foot care is always a good idea with a patient with diabetes. Bed rest is not necessary, and glucose levels may be better controlled when a patient is more active. The Atkins diet recommends decreasing the consumption of carbohydrates and is not a good diet for patient with diabetes. Focus: Prioritization.

A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications 6. Turning the client to his or her side to avoid aspiration

1, 2, 6 Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.

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

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

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply. 1. When did you first experience the headache symptoms? 2. Who is the Mayor of Cleveland? 3. What is your health care provider's name? 4. What year and month is this? 5. What is your parents' address? 6. What is the name of this health care facility?

1, 3, 4, 6 After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation. Focus: Prioritization.

The nurse is preparing to discharge a patient with hyperpituitarism caused by a benign pituitary tumor, who is prescribed the drug bromocriptine. Which key points would the nurse teach the patient about this drug? Select all that apply. 1. Take this drug with a meal or snack to avoid gastrointestinal (GI) symptoms. 2. Side effects of bromocriptine include severe fatigue and reflux after meals. 3. Seek medical care if you experience chest pain or dizziness while taking this drug. 4. If the drug causes headaches, you can take over-the-counter acetaminophen. 5. Treatment starts with a high dose, which is gradually lowered. 6. The purpose of bromocriptine is to shrink your pituitary to normal size.

1, 3, 4, 6 Bromocriptine is a dopamine agonist drug that stimulates dopamine receptors in the brain and inhibits the release of growth hormone and prolactin. In most cases, small tumors decrease until the pituitary gland is of normal size. Side effects of bromocriptine include orthostatic (postural) hypotension, headaches, nausea, abdominal cramps, and constipation. Give bromocriptine with a meal or a snack to reduce GI side effects. Treatment starts with a low dose and is gradually increased until the desired level is reached. Patients taking bromocriptine should be taught to seek medical care immediately if chest pain, dizziness, or watery nasal discharge occurs because of the possibility of serious side effects, including cardiac dysrhythmias, coronary artery spasms, and cerebrospinal fluid leakage. Also, if the patient is a female of childbearing age who becomes pregnant, the drug should be stopped. Focus: Prioritization.

A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client 6. Administering oral medications as ordered

1, 3, 4, 6 Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Administering oral drugs is within the scope of practice for an LPN/LVN. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Assignment, Supervision Test Taking Tip: The RN must be aware of the scope of practice for an LPN/LVN. This may vary from state to state and may depend on whether the LPN/LVN has additional education. Generally, in- depth assessment, care plan development, and in-depth client education remain within the scope of practice of the professional RN.

The nurse is preparing a teaching plan for a patient with type 2 diabetes who has been prescribed albiglutide. Which key points would the nurse include? Select all that apply. 1. The drug works in the intestine in response to food intake and acts with insulin for glucose regulation. 2. This drug increases cellular utilization of glucose, which lowers blood glucose levels. 3. This drug is used with diet and exercise to improve glycemic control in adults with type 2 diabetes. 4. The drug is an oral insulin that should be given only when the patient has something to eat immediately available. 5. Albiglutide is administered by the subcutaneous route once a week. 6. Albiglutide should be given with caution for a patient with a history of pancreatic problems.

1, 3, 5 Albiglutide is an incretin mimetic. These drugs work like the natural "gut" hormones, glucagon-like peptide-1 (GLP-1) and glucose- dependent insulinotropic polypeptide (GIP), that are released by the intestine in response to food intake and act with insulin for glucose regulation. They are used in addition to diet and exercise to improve glycemic control in adults with type 2 diabetes. Albiglutide is administered subcutaneously once a week. Focus: Prioritization.

All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

1, 3, 5 UAP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the UAP to report heart rate and blood pressure findings. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.

In the care of a patient with type 2 diabetes, which actions should the nurse delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Providing the patient with extra packets of artificial sweetener for coffee 2. Assessing how well the patient's shoes fit 3. Recording the liquid intake from the patient's breakfast tray 4. Teaching the patient what to do if dizziness or lightheadedness occurs 5. Checking and recording the patient's blood pressure 6. Assisting the patient to ambulate to the bathroom

1, 3, 5, 6 Giving the patient extra sweetener, recording oral intake, assisting with ambulation, and checking blood pressure are all within the scope of practice of the UAP. Assessing shoe fit and patient teaching are within the professional nurse's scope of practice. Focus: Assignment.

The unlicensed assistive personnel reports to the RN that a patient with type 1 diabetes has a question about exercise. What important points would the RN be sure to teach this patient? Select all that apply. 1. Exercise guidelines are based on blood glucose and urine ketone levels. 2. Be sure to test your blood glucose only after exercising. 3. You can exercise vigorously if your blood glucose is between 100 and 250 mg/dL (5.6 and 13.9 mmol/L). 4. Exercise will help resolve the presence of ketones in your urine. 5. A 5- to 10-minute warm-up and cool-down period should be included in your exercise. 6. For unplanned exercise, increased intake of carbohydrates is usually needed.

1, 3, 5, 6 Guidelines for exercise are based on blood glucose and urine ketone levels. Patients should test blood glucose before, during, and after exercise to be sure that it is safe to exercise. When ketones are present in urine, the patient should not exercise because ketones indicate that current insulin levels are not adequate. Vigorous exercise is permitted in patients with type 1 diabetes if glucose levels are between 100 and 250 mg/dL (5.6 and 13.9 mmol/L). Warm-up and cool-down should be included in exercise to gradually increase and decrease the heart rate. For planned exercise, reduction in insulin dosage is used for hypoglycemia prevention. For unplanned exercise, intake of additional carbohydrate is usually needed. Focus: Prioritization.

The nurse is caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? Select all that apply. 1. Hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 2. Weight gain of 6 lb (2.7 kg) over the past month 3. Avoids consuming liquids in the evening 4. Blood pressure of 168/94 mm Hg 5. Urine output of 50 to 75 mL/hr 6. Glucose greater than 600 mg/dL (33.3 mmol/L)

1, 3, 6 HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Serum glucose is greater than 600 mg/dL (33.3 mmol/L). Weight loss (not weight gain) would be a symptom. Although the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr is adequate. Focus: Prioritization.

The RN is caring for a patient with diabetes admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would the nurse include in a teaching plan for the patient and family before discharge? Select all that apply. 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL (3.3 mmol/L). 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1⁄4 cup (60 mL) of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. 6. If the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED).

1, 4, 5, 6 The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. When a patient has severe hypoglycemia, does not respond to administration of glucagon, and remains unconscious, he or she should be transported to the ED and the health care provider notified. Focus: Prioritization.

The LPN/LVN who is assigned to care for a patient with Cushing disease asks the RN why the patient has bruising and petechiae across her abdomen. What is the RN's best response? 1. "Patients with Cushing disease often have bleeding disorders." 2. "Patients with Cushing disease have very fragile capillaries." 3. "Please ask the patient if she slipped or fell during the night." 4. "Thin and delicate skin can result in development of bruising."

2 A key cardiovascular feature seen in patients with Cushing disease is capillary fragility, which results in bruising and petechiae. Bleeding disorders are not a sign of Cushing disease, and although these patients have delicate skin, this is not the cause of the bruising. The nurse may want to investigate whether the patient fell, but these patients have bruising and petechiae without falls. Focus: Assignment, Supervision, Prioritization.

While the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beers a day. What is the nurse's priority follow-up question at this time? 1. "Do you have any days when you do not drink?" 2. "When during the day do you drink your beers?" 3. "Do you drink any other forms of alcohol?" 4. "Have you ever had a lipid profile completed?"

2 Alcohol has the potential for causing alcohol-induced hypoglycemia. It is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication. The other questions are important but not urgent. The lipid profile question is important because alcohol can raise plasma triglycerides but is not as urgent as the potential for hypoglycemia. Focus: Prioritization.

The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? 1. Administer codeine 15 mg orally for the client's headache. 2. Infuse ceftriaxone 2000 mg IV to treat the infection. 3. Give acetaminophen 650 mg orally to reduce the fever. 4. Give furosemide 40 mg IV to decrease intracranial pressure.

2 Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy.

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

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

The nurse is caring for a 25-year-old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw-colored urine output (up to 15 L/day). What does the nurse suspect? 1. Type 2 diabetes 2. Diabetes insipidus (DI) 3. Cushing disease 4. Addison disease

2 DI is a disorder of the posterior pituitary gland in which water loss is caused by either an antidiuretic hormone (ADH) deficiency or an inability of the kidneys to respond to ADH. The result of DI is the excretion of large volumes of dilute urine because the distal kidney tubules and collecting ducts do not reabsorb water; this leads to polyuria. Dehydration from massive water loss increases plasma osmolarity, which stimulates the sensation of thirst. Thirst promotes increased fluid intake and aids in maintaining hydration. Focus: Prioritization.

A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 (2.3 x 10^9/L). 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

2 Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.

For a patient with hyperthyroidism, which task should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine 4. Teaching the patient about side effects of the drug propylthiouracil

2 Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training. Focus: Delegation, Supervision, Assignment.

The LPN/LVN is assigned to provide care for a patient with pheochromocytoma. Which physical assessment technique should the RN instruct the LPN/LVN to avoid? 1. Listening for abdominal bowel sounds in all four quadrants 2. Palpating the abdomen in all four quadrants 3. Checking the blood pressure every hour 4. Assessing the mucous membranes for hydration status

2 Palpating the abdomen can cause the sudden release of catecholamines and severe hypertension. All of the other assessments are appropriate for the LPN/LVN assigned to care for this patient. Focus: Assignment, Supervision.

Two unlicensed assistive personnel (UAP) are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires the nurse's immediate intervention? 1. Positioning themselves on opposite sides of the patient's bed 2. Grasping under the patient's arms to pull him up in bed 3. Lowering the side rails of the patient's bed before moving him 4. Removing the pillow before moving the patient up in bed

2 Patients with Cushing disease usually have paper-thin skin that is easily injured. The UAPs should use a lift or a draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed. Focus: Delegation, Supervision.

In the emergency department, during initial assessment of a newly admitted patient with diabetes, the nurse discovers all of these findings. Which finding should be reported to the health care provider immediately? 1. Hammer toe of the left second metatarsophalangeal joint 2. Rapid respiratory rate with deep inspirations 3. Numbness and tingling bilaterally in the feet and hands 4. Decreased sensitivity and swelling of the abdomen

2 Rapid, deep respirations (Kussmaul respirations) are symptomatic of diabetic ketoacidosis. Hammer toe, as well as numbness and tingling, are chronic complications associated with diabetes. Decreased sensitivity and swelling (lipohypertrophy) occur at a site of repeated insulin injections, and treatment involves teaching the patient to rotate injection sites within one anatomic site. Focus: Prioritization.

For which client with severe migraine headaches would the nurse question an order for sumatriptan? 1. A 58-year-old client with gastrointestinal reflux disease 2. A 48-year-old client with hypertension 3. A 65-year-old client with mild emphysema 4. A 72-year-old client with hyperthyroidism

2 Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal angina because of the potential for coronary vasospasm.

Which patient should the charge nurse assign to the care of an LPN/LVN, under the supervision of the RN team leader? 1. A 51-year-old patient who has just undergone bilateral adrenalectomy 2. A 83-year-old patient with type 2 diabetes and chronic obstructive pulmonary disease 3. A 38-year-old patient with myocardial infarction preparing for discharge 4. A 72-year-old patient with mental status changes admitted from a long- term care facility

2 The 83-year-old has no complicating factors at the moment. Providing care for patients in stable and uncomplicated condition falls within the LPN/LVN's educational preparation and scope of practice, with the care always being provided under the supervision and direction of an RN. The RN should assess the patient who has just undergone surgery and the newly admitted patient. The patient who is preparing for discharge after myocardial infarction may need some complex teaching. Focus: Assignment, Supervision.

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? 1. The client's condition is improving. 2. The client's condition is deteriorating. 3. The client will need intubation and mechanical ventilation. 4. The client's medication regime will need adjustments.

2 The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

2 The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. Focus: Assignment, Supervision.

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? 1. Assessing the client's respiratory status every 4 hours 2. Checking and recording the client's vital signs every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

2 The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not\ teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses. Focus: Delegation, Supervision.

The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? 1. Administer an acetaminophen suppository. 2. Notify the health care provider immediately. 3. Recheck vital signs in 1 hour. 4. Reschedule the client's physical therapy.

2 The changes that the RN notes are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the health care provider or Rapid Response Team, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation.

A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomography (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

2 The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? 1. Administer the ordered acetaminophen. 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the health care provider about the change in status.

2 The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization.

A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this client? 1. Acute client confusion 2. Care provider role stress 3. Increased risk for falls 4. Noncompliance with therapeutic plan

2 The husband's statement about lack of sleep and concern about whether his wife is receiving the correct medications are behaviors that support the problem of care provider role stress. The husband's statements about how he monitors the client and his concern with medication administration do not indicate difficulty complying with the therapeutic plan. The client may be confused, but the nurse would need to gather more data, and this is not the main focus of the husband's concerns. Falls are not an immediate concern at this time.

Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1. A 28-year-old newly admitted client with a spinal cord injury 2. A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old client with dementia who is to be transferred to long-term care today 4. A 54-year-old client with Parkinson disease who needs assistance with bathing

2 The new graduate RN who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the unlicensed assistive personnel (UAP). The client being transferred to the nursing home, and the newly admitted client with spinal cord injury should be assigned to experienced nurses. Focus: Assignment.

The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse? 1. A 68-year-old patient with diabetes who is showing signs of hyperglycemia 2. A 58-year-old patient with diabetes who has cellulitis of the left ankle 3. A 49-year-old patient with diabetes just returned from the postanesthesia care unit after a below-knee amputation 4. A 72-year-old patient with diabetes with diabetic ketoacidosis who is receiving IV insulin

2 The new nurse is very early in orientation to the unit. Appropriate patient assignments at this time include patients whose conditions are stable and not complex. Patients 1, 3, and 4 are more complex and will benefit from care by a nurse experienced in care of patients with diabetes. Focus: Assignment; Test Taking Tip: For nurses new to a unit, always assign patients who are most stable and least complex.

A patient with diabetes has hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated RN performing all the following patient tasks. Which action requires that the charge nurse intervene immediately? 1. Checking the patient's fingerstick glucose level 2. Encouraging the patient to drink orange juice 3. Checking the patient's order for sliding-scale insulin dosing 4. Assessing the patient's vital signs every 15 minutes

2 The signs and symptoms the patient is exhibiting are consistent with hyperglycemia. The RN should not give the patient additional glucose. All of the other interventions are appropriate for this patient. The RN should also notify the health care provider at this time. Focus: Prioritization.

Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. A 34-year-old client with newly diagnosed multiple sclerosis (MS) 2. A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) 3. A 56-year-old client with Guillain-Barré syndrome (GBS) in respiratory distress 4. A 25-year-old client admitted with a C4-level spinal cord injury (SCI)

2 The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care.

The RN is the preceptor for a senior nursing student who will teach a patient with diabetes about self-care during sick days. For which statement by the. student must the RN intervene? 1. "When you are sick, be sure to monitor your blood glucose at least every 4 hours." 2. "Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL (13.3 mmol/L)." 3. "To prevent dehydration, drink 8 ounces (236 mL) of sugar-free liquid every hour while you are awake." 4. "Continue to eat your meals and snacks at the usual times."

2 Urine ketone testing should be done whenever the patient's blood glucose is greater than 240 mg/dL (13.3 mmol/L). All of the other teaching points are appropriate "sick day rules." For dehydration, teaching should also include that if the patient's blood glucose is lower than her target range, she should drink fluids containing sugar. Focus: Supervision, Delegation.

The nurse is responsible for the care of a patient with diabetes who is unable to swallow, is unconscious and seizing, and has a blood glucose of less than 20 mg/dL (1.1 mmol/L). Which actions are most appropriate responses for this patient at this time? Select all that apply. 1. Check the chart for the patient's most recent A1c level. 2. Give glucagon 1 mg subcutaneously or intramuscularly (IM). 3. Repeat the dose of glucagon in 10 minutes if the patient remains unconscious. 4. Apply aspiration precautions because glucagon can cause vomiting. 5. Give the patient an oral simple sugar or snack. 6. Notify the health care provider (HCP) immediately.

2, 3, 4, 6 This patient's manifestations suggest severe hypoglycemia. Essential actions at this time include notifying the HCP immediately and giving glucagon 1 mg subcutaneously or IM. Glucagon is the main counterregulatory hormone to insulin and is used as first-line therapy for severe hypoglycemia in patients with diabetes. The dose or glucagon is repeated after 10 minutes if the patient remains unconscious. Aspiration precautions are important because this drug can cause vomiting. Checking the patient's A1c level is not important at this time. Offering oral glucose or a snack when a patient is unable to swallow or unconscious is inappropriate. Focus: Prioritization.

The nurse is preparing a care plan for a patient with Cushing disease. Which abnormal laboratory values would the nurse expect? Select all that apply. 1. Increased serum calcium level 2. Increased salivary cortisol level 3. Increased urinary cortisol level 4. Decreased serum glucose level 5. Decreased sodium level 6. Increased serum cortisol level

2, 3, 6 A patient with Cushing disease experiences increased levels of serum, urinary, and salivary cortisol. Other laboratory findings may include increased blood glucose level, decreased lymphocyte count, increased sodium level, and decreased serum calcium level. Focus: Prioritization.

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

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

The nurse is providing care for a male patient with hypogonadotropin who is receiving sex steroid replacement therapy with testosterone. Which changes indicate to the nurse that therapy is successful? Select all that apply. 1. Decreased facial hair 2. Increased libido 3. Decreased bone size 4. Increased muscle mass 5. Increased axillary hair growth 6. Increased breast tissue

2, 4, 5 Therapy for gonadotropin deficiency begins with high-dose testosterone and is continued until virilization (presence of male secondary sex characteristics) is achieved, with responses that include increases in penis size, libido, muscle mass, bone size, and bone strength. Chest, facial, pubic, and axillary hair growth also increase. Patients usually report improved body image after therapy is initiated. Side effects of therapy include gynecomastia (male breast tissue development), acne, baldness, and prostate enlargement. Focus: Prioritization.

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action? 1. Perform a complete neurologic assessment. 2. Assess the cranial nerve functions. 3. Contact the Rapid Response Team. 4. Reassess the client in 30 minutes.

3 A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes. Focus: Prioritization.

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."

3 Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug, such as alteplase, dissolves the clot and can cause more bleeding in the brain. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.

A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

3 Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence. Focus: Delegation, Supervision.

As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 38-year-old patient with Graves disease and a heart rate of 94 beats/min 2. A 63-year-old patient with type 2 diabetes and fingerstick glucose level of 137 mg/dL (7.6 mmol/L) 3. A 58-year-old patient with hypothyroidism and a heart rate of 48 beats/min 4. A 49-year-old patient with Cushing disease and dependent edema rated as + 1

3 Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/min is within normal limits. The patient with diabetes may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema. Focus: Prioritization.

The nurse is assessing a newly admitted older adult with diabetes. Assessment reveals abnormal appearance of the feet (see figure). The nurse recognizes this as which deformity? 1. Claw toe deformity 2. Hammer toe deformity 3. Charcot foot deformity 4. Hypertrophic ungula labium deformity

3 Charcot foot is a diabetic foot deformity. The foot is warm, swollen, and painful. Walking collapses the arch, shortens the foot, and gives the sole of the foot a "rocker bottom" shape. Focus: Prioritization.

The patient with hyperparathyroidism who is not a candidate for surgery asks the nurse why she is receiving IV normal saline and IV furosemide. What is the nurse's best response? 1. "This therapy is to protect your kidney function." 2. "You are receiving these therapies to prevent edema formation." 3. "Diuretic and hydration therapies are used to reduce your serum calcium." 4. "These therapies may help to improve your candidacy for surgery."

3 Diuretics and hydration help reduce serum calcium for patients with hyperparathyroidism who are not surgery candidates. Furosemide increases kidney excretion of calcium when combined with IV saline in large volumes. Focus: Prioritization.

A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis? 1. Periorbital edema 2. Bradycardia 3. Exophthalmos 4. Hoarse voice

3 Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism caused by Graves disease. Periorbital edema, bradycardia, and a hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization.

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1. A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose 2. A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4. A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy

3 Of the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses.

An LPN/LVN is assigned to perform assessments on two patients with diabetes. Assessments reveals all of these findings. Which finding would the RN instruct the LPN/LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/dL (10.3 mmol/L) 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

3 Profuse perspiration is a symptom of hypoglycemia, a complication of diabetes that requires urgent treatment. A glucose level of 185 mg/dL (10.3 mmol/L) will need coverage with sliding-scale insulin, but this is not urgent. Numbness and tingling, as well as bunions, are related to the chronic nature of diabetes and are not urgent problems. Focus: Prioritization.

The patient with type 2 diabetes has a health care provider prescription for NPO status for a cardiac catheterization. An LPN/LVN who is assigned to administer medications to this patient asks the supervising RN whether the patient should receive his ordered repaglinide. What is the RN's best response? 1. "Yes, because this drug will increase the patient's insulin secretion and prevent hyperglycemia." 2. "No, because this drug may cause the patient to experience gastrointestinal symptoms such as nausea." 3. "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO." 4. "Yes, because this drug should be taken three times a day whether the patient eats or not."

3 Repaglinide is a meglitinide analog drug. These drugs are short-acting agents used to prevent postmeal blood glucose elevation. They should be given within 1 to 30 minutes before meals and cause hypoglycemia shortly after dosing when a meal is delayed or omitted. Focus: Supervision, Assignment, Prioritization.

The nurse is evaluating a patient with diabetes for foot risk category. The patient lacks protective sensation and shows evidence of peripheral vascular disease. According to the American Diabetes Association (ADA), which foot risk category best fits this patient? 1. Risk category 0 2. Risk category 1 3. Risk category 2 4. Risk category 3

3 The ADA's foot risk categories are category 0 (has protective sensation, has no evidence of peripheral vascular disease, has no evidence of foot deformity), category 1 (does not have protective sensation; may have evidence of foot deformity), category 2 (does not have protective sensation; has evidence of peripheral vascular disease), and category 3 (has history of ulcer or amputation). Focus: Prioritization.

A patient has newly diagnosed type 2 diabetes. Which action should the RN assign to an LPN/LVN rather than an experienced unlicensed assistive personnel (UAP)? 1. Measuring the patient's vital signs every shift 2. Checking the patient's glucose level before each meal 3. Administering subcutaneous insulin on a sliding scale as needed 4. Assisting the patient with morning care

3 The UAP's scope of practice includes checking vital signs and assisting with morning care. Experienced UAPs with special training can check the patient's glucose level before meals and at bedtime. It is generally not within the UAP's scope of practice to administer medications, but this is within the scope of practice of the LPN/LVN. Focus: Assignment.

The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority? 1. Risk for injury 2. Decreased nutrition 3. Difficulty with coping 4. Impairment of body image

3 The client's statement indicates difficulty with coping in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing problems may be appropriate for a client with SCI but are not related to the client's statement. Focus: Prioritization.

The nurse is preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would the nurse be sure to review? 1. Fasting glucose level 2. Oral glucose tolerance test results 3. Glycosylated hemoglobin (HgbA1c) level 4. Fingerstick glucose findings for 24 hours

3 The higher the blood glucose level is over time, the more glycosylated the hemoglobin becomes. The HgbA1c level is a good indicator of the average blood glucose level over the previous 120 days. Fasting glucose and oral glucose tolerance tests are important diagnostic tools. Fingerstick blood glucose monitoring provides information that allows adjustment of the patient's therapeutic regimen. Focus: Prioritization.

A client with Guillain-Barré syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Observe the access site for ecchymosis or bleeding. 2. Instruct the client that there will be three or four treatments. 3. Weigh the client before and after the procedure. 4. Assess the access site for bruit and thrill every 2 to 4 hours.

3 The scope of practice for an experienced UAP would include weighing clients. Observing, assessing, and providing instructions all require additional educational preparation and are appropriate to the scope of practice for a professional nurse.

The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first? 1. A 21-year-old patient with diabetes insipidus whose urine output overnight was 2000 mL 2. A 55-year-old patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the unlicensed assistive personnel refill his water pitcher 3. A 65-year-old patient with Addison disease whose morning potassium level is 6.2 mEq/L (6.2 mmol/L) 4. A 48-year-old patient with Cushing

3 This patient's potassium level is very high, placing the patient at risk for cardiac dysrhythmias that could be life threatening. The other patients also need to be seen but are not as urgent. Focus: Prioritization.

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection

3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury. Focus: Delegation, Supervision.

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."

4 A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. Focus: Delegation, Supervision Test Taking Tip: Remember that there are many drug interactions. For this reason, clients should consult with the health care provider before taking over-the-counter drugs

A 24-year-old patient with diabetes insipidus makes all of these statements when the nurse is preparing the patient for discharge from the hospital. Which statement indicates to the nurse that the patient needs additional teaching? 1. "I will drink fluids equal to the amount of my urine output." 2. "I will weigh myself every day using the same scale." 3. "I will wear my medical alert bracelet at all times." 4. "I will gradually wean myself off the vasopressin."

4 A patient with permanent diabetes insipidus requires lifelong vasopressin therapy. All of the other statements are appropriate to the home care of this patient. Focus: Prioritization.

The RN is supervising a senior student nurse who is caring for a fresh postoperative patient who had a hypophysectomy. The RN observes the student nurse perform all of these actions. For which action must the RN intervene? 1. Assess for changes in vision or mental status. 2. Keep the head of the bed elevated. 3. Remind the patient to perform deep breathing every hour while awake. 4. Encourage the patient to cough vigorously.

4 After hypophysectomy, the nurse should monitor the patient's neurologic response and document any changes in vision or mental status, altered level of consciousness, or decreased strength of the extremities. The head of the bed should be kept elevated. Patients should be reminded to perform deep-breathing exercises hourly while awake to prevent pulmonary problems. However, the patient should be taught to avoid coughing early after surgery because it increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. Focus: Delegation, Supervision.

The experienced unlicensed assistive personnel (UAP) has been delegated to take vital signs and check fingerstick glucose on a postoperative patient with diabetes. Which vital sign change would the RN instruct the UAP to report immediately? 1. Blood pressure increase from 132/80 to 138/84 mm Hg 2. Temperature increase from 98.4°F to 99°F (36.9°C to 37.2°C) 3. Respiratory rate increase from 18 to 22 breaths/min 4. Glucose increase from 190 to 236 mg/dL (10.6 to 13.1 mmol/L)

4 An unexpected rise in blood glucose is associated with increased mortality and morbidity after surgical procedures. American Diabetes Association guidelines recommend insulin protocols to maintain blood glucose levels between 140 and 180 mg/dL (7.8 and 10 mmol/L). Also, unexpected rises in blood glucose values may indicate wound infection. Focus: Delegation, Supervision, Prioritization.

A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first? 1. Check the patient's blood pressure. 2. Give the patient some orange juice. 3. Give the patient's morning dose of insulin. 4. Use a glucometer to check the patient's glucose level.

4 Before orange juice or insulin is given, the patient's blood glucose level should be checked. Checking blood pressure is a good idea but is not the first action the nurse should take. Focus: Prioritization.

A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? 1. Revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively 2. Instructing the patient to avoid smoking and drinking caffeine-containing beverages 3. Assessing the patient's skin and mucous membranes for signs of adequate hydration 4. Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm

4 Monitoring vital signs is within the education and scope of practice for UAPs. The nurse should be sure to instruct the UAP that blood pressure measurements are to be taken with the cuff on the same arm each time and instructed to record and inform the RN of the results. Revising the care plan and instructing and assessing patients are beyond the scope of UAPs and fall within the purview of licensed nurses. Focus: Delegation, Supervision.

A patient has newly-diagnosed type 2 diabetes. Which task should the RN delegate to an experienced unlicensed assistive personnel (UAP)? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Checking the patient's glucose level before each meal

4 The experienced UAP would have been taught to perform tasks such as checking pulse oximetry and glucose checks, and these actions would be part of his or her scope of practice. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses. Focus: Delegation, Supervision, Assignment.

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

4 The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority. Focus: Prioritization.

While working in the diabetes clinic, the RN obtains the following information about an 8-year-old patient with type 1 diabetes. Which finding is most important to address when planning child and parent education? 1. Most recent hemoglobin A1clevel of 7.8% 2. Many questions about diet choices from the parents 3. Child's participation in soccer practice after school 2 days a week 4. Morning preprandial glucose range of 55 to 70 mg/dL (3.1 to 3.9 mmol/L)

4 The low morning fasting blood glucose level indicates possible nocturnal hypoglycemia. Research indicates that it is important to avoid hypoglycemic episodes in pediatric patients because of the risk for permanent neurologic damage and adverse developmental outcomes. Although a lower hemoglobin A1c might be desirable, the upper limit for hemoglobin A1c levels ranges from 7.5% to 8.5% in pediatric patients. The parents' questions about diet and the child's activity level should also be addressed, but the most urgent consideration is education about the need to avoid hypoglycemia. Focus: Prioritization.

Assessment findings for a patient with Cushing disease include all of the following. For which finding would the nurse notify the health care provider (HCP) immediately? 1. Purple striae present on the abdomen and thighs 2. Weight gain of 1 lb (0.5 kg) since the previous day 3. Dependent edema rated as + 1 in the ankles and calves 4. Crackles bilaterally in the lower lobes of the lungs

4 The presence of crackles in the patient's lungs indicates excess fluid volume caused by excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients with Cushing disease. These findings should be monitored but do not require urgent action. Focus: Prioritization; Test Taking Tip: Findings that the nurse should immediately report to the HCP are those that can indicate a worsening of the patient's condition that must be treated to prevent further worsening or threat to life.

An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

4 The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening.

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation? 1. Always stand to the side of the patient. 2. Instruct the patient not to swallow. 3. Palpate using one hand and then the other. 4. Always palpate the thyroid gland gently.

4 The thyroid gland should always be palpated gently because vigorous palpation can stimulate a thyroid storm in a patient who may have hyperthyroidism. The student nurse should stand either behind or in front of the patient and use both hands to palpate the thyroid. Having the patient swallow can help with locating the thyroid gland. Focus: Supervision, Delegation.

After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first? 1. A 23-year-old client with a migraine headache who reports severe nausea associated with retching 2. A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast 4. A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain

4 Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.

An unlicensed assistive personnel (UAP) tells the nurse that while assisting with the morning care of a postoperative patient with type 2 diabetes who has been given insulin, the patient asked if she will always need to take insulin now. What is the RN's priority for teaching the patient? 1. Explain to the patient that she is now considered to have type 1 diabetes. 2. Tell the patient to monitor fingerstick glucose level every 4 hours after discharge. 3. Teach the patient that a person with type 2 diabetes does not always need insulin. 4. Discuss the relationship between illness and increased glucose levels.

4 When a patient with diabetes is ill or has surgery, glucose levels become elevated, and administration of insulin may be necessary. This is a temporary change that usually resolves with recovery from the illness or surgery. Option 3 is correct but does not explain why the patient may currently need insulin. The patient does not have type 1 diabetes, and fingerstick glucose checks are usually prescribed for before meals and at bedtime. Focus: Prioritization.