Prioritization, Delegation, Assignment- Chapter 13, Chapter16, Chapter 12, Chapter 14

12. You are teaching the client and family how to perform colostomy irrigation. Place the following information in the correct order. 1. Hang the container at about shoulder height. 2. Allow the solution to flow slowly and steadily for 5 to 10 minutes. 3. Put 500 to 1000 mL of lukewarm water in the container. 4. Clip the irrigation sleeve and have the client walk for 30 to 45 minutes for secondary evacuation. 5. Lubricate the stoma cone and gently insert the tubing tip into the stoma. 6. Clean, rinse, and dry the skin, and apply a new drainage pouch. 7. Put on a pair of clean gloves. 8. Allow 15 to 20 minutes for the initial evacuation. _____, _____, _____, _____, _____, _____, ____, _____

12. Ans: 7, 3, 1, 5, 2, 8, 4, 6 7. Put on a pair of clean gloves. 3. Put 500 to 1000 mL of lukewarm water in the container. 1. Hang the container at about shoulder height. 5. Lubricate the stoma cone and gently insert the tubing tip into the stoma. 2. Allow the solution to flow slowly and steadily for 5 to 10 minutes. 8. Allow 15 to 20 minutes for the initial evacuation. 4. Clip the irrigation sleeve and have the client walk for 30 to 45 minutes for secondary evacuation. 6. Clean, rinse, and dry the skin, and apply a new drainage pouch. Putting on a pair of clean gloves protects the hands from colostomy secretions. The water should be warm (cold water can cause cramping) and the container should be hung at shoulder height (hanging the container too high or too low will alter the rate of flow). Lubricating the stoma and gently inserting the tubing tip will allow the water to flow into the stoma. A slow and steady flow prevents cramps and spillage. Providing adequate time allows for complete evacuation. Walking stimulates the bowel. Careful attention to the skin prevents breakdown. Focus: Prioritization

15. A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis? 1. Diarrhea related to irritated bowel 2. Imbalanced Nutrition: Less than Body Requirements related to nutrient loss 3. Acute Pain related to increased GI motility 4. Ineffective Self-Health Management related to treatment plan"

15. Ans: 1 Diarrhea related to irritated bowel The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and compliance with the treatment plan are important long-term goals that can be addressed when the client is feeling better physically. Focus: Prioritization"

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

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

30. You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. You would intervene if the student performs which action? 1. Maintains the client in a semi-Fowler position 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation

30. Ans: 3 Gently aspirates the drainage from the tube T-tubes should not be irrigated, aspirated, or clamped without a specific order from the physician. All of the other actions are appropriate in the care of this client. Focus: Supervision

26. You are supervising a senior nursing student who is caring for a 78-year-old scheduled for an intravenous pyelography. What information would you be sure to stress about this procedure to the nursing student? 1. "After the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults." 2. "The purpose of this procedure is to measure kidney size." 3. "Because this procedure assesses kidney function, there is no need for a bowel prep." 4. "Keep the patient NPO after the procedure because during the procedure the patient will receive drugs that affect the gag reflex."

Ans: 1 "After the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults." The risk for contrast-induced kidney failure is greatest in patients who are older or dehydrated. If possible, arrange for the patient to have this procedure early in the day to prevent dehydration. The purpose of this procedure is to assess kidney function and identify anomalies. The administration of drugs that affect the gag reflex is not done during this procedure. Focus: Supervision, prioritization

9. A patient with incontinence will be taking oxybutynin chloride (Ditropan) 5 mg by mouth three times a day after discharge. Which information would you be sure to teach this patient before discharge? 1. "Drink fluids or use hard candy when you experience a dry mouth." 2. "Be sure to notify your physician if you experience a dry mouth." 3. "If necessary, your physician can increase your dose up to 40 mg/day." 4. "You should take this medication with meals to avoid stomach ulcers."

Ans: 1 "Drink fluids or use hard candy when you experience a dry mouth." Oxybutynin is an anticholinergic agent, and these drugs often cause an extremely dry mouth. The maximum dosage is 20 mg/day. Oxybutynin should be taken between meals, because food interferes with absorption of the drug. Focus: Prioritization

20. A UAP reports to you that a patient with acute kidney failure has had a urine output of 350 mL over the past 24 hours after receiving furosemide 40 mg IV push. The UAP asks you how this can happen. What is your best response? 1. "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." 2. "There must be some sort of error. Someone must have failed to record the urine output." 3. "A patient with acute kidney failure retains sodium and water, which counteracts the action of the furosemide." 4. "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium."

Ans: 1 "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." During the oliguric phase of acute kidney failure, a patient's urine output is greatly reduced. Fluid boluses and diuretics do not work well. This phase usually lasts from 8 to 15 days. Although there are frequent omissions in recording intake and output, this is probably not the cause of the patient's decreased urine output. Retention of sodium and water is the rationale for giving furosemide, not the reason that it is ineffective. Nitrogenous wastes build up as a result of the kidneys' inability to perform their elimination function. Focus: Prioritization, supervision

20. You are caring for a client with cirrhosis and portal hypertension. Which statement by the client concerns you the most? 1. "I'm very constipated and have been straining during bowel movements." 2. "I can't button my pants anymore because my belly is so swollen." 3. "I have a tight sensation in my lower legs when I forget to put my feet up." 4. "When I sleep, I have to sit in a recliner so that I can breathe more easily."

Ans: 1 "I'm very constipated and have been straining during bowel movements." There is a potential for sudden rupture of fragile blood vessels with massive hemorrhage from straining that increases thoracic or abdominal pressure. The client could have fluid accumulation in the abdomen (ascites) that can be mild and hard to detect or severe enough to cause orthopnea. Dependent peripheral edema can also be observed but is less urgent. Focus: Prioritization

3. As charge nurse, you would assign the nursing care of which patient to an LPN/LVN, working under the supervision of an RN? 1. 48-year-old with cystitis who is taking oral antibiotics 2. 64-year-old with kidney stones who has a new order for lithotripsy 3. 72-year-old with urinary incontinence who needs bladder training 4. 52-year-old with pyelonephritis who has severe acute flank pain

Ans: 1 48-year-old with cystitis who is taking oral antibiotics The patient with cystitis who is taking oral antibiotics is in stable condition with predictable outcomes, and caring for this patient is therefore appropriate to the scope of practice of an LPN/LVN under the supervision of an RN. The patient with a new order for lithotripsy will need teaching about the procedure, which should be accomplished by the RN. The patient in need of bladder training will need the RN to plan this intervention. The patient with flank pain needs careful and skilled assessment by the RN. Focus: Assignment

22. A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding? 1. Abdominal distention and rigidity 2. Displacement of the NG tube by the client 3. Absent or hypoactive bowel sounds 4. Nausea and occasional vomiting

Ans: 1 Abdominal distention and rigidity Distention and rigidity can signal hemorrhage or peritonitis. The physician may also decide that these symptoms require a medication to stimulate peristalsis. Absence of bowel sounds is expected within the first 24 to 48 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and an "as needed" (PRN) order for an antiemetic is usually part of the routine postoperative orders. The reason for displacement of the NG tube should be assessed and the tube secured as necessary. Focus: Prioritization

11. A patient has urolithiasis and is passing the stones into the lower urinary tract. What is the priority nursing diagnosis for the patient at this time? 1. Acute Pain 2. Risk for Infection 3. Risk for Injury 4. Anxiety related to the risk for recurrent stones

Ans: 1 Acute Pain When patients with urolithiasis pass stones, they can be in excruciating pain for up to 24 to 36 hours. All of the other nursing diagnoses for this patient are accurate; however, at this time, pain is the most urgent concern for the patient. Focus: Prioritization

11. You are caring for a diabetic patient who is developing diabetic ketoacidosis (DKA). Which task delegation is most appropriate? 1. Ask the unit clerk to page the physician to come to the unit. 2. Ask the LPN/LVN to administer IV push insulin according to a sliding scale. 3. Ask the UAP to hang a new bag of normal saline. 4. Ask the UAP to get the patient a cup of orange juice.

Ans: 1 Ask the unit clerk to page the physician to come to the unit. The nurse should not leave the patient. The scope of the unit clerk's job includes calling and paging physicians. LPNs/LVNs generally do not administer IV push medication. IV fluid administration is not within the scope of practice of UAPs. Patients with DKA already have a high glucose level and do not need orange juice. Focus: Delegation, supervision

24. A patient on the medical-surgical unit with acute kidney failure is to begin continuous arteriovenous hemofiltration (CAVH) as soon as possible. What is the priority action at this time? 1. Call the charge nurse and transfer the patient to the ICU. 2. Develop a teaching plan for the patient that focuses on CAVH. 3. Assist the patient with morning bath and mouth care before transfer. 4. Notify the physician that the patient's mean arterial pressure is 68 mm Hg.

Ans: 1 Call the charge nurse and transfer the patient to the ICU. CAVH is a continuous renal replacement therapy that is prescribed for patients with kidney failure who are critically ill and do not tolerate the rapid shifts in fluids and electrolytes that are associated with hemodialysis. A teaching plan is not urgent at this time. A patient must have a mean arterial pressure (MAP) of at least 60 mm Hg or more for CAVH to be of use. The physician should be notified about this patient's MAP; it is a priority, but not the highest priority. When a patient urgently needs a procedure, morning care does not take priority and may be deferred until later in the day. Focus: Prioritization

5. The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP? 1. Checking to make sure that the patient's bath water is not too hot 2. Discussing community resources for diabetic outpatient care 3. Teaching the patient to perform daily foot inspection 4. Assessing the patient's technique for drawing insulin into a syringe

Ans: 1 Checking to make sure that the patient's bath water is not too hot Checking the bath water temperature is part of assisting with activities of daily living and is within the education and scope of practice of the UAP. Discussing community resources, teaching, and assessing require a higher level of education and are appropriate to the scope of practice of licensed nurses. Focus: Delegation

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

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

16. You are the admitting nurse for a patient with nephrotic syndrome. Which assessment finding supports this diagnosis? 1. Edema formation 2. Hypotension 3. Increased urine output 4. Flank pain

Ans: 1 Edema formation The underlying pathophysiology of nephrotic syndrome involves increased glomerular permeability, which allows larger molecules to pass through the membrane into the urine and be removed from the blood. This process causes massive loss of protein, edema formation, and decreased serum albumin levels. Key features include hypertension and renal insufficiency (decreased urine output) related to concurrent renal vein thrombosis, which may be a cause or an effect of nephrotic syndrome. Flank pain is seen in patients with acute pyelonephritis. Focus: Prioritization

8. You are providing immediate postoperative care for a client who had fundoplication to reinforce the lower esophageal sphincter for the purpose of a hiatal hernia repair. What is the priority action for the care of this client? 1. Elevate the head of the bed at least 30 degrees. 2. Assess the nasogastric tube for yellowish-green drainage. 3. Assist the client to start taking a clear liquid diet. 4. Assess the client for gas bloat syndrome.

Ans: 1 Elevate the head of the bed at least 30 degrees. The primary concern is the potential for airway complications. Elevating the head, at least 30 degrees, decreases the chance for aspiration and facilitates respiratory effort. The other options are also correct, but will occur later in the postoperative period. Focus: Prioritization

19. In the care of a client with acute viral hepatitis, which task should be delegated to the UAP? 1. Emptying the bedpan while wearing gloves 2. Playing games or engaging the client in diversional activities 3. Monitoring dietary preferences 4. Reporting signs and symptoms of jaundice

Ans: 1 Emptying the bedpan while wearing gloves The UAP should use infection control precautions for the protection of self, employees, and other clients. Monitoring is an RN responsibility. UAPs can report valuable information; however, they are not responsible for detecting signs and symptoms that can be subtle or hard to detect, such as skin changes. While playing games with the client may be ideal, it is rarely possible on a medical-surgical unit. Focus: Delegation

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

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

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

Ans: 1 Give this insulin after the patient's food tray has been delivered and the patient is ready to eat. The onset of action for rapid-acting insulin is within minutes, so it should be given only when the patient has food and is ready to eat. Because of this, rapid-acting insulin is sometimes called "see food" insulin. Options 2, 3, and 4 are incorrect. Long-acting insulins mimic the action of the pancreas. Regular insulin is the only insulin that can be given IV. Focus: Assignment, supervision

12. You are serving as preceptor to a nurse who has recently graduated and passed the RN licensure examination. The new nurse has only been on the unit for 2 days. Which patient should you assign to the new nurse? 1. 68-year-old with diabetes who is showing signs of hyperglycemia 2. 58-year-old with diabetes who has cellulitis of the left ankle 3. 49-year-old with diabetes who has just returned from the postanesthesia care unit after a below-knee amputation 4. 72-year-old with diabetes with DKA who is receiving IV insulin

Ans: 2 58-year-old with diabetes who has cellulitis of the left ankle The new nurse is still on orientation to the unit. Appropriate patient assignments at this time include patients whose conditions are stable and not complex. Focus: Assignment

27. Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome? 1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. 2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention. 3. Observe for signs of secret purging and ingestion of water to increase weight. 4. Assess for alternating constipation and diarrhea and pale clay-colored stools.

Ans: 1 Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload. Changes in bowel sounds, nausea, and distention may occur but are also appropriate for any client with nutritional issues or for clients receiving enteral feedings. Observing for purging and water ingestion would be appropriate for a client with an eating disorder. Change in stool patterns may occur, but are not related to refeeding syndrome. Focus: Prioritization

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

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

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

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

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

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

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

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

22. Your patient is receiving IV piggyback doses of gentamicin (Garamycin) every 12 hours. Which would be your priority for monitoring during the period that the patient is receiving this drug? 1. Serum creatinine and blood urea nitrogen levels 2. Patient weight every morning 3. Intake and output every shift 4. Temperature

Ans: 1 Serum creatinine and blood urea nitrogen levels Gentamicin can be a highly nephrotoxic substance. You would monitor creatinine and blood urea nitrogen levels for elevations indicating possible nephrotoxicity. All of the other measures are important but are not specific to gentamicin therapy. Focus: Prioritization

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

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

18. You are teaching a patient how best to prevent renal trauma after an injury that required a left nephrectomy. Which points would you include in your teaching plan? (Select all that apply.) 1. Always wear a seat belt. 2. Avoid all contact sports. 3. Practice safe walking habits. 4. Wear protective clothing to participate in contact sports. 5. Use caution when riding a bicycle.

Ans: 1, 2, 3, 5 1. Always wear a seat belt. 2. Avoid all contact sports. 3. Practice safe walking habits. 5. Use caution when riding a bicycle. A patient with only one kidney should avoid all contact sports and high-risk activities to protect the remaining kidney from injury and preserve kidney function. All of the other points are key to preventing renal trauma. Focus: Prioritization

14. You are preparing a care plan for a patient with Cushing disease. Which nursing diagnoses would you be sure to include? (Select all that apply.) 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 3. Imbalanced Nutrition: Less than Body Requirements 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection

Ans: 1, 2, 4, 5 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection A patient with Cushing disease experiences body changes affecting body image and is at risk for bruising, infection, and hypertension. Such a patient usually gains weight. Focus: Prioritization

19. You are providing nursing care for a patient with acute kidney failure for whom a nursing diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? (Select all that apply.) 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 3. Administering furosemide (Lasix) 40 mg orally twice a day 4. Reminding the patient to save all urine for intake and output measurement 5. Assessing breath sounds every 4 hours 6. Ensuring that the patient's urinal is within reach

Ans: 1, 2, 4, 6 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 4. Reminding the patient to save all urine for intake and output measurement 6. Ensuring that the patient's urinal is within reach Administering oral medications is appropriate to the scope of practice for an LPN/LVN or RN. Assessing breath sounds requires additional education and skill development and is most appropriately within the scope of practice of an RN, but it may be part of the observations of an experienced and competent LPN/LVN. All other actions are within the educational preparation and scope of practice of an experienced UAP. Focus: Delegation, supervision

3. A nursing diagnosis for a patient with newly-diagnosed diabetes is Risk for Injury related to sensory alterations. Which key points should you include in the teaching plan for this patient? (Select all that apply.) 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 3. "Nylon socks are best to prevent friction on your toes from shoes." 4. "Only a podiatrist should trim your toenails." 5. "Report any nonhealing skin breaks to your health care provider."

Ans: 1, 2, 5 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 5. "Report any nonhealing skin breaks to your health care provider." Sensory alterations are the major cause of foot complications in diabetic patients, and patients should be taught to examine their feet on a daily basis. Properly-fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Patients, family, or health care providers may trim toenails. Focus: Prioritization

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

Ans: 1, 2, 5 1. Fingerstick blood glucose checks before meals and at bedtime 2. Sliding-scale insulin dosing as ordered 5. Demonstration of the components of foot care When a diabetic patient is ill, glucose levels become elevated, and administration of insulin may be necessary. Teaching or reviewing the components of proper foot care is always a good idea with a diabetic patient. Bed rest is not necessary, and glucose level may be better controlled when a patient is more active. The Atkins diet recommends decreasing the consumption of carbohydrates and is not a good diet for diabetic patients. Focus: Prioritization

22. You are caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? (Select all that apply.) 1. Hydrochlorothiazide (HCTZ) prescribed to control her diabetes 2. Weight gain of 6 pounds over the past month 3. Avoids consuming liquids in the evening 4. Blood pressure of 168/94 mm Hg 5. Urine output of 50 to 75 mL/hr

Ans: 1, 3 1. Hydrochlorothiazide (HCTZ) prescribed to control her diabetes 3. Avoids consuming liquids in the evening HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Weight loss (not weight gain) would be a symptom. While the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr is adequate. Focus: Prioritization

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

Ans: 1, 3, 5 1. Exercise guidelines are based on blood glucose and urine ketone levels. 3. You can exercise vigorously if your blood glucose is between 100 and 250 mg/dL. 5. A 5- to 10-minute warm-up and cool-down period should be included in your exercise. Guidelines for exercise are based on blood glucose and urine ketone levels. Patients should test blood glucose before, during, and after exercise to be sure that it is safe. When ketones are present in urine, the patient should not exercise because they indicate that current insulin levels are not adequate. Vigorous exercise is permitted in patients with type 1 diabetes if glucose levels are between 100 and 250 mg/dL. Warm-up and cool-down should be included in exercise to gradually increase and decrease the heart rate. Focus: Prioritization

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

Ans: 1, 3, 5 1. Providing the patient with extra packets of artificial sweetener for coffee 3. Recording the liquid intake from the patient's breakfast tray 5. Checking and recording the patient's blood pressure Giving the patient extra sweetener, recording oral intake, and checking blood pressure are all within the scope of practice of the UAP. Assessing shoe fit and patient teaching are not within the UAP's scope of practice. Focus: Assignment

2. Which laboratory result is of most concern to you for an adult patient with cystitis? 1. Serum white blood cell (WBC) count of 9000/mm3 2. Urinalysis results showing 1 or 2 WBCs present 3. Urine bacteria count of 100,000 colonies per milliliter 4. Serum hematocrit of 36%

Ans: 3 Urine bacteria count of 100,000 colonies per milliliter The presence of 100,000 bacterial colonies per milliliter of urine or the presence of many white blood cells (WBCs) and red blood cells (RBCs) indicates a urinary tract infection. The WBC count is within normal limits and the hematocrit is a little low, which may need follow-up. Neither of these results indicates infection. Focus: Prioritization

25. You are caring for a diabetic patient admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a teaching plan for the patient and family before discharge? (Select all that apply.) 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1⁄4 cup of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away.

Ans: 1, 4, 5 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. Focus: Prioritization

15. In a male patient who must undergo intermittent catheterization, you are preparing to insert a catheter to assess the patient for postvoid residual. Place the steps for catheterization in the correct order. 1. Assist the patient to the bathroom and ask the patient to attempt to void. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 3. Open the catheterization kit and put on sterile gloves. 4. Lubricate the catheter and insert it through the meatus of the penis. 5. Position the patient supine in bed or with the head slightly elevated. 6. Drain all the urine present in the bladder into a container. 7. Cleanse the glans penis starting at the meatus and working outward. 8. Remove the catheter, clean the penis, and measure the amount of urine returned. ____, ____, _____, _____, ____, ____, _____, _____

Ans: 1, 5, 3, 2, 7, 4, 6, 8 1. Assist the patient to the bathroom and ask the patient to attempt to void. 5. Position the patient supine in bed or with the head slightly elevated. 3. Open the catheterization kit and put on sterile gloves. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 7. Cleanse the glans penis starting at the meatus and working outward. 4. Lubricate the catheter and insert it through the meatus of the penis. 6. Drain all the urine present in the bladder into a container. 8. Remove the catheter, clean the penis, and measure the amount of urine returned. Before checking postvoid residual, you should ask the patient to void, and then position him. Next you should open the catheterization kit and put on sterile gloves, position the patient's penis, clean the meatus, then lubricate and insert the catheter. All urine must be drained from the bladder to assess the amount of postvoid residual the patient has. Finally, the catheter is removed, the penis cleaned, and the urine measured. Focus: Prioritization

23. A patient in whom acute kidney failure has been diagnosed has had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient, under your supervision, asks you how a patient with kidney failure can have such a large urine output. What is your best response? 1. "The patient's kidney failure was due to hypovolemia and we have given him IV fluids to correct the problem." 2. "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." 3. "With that much urine output, there must have been a mistake in the patient's diagnosis." 4. "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure."

Ans: 2 "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." Patients with acute kidney failure usually go through a diuretic phase 2 to 6 weeks after the onset of the oliguric phase. The diuresis can result in an output of up to 10 L/day of dilute urine. During this phase it is important to monitor for electrolyte and fluid imbalances. This is followed by the recovery phase. A patient with acute kidney failure caused by hypovolemia would receive IV fluids to correct the problem; however, this would not necessarily lead to the onset of diuresis. Focus: Supervision

17. A patient has renal cell carcinoma (adenocarcinoma of the kidney). You are providing orientation to a new nurse on the unit, who asks you why this patient is not receiving chemotherapy. What is your best response? 1. "The prognosis for this form of cancer is very poor, and we will be providing only comfort measures." 2. "Nephrectomy is the preferred treatment as chemotherapy has been shown to have only limited effectiveness against this type of cancer." 3. "Research has shown that the most effective means of treating this form of cancer is with radiation therapy." 4. "Radiofrequency ablation is a minimally invasive procedure that is the best way to treat renal cell carcinoma."

Ans: 2 "Nephrectomy is the preferred treatment as chemotherapy has been shown to have only limited effectiveness against this type of cancer." Chemotherapy has limited effectiveness against renal cell carcinoma. This form of cancer is usually treated surgically by nephrectomy. Focus: Supervision, prioritization

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

Ans: 2 "Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL." Urine ketone testing should be done whenever the patient's blood glucose is greater than 240 mg/dL. All of the other teaching points are appropriate "sick day rules." For dehydration, teaching should also include that if the patient's blood glucose is lower than her target range, she should drink fluids containing sugar. Focus: Supervision, delegation

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

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

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

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

21. For clients coming to the ambulatory care GI clinic, which task would be most appropriate to assign to an LPN/LVN? 1. Teaching a client self-care measures for an ulcer 2. Assisting the physician in incision and drainage of a pilonidal cyst 3. Evaluating a client's response to sitz baths for an anorectal abscess 4. Describing the basic pathophysiology of an anal fistula to a client

Ans: 2 Assisting the physician in incision and drainage of a pilonidal cyst Assisting with procedures for clients in stable condition with predictable outcomes is within the educational preparation of the LPN/LVN. Teaching the client about self-care or pathophysiology and evaluating the outcome of interventions are responsibilities of the RN. Focus: Delegation

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

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

4. You are admitting a 66-year-old male patient suspected of having a urinary tract infection (UTI). Which piece of the patient's medical history supports this diagnosis? 1. Patient's wife had a UTI 1 month ago 2. Followed for prostate disease for 2 years 3. Intermittent catheterization 6 months ago 4. Kidney stone removal 1 year ago

Ans: 2 Followed for prostate disease for 2 years Prostate disease increases the risk of UTIs in men because of urinary retention. The wife's UTI should not affect the patient. The times of the catheter usage and kidney stone removal are too distant to cause this UTI. Focus: Prioritization

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

Ans: 2 Grasping under the patient's arms to pull him up in bed The patient with Cushing disease usually has paper-thin skin that is easily injured. The UAPs should use a lift or a draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed. Focus: Delegation, supervision

5. You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with additional history taking or physical assessment? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height

Ans: 2 History of counseling for body dysmorphic disorder Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization

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

Ans: 2 Monitoring the apical pulse, blood pressure, and temperature every 4 hours Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training. Focus: Delegation, supervision, assignment

8. For the patient with pheochromocytoma, which physical assessment technique should you instruct an LPN/LVN to avoid? 1. Listening for abdominal bowel sounds in all four quadrants 2. Palpating the abdomen in all four quadrants 3. Checking the blood pressure every hour 4. Assessing the mucous membranes for hydration status

Ans: 2 Palpating the abdomen in all four quadrants Palpating the abdomen can cause the sudden release of catecholamines and severe hypertension. Focus: Delegation, supervision

21. You are the charge nurse. Which patient will you assign to a nurse floated to your unit from the surgical intensive care unit (ICU)? 1. Patient with kidney stones scheduled for lithotripsy this morning 2. Patient who has just undergone surgery for renal stent placement 3. Newly-admitted patient with an acute UTI 4. Patient with chronic kidney failure who needs teaching on peritoneal dialysis

Ans: 2 Patient who has just undergone surgery for renal stent placement A nurse from the surgical ICU will be thoroughly familiar with the care of patients who have just undergone surgery. The patient scheduled for lithotripsy may need education about the procedure. The newly-admitted patient needs an in-depth admission assessment, and the patient with chronic kidney failure needs teaching about peritoneal dialysis. All of these interventions would best be accomplished by an experienced nurse with expertise in the care of patients with kidney problems. Focus: Assignment

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

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

23. You must rearrange the room assignments for several clients. Which two clients would be best to put in the same room? 1. 35-year-old woman with copious intractable diarrhea and vomiting 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis 4. 62-year-old woman with colon cancer receiving chemotherapy and radiation _____, _____

Ans: 2, 3 2. 43-year-old woman who underwent cholecystectomy 2 days ago 3. 53-year-old woman with pain related to alcohol-associated pancreatitis Both clients will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting will frequently need enteric isolation. Cancer clients receiving chemotherapy are at risk for immunosuppression and are likely to need protective isolation. Focus: Assignment

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

Ans: 2, 4, 5 2. Administering oral glucose tablets when blood glucose level falls below 60 mg/dL 4. Obtaining blood glucose readings using the child's blood glucose monitor 5. Reminding the child to have a snack after the physical education class National guidelines published by the American Diabetes Association (ADA) indicate that administration of emergency treatment for hypoglycemia, obtaining blood glucose readings, and reminding children are appropriate tasks for non-health care professional personnel such as teachers, paraprofessionals, and unlicensed health care personnel. Assessments and education require more specialized education and scope of practice and should be done by the school nurse. Focus: Delegation

17. You are caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination you note wound evisceration. Place in order the steps for handling this complication. 1. Cover the intestine with sterile moistened gauze. 2. Stay calm and stay with the client. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the physician. 5. Put the client into semi-Fowler position with knees slightly flexed. 6. Prepare the client for surgery as ordered. _____, _____, _____, _____, _____, _____

Ans: 2, 5, 3, 4, 1, 6 2. Stay calm and stay with the client. 5. Put the client into semi-Fowler position with knees slightly flexed. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the physician. 1. Cover the intestine with sterile moistened gauze. 6. Prepare the client for surgery as ordered. Stay calm and stay with the client. Any increase in intra-abdominal pressure will worsen the evisceration; placement of the client in a semi-Fowler position with knees flexed will decrease the strain on the wound site. (Note: If shock develops, the client's head should be lowered.) Continuously monitor vital signs, particularly for a decrease in blood pressure or increase in pulse rate, while your colleague gathers supplies and notifies the physician. Covering the site protects tissue. Ultimately, the client will need emergency surgery. Focus: Prioritization

1. When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to the UAP? 1. Explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. Reinforcing "nothing by mouth" status 8 hours before the procedure 3. Administering laxatives 1 to 3 days before the procedure 4. Administering an enema the night before the procedure

Ans: 2. Reinforcing "nothing by mouth" status 8 hours before the procedure The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation

24. The patient with type 2 diabetes is "nothing by mouth" (NPO) for a cardiac catheterization. An LPN/LVN who is administering medications to this patient asks you (the supervising RN) whether the patient should receive his ordered repaglinide (Prandin). What is your best response? 1. "Yes, because this drug will increase the patient's insulin secretion and prevent hyperglycemia." 2. "No, because this drug may cause the patient to experience gastrointestinal symptoms such as nausea." 3. "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO." 4. "Yes, because this drug should be taken 3 times a day whether the patient eats or not."

Ans: 3 "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO." Repaglinide is a meglitinide analog drug. These drugs are short-acting agents used to prevent postmeal blood glucose elevation. They should be given within 1 to 30 minutes before meals and cause hypoglycemia shortly after dosing when a meal is delayed or omitted. Focus: Supervision, delegation, prioritization

12. You are supervising a nurse on orientation to the unit who is discharging a patient admitted with kidney stones who underwent lithotripsy. Which statement by the nurse to the patient requires that you intervene? 1. "You should finish all of your antibiotics to make sure that you don't get a UTI." 2. "Remember to drink at least 3 L of fluids every day to prevent another stone from forming." 3. "Report any signs of bruising to your physician immediately, since this indicates bleeding." 4. "You can return to work in 2 days to 6 weeks, depending on what your physician prescribes."

Ans: 3 "Report any signs of bruising to your physician immediately, since this indicates bleeding." Bruising is to be expected after lithotripsy. It may be quite extensive and take several weeks to resolve. All of the other statements are accurate for a patient after lithotripsy. Focus: Prioritization

6. You are supervising a new RN graduate who is on orientation to the unit. The new RN asks you why the patient with uncomplicated cystitis is being discharged with orders for ciprofloxacin (Cipro) 250 mg twice a day for only 3 days. What is your best response? 1. "We should check with the physician, because the patient should take this drug for 10 to 14 days." 2. "A 3-day course of ciprofloxacin is not the appropriate treatment for a patient with uncomplicated cystitis." 3. "Research has shown that, with a 3-day course of ciprofloxacin, there is increased patient adherence to the plan of care." 4. "Longer courses of antibiotic therapy are required for hospitalized patients to prevent nosocomial infections."

Ans: 3 "Research has shown that, with a 3-day course of ciprofloxacin, there is increased patient adherence to the plan of care." For uncomplicated cystitis, a 3-day course of antibiotics is an effective treatment, and research has shown that patients are more likely to adhere to shorter antibiotic courses. Seven-day courses of antibiotics are appropriate for complicated cystitis, and 10- to 14-day courses are prescribed for uncomplicated pyelonephritis. This patient is being discharged and should not be at risk for a nosocomial infection. Focus: Prioritization, supervision

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

Ans: 3 58-year-old with hypothyroidism and a heart rate of 48 beats/min Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/min is within normal limits. The diabetic patient may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema. Focus: Prioritization

19. You are caring for the following patients with endocrine disorders. Which one must you assess first? 1. 21-year-old with diabetes insipidus whose urine output overnight was 2000 mL 2. 55-year-old with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the UAP refill his water pitcher 3. 65-year-old with Addison disease whose morning potassium level is 6.2 mEq/L 4. 48-year-old with Cushing disease with a weight gain of 1.5 lb over the past 4 days

Ans: 3 65-year-old with Addison disease whose morning potassium level is 6.2 mEq/L This patient's potassium level is very high, placing the patient at risk for cardiac dysrhythmias that could be life threatening. The other patients need to be seen also, but are not as urgent as this patient. Focus: Prioritization

14. A patient has newly-diagnosed type 2 diabetes. Which action should you assign to an LPN/LVN instead of a UAP? 1. Measuring the patient's vital signs every shift 2. Checking the patient's glucose level before each meal 3. Administering subcutaneous insulin on a sliding scale as needed 4. Assisting the patient with morning care

Ans: 3 Administering subcutaneous insulin on a sliding scale as needed The UAP's scope of practice includes checking vital signs and assisting with morning care. UAPs with special training can check the patient's glucose level before meals. It is generally not within the UAP's scope of practice to administer medications, but this is within the scope of practice of the LPN/LVN. Focus: Assignment

14. You are planning a treatment and prevention program for chronic fecal incontinence for an elderly client. Which intervention should you try first? 1. Administer a glycerin suppository 15 minutes before evacuation time. 2. Insert a rectal tube at specified intervals each day. 3. Assist the client to the bedpan or toilet 30 minutes after meals. 4. Use incontinence briefs or adult-sized diapers.

Ans: 3 Assist the client to the bedpan or toilet 30 minutes after meals. The goal of bowel training is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal. If this is not successful, a suppository can be used to stimulate the urge. The use of incontinence briefs is embarrassing for the client, and they must be changed frequently to prevent skin breakdown. Routine use of rectal tubes is not recommended because of the potential for damage to the mucosa and sphincter tone. Focus: Prioritization

10. The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN/LVN? 1. Obtaining an oversized blood pressure cuff and a large-size bed 2. Setting up a reinforced trapeze bar 3. Assisting in the planning of toileting, turning, and ambulation 4. Assigning tasks to UAPs and other ancillary staff

Ans: 3 Assisting in the planning of toileting, turning, and ambulation The LPN/LVN can assist in the planning of interventions, but the RN should take ultimate responsibility for planning. The LPN/LVN can delegate and assign tasks to UAPs; however, if the RN is in charge, it is better if UAPs are not receiving instructions from multiple people. Obtaining equipment should be delegated to a UAP. A physical therapist should be contacted to set up specialized equipment. Focus: Delegation

25. You are caring for a client who was admitted to your medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to the UAP? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check the urine in the urometer every hour and observe for red- or pink-tinged urine. 3. Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.

Ans: 3 Check vital signs every hour and report all of the values. The UAP can take vital signs and report all of the values to the RN. In this case, all of the values are needed in order to detect trends. In other cases, you may decide to give parameters for reporting. The RN should assess skin temperature and pain, and closely monitor the urine because quantity is an indicator of perfusion and red/pink urine can signal damage to the urinary system, transfusion reaction, or rhabdomyolysis. Focus: Delegation

13. As charge nurse, you must rearrange room assignments to admit a new patient. Which two patients would be best suited to be roommates? 1. 58-year-old with urothelial cancer receiving multiagent chemotherapy 2. 63-year-old with kidney stones who has just undergone open ureterolithotomy 3. 24-year-old with acute pyelonephritis and severe flank pain 4. 76-year-old with urge incontinence and a UTI _____, _____

Ans: 3, 4 3. 24-year-old with acute pyelonephritis and severe flank pain 4. 76-year-old with urge incontinence and a UTI Both these patients will need frequent assessments and medications. The patient receiving chemotherapy and the patient who has just undergone surgery should not be exposed to any patient with infection. Focus: Assignment

13. You are caring for a client with a nasogastric (NG) tube. Which task can be delegated to an experienced UAP? 1. Removing the NG tube per physician order 2. Securing the tape if the client accidentally dislodges the tube 3. Disconnecting the suction to allow ambulation to the toilet 4. Reconnecting the suction after the client has ambulated

Ans: 3 Disconnecting the suction to allow ambulation to the toilet Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse, so that correct pressure is checked. If the UAP is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured. Focus: Delegation

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

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

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

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

29. A client with end-stage liver disease is talking to you about being on the transplant list. Which statement by the client concerns you the most? 1. "I have a family history of diabetes." 2. "I had symptoms of asthma when I was a kid." 3. "I am going to cut down on my drinking very soon." 4. "I am not very good about taking prescribed medication."

Ans: 3 I am going to cut down on my drinking very soon." Substance abuse may exclude a person from the transplant list, so the nurse should conduct additional assessment about this comment. The comment about difficulty in taking prescription medications should also be investigated because a true inability to follow the treatment regimen would also exclude the client from the list. Focus: Prioritization

8. You are creating a nursing care plan for older adult patients with incontinence. For which patient will a bladder-training program be an appropriate intervention? 1. Patient with functional incontinence caused by mental status changes 2. Patient with stress incontinence due to weakened bladder neck support 3. Patient with urge incontinence and abnormal detrusor muscle contractions 4. Patient with transient incontinence related to loss of cognitive function

Ans: 3 Patient with urge incontinence and abnormal detrusor muscle contractions A patient with urge incontinence can be taught to control the bladder as long as the patient is alert, aware, and able to resist the urge to urinate by starting a schedule for voiding, then increasing the intervals between voids. Patients with functional incontinence related to mental status changes or loss of cognitive function will not be able to follow a bladder-training program. A better treatment for a patient with stress incontinence is exercises such as pelvic floor (Kegel) exercises to strengthen the pelvic floor muscles. Focus: Prioritization

28. You are caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. For the nursing diagnosis of Excess Fluid Volume, which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing to baseline

Ans: 3 Performing daily weights with the same amount of clothing All of these measures should be performed for total care of the client; however weighing the client every day is considered the single best indicator of fluid volume. Focus: Prioritization

4. An LPN/LVN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

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

7. In the care of a client with gastroesophageal reflux disease, which task would be appropriate to assign to a UAP? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals

Ans: 3 Reminding the client not to lie down for 2 to 3 hours after eating Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing client concerns. Focus: Delegation

18. You are providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the physician? 1. The client cannot void 5 hours postoperatively. 2. The client reports shoulder pain. 3. The client reports right upper quadrant pain. 4. Output does not equal input for the first few hours.

Ans: 3 The client reports right upper quadrant pain. Right upper quadrant pain is a sign of hemorrhage or bile leak. The ability to void should return within 6 hours postoperatively. Right shoulder pain is related to unabsorbed carbon dioxide and will be resolved by placing the client in Sims position. Output that does not equal input after surgery for the first several hours is expected. Focus: Prioritization

16. While transferring a dirty laundry bag, a UAP sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome (AIDS); the needle source is unknown. Place in order of priority the instructions that should be given to the UAP. 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 5. Follow up for results and counseling. 6. Begin prophylactic drug therapy. _____, _____, _____, _____, _____, _____

Ans: 3, 4, 1, 2, 6, 5 3. Perform a thorough aseptic hand washing. 4. Report to the occupational health nurse. 1. Have blood test(s) performed per protocol. 2. Complete and file an incident report. 6. Begin prophylactic drug therapy. 5. Follow up for results and counseling. Immediate decontamination is appropriate, because time can affect viral load. The occupational health nurse will direct the UAP in filing the correct forms, getting the appropriate laboratory tests, obtaining appropriate prophylaxis, and following up on results. Focus: Prioritization, supervision

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

Ans: 4 "I will gradually wean myself off the vasopressin." A patient with permanent diabetes insipidus requires lifelong vasopressin therapy. All of the other statements are appropriate to the home care of this patient. Focus: Prioritization

7. A 28-year-old married female patient with cystitis requires instruction about how to prevent future UTIs, and you have delegated this teaching to a newly-graduated RN. Which statement by the new nurse requires that you intervene? 1. "You should always drink 1 to 3 L of fluid every day." 2. "Empty your bladder regularly even if you do not feel the urge to urinate." 3. "Drinking cranberry juice daily will decrease the number of bacteria in your bladder." 4. "It's okay to soak in the tub with bubble bath because it will keep you clean."

Ans: 4 "It's okay to soak in the tub with bubble bath because it will keep you clean." Women should avoid irritating substances such as bubble bath, nylon underwear, and scented toilet tissue to prevent UTIs. Adequate fluid intake, consumption of cranberry juice, and regular voiding are all good strategies for preventing UTIs. Focus: Delegation, supervision, prioritization

25. You are caring for a patient admitted with dehydration secondary to deficient antidiuretic hormone (ADH). Which specific gravity value supports this diagnosis? 1. 1.010 2. 1.035 3. 1.020 4. 1.002

Ans: 4 1.002 A patient with dehydration due to deficient ADH would have diluted urine with a decreased urine specific gravity. Normal urine specific gravity ranges from 1.003 to 1.030. A specific gravity of 1.035 would indicate urine that is concentrated. Focus: Prioritization

14. The nursing diagnosis of Constipation related to compression of the intestinal tract has been identified in a patient with polycystic kidney disease. Which nursing care action should you delegate to a newly-trained LPN/LVN? 1. Instructing the patient about foods that are high in fiber 2. Teaching the patient about foods that assist in promoting bowel regularity 3. Assessing the patient for previous bowel problems and bowel routine 4. Administering docusate sodium (Colace) 100 mg by mouth twice a day

Ans: 4 Administering docusate sodium (Colace) 100 mg by mouth twice a day Administering oral medications appropriately is covered in the educational program for LPNs/LVNs and is within their scope of practice. Teaching and assessing the patient require additional education and skill and are appropriate to the scope of practice of RNs. Focus: Delegation, supervision

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

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

9. Which client is the most appropriate to assign to an LPN/LVN, under the supervision of an RN? 1. Client with oral cancer who is scheduled in the morning for glossectomy 2. Obese client returned from surgery after a vertical banded gastroplasty 3. Client with anorexia nervosa who has muscle weakness and decreased urine output 4. Client with intermittent nausea and vomiting related to chemotherapy

Ans: 4 Client with intermittent nausea and vomiting related to chemotherapy Nausea and vomiting are common after chemotherapy. Administration of antiemetics and fluid monitoring can be done by an LPN/LVN. The RN should perform the preoperative teaching for the glossectomy client. Clients returning from surgery need extensive assessment. The client with anorexia is showing signs of hypokalemia and is at risk for cardiac dysrhythmias. Focus: Assignment

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

Ans: 4 Crackles bilaterally in the lower lobes of the lungs The presence of crackles in the patient's lungs indicate excess fluid volume due to excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients with Cushing disease. These findings should be monitored but do not require urgent action. Focus: Prioritization

2. You would be most concerned about an order for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur

Ans: 4 Fractured femur A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization

20. The experienced UAP has been delegated to take vital signs and check fingerstick glucose on a diabetic patient who is postoperative. Which vital sign change would you instruct the UAP to report immediately? 1. Blood pressure increase from 132/80 mm Hg to 138/84 mm Hg 2. Temperature increase from 98.4° F (36.8° C) to 99° F (37.2° C) 3. Respiratory rate increase from 18 breaths/min to 22 breaths/min 4. Glucose increase from 190 mg/dL to 236 mg/dL

Ans: 4 Glucose increase from 190 mg/dL to 236 mg/dL An unexpected rise in blood glucose is associated with increased mortality and morbidity after surgical procedures. Current ADA guidelines recommend insulin protocols to maintain blood glucose levels between 140 and 180 mg/dL. Also, unexpected rises in blood glucose values may indicate wound infection. Focus: Delegation, supervision, prioritization

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

Ans: 4 Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm Monitoring vital signs is within the education and scope of practice for UAPs. The nurse should be sure to instruct the UAP that blood pressure measurements are to be taken with the cuff on the same arm each time. Revising the care plan and instructing and assessing patients are beyond the scope of UAPs and fall within the purview of licensed nurses. Focus: Assignment

16. While working in the diabetes clinic, you obtain this information about an 8-year-old with type 1 diabetes. Which finding is most important to address when planning child and parent education? 1. Most recent hemoglobin A1c level of 7.8% 2. Many questions about diet choices from the parents 3. Child's participation in soccer practice after school 2 days a week 4. Morning preprandial glucose range of 55 to 70 mg/dL

Ans: 4 Morning preprandial glucose range of 55 to 70 mg/dL The low morning fasting blood glucose level indicates possible nocturnal hypoglycemia. Research indicates that it is important to avoid hypoglycemic episodes in pediatric patients because of the risk for permanent neurologic damage and adverse developmental outcomes. Although a lower hemoglobin A1c might be desirable, the upper limit for hemoglobin A1c levels ranges from 7.5% to 8.5% in pediatric patients. The parents' questions about diet and the child's activity level should also be addressed, but the most urgent consideration is education about the need to avoid hypoglycemia. Focus: Prioritization

1. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? 1. Teaching the patient how to secure a clean-catch urine sample 2. Assessing the patient's urine for color, odor, and sediment 3. Reviewing the nursing care plan and add nursing interventions 4. Providing the patient with a clean-catch urine sample container

Ans: 4 Providing the patient with a clean-catch urine sample container Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision

10. You are providing care for a patient with reflex urinary incontinence. Which action could be appropriately delegated to a new LPN/LVN? 1. Teaching the patient bladder emptying by the Credé method 2. Demonstrating how to perform intermittent self-catheterization 3. Discussing the side effects of bethanechol chloride (Urecholine) 4. Reinforcing the importance of proper hand washing to prevent infection

Ans: 4 Reinforcing the importance of proper hand washing to prevent infection Teaching about bladder emptying, self-catheterization, and medications requires additional knowledge and training and is appropriate to the scope of practice of the RN. The LPN/LVN can reinforce information that has already been taught to the patient. Focus: Delegation, supervision

2. A patient has newly-diagnosed type 2 diabetes. Which task should you delegate to a UAP? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Reminding the patient to check glucose level before each meal

Ans: 4 Reminding the patient to check glucose level before each meal The UAP's role includes reminding patients about interventions that are already part of the plan of care. Arranging for a consult with the dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurses. Focus: Delegation, supervision, assignment

11. A client with proctitis needs a rectal suppository. A senior nursing student assigned to care for this client tells you that she is afraid to insert a suppository because she has never done it before. What is the most appropriate action in supervising this student? 1. Give the medication yourself and tell the student to talk to the instructor. 2. Ask the student to leave the clinical area because she is unprepared. 3. Reassign the client to an LPN/LVN and send the student to observe. 4. Show the student how to insert the suppository and talk to the instructor.

Ans: 4 Show the student how to insert the suppository and talk to the instructor. Showing the student how to insert the suppository meets both the immediate client need and the student's learning need. The instructor can address the student's fears and long-term learning needs once he or she is aware of the incident. It is preferable that students express fears and learning needs. The other options will discourage the student's future disclosure of clinical limitations and need for additional training. Focus: Supervision, assignment

7. A UAP tells you that, while assisting with the morning care of a postoperative patient with type 2 diabetes who has been given insulin, the patient asked if she will always need to take insulin now. What is your priority for teaching the patient? 1. Explain to the patient that she is now considered to have type 1 diabetes. 2. Tell the patient to monitor fingerstick glucose level every 4 hours after discharge. 3. Teach the patient that a person with type 2 diabetes does not always need insulin. 4. Talk with the patient about the relationship between illness and increased glucose levels.

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

5. A patient is being admitted to rule out interstitial cystitis. What should your plan of care for this patient include? 1. Take daily urine samples for urinalysis. 2. Maintain accurate intake and output records. 3. Obtain an admission urine sample to determine electrolyte levels. 4. Teach the patient about the cystoscopy procedure.

Ans: 4 Teach the patient about the cystoscopy procedure. A cystoscopy is needed to accurately diagnose interstitial cystitis. Urinalysis may show WBCs and RBCs, but no bacteria. The patient will probably need a urinalysis upon admission, but daily samples do not need to be obtained. Intake and output may be assessed, but results will not contribute to the diagnosis. Cystitis does not usually affect urine electrolyte levels. Focus: Prioritization

24. You are caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate for the care of this client? 1. Tell the unit secretary to call radiology and schedule a barium enema. 2. Instruct the LPN/LVN to give PRN laxatives when the client reports constipation. 3. Advise the nursing student to help the client ambulate up and down the hall. 4. Tell the UAP that a stool specimen must be saved to test for occult blood.

Ans: 4 Tell the UAP that a stool specimen must be saved to test for occult blood. Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood. A barium enema is not usually ordered because of the danger of perforation. Laxatives and ambulation increase intestinal motility and are to be avoided in the initial phase of treatment. If a barium enema, PRN laxative, or ambulation is ordered, question the orders before delegating these interventions. Focus: Delegation

6. You are taking report on an elderly client who was admitted with abdominal pain and nausea, vomiting, and diarrhea. The client also has a history of chronic dementia. Which comment by the night shift nurse concerns you the most? 1. The client has a flat affect and rambling and repetitive speech. 2. The client has memory impairments and thinks the year is 1948. 3. The client lacks motivation and demonstrates early morning awakening. 4. The client has a fluctuating level of consciousness and mood swings.

Ans: 4 The client has a fluctuating level of consciousness and mood swings. Fluctuating level of consciousness and mood swings are associated more with acute delirium, which could be caused by many things, such as electrolyte imbalances, sepsis, or medications. Information about the client's baseline behavior is essential; however, based on your knowledge of pathophysiology, you know that flat affect and rambling and repetitive speech, memory impairments, and disorientation to time are behaviors typically associated with chronic dementia. Lack of motivation and early morning awakening are associated with depression. Focus: Prioritization

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

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

4. You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious? 1. Projectile vomiting 2. Burning sensation 2 hours after eating 3. Coffee-ground emesis 4. Boardlike abdomen with shoulder pain

Ans: 4. Boardlike abdomen with shoulder pain A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization

26. Place the steps for performing colostomy care in the correct order. 1. Fit the pouch snugly around the stoma. 2. Assess the color and appearance of the stoma. 3. Wash the skin with mild soap and rinse with warm water. 4. Apply a skin barrier to protect the peristomal skin. 5. Dry the skin carefully. 6. Don a pair of clean gloves and remove the old pouch. _____, ____, _____, _____, _____, _____

Ans: 6, 2, 3, 5, 4, 1 6. Don a pair of clean gloves and remove the old pouch. 2. Assess the color and appearance of the stoma. 3. Wash the skin with mild soap and rinse with warm water. 5. Dry the skin carefully. 4. Apply a skin barrier to protect the peristomal skin. 1. Fit the pouch snugly around the stoma. A pair of clean gloves should be put on before touching the skin or pouch. The stoma should be assessed for a healthy pink color. Washing, rinsing, and drying the skin and applying a skin barrier help to protect the skin. A good fit prevents gastric contents from spilling onto the skin. Focus: Prioritization

3. You are preparing to administer TPN through a central line. Place the following steps for administration in the correct order. 1. Use aseptic technique when handling the injection cap. 2. Thread the IV tubing through an infusion pump. 3. Check the solution for cloudiness or turbidity. 4. Connect the tubing to the central line. 5. Select and flush the correct tubing and filter. 6. Set the infusion pump at the prescribed rate. 7. Confirm the order for TPN prior to administration. _____, _____, _____, _____, _____, _____, _____

Ans: 7, 3, 5, 2, 1, 4, 6 7. Confirm the order for TPN prior to administration. 3. Check the solution for cloudiness or turbidity. 5. Select and flush the correct tubing and filter. 2. Thread the IV tubing through an infusion pump. 1. Use aseptic technique when handling the injection cap. 4. Connect the tubing to the central line. 6. Set the infusion pump at the prescribed rate. Always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization