Management Quiz 4
the pt is admitted to the critical care unit after a motor vehicle accident. the client asks the nurse, "do you know if the person in the other car is all right?" the nurse knows the person died. which statement supports the ethical principle of veracity? a. I am not sure how the other person is doing b. I will try to find out how the other person is doing c. you should rest now and try not to worry about it d. I am sorry to have to tell you, but the person died
I am sorry to have to tell you, but the person died
the pt is dx with gastroenteritis. which lab data warrants immediate intervention by the nurse? a. a serum Na of 152 b. an ABG of pH 7.37, PaO2 95, PaCO2 43, HCO3 24 c. a serum K of 4.8 d. a stool sample that is positive for fecal leukocytes
a serum Na of 152
the nurse and UAP are caring for a client on a med unit who had difficulty swallowing and is incontinent of urine and feces. which task should the nurse delegate to the UAP? a. check the pt's PEG feeding tube for patency b. place duoderm wound care patches to the client's coccyx c. apply non-medicated ointment to the pt's perineum d. suction the client during feeding to prevent aspiration
apply non-medicated ointment to the pt's perineum
the nurse is working in a community health clinic. which nursing task should the nurse delegate to the UAP? a. instruct the UAP to take the pt's history b. request the UAP to document the pt's complaints c. ask the UAP to obtain the pt's wt and ht d. tell the UAP to complete the pt's follow up care
ask the UAP to obtain the pt's wt and ht
the nurse is preparing to teach the male client how to irrigate his sigmoid colostomy. which intervention should the nurse implement first? a. demonstrate the procedure on a model b. provide the pt with written instructions c. ask the pt whether he has any questions d. show the pt all of the equipment needed
ask the pt whether he has any questions
the staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. which action should be taken by the nurse? a. ask the supervisor to come to the unit b. determine what is bothering the nurse c. suggest the nurse go home d. smell the nurse's breath for alcohol
ask the supervisor to come to the unit
the nurse is caring for a client 1 day post op sigmoid resection. there is a large amt of bright red blood on the dressing. which intervention should the nurse implement first? a. assess the client's apical pulse and BP b. auscultate the pt's bowel sounds c. notify the HCP immediately d. reinforce the dressing with a sterile gauze pad
assess the client's apical pulse and BP
the nurse is caring for clients on a medical unit. which task should the nurse implement? a. change abd surgical dressing for a client who has ambulated in the hall b. discuss the correct method of placing montgomery straps on the client with a UAP c. assess the male client who called the desk to say he is nauseated and just vomited d. place a call to the extended care facility to give the report on a discharged pt
assess the male client who called the desk to say he is nauseated and just vomited
the UAP tells the nurse a female pt, who had a laparoscopic cholecystectomy, is complaining of abdominal pain, which intervention should the nurse implement first? a. check the MAR for the last pain med the client received b. instruct the UAP to ask the pt to rate her pain on a 1 to 10 scale c. assess the pt to rule out any post op surgical complications d. tell the UAP to obtain the client's VS and pulse ox reading
assess the pt to rule out any post op surgical complications
the LPN tells the nurse the pt dx with liver failure is getting more confused. which intervention should the nurse implement first? a. assess the pt's neuro status b. notify the pt's HCP c. request a STAT ammonia serum level d. tell the LPN to obtain the pt's VS
assess the pt's neuro status
the pt who has had abd surgery is complaining of pain and tells the nurse, "I felt something pop in my stomach." which intervention should the nurse implement first? a. check the pt's AP and BP b. determine the pt's pain on a 1 to 10 scale c. assess the pt's surgical wound site d. administer pain meds IV
assess the pt's surgical wound site
which task should the nurse in the long term care facility delegate to the UAP? a. assist the resident up in a wheelchair for meals b. assess the incontinent pt's perianal area c. discuss requirements with the client for going out on a pass d. explain how to care for the pt's colostomy to the family
assist the resident up in a wheelchair for meals
the pt, who is terminally ill, tells the nurse "I just want to live to see my grandson graduate in 2 months." which stage of grief is the client experiencing? a. anger b. bargaining c. depression d. acceptance
bargaining
the male mexican american pt, who is terminally ill, refuses hospice services because he says it is "giving up" and he is not going to die. which is the most appropriate action by the nurse? a. discuss the philosophy and services of palliative care with the pt b. take no other action and support the client's decision c. contact the client's HCP to discuss the prognosis d. talk to the pt's family members about his choice to refuse hospice
discuss the philosophy and services of palliative care with the pt
the UAP notifies the charge nurse that the male pt is angry with the care he is receiving and is packing to leave the hospital. which intervention should the charge nurse implement first? a. ask the pt's nurse why the pt is upset b. discuss the problem with the pt c. notify the HCP d. have the pt sign the AMA form
discuss the problem with the pt
the nurse is changing the pt's colostomy bag. which interventions should the nurse implement? rank in order of priority 1. removed the pt's colostomy bag 2. apply the pt's new colostomy bag 3. don non-sterile gloves 4. assess the pt's stoma site 5. cleanse the area around the pt's stoma
don non-sterile gloves, removed the pt's colostomy bag, assess the pt's stoma site, cleanse the area around the pt's stoma, apply the pt's new colostomy bag
the UAP tells teh nurse angrily, "you are the worst nurse I have ever worked with and ai really hate working with you." which action should the nurse implement first? a. don't respond to the comment and appraise the situation b. tell the UAP to leave the unit immediately c. report this comment and behavior to the charge nurse d. explain to the UAP that he or she cannot talk to the primary nurse like this
don't respond to the comment and appraise the situation
the nurse is discussing end of life issues with a pt. the nurse is explaining about a document used for listing the person the pt will allow to make healthcare decision should he or she become unable to make informed decisions for him or herself. which document is the nurse discussing with the pt? a. advance directive b. directive to physicians c. living will d. durable POA for healthcare
durable POA for healthcare
the nurse is working in a digestive disease disorder clinic. which nursing action is an example of evidenced-based practice (EBP)? a. turn on the tap water to help a pt urinate b. use 2 identifiers to id a pt before a procedure c. educate a pt based on current published info d. read nursing journals about the latest procedures
educate a pt based on current published info
the nurse is planning the care of a client dx with acute gastroenteritis. which nursing problem is priority? a. altered nutrition b. self care deficit c. impaired body image d. fluid and electrolyte imbalance
fluid and electrolyte imbalance
which nursing problem is the highest priority for the pt dx with gastroenteritis from staphylococcal food poisoning? a. fluid and electrolyte imbalance b. alteration in bowel elimination c. nutrition, altered; less than body requirements d. oral mucous membrane, altered
fluid and electrolyte imbalance
the pt admitted to the critical care unit tells the nurse, "I have an advance directive and I do not want to have CPR." which intervention should the nurse implement first? a. ask the pt for a copy of the AD so that it can be placed in the chart b. inform the HCP of the pt's request as soon as possible c. determine whether the pt has a durable POA for healthcare d. request the hospital chaplain to come and talk to the client about this request
inform the HCP of the pt's request as soon as possible
the nurse and UAP are caring for pts on a med surg unit. which task should not be delegated to the UAP? a. instruct the UAP to feed the 69 yo client who is experiencing dysphagia b. request the UAP to change linens for the 89 yo pt with fecal incontinence c. tell the UAP to assist the 54 yo pt with a bowel management program d. ask the UAP to obtain VS on the 72 yo pt dx with cirrhosis
instruct the UAP to feed the 69 yo client who is experiencing dysphagia
the pt who is morbidly obese is 8 hours post op gastric bypass surgery. which nursing intervention is of the greatest priority? a. instruct the pt to use the incentive spirometer b. weight the pt daily in the same clothes at the same time c. apply SCDs to the pt's lower extremities d. assist the pt to sit in the bedside chair
instruct the pt to use the incentive spirometer
the significant other of a pt dx with liver cancer and who is dying asks the nurse, "what is bereavement counseling?" which statement is the nurse's best response? a. bereavement counseling helps the pt accept the terminal illness b. it provides support to you and your family in the transition to a life without your loved one c. we provide counseling to you and your loved one during the dying process d. I tis group counseling for family members whose loved ones have died
it provides support to you and your family in the transition to a life without your loved one
the nurse is caring for a 14 yo female pt dx with bulimia. which intervention should the nurse delegate to the UAP? a. talk with the parents about setting goals for the pt b. stay with the pt for 15 to 20 min after each meal c. encourage the pt to verbalize low self-esteem d. list the dietician the amt of food the pt consumed
list the dietician the amt of food the pt consumed
the pt with hepatitis asks the nurse, "is there any herb I can take to help my liver get better?" which statement is the nurse's best response? a. you should ask your HCP about taking herbs b. milk thistle is a powerful oxidant and promotes liver cell growth c. you should not take any med that is not prescribed d. why would you want to take any herbs
milk thistle is a powerful oxidant and promotes liver cell growth
the nurse is performing ostomy care for a client who had and abdominal-peritoneal resection with a permanent sigmoid colostomy. rank the following interventions in order of priority. 1. cleanse the stomal site with mild soap and water 2. assess the stoma for a pink, moist appearance 3. monitor the drainage in the ostomy drainage bag 4. apply stoma adhesive paste to the skin around the stoma 5. attach the ostomy drainage bag to the abdomen
monitor the drainage in the ostomy drainage bag, assess the stoma for a pink, moist appearance, cleanse the stomal site with mild soap and water, apply stoma adhesive paste to the skin around the stoma, attach the ostomy drainage bag to the abdomen
the administrative supervisor is staffing the hospital's med surg units during an ice storm and has received many calls from staff members who are unable to get to the hospital. which action should the supervisor implement first? a. inform the CNO b. notify the on duty staff to stay c. call staff members who live close to the facility d. implement the emergency disaster protocol
notify the on duty staff to stay
the nurse is transcribing the HCP's orders for a client who is schedule for an emergency appendectomy and is being transferred from the ED to the surgical unit. which order should the nurse implement first? a. obtain the pt's informed consent b. administer 2 mg of IV morphine, Q4H PRN c. shave the lower right abd quadrant d. administer the on-call IVPB antibiotic
obtain the pt's informed consent
which behavior by the UAP warrants intervention by the home health nurse? the pt tells the home health nurse the UAP: a. would not accept a bday gift from the pt b. gave the pt a vase of flowers from the UAP's garden c. pick up the pt's prescriptions from the pharmacy d. cleaned the pt's bathroom including scrubbing the commode
pick up the pt's prescriptions from the pharmacy
the pt dx with liver failure is experiencing pruritus secondary to severe jaundice and is scratching the upper extremities. which intervention should the nurse implement first? a. request teh UAP to assist the pt to take a hot, soapy shower b. apply an emollient to the pt's upper extremities c. place mittens on both hands of the pt d. administer benadryl 25 mg PO to the pt
place mittens on both hands of the pt
the client 1 day post op abd surgery has an evisceration of the wound. which intervention should the nurse implement first? a. place sterile normal saline gauze on the eviscerated area b. reinforce the abd dressing with an ABD pad c. assess the pt's abd bowel sounds d. place the p tin the left lateral position
place sterile normal saline gauze on the eviscerated area
the pt is experiencing severe diarrhea and a serum K level of 3.3. which intervention should the nurse implement first? a. notify the HCP b. assess the pt for leg cramps c. place the client on cardiac telemetry d. prepare to administer IV potassium
place the client on cardiac telemetry
the nurse is caring for a pt who is hemorrhaging from a duodenal ulcer. which collaborative interventions should the nurse implement? SATA a. prepare to administer a sengstaken-blakemore tube b. assess the pt's VS c. administer a proton-pump intravenously d. obtain a type and crossmatch for four units of blood e. monitor the client's I&Os
prepare to administer a sengstaken-blakemore tube, administer a proton-pump intravenously, obtain a type and crossmatch for four units of blood
the nurse is caring for a pt dx with peptic ulcer disease. which assessment data would cause the pt to require an immediate intervention by the nurse? a. pt has hypoactive bowel sounds b. pt's output is 480 mL for 12 hour shift c. pt has T 98.6 AP 98 RR 22 BP 102/78 d. pt has coffee ground emesis
pt has coffee ground emesis
the nurse has received the AM shift report on a surgical unit in a community hospital. which pt should the nurse assess first? a. pt who is 6 hours post op small bowel resection who has hypoactive bowel sounds in all 4 quadrants b. pt who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset c. pt who is 1 day post op for abd surgery and has a rigid, hard abd d. pt who is 2 days post op for an emergency appendectomy and is complaining of abd pain, rating it as an 8 on a pain scale of 1 to 10
pt who is 1 day post op for abd surgery and has a rigid, hard abd
the med surg nurse has just received the AM shift report. which client should the nurse assess first? a. pt who has a paralytic ileus and has absent bowel sounds b. pt who is 2 days post op abd surgery and has a soft, tender abdomen c. pt who is 6 hours post op and has an abd wound dehiscence 4. pt who had a liver transplant and is being transferred to the rehab unit
pt who is 6 hours post op and has an abd wound dehiscence
which client should the nurse assess first after receiving the PM shift assessment? a. pt with barrett's esophagus who has dysphagia and pyrosis b. pt with proctitis who has tenesmus and passage of mucus through the rectum c. pt with liver failure who is jaundiced and has ascites d. pt with abd pain who has an 8 hour UOP of 150 mL/hr
pt with abd pain who has an 8 hour UOP of 150 mL/hr
which client warrants immediate intervention from the nurse on the medical unit? a. pt dx with dyspepsia who has eructation and bloating b. pt dx with pancreatitis who has steatorrhea and pyrexia c. pt with diverticulitis who has LLQ pain and fever d. pt with crohn's disease who has right lower abd pain and diarrhea
pt with crohn's disease who has right lower abd pain and diarrhea
the nurse has received the AM shift report. which client should the nurse assess first? a. pt with peptic ulcer disease who is complaining of acute epigastric pain b. the pt with acute gastroenteritis who is upset and wants to go home c. the pt with inflammatory bowel disease who is receiving TPN d. the pt with hep b who is complaining and who is jaundiced and anorexic
pt with peptic ulcer disease who is complaining of acute epigastric pain
the charge nurse notices a nurse recapping a needle in a pt's room. which action should the charge nurse take first? a. tell the nurse not to recap the needle b. quietly ask the nurse to step into the hall c. reprimand the nurse for not following procedure d. notified the house sup of the nurse's behavior
quietly ask the nurse to step into the hall
the pt with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. which intervention is most appropriate for the home health nurse to implement? a. refer the pt to the wound care nurse b. notify the pt's healthcare provider c. continue to monitor the stoma site d. place karaya paste on the excoriated area
refer the pt to the wound care nurse
the nurse is preparing to administer morning meds to pts on a med unit. which med should the nurse administer first? a. methylprednisolone (solu-medrol), a steroid, to a pt dx with crohn's b. donepezil (aricept), an acetylcholinesterase inhibitor, to a pt with dementia c. sucralfate (carafate), a mucosal barrier agent, to a pt diagnosed with ulcer disease d. enoxaparin (lovenox), an anticoagulant, to a pt on bed rest after abd surgery
sucralfate (carafate), a mucosal barrier agent, to a pt diagnosed with ulcer disease
the pt is being prepared for a colonoscopy in the day surgery center. the charge nurse observes the primary nurse instructing the UAP to assist the pt to the bathroom. which action should the charge nurse implement? a. take no action bc this is appropriate delegation b. tell the UAP to obtain a bedside commode for the pt c. discuss the inappropriate delegation of the nursing task d. document the situation in an adverse occurrence report
take no action bc this is appropriate delegation
the nurse, a LPN, and an UAP are caring for pts on a medical floor. which nursing task is most appropriate to assign/delegate? a. instruct the UAP to dc the pt's TPN b. ask the UAP to vie the pt 30 mL of maalox for heartburn c. tell the LPN to administer a bulk laxative to a pt dx with constipation d. request the LPN assess the abdomen of a pt who has had complaints of pain
tell the LPN to administer a bulk laxative to a pt dx with constipation
which task would be most appropriate for the nurse on the GI unit to delegate to the UAP? a. request the UAP to draw the serum liver function test b. ask teh UAP to remove the NG tube c. tell the UAP to empty the pt's colostomy bag d. instruct the UAP to assist the unit secretary to transcribe HCP orders
tell the UAP to empty the pt's colostomy bag
which task is most appropriate for the home healthcare nurse to delegate to the UAP? a. instruct the UAP to give the herb ginkgo biloba to the pt with alzheimer's b. ask teh UAP to perform the tube feedings for a pt with a gastrostomy tube c. request the UAP to perform the daily colostomy irrigation for the pt d. tell the UAP to wash and dry the pt's hair
tell the UAP to wash and dry the pt's hair
the nurse is preparing a client dx with peptic ulcer disease for a barium study of the stomach and esophagus. which nursing intervention is the priority for this client? a. obtain informed consent from the client for the diagnostic procedure b. discuss the need to increase oral fluid intake after the procedure c. explain to the client that he or she will have to drink a white, chalky substance d. tell the client not to eat or drink anything prior to the procedure
tell the client not to eat or drink anything prior to the procedure
the female pt, dx with diverticulitis, called the home healthcare agency and told the nurse, "I am having really bad pain in my L lower stomach and I think I have a fever." which action should the nurse take? a. recommend teh pt take an antacid and lie flat in the bed b. instruct one of the nurses to visit the pt immediately c. tell the pt to have someone drive them to the ER d. ask the pt what she has ad to eat in the last 8 hours
tell the pt to have someone drive them to the ER
which behavior by the UAP warrants intervention by the long term care nurse? a. the UAP is giving the pt with a GT tube a glass of water b. the UAP is ambulating the pt outside using a safety belt c. the UAP is assisting the pt with putting a jigsaw puzzle together d. the UAP is giving a back rub to the pt who is on bed rest
the UAP is giving the pt with a GT tube a glass of water
which behavior by the UAP requires immediate intervention by the nurse? a. the UAP is refusing to feed the pt dx with acute diverticulitis b. the UAP would not place the pt on the bedside commode who was on bed rest c. the UAP placed the pt with a continuous feeding tube in the supine position d. the UAP placed SCDs on the pt who is on strict bed rest
the UAP placed the pt with a continuous feeding tube in the supine position
the male pt is 30 mins post-procedure liver biopsy. which action by the UAP requires the nurse to intervene? a. the UAP offered teh pt a urinal to void b. the UAP gave the pt a glass of water c. the UAP turned the pt on the left side d. the UAP took the pt's VS
the UAP turned the pt on the left side
the charge nurse is transcribing HCP orders for a pt scheduled for a barium enema. in addition to the radiology dept, which dept of the hospital should be notified of the procedure? a. the cardiac cath dept b. the dietary dept c. th nuc med dept d. the hospital lab dept
the dietary dept
the pt who is 2 days post op abd surgery has a hemovac drainage tube. which assessment data indicates the jp drain is functioning appropriately? a. the hemovac is round and has 40 mL of fluid b. the drainage tube is pinned to the dressing c. the hemovac insertion site is pink and has no drainage d. the hemovac has suction and is compressed
the hemovac has suction and is compressed
the charge nurse is making assignments on a med surg unit. which client should be assigned to the most experienced nurse? a. the pt dx with lower esophageal dysfunction who is experiencing regurgitation b. the pt diagnosed with barrett's esophagitis who is scheduled for an endoscopy c. the pt diagnosed with GERD who has bilateral wheezes d. the pt dx with 1 day post op hiatal hernia who has pain rated on a 4 out of 10
the pt diagnosed with GERD who has bilateral wheezes
the charge nurse is making assignments on a med unit. which pt should the nurse assign to the graduate nurse? a. the pt who has received 3 units of pRBCs b. the pt scheduled for a EGD in the morning c. the pt with short bowel syndrome who has diarrhea and a K level of 3.3 mEq/L d. the pt who has just returned from surgery for a sigmoid colostomy
the pt scheduled for a EGD in the morning
the nurse is preparing pts for surgery. which client has the greatest potential for experiencing complications? a. the pt scheduled for removal of an abdominal mass who is overweight b. the pt scheduled for a gastrectomy who has arterial HTN c. the pt scheduled for an open cholecystectomy who smokes 2 packs of cigs per day d. the pt scheduled for an emergency appendectomy who smokes marijuana on a daily basis
the pt scheduled for an open cholecystectomy who smokes 2 packs of cigs per day
the charge nurse is reviewing the morning lab results. which data should the charge nurse report to the HCP via telephone? a. the pt who is 4 hours post op for gastric lap banding with WBC count of 15,000 mm b. the pt who is 1 day post op total colectomy with creation of an ileal conduit who has a Hgb and Hct level of 12/36 c. the pt who is 4 days post op for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL d. the pt who is 8 hours post op for exploratory laparotomy who has a serum K level of 4.5 mEq/L
the pt who is 4 hours post op for gastric lap banding with WBC count of 15,000 mm
the nurse is caring for pts on a surgical unit. which client should the nurse assess first? a. the pt who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO2 44, HCO3 30 b. the pt who is 8 hours post op for splenectomy and who is complaining of abd pain, rating it a 9 out of 10 c. the pt who is 12 hours post op abd surgery and has dark green bile draining in the NG tube d. the pt who is 2 days post op for hiatal hernia repair and is complaining of feeling constipated
the pt who is 8 hours post op for splenectomy and who is complaining of abd pain, rating it a 9 out of 10
the nurse is caring for the following pts on a surgical unit. which client should the nurse assess first? a the pt with an inguinal hernia repair who has a UOP of 160 mL in 4 hours b. the pt with an emergency appendectomy who was transferred form PACU c. the pt who is 4 hours post op abd surgery who has flatulence d. the pt who is 6 hours post procedure colonoscopy and is being discharged
the pt with an emergency appendectomy who was transferred form PACU
the charge nurse has complete report. which pt should be seen first? a. pt dx with ulcerative colitis who had 5 loose stools the previous shift b. the elderly pt admitted from another facility who is refusing to be seen by the nurse c. the pt with intractable vomiting who has tented skin turgor and dry mucous membranes d. the pt with hemorrhoids who had spotting of bright red blood on the toilet tissue
the pt with intractable vomiting who has tented skin turgor and dry mucous membranes
the pt is dx with esophageal bleeding. which fo the following assessment data warrants immediate intervention by the nurse? a. the client's hgb/hct is 11.4/32 b. the pt's abd is soft to touch and non-tender c. the pt's VS are T 99, AP 114, RR 18, BP 88/60 d. the pt's NG tube has coffee ground drainage
the pt's VS are T 99, AP 114, RR 18, BP 88/60
the pt 2 days post op from laparoscopic cholecystectomy tells the office nurse, "my R shoulder hurts so bad I can't stand it." which statement is the nurse's best advice? a. this is a result of the carbon dioxide gas used in surgery b. call 911 and go to the ER immediately c. increase the pain med the surgeon ordered d. you need to ambulate in the hall to walk off those gas pains
this is a result of the carbon dioxide gas used in surgery
the nurse is discussing end of life care with the pt dx with pancreatic cancer. which statements are the goals of end of life care? SATA a. to provide comfort and supportive care during the dying process b. to plan and arrange the funeral for the client c. to improve the pt's quality of life for the remaining time d. to help ensure a dignified death for the client and family e. to assist with the financial cost of the dying process
to provide comfort and supportive care during the dying process, to improve the pt's quality of life for the remaining time, to help ensure a dignified death for the client and family
the nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. which action is most appropriate for the nurse to implement first? a. discuss the blood admin flow sheet with the CNO b. contact and individual to help design a new blood transfusion flow sheet c. learn to adapt to the present form and do not take any further action d. volunteer to be on an ad hoc committee to research alternative flow sheets
volunteer to be on an ad hoc committee to research alternative flow sheets
the pt tells the nurse in the bariatric clinic, "I have tried to lose wt on about every diet out there but nothing works." which statement is the nurse's best response? a. which diets and modifications have you tried? b. how much weight are you trying to lose? c. this must be difficult. would you like to talk? d. you may need to get used to being overweight
which diets and modifications have you tried?
