Prioritization, Delegation, and Assignment, 5th Edition- Respiratory, Neruo, & Mental Health

The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient 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."

"I will avoid exercise because the pain gets worse." 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.

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

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

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

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

The nurse is acting as preceptor for a newly graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 6. A 69-year-old patient with emphysema to be discharged tomorrow The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

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

1. A 68-year-old patient with a history of smoking and emphysema Older patients, especially those who have smoked or who have chronic lung problems such as chronic obstructive pulmonary disease (COPD)., are at risk for ventilator dependence and failure to wean. Age-related changes, such as chest wall stiffness, reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. Younger patients without respiratory illnesses are likely to wean from the ventilator without difficulty.

Which patient needs assessment first? 1. A patient who is having command hallucinations 2. A patient who is demonstrating clang associations 3. A patient who is verbalizing ideas of reference 4. A patient who is using neologisms

1. A patient who is having command hallucinations During command hallucinations, the patient may be getting a command to harm self or others; content must be assessed. Ideas of reference occur when an ordinary thing or event (e.g., a song on the radio) has personal significance (e.g., belief that the lyrics were written for him or her). Ideas of reference could escalate into aggression, if delusions of persecution are present; content must be assessed. Clang association is a meaningless rhyming of words, and neologisms are new words created by patients. These communication patterns create frustration for staff and patients, but there is no need for immediate intervention

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

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

Which actions should the nurse delegate to an experienced assistive personnel (AP) when caring for a patient with a thrombotic stroke who has residual left-sided weakness? Select all that apply. 1. Assisting the patient to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the patient to perform active range-of-motion 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 patient up to a bedside chair

1. Assisting the patient to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the patient to perform active range-of-motion exercises 5. Setting up meal trays and assisting with feeding 6. Using a lift to assist the patient up to a bedside chair An experienced AP would know how to reposition the patient, reapply compression boots, and feed a patient and would remind the patient to perform activities the patient has been taught to perform. APs are also trained to use a patient lift to get patients 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.

A patient has chronic obstructive pulmonary disease. Which intervention for airway management should the nurse delegate to the assistive personnel (AP)? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

1. Assisting the patient to sit up on the side of the bed Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of APs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses.

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

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 4. Checking oxygen saturation using pulse oximetry The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, or evaluating a patient's abilities requires additional education and skills within the scope of practice of the professional RN.

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

1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate. 6. Keep a symptom and intervention diary to learn specific triggers for your asthma. Bedding should be washed in hot water to destroy dust mites.

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 assistive personnel (AP). 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. Checking for improvement in resident memory after medication therapy is initiated 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 APs working at the long-term care facility.

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 assistive personnel (AP)? 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 patient to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the patient with prescribed strengthening exercises 6. Adapting the patient's preferred activities to his level of function

1. Checking for orthostatic changes in pulse and blood pressure 3. Reminding the patient to allow adequate time for meals 5. Assisting the patient with prescribed strengthening exercises AP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the AP to report heart rate and blood pressure findings. In addition, APs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating patient response to medications and developing and individualizing the plan of care require RN-level education and scope of practice

A patient with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient, the nurse may assign which actions to the LPN/LVN? Select all that apply. 1. Checking the patient's skin for pressure from the device 2. Assessing the patient'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 patient 6. Administering oral medications as prescribed

1. Checking the patient's skin for pressure from the device 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 6. Administering oral medications as prescribed 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.

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

1. Do not rush through your morning activities of daily living. 2. Avoid working with your arms raised. 4. Organize your work area so that what you use most is easy to reach. 6. Don't hold your breath while performing any activities. Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to alternate activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller, more frequent meals may be less tiring. Teach the patient to avoid holding their breath when performing any activity because this interferes with gas exchange.

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

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

The nurse is mentoring a student nurse in the intensive care unit while caring for a patient 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 patient a warm blanket when he says he feels cold 4. Checking the patient's pupil response to light every 30 minutes

1. Entering the room without putting on a protective mask and gown 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 patients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease patient confusion and agitation. Patients with hyperthermia frequently report feeling chilled, but warming the patient 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 patient with photophobia.

A patient with multiple sclerosis tells the assistive personnel after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1. Fatigue 2. Impaired safety 3. Decreased mobility 4. Muscular weakness

1. Fatigue At this time, based on the patient'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 patient with MS but are not related to the patient's statement.

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

1. Turn the patient to one side. The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the patient 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 the level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.

The nurse is creating a teaching plan for a patient 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 patient's health care provider.

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. Medications such as estrogen supplements may actually trigger a migraine headache attack and should be avoided. All of the other statements are accurate and should be included in the teaching plan.

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation.Which questions would the nurse suggest the student ask to determine nicotine dependence Select all that apply? 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or only outside? 6 .Do you have a difficult time not smoking in places where it is not allowed? 7. Have you tried e-cigarettes? 8. Has anyone in your family developed lung cancer? 9. Have you ever tried to quit smoking?

1. How soon after you wake up in the morning do you smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 6 .Do you have a difficult time not smoking in places where it is not allowed? When a patient expresses interest in smoking cessation, this is an important teaching moment for the nurse. It is essential that the nurse first determine the patient's level of nicotine dependence by asking questions such as 1, 3, 4, and 6, which will give clues to this important information. Although it is important to know about other family smokers, whether the patient smokes inside or outside, and if a patient has tried e-cigarettes, this information does not necessarily help with determining nicotine dependence.

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

1. Instructing the patient to sit up straight and the patient responds with a puzzled expression Patients 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.

A 23-year-old patient 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 patient's care would be best to assign to an LPN/LVN under the nurse's supervision? 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 patient 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 patient to his or her side to avoid aspiration

1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin 200 mg PO three times a day 6. Turning the patient to his or her side to avoid aspiration Any nursing staff member who is involved in caring for the patient 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 oral medications is included in LPN/LVN education and scope of practice. Turning the patient 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.

A patient with chronic obstructive pulmonary disease has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to APs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

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

1. Pain The priority for interdisciplinary care for the patient 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.

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

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

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider (HCP) will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Begin IV normal saline at a high rate up to 250 mL per hour. 3. Administer furosemide (Lasix) 100 mg IV push immediately. 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation. A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless HCPs intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Research has shown that patients with ARDS who are treated with conservative amounts of IV fluids while ventilated have improved lung function and shorter intensive care unit stays. Furosemide is a loop diuretic, which will not help with oxygenation.

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

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

The nurse is providing care for a patient 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. Short-term memory impairment 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 patient is excessively fatigued.

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

1. Stroking the patient's inner thigh 2. Pulling on the patient's pubic hair 4. Pouring warm water over the patient's perineum 5. Tapping the bladder to stimulate the detrusor muscle All of the strategies except straight catheterization may stimulate voiding in patients with an SCI. Intermittent bladder catheterization can be used to empty the patient's bladder, but it will not stimulate voiding. To use a urinal, the patient must have bladder control, which is often absent after an SCI. In addition, every hour while awake would be too often and would ignore the bladder filling at night.

The nurse is caring for a patient 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 patient no longer recognizes family members. 2. The blood glucose level is 234 mg/dL (13 mmol/L). 3. The patient reports a continuing headache. 4. The daily weight has increased 2.2 lb (1 kg).

1. The patient no longer recognizes family members. The inability to recognize family members is a new neurologic deficit for this patient 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 admitting a patient for whom a diagnosis of pulmonary embolus (PE) must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of PE? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle crash. Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT) and PE. None of the other options are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short.

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

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

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

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. When a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practice for professional nurses. All of the other instructions are appropriate for the AP scope of practice when caring for a patient receiving anticoagulants.

The nurse on the neurologic acute care unit is assessing the orientation of a patient 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. Did the mayor of Cleveland run as a Democrat or Republican? 3. What is your health care provider's name? 4. What year and month is it? 5. What is the color of your parents' house? 6. What is the name of this health care facility?

1. When did you first experience the headache symptoms? 3. What is your health care provider's name? 4. What year and month is it? 6. What is the name of this health care facility? After determining alertness in a patient, the next step is to evaluate orientation. When the patient's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the patient from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time, so the nurse should ask for information relating to the onset of the patient's 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 the mayor's affiliation or for his or her parents' address may be inappropriate to assess orientation.

A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task would be delegated to the psychiatric nursing assistant (PNA)? 1. Wiping the patient's body with cool moist towels 2. Monitoring and interpreting vital signs every 15 minutes 3. Attaching the patient to the electrocardiogram (ECG) monitor 4. Transporting the patient to the medical intensive care unit (ICU)

1. Wiping the patient's body with cool moist towels A PNA can perform this simple cooling measure with minimal instruction. Neuroleptic malignant syndrome is a rare but potentially fatal reaction to antipsychotic medication. Symptoms include fever, altered mental status, muscle rigidity, and autonomic instability. The RN should continuously interpret vital signs, although taking vital signs can be delegated. Assistive personnel in the ICU and emergency department will be familiar with how to attach ECG leads, but PNAs will rarely have occasion to use this equipment; therefore the RN should perform this task. The RN (or health care provider) should accompany the patient to the ICU, although the PNA could assist.

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

1.Remove the inhaler cap and shake the inhaler. 3.Breathe out completely. 2.Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away. 5.Press down firmly on the canister and breathe deeply through your mouth. 4.Hold your breath for at least 10 seconds. 6.Wait at least 1 minute between puffs. Before each use, the cap is removed, and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler.

The nurse is interviewing a patient with suicidal ideations and a history of major depression. Which comment is cause for greatest concern? 1. "I have had problems with depression most of my adult life." 2. "My father and my brother both committed suicide." 3. "My wife is having health problems, and she relies on me." 4. "I am afraid to kill myself, and I wish I had more courage."

2. "My father and my brother both committed suicide." The patient has a strong family history of completed suicide, which is an increased risk factor. The patient may believe that other family members have successfully used suicide to solve their problems. A long history of depression suggests that the problem is chronic; assess for treatment history, risk factors, and coping strategies. Having a feeling of responsibility toward others and feeling fear are protective factors that can be used in the treatment plan.

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

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

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

2. A 48-year-old patient with hypertension Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in patients 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 a newly graduated RN who is orientating to the neurologic care unit? 1. A 28-year-old newly admitted patient with a spinal cord injury 2. A 67-year-old patient who had a stroke 3 days ago and has left-sided weakness 3. An 85-year-old patient with dementia who is to be transferred to long-term care today 4. A 54-year-old patient with Parkinson disease who needs assistance with bathing

2. A 67-year-old patient who had a stroke 3 days ago and has left-sided weakness The newly graduated RN who is on orientation to the unit should be assigned to care for patients with stable, noncomplex conditions, such as the patient with stroke. The task of helping the patient with Parkinson disease to bathe is best delegated to the assistive personnel. The patient being transferred to the nursing home and the newly admitted patient with a spinal cord injury should be assigned to nurses with experience in neurological nursing care.

Which patient 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 patient with newly diagnosed multiple sclerosis (MS) 2. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) 3. A 56-year-old patient with Guillain-Barré syndrome (GBS) in respiratory distress 4. A 25-year-old patient admitted with a C4-level spinal cord injury (SCI)

2. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) The traveling nurse is relatively new to neurologic nursing and should be assigned patients whose condition is stable and not complex, such as the patient with chronic ALS. The newly diagnosed patient with MS will need a lot of teaching and support. The patient with GBS in respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The patient with a C4-level SCI is at risk for respiratory arrest. All three of these patients should be assigned to nurses experienced in neurologic nursing care.

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

2. Apply direct lateral pressure to the nose for 5 minutes 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing. The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed.

The nurse in the ER assesses a 21-year-old new admission who was in a motor vehicle crash. On assessment, the nurse discovers the patient has bruising behind the ear. Which injury does this finding indicate to the nurse? 1. Frontal skull fracture 2. Basilar skull fracture 3. Orbital fracture 4. Temporal fracture

2. Basilar skull fracture The location of a fracture determines the signs and symptoms that develop over several hours. This figure shows Battle sign (postauricular ecchymosis), which is a common clinical sign for a basilar skull fracture (a type of linear fracture involving the base of the skull). Another sign of this type of fracture is raccoon eyes (periorbital ecchymosis). It is usually accompanied by a tear in the dura with leaking of cerebrospinal fluid so rhinorrhea (nose) or otorrhea (ears) are also present. The other three types of fracture have different signs depending on the location.

A patient 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 patient does not wander during the night. He insists on checking each of the medications the nurse gives the patient to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this patient? 1. Acute patient confusion 2. Care provider role stress 3. Increased risk for falls 4. Noncompliance with therapeutic plan

2. Care provider role stress 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 patient and his concern with medication administration do not indicate difficulty complying with the therapeutic plan. The patient 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.

A patient with a spinal cord injury reports a sudden severe throbbing headache that started a short time ago. Assessment of the patient 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 indwelling catheter tubing for kinks or obstruction. 3. Adjust the temperature in the patient's room. 4. Notify the health care provider (HCP) about the change in status.

2. Check the indwelling catheter tubing for kinks or obstruction. The patient'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 patient's headache. Notifying the HCP may be necessary if nursing actions do not resolve symptoms.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated by the nurse to the assistive personnel (AP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient the symptoms of pneumothorax.

2. Check vital signs every 15 minutes for 1 hour. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 2,4,5 Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for an AP. Assessing or teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

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

2. Checking and recording the patient's vital signs every 4 hours The AP's training and education covers measuring and recording vital signs. The AP may help with turning and repositioning the patient and may remind the patient to cough and deep breathe, but he or she does not teach the patient how to perform these actions. Assessing and monitoring patients require additional education and are appropriate to the scope of practice of professional nurses.

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

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

The nurse is supervising a senior nursing student who will provide nursing care for a 63-year-old man diagnosed with amyotrophic lateral sclerosis (ALS).Which statements by the student indicate accurate understanding of the disease process, assessment findings, and nursing care needed for this patient? Select all that apply. 1. Patients usually die within 10 to 15 years of diagnosis. 2. Early symptoms include tripping, dropping things, and fatigue of extremities 3. ALS always leads to changes in consciousness and confusion. 4. Nursing care for a patient with ALS includes decreasing risk for aspiration and falls 5. There are no drugs and there is no cure for ALS. 6. The patient is likely to exhibit signs of depression. 7. The most common cause of death is respiratory tract infection. 8. Riluzole is a drug that can slow the progression of ALS.

2. Early symptoms include tripping, dropping things, and fatigue of extremities 4. Nursing care for a patient with ALS includes decreasing risk for aspiration and falls 6. The patient is likely to exhibit signs of depression 8. Riluzole is a drug that can slow the progression of ALS. Early symptoms include tripping, dropping things, extremity fatigue, slurred speech, and muscle cramps or twitching. Nursing care focuses on facilitating communication, decreasing risk for aspiration and falls, early identification of respiratory problems, decreasing pain related to muscle weakness, and providing diversion activities. With ALS, patients are usually cognitively intact while their bodies waste away. This can lead to depression. Death most commonly occurs 2 to 5 years after diagnosis. Riluzole (Rilutek) is a drug that can be used to slow the progression of ALS; however, there is no cure.

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

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

Which patient is the most likely candidate for outpatient depot antipsychotic therapy? 1. Older man with psychosis secondary to dementia who lives with his daughter 2. Homeless veteran with schizophrenia who occasional sleeps in a nearby shelter 3. Housewife with bipolar disorder who has psychotic features during the manic phase 4. Student with recently diagnosed schizophrenia who lives at home with his parents

2. Homeless veteran with schizophrenia who occasional sleeps in a nearby shelte Depot antipsychotic therapy uses long-acting injectable medications. These medications are used for long-term maintenance for schizophrenia for patients who may have some difficulties with adherence to taking medications. The homeless veteran has the least amount of social support and stability, which are factors in medication adherence. For the older adult patient with dementia and psychosis, identifying underlying factors and then behavioral therapies would be recommended first. Psychotic features in the manic phase of bipolar disorder would be treated as an acute episode. The student has the support of family, and the health care team will try to work with the patient and the family to build behaviors that support lifetime adherence to therapy.

The nurse has just admitted a patient with bacterial meningitis who reports a severe headache with photophobia (sensitivity to light) 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 patient'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. Infuse ceftriaxone 2000 mg IV to treat the infection. 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.

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

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

The RN notes that a patient 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 (HCP) immediately. 3. Recheck vital signs in 1 hour. 4. Reschedule the patient's physical therapy.

2. Notify the health care provider (HCP) immediately. The changes that the RN notes are characteristic of myasthenic crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the HCP or rapid response team, the nurse should carefully monitor the patient's respiratory status. The patient may need intubation and mechanical ventilation.

A patient with a mental health disorder is brought to the emergency department by the police. In determining hospitalization versus discharge back into the community, which consideration is given the highest priority 1. Willingness of person to follow the treatment plan 2. Potential for harm to self or others 3. Availability of family or social support 4. Ability of person to meet own basic physical needs

2. Potential for harm to self or others Potential for harm to self or others would be the priority; however, the other options are also important in planning for long-term outcomes.

The nurse is working with a health care provider (HCP) who recently started treating patients with depression. Which action by the HCP would prompt the nurse to intervene? 1. Tells the patient and family that it may take 4 to 8 weeks before the antidepressant medication begins to relieve symptoms 2. Prescribes 3 months of antidepressants for a patient newly diagnosed with depression and gives a 3 month follow-up appointment 3. Instructs the patient that the initial dose is low but will gradually be increased to reach a maintenance dosage 4. Tells the patient and the family to watch for and immediately report anxiety, agitation, irritability, or suicidal thoughts

2. Prescribes 3 months of antidepressants for a patient newly diagnosed with depression and gives a 3 month follow-up appointment Patients with depression are at high risk for suicide, and antidepressants can be used to commit suicide. For the patient who was recently diagnosed with depression and prescribed antidepressants, the nurse intervenes because a small number of doses should be prescribed and dispensed, and follow-up should be weekly to allow for close monitoring and assessment. The other options are correct information to share with patients and family members.

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

2. Respiratory rate of 8 breaths/min For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If the nurse does not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema.

The nurse is preparing to admit a patient 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 patient arrives

2. Setting up oxygen and suction equipment 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 patient and family. Tongue blades should never be at the bedside and should never be inserted into the patient's mouth after a seizure begins.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced assistive personnel (AP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

2. Taking vital signs and pulse oximetry readings every 4 hours The AP's educational preparation includes measuring vital signs, and an experienced AP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.

The critical care nurse is assessing a patient 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 patient's condition is improving. 2. The patient's condition is deteriorating. 3. The patient will need intubation and mechanical ventilation. 4. The patient's medication regime will need adjustments.

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

A patient 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 109/L). 3. The patient sometimes forgets to take the phenytoin until the afternoon. 4. The patient wants to renew her driver's license in the next month.

2. The white blood cell count is 2300/mm3 (2.3 x 109/L). 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 patient teaching but will not require a change in medical treatment for the seizures.

A 70-year-old patient 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 patient on the hospital alcohol withdrawal protocol. 2. Transport the patient to the radiology department for a computed tomography scan. 3. Make a referral to the social services department. 4. Give the patient phenytoin 100 mg PO

2. Transport the patient to the radiology department for a computed tomography scan. The patient'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 patient 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.

The charge nurse is reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? 1. Male LVN assigned to an older male patient with chronic depression and excessive rumination 2. Young male psychiatric nursing assistant assigned to a female adolescent with anorexia nervosa 3. Female RN assigned to a newly admitted female patient who has command hallucinations and delusions of persecution 4. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

2. Young male psychiatric nursing assistant assigned to a female adolescent with anorexia nervosa Adolescents, in general, are self-conscious in the presence of members of the opposite sex, and teenagers with anorexia are overly concerned with their appearance; therefore it would be better to assign this patient to a mature female staff member. An experienced LVN is able to set boundaries and to assist patients with chronic health problems. An experienced RN should be assigned to new admissions and to patients with acute safety issues. An RN with medical-surgical experience would be well acquainted with care issues related to dementia.

The nurse is providing care for a patient with an acute hemorrhagic stroke. The patient'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 patients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife just had gallbladder surgery 6 months ago, so we can't use alteplase."

3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." Alteplase is a clot buster. In a patient 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 patient's diagnosis and do not answer the spouse's question.

A patient comes into the walk-in clinic and tells the nurse that he would like to be admitted to an alcohol rehabilitation program. Which question is the most important to ask? 1. "What made you decide to enter a program at this time?" 2. "How much alcohol do you usually consume in a day?" 3. "When was the last time you had a drink?" 4. "Have you been in a rehabilitation program before?"

3. "When was the last time you had a drink?" Before someone enters an alcohol rehabilitation program, there should be a medically supervised detoxification. This patient has walked in off the street; therefore the nurse must determine whether he is at risk for withdrawal symptoms. Withdrawal from alcohol can be life threatening. The other questions are relevant and are likely to be included in the interview.

Which patient 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 patient with a basilar skull fracture who has clear drainage coming out of the nose 2. A 42-year-old patient admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an intravenous antibiotic dose due 4. A 65-year-old patient with an astrocytoma who has just returned to the unit after undergoing a craniotomy

3. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an intravenous antibiotic dose due Of the patients listed, the patient 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 patients require assessments and care from RNs more experienced in caring for patients with neurologic diagnoses.

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

3. A 72-year-old patient who needs teaching about the use of incentive spirometry Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

Which task can be delegated to a medical-surgical assistive personnel (AP) who has been temporarily floated to the acute psychiatric unit to help? 1. Performing one-to-one observation of a patient who is suicidal 2. Assisting the occupational therapist to conduct a craft class 3. Accompanying an older adult patient who wanders on a walk outside 4. Assisting the medication nurse who is having problems with a patient

3. Accompanying an older adult patient who wanders on a walk outside Medical-surgical APs assist patients to ambulate, and they frequently care for older confused patients. Performing one-to-one suicide watch requires experience to recognize behaviors and to immediately alert the nurse and intervene. Assisting the occupational therapist or medication nurse may be possible, but the medical-surgical AP is unlikely to be familiar with the behavioral interventions required in these situations.

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

3. Checking the patient's vital signs Measurement of vital signs is within the education and scope of practice of APs. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient's movements if necessary to prevent injury.

The nurse is assessing a patient 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 patient in 30 minutes.

3. Contact the rapid response team. 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, the nurse should 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.

The nurse is preparing a nursing care plan for a patient 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 patient 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. Difficulty with coping The patient'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 patient with an SCI but are not related to the patient's statement.

The patient has a panic disorder and is having difficulty controlling his anxiety. Which symptoms are cause for greatest concern? 1. His heart rate is increased, and he reports chest tightness. 2. He demonstrates tachypnea and carpopedal spasms. 3. He is pacing to and fro and pounding his fists together. 4. He is muttering to himself and is easily startled.

3. He is pacing to and fro and pounding his fists together All of these symptoms signal an increase of anxiety; however, physically aggressive behavior signals a danger to others and to self. Verbal intervention is still possible, but the pacing and fist pounding are a step above the other symptoms. Tachycardia and chest tightness are assessed, but should abate as the patient becomes less anxious. Carpopedal spasms occur during hyperventilation; assisting the patient to breathe in a paper bag will help. Muttering to self can be interrupted by using a normal conversational tone and topic.

There is a patient on the rehabilitation unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should the charge nurse handle the assignment? 1. Rotate the assignment schedule so that no one has to care for him more than once or twice a week. 2. Pair a float nurse and a nursing student and assign this team to care for the patient; they will have a fresh perspective. 3. Identify several experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions. 4. Assign self as primary caregiver and role-model how patients should be treated.

3. Identify several experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions. This patient has trouble with interpersonal interactions, so consistent caregivers who use psychosocial interventions have the best chance of developing a functional nurse-patient relationship. Rotating the assignment sheet to give the staff a break and using float staff are frequent strategies that are used, but these are not necessarily the best for the patient. Taking the patient may seem like the easiest solution for the charge nurse, but in the long run, strengthening and supporting the staff are better strategies.

After reviewing medication prescriptions on an acute psychiatric unit, which prescription is the nurse most likely to question? 1. Fluoxetine for a middle-aged patient with depression 2. Chlorpromazine for a young patient with schizophrenia 3. Loxapine for an older adult patient with dementia and psychosis 4. Lorazepam for a young patient with generalized anxiety disorder

3. Loxapine for an older adult patient with dementia and psychosis Conventional (first-generation) antipsychotics are usually not prescribed for older adult patients with psychosis secondary to dementia because of the increased incidence of death, usually from cardiac problems or infection. Fluoxetine for depression, chlorpromazine for schizophrenia, and lorazepam for generalized anxiety disorder are viable options.

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

3. Maintain the head of bed at a 30- to 45-degree angle. Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3. Marks the tube 1 cm from where it touches the incisor tooth or nares The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

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

3. Performing the patient's complete bathing and oral care Although all of these actions fall within the scope of practice for an AP, the AP should help the patient with morning care as needed, but the goal is to keep the patient as independent and mobile as possible. The patient should be encouraged to perform as much morning care as possible. Assisting the patient in ambulating, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to the goal of maintaining independence.

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

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

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the assistive personnel (AP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake APs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic AP, but an experienced AP could assist the patient with positioning after the AP and the patient had been taught the proper technique. In that case, the AP would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

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

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

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

3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure.

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

3. The patient is unable to remember her husband's first name. Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the HCP needs to be called.

The nurse arrives home and finds that a neighbor's (Jane's) house is on fire. A fireman is physically restraining Jane as she screams and thrashes around to get free to run back into the house. What is the nurse's best action? 1. Make eye contact and encourage Jane to verbalize feelings. 2. Physically restrain Jane so that the fireman can resume his job. 3. Use a firm tone of voice and give Jane simple commands. 4. Use a gentle persuading tone and ask Jane to be calm.

3. Use a firm tone of voice and give Jane simple commands. Jane is experiencing a panic level of anxiety, and initially she needs firm, simple, and direct instructions. It may be very difficult for the nurse to safely restrain Jane. Speaking softly and gently and encouraging her to express feelings are appropriate when her anxiety is more under control.

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

3. Weigh the patient before and after the procedure. The scope of practice for an experienced AP would include weighing patients. Observing, assessing, and providing instructions all require additional educational preparation and are appropriate to the scope of practice for a professional nurse.

A nursing student is teaching a patient and family about epilepsy before the patient'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. "It's OK to take over-the-counter medications." A patient 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 patients with seizure disorders and their families.

A patient diagnosed with paranoid schizophrenia says, "Dr. Smith has killed several other patients, and now he is trying to kill me." What is the best response? 1. "I have worked here a long time. No one has died. You are safe here." 2. "What has Dr. Smith done to make you think he would like to kill you?" 3. "All of the staff, including Dr. Smith, are here to ensure your safety." 4. "Whenever you are concerned or nervous, talk to me or any of the nurses."

4. "Whenever you are concerned or nervous, talk to me or any of the nurses." The nurse can acknowledge the patient's fears without agreeing or disagreeing with his accusation. Directing him to talk to the nursing staff provides a source of emotional support and an action that he can use to decrease his anxiety. Telling the patient that no one has died and that the staff will ensure safety is presenting reality; however, he has a delusional belief and arguments should be avoided. Asking him to explain his rationale for his beliefs encourages him to elaborate on his delusion.

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

4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. In patients with COPD, pulse oximetry oxygen saturations of more than 90% are acceptable.

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

4. A 63-year-old patient with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain Urinary tract infections (UTIs) are a frequent complication in patients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these patients. The elevated temperature and flank pain suggest that this patient may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other patients should be assessed as soon as possible, but their needs are not as urgent as those of this patient.

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

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

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

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

What is the nurse's most important role in helping patients, who have schizophrenia, to benefit from a comprehensive approach that includes medication and multidisciplinary nondrug therapies? 1. Help identify patients who would benefit from conventional psychotherapy. 2. Refer patients to a psychiatric nurse specialist for education about the disease. 3. Suggest that patients talk to vocational specialists for additional training. 4. Establish a therapeutic relationship with patients and encourage participation.

4. Establish a therapeutic relationship with patients and encourage participation. The nurse and the psychiatric nursing assistant spend more time with the patients than any of the other members of the health care team; thus establishing a good therapeutic relationship is essential to building trust; increasing social skills; encouraging medication adherence; and suggesting participation in educational, socialization, and vocational opportunities. Conventional psychotherapy is generally not used with patients with schizophrenia.

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

4. Monitor respiratory effort and oxygen saturation level. The first priority for the patient with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A patient 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.

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

4. Oral temperature of 101.2°F (38.4°C A patient who did not have the pneumonia vaccination or flu shot is at an increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern.

A newly graduated nurse has just started working at the acute psychiatric unit. Which patient would be the best to assign to this nurse? 1. Patient who is frequently admitted for borderline personality disorder and suicidal gestures 2. Patient admitted yesterday for disorganized schizophrenia and psychosis 3. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium 4. Patient newly diagnosed with major depression and rumination about loss and suicide

4. Patient newly diagnosed with major depression and rumination about loss and suicide Although the patient is ruminating about suicide, in the early phase of major depression the patient has minimal energy to act. The danger for suicide will increase as the medication and therapy begin to help. A new nurse lacks experience with therapeutic boundary setting that is necessary for patients with borderline personality disorder. Psychotic patients can seem very threatening to new nurses and it takes experience to interpret psychotic behavior. Depression, dementia, and delirium have some behavior and symptom overlap; this patient should be assigned to an experienced nurse until the delirium is treated or ruled out.

An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a patient 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. Shallow respirations and decreased breath sounds The priority intervention for a patient with GBS is maintaining adequate respiratory function. Patients 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 talking to the primary caregiver of Martha, who was diagnosed 8 years ago with Alzheimer disease. The caregiver says, "We love Martha, but my daughter needs help with her kids, and my husband's health is poor. I really need help." Which member of the health care team should the nurse consult first? 1. Health care provider to review long-term prognosis and new treatments for Alzheimer disease 2. Psychiatric clinical nurse specialist to design behavioral modification therapies for Martha 3. Clinical psychologist to assess caregiver for major depression and need for treatment 4. Social worker to identify and arrange placement for Martha in an acceptable nursing home

4. Social worker to identify and arrange placement for Martha in an acceptable nursing home The caregiver needs assistance to identify and locate an alternative care situation for Martha. The family has been coping and caring for Martha for a long time, but family circumstances and a patient's condition will change over time. The nurse may do additional assessment to see if the caregiver needs to be referred for depression, guilt, or anxiety related to having to make this change for Martha. New treatments and behavioral modification can be attempted, but currently there are no therapies that reverse the gradual decline.

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

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

A patient who was recently diagnosed with conversion disorder is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? 1. Reassure her that her blindness is temporary and will resolve with time. 2. Gently point out that she can see well enough to function independently. 3. Encourage expression of feelings and link emotional trauma to the blindness. 4. Teach ways to cope with blindness, such as methodically arranging personal items.

4. Teach ways to cope with blindness, such as methodically arranging personal items. Patients with conversion disorders are experiencing symptoms, even though there is no identifiable organic cause; therefore the patient should be assisted in learning ways to cope and live with the disability. The patient may physically be able to see, but pointing this out is not helpful. Encouraging the expression of feelings is okay, but it is premature to expect the patient to link the fight to her blindness. It is likely that the sudden onset of blindness will resolve, but the priority therapeutic approach is teaching her ways to cope in the meantime.

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

4. Tympanic temperature of 101.4°F (38.6°C) Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not as urgent