uworld leadership

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf ache with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airplane trip

1. An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure.

two triggers of autonoic dysreflexia

bladder/rectum distention and pressure ulcers

3 ways to treat rotator cuff injury

imaging, NSAIDs, and physical therapy

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? 1. Client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void 2. Client being discharged after deep vein thrombosis who needs teaching on how to self-administer enoxaparin injections 3. Client who has just been admitted to the telemetry unit from the emergency department with a rule-out myocardial infarction 4. Client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure <150 mm Hg; currently is 110/62 mm Hg

1 The charge nurse should assign the most stable and predictable client to the LPN. The client who needs to have a urinary catheter reinserted is within the scope of practice for the LPN. The other clients need nursing interventions that require independent nursing knowledge, skill, and judgment such as assessment, client teaching, and evaluation of care.

A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a tube." What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply. 1. Document this communication in the electronic health record 2. Encourage the client to discuss this decision with the health care proxy 3. Facilitate completion of an advance directive that reflects the client's decision 4. Obtain a signed informed consent from the client 5. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order

1,2,3 Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record (Option 1) Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future (Option 3) Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client (Option 2) The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. (Option 4) An informed consent is necessary for the client or surrogate decision maker to approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed consent is to obtain and witness a signature once the HCP has explained the procedure, its risks and benefits, and answered any questions. This client is not providing consent for any procedure at this time. (Option 5) A DNR order is used to prevent resuscitation in someone with a life-limiting illness. A DNR order does not provide direction for nutrition supplementation.

The registered nurse (RN) is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client to the bathroom 2. Deciding if supplemental oxygen is necessary when the client is ambulating 3. Documenting vital signs in the electronic medical record 4. Notifying the nurse immediately if the client's respirations exceed 20/min 5. Reapplying the nasal cannula if it accidentally comes off

1,3,4,5 Before assigning any task, the RN must assess the competency level of the UAP. The RN must review proper safety principles when using an oxygen delivery device and the procedure for reapplication of a nasal cannula before assigning the task. Meeting hygiene and elimination needs, documenting observations made during usual care (eg, shortness of breath) in the section of the medical record designated for the UAP, taking vital signs, and reapplying an oxygen delivery device (cannula) at the preset liter flow are tasks appropriate for an experienced UAP. However, any abnormal finding, such as shortness of breath, or change in vital signs (eg, respirations greater than 20/min), must be validated and assessed by the RN.

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all that apply. 1. "Elevate the right leg on two pillows." 2. "Measure client for compression stockings." 3. "Please let me know what the urine looks like." 4. "Tell me what the client eats at lunch." 5. "Verify wrist restraints are on correctly."

1,4 Elevate leg on 2 pillows is very specific and does not require specialized knowledge or skill (Option 1). Report what the client eats at lunch is data collection only (Option 4). The RN will analyze the data to see if the amount of food is adequate. (Option 2) The UAP may apply compression stockings or devices, but the RN or LPN should measure the client to choose the appropriate size as this is beyond the UAP's scope of practice. (Option 3) This involves an assessment that the RN should perform. The RN could ask for specific data, such as amount of urine or presence of blood clots. (Option 5) This requires a judgment (is the restraint tight enough/too tight and causing impaired circulation?) that the RN should make. The UAP could be assigned a specific task, such as offering a drink to the client.

Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5. Nonmaleficence is reporting abuse for a client with Alzheimer disease

1,4,5 Ethical principles guide decision making and appropriate behavior. Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Option 4). Accountability refers to accepting responsibility for one's actions and admitting errors (Option 1). Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia (Option 5).

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? 1. Assess skin to determine severity of burns and wounds 2. Assign client to a cot with other similarly triaged clients 3. Assist the client to the designated showering area 4. Prepare supplies to establish intravenous access

3. n the event of a disaster involving the release of hazardous substances (eg, bioterrorism, chemical warfare agents), decontamination is vital to limit injury to the client and prevent exposure to other clients and staff (Option 3). Disaster triage areas typically include a decontamination area (eg, showering station, cleansing station) that should be used to eliminate any residual hazardous materials and debris from the client.

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be prioritized for more definitive care? 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and photophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge 4. Client with sudden onset of the "worst headache of my life"

4. A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent bleeding and is the highest priority presentation. (Option 1) Gout is hyperuricemia. If not properly treated, urate crystal deposits (tophi) develop on the joints. Although gout can cause severe pain, it is not the highest priority. (Option 2) A headache in a client with a known history of migraines is not an urgent concern if it is the same as or similar to previous headaches. These clients usually have accompanying neurologic dysfunction such as nausea/vomiting or sensitivity to light or sound. (Option 3) Severe epigastric pain radiating to the back after an alcohol binge is most likely due to acute pancreatitis. It is a serious condition but usually not immediately life-threatening.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications [13%] 2. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain [16%] 3. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage [5%] 4. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting [63%]

4. An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. (Option 1) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary. (Option 2) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia). Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel. (Option 3) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are expected in a client with an infected venous leg ulcer. Educational objective:Intestinal obstruction and strangulated bowel are life-threatening complications associated with an incarcerated hernia and require immediate evaluation and urgent surgical intervention.

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse, and unlicensed assistive personnel (UAP). Which tasks can the charge nurse appropriately delegate to UAP? Select all that apply. 1. Apply protective skin ointment after perineal cleansing 2. Determine if a client has adequate relief after administration of an analgesic 3. Document daily weight for a client with congestive heart failure 4. Feed a client who had a stroke 24 hours after admission 5. Perform passive range-of-motion exercises for a client on a ventilator

1,3,5 Unlicensed assistive personnel (UAP) are assigned tasks for stable clients by the registered nurse (RN), who directs and manages overall client care. The RN cannot delegate the nursing process. UAP can perform active and passive range-of-motion exercises (Option 5). Under the direction of the RN, UAP can apply protective ointment (such as zinc oxide) after cleaning a client (Option 1). UAP can obtain data but the RN is responsible for interpreting (evaluating) it. For example, UAP can obtain objective data such as the client's height and weight, but the RN will analyze this data to determine the need in the nursing care plan (eg, effect on drug dosing) (Option 3). (Option 2) UAP can collect data (eg, an objective pain score), but the RN is responsible for evaluating if the relief is adequate. The word "adequate" refers to the evaluation of treatment and is not part of UAP scope of practice. The RN may consider other aspects (eg, vital signs, body language) when making such evaluations, especially in a nonverbal client. (Option 4) A stroke is not considered stabilized until approximately 48 hours have passed without changes. The client's risk of losing the gag reflex is still high as the stroke could be evolving. UAP should feed only stable clients. Educational objective:Unlicensed assistive personnel (UAP) can perform passive range-of-motion exercises, apply protective ointment, and obtain objective data for stable clients under the direction of a registered nurse. However, UAP cannot feed clients with potential dysphagia or make evaluations about treatment effectiveness.

A blizzard is predicted to hit a large city within a few hours. The home care nurse is prioritizing and revising the schedule and estimates that 3 home visits can be made before the blizzard hits. Which clients should the nurse see? Select all that apply. 1. A client who fell and hit the head but refuses to go to the emergency department 2. A client who is due for a maintenance dose of cyanocobalamin 3. A client who needs pre-filled insulin syringes 4. A client who was discharged from the hospital yesterday after heart failure treatment 5. A client with a stage 3 pressure injury in need of a dressing change

1,3,5 n this scenario, it is unknown when home care visits will resume due to severe inclement weather. The high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more. The client who fell could have sustained a head injury and needs assessment. The client in need of pre-filled insulin syringes could become hyperglycemic if insulin is unavailable. The client with the stage 3 pressure injury has a scheduled dressing change for a serious wound and this should not be postponed. (Option 2) Maintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks. Although this client should receive the injection as soon as possible, postponing the home care visit for 1 or 2 days will not harm the client. (Option 4) This client can be provided with telephonic care management; the nurse can perform medication reconciliation over the phone and provide instructions regarding care.

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met? 1. Chart audits indicate that client incidence of nosocomial pneumonia decreased by 20% 2. Documentation shows that 100% of nurses attended an inservice seminar on the topic 3. Nurses report an increased number of written reminders given to appropriate clients 4. Surgeons who admit to the unit report increased satisfaction with current client IS use

1.

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse? 1. "Would you mind answering the lights anyway?" 2. "I need you to answer the lights because we want to provide good client care." 3. Say nothing and answer the lights, but write up a disciplinary action 4. Tell the UAP that this is unacceptable and speak to the nurse manager

2 The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action. (Option 1) The request should not be given as an option as there is a legitimate need the UAP can meet. The nurse needs to be directive and assertive when indicating what needs to be done. (Option 3) This is an avoidance action and does not resolve the bigger issue. The nurse should attempt to rectify the issue first rather than focus on discipline. Discipline measures are appropriate if there is insubordination (the UAP refuses) or a pattern of behavior (on every shift the UAP does not answer lights despite being told). (Option 4) The nurse should give the UAP a chance to change behavior first. Speaking to the manager in the future does not resolve the current issue. The nurse can take this step if there is insubordination or a pattern of behavior. Educational objective: The nurse should use assertive communication techniques to deal with a staff member directly and immediately by telling rather than asking for certain actions. The nurse should not attack the individual's character or initially make threats (aggression) and should not avoid the issue by just performing the action itself (avoidance).

A client with a 10-year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? 1. "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems." 2. "I will talk with the HCP about your concerns, but in the meantime it's important that you stay here." 3. "It's important that you stay in the hospital so that we can treat you quickly if you have problems." 4. "You have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now."

1.

After the nurse receives the change-of-shift report, which client should the nurse assess first? 1. Client with asthma who has shortness of breath and high-pitched expiratory wheezing 2. Client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage 3. Client with heart failure who is short of breath and coughing up pink frothy sputum 4. Client with left pleural effusion and absent breath sounds in the left base

3. The ABC (airway, breathing, circulation) and Maslow's hierarchy of needs frameworks are commonly used to prioritize client needs. This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema (fluid filling the alveoli), a potentially life-threatening condition. This client's status has deteriorated from baseline, is potentially the most hemodynamically unstable, and should be assessed first. (Option 1) This client with shortness of breath and high-pitched expiratory wheezing is experiencing expected clinical manifestations of asthma and is the second most unstable client at this time. (Option 2) Diabetic stasis leg ulcers can be associated with large amounts of serous or serosanguineous drainage and is an expected manifestation. This client is not the most unstable at this time. (Option 4) Absent breath sounds in the lung base in this client with pleural effusion is an expected finding as the collection of fluid in the pleural space prevents the lung from expanding. This client is not the most unstable at this time.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea 2. Client receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago 3. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 4. Client with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site

4. Phlebitis is an inflammation of a vein. Common manifestations include pain, swelling, warmth at the site, and redness extending along the vein. Causes include irritating drugs (eg, vancomycin), catheter movement within the vein (eg, inadequate stabilization), or bacteria (eg, poor aseptic technique). If signs of phlebitis are present, immediate removal of the catheter is necessary as phlebitis can lead to thrombophlebitis and emboli or a bloodstream infection.

magnesium normal levels

1.5 -2.5

neonates resting pulse

110-160

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? 1. Client with anemia who began receiving a unit of packed red blood cells 1 hour ago 2. Client with hemoglobin of 7 g/dL (70 g/L) who needs to be started on IV iron therapy 3. Client with seizure activity who received lorazepam 20 minutes ago 4. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour

3 A client with seizure activity should be assessed as soon as possible after a hand-off report due to increased risk for recurrent seizures, injury, aspiration, and airway obstruction.

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan

2,4,5 Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury. The risk fall assessment should be adjusted. Option 5 is an avoidable delay in application of a test, which will affect timely diagnosis. The nurse should advocate for a more timely completion of the test. Option 2 is a failure to provide appropriate treatment and has a direct correlation for worsening cellulitis.

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation 4. Client with spontaneous rupture of membranes with greenish amniotic fluid

4. reen amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary. (Option 1) Neonates born to mothers with gestational diabetes are at risk for hypoglycemia after birth and should be monitored closely during the first 6 hours of life. The risk of newborn hypoglycemia is lower if the mother's diabetes is well-controlled and not insulin-dependent. (Option 2) Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention. Maternal magnesium therapy can cause newborn respiratory depression at birth. However, this client's mild preeclampsia does not require magnesium therapy. (Option 3) Premature rupture of membranes (PROM) refers to the rupture of membranes prior to the onset of labor at term gestation (≥37wk 0d). PROM on its own does not harm the fetus. However, if labor does not begin after PROM, induction of labor may be necessary to decrease the risk for infection (eg, chorioamnionitis). Educational objective:Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome. A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization.

infant normal respiratory rate

30 to 60

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg/dL." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1,4,5 Acceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point.

The registered nurse (RN) is caring for a postoperative client who becomes short of breath on the night of surgery and initiates the prn prescription for oxygen at 3 L/min by nasal cannula. The client makes frequent requests to use the bathroom during the night. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client to the bathroom 2. Deciding if supplemental oxygen is necessary when the client is ambulating 3. Documenting vital signs in the electronic medical record 4. Notifying the nurse immediately if the client's respirations exceed 20/min 5. Reapplying the nasal cannula if it accidentally comes off

1,3,4,5 Administration of oxygen is considered similar to administration of a medication and is therefore the responsibility of the RN; it would not be delegated to UAP. However, the UAP may reapply the oxygen delivery device and make and record observations related to oxygen therapy. Any abnormal findings must be reported to the RN for validation and assessment. Additional Information Management of Care NCSBN Client Need

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply. 1. "A continuous IV heparin infusion was initiated at 18 units/kg/hr at 0800, and the infusion bag will need to be replaced at 2100." 2. "I gave acetaminophen 500 mg PO to the client for a headache, with good relief." 3. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale of 0-10." 4. "The client's sisters visited today and were very rude, but they did bring the client's medication list." 5. "The radiology department called to say that an ultrasound will be performed at 2100."

1,3,5 A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: Provide identifying information (eg, client's name and room number). Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option 1). Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3). Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5). Relay significant client changes in a clear manner (ie, assessment, interventions, outcomes, evaluation).

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? Select all that apply.1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1,4 Everyone on the health care team contributes to the client's pain management. The registered nurse (RN) is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain (ie, P - provocation/palliation, Q - quality, R - region/radiation, S - severity, T - timing); performing initial client and caregiver teaching, including discharge instructions; and evaluating the effectiveness of the care plan (Options 2 and 5). The nurse should always consider the 5 rights of delegation prior to delegating a task. In this case, the RN may delegate the following tasks to the licensed practical nurse (LPN): Administering oral pain medication; individual practice region and facility policy will determine which of the various routes of medication the LPN is permitted to use (Option 1) Monitoring current objective pain level (numeric scale) (Option 4) (Option 3) The RN should delegate vital sign measurement to the unlicensed assistive personnel (UAP). Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more efficient use of resources. The RN should provide instructions regarding timing of vital sign measurement and is responsible for evaluating the client's vital signs. Educational objective:The registered nurse is responsible for assessing pain characteristics, developing the care plan, and providing initial and discharge teaching. A licensed practical nurse may monitor pain level and administer pain medication. The nurse should consider the 5 rights of delegation and effective use of resources when delegating tasks.

The nurse is caring for a client in soft wrist restraints. Which tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply. 1. Assist the client with using a bedpan 2. Check pulses and sensation of extremities 3. Observe skin for signs of impairment 4. Perform range-of-motion exercises 5. Turn and reposition the client in bed

1,4,5 Delegating care to unlicensed assistive personnel (UAP) requires understanding of both body policies and staff member training. UAP may assist with care of stable clients related to tasks of basic hygiene (eg, bathing, toileting) and daily living (eg, feeding, positioning, range-of-motion exercises); measurement and documentation of vital signs and intake and output; and technical skills (eg, capillary blood glucose monitoring, IV catheter removal) with appropriate training (Options 1, 4, and 5). Assurance of appropriateness and completion of delegated tasks remain the duty of the nurse. (Options 2 and 3) When physical restraints are applied to a client, the nurse is responsible for the primary and ongoing assessments (eg, skin integrity, peripheral pulses, neurovascular status), determining appropriateness of restraint type, need for continued use, and psychological response. These tasks may not be delegated to the UAP. The UAP may report changes in these areas if noted but must not be expected to monitor for changes.

The registered nurse (RN) is working with unlicensed assistive personnel (UAP). Which task can the RN safely delegate to the UAP? 1. Assisting a 2-day postoperative hip arthroplasty client with morning care [74%] 2. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter [21%] 3. Initial change of colostomy bag for a client who is 1-day postoperative colostomy [0%] 4. Refilling the empty enteral feeding container with tube feeding [3%]

1. The RN should always observe the 5 rights of delegation when considering appropriate task assignments. Bathing along with mouth and skin care are standardized, routine procedures. Therefore, the RN can delegate to the UAP the task of assisting the 2-day postoperative client with morning care. A client who is 2-days postoperative hip arthroplasty is usually stable, but the nurse can reassess the delegated tasks if the client's condition changes. (Option 2) Specimen collection from a Foley catheter is considered a sterile procedure. It involves accessing a sterile collection port, but there is a risk of introducing bacteria into the closed drainage system if done improperly. However, the UAP or even the client may collect a clean-catch or midstream urine specimen when appropriate instructions are given. (Option 3) Changing the colostomy bag for a client with an established stoma (not fresh) can be delegated by the RN to the UAP. However, the RN must first assess the appearance and function of the new colostomy stoma during the initial bag change. This requires nursing knowledge and judgment. The RN is also responsible for providing both initial client education regarding the new colostomy and emotional support as many clients have difficulty adjusting to the change in body image. (Option 4) The RN does not delegate care related to enteral feedings to the UAP as this requires professional nursing skills regarding abdominal and placement assessment, aspiration of residual volumes, and irrigation. Educational objective:The UAP with the skills and knowledge can perform standardized procedures (eg, assisting a client with morning care, emptying a colostomy bag in a client with an established stoma). However, UAP are not responsible for sterile procedures, enteral feedings, or performing standardized procedures in an unstable client as these require the RN's knowledge, judgment, and skill.

The nurse has received report on 4 clients. Which client should the nurse see first? 1. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated 2. Client scheduled for surgery in 2 hours who has questions about the procedure 3. Client who had a colostomy yesterday and now has a leaking colostomy bag 4. Client with a total hip replacement 3 days ago who reports no bowel movement in 2 days

1. Acute pyelonephritis is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the kidney and can be life-threatening. Initial treatment includes vigorous parenteral IV fluids and IV antibiotics. This client's needs are the priority as treatment is dependent on patent IV access. (Option 2) A client scheduled for surgery who has questions about the procedure will need to speak to the health care provider (HCP). The nurse should arrange this as soon as possible as the surgery is scheduled in 2 hours. This client is the second priority. (Option 3) A colostomy is a surgical opening (stoma) in the abdominal wall through which a section of large intestine is brought outside the body, either temporarily or permanently. A colostomy bag is placed over the stoma to collect stool. It is very important that the bag have a good fit and seal around the stoma to prevent skin breakdown due to leaking stool. The colostomy bag can leak if not emptied or cared for properly. This client needs assessment but is not a priority over the client with acute pyelonephritis. (Option 4) The client who had a total hip replacement and reports no bowel movement for 2 days requires assessment. Postoperative pain medications often cause constipation, and client teaching about the importance of adequate fluid and fiber intake needs to be reinforced. The nurse should check the medical record for a prescription for a PRN stool softener, laxative, or enema; if it is not included, the nurse should contact the HCP for further instructions. Educational objective:Clients with acute pyelonephritis require aggressive IV fluids and IV antibiotics to stop progression of the infection and kidney scarring. A patent IV line is the priority.

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

1. mmediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit. (Option 2) Mild oozing of blood from the surgical site is normal during the postoperative period. The nurse will note the amount and appearance of the drainage, reinforce the dressings, and continue to monitor the client. This client would be seen third. (Option 3) Pain control after surgery is important for client recovery. Because short-acting pain medications are given to minimize respiratory depression, a client's pain can increase quickly. This client would be seen second. (Option 4) After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period. This client would be seen last.

The registered nurse (RN) is caring for a postoperative client with a Hemovac drain. Which task is inappropriate for the RN to ask the experienced unlicensed assistive personnel (UAP) to perform? 1. "Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client." 2. "Please measure the Hemovac drainage at 2:00 PM and let me know how much there was." 3. "Please record the amount of the Hemovac drainage on the intake and output record at the end of the shift." 4. "Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught."

1. Although the UAP can perform procedures that require observing principles of infection control and transmission of microorganisms, the UAP should not change sterile dressings or perform drain care. That is the responsibility of the RN. (Options 2, 3, and 4) When caring for a client with a closed-wound drainage Hemovac device, emptying and compressing the Hemovac drainage device to reestablish negative pressure and measuring and recording the drainage output are tasks that can be delegated to an experienced UAP. The RN can safely delegate these tasks because the knowledge, skill, and competency of the UAP has been established and the tasks and time frames are clearly defined. Measuring intake and output from drainage devices (eg, Foley, Hemovac, Jackson-Pratt), documenting in the electronic medical record in the place designated for the UAP, observing infection control principles, and maintaining asepsis while providing client care are within the UAP's scope of practice.

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms 3. 60-year-old with marked anemia reports shortness of breath when ambulating 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66)

1. The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action. (Option 2) Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. Petechiae are an expected finding. (Option 3) A client with marked anemia can develop exertional dyspnea due to the body's inability to meet the metabolic demands (oxygen supply) associated with activity. This is an expected finding. (Option 4) Polycythemia vera (true primary polycythemia) is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. This leads to increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. A hematocrit of 66% (0.66) is an expected finding. Educational objective:Overwhelming postsplenectomy bacterial infection is a major lifelong complication in clients without a functioning spleen. A minor infection can quickly become life-threatening and septic; therefore, any indicator of infection requires immediate attention and treatment intervention. Additional Information Reduction of Risk Potential NCSBN Client Need

A nurse working in the office of a health care provider (HCP) must respond to client telephone messages. The nurse should return which call first?A nurse working in the office of a health care provider (HCP) must respond to client telephone messages. The nurse should return which call first? 1. Client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone 2. Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot 3. Client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting 4. Client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

2 The nurse should first call the client with tingling in the right foot. Musculoskeletal injuries and immobilization devices (cast) can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia (eg, numbness, tingling) is an early sign of neurovascular impairment (nerve ischemia). It would be important for the client to report to the HCP for immediate evaluation. This is the most urgent call to return

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply.1. 2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection 2. 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 3. A client in sickle cell disease crisis and a client with streptococcal pneumonia 4. A client who had abdominal surgery today and a client with universal precautions 5. A young client in Buck's traction with an elderly client with Parkinson's disease

2,4,5 When clients must be housed together in less than ideal circumstances, those infected with the same causative pathogens can be placed together. However, a client who is infectious should not be placed with an immunosuppressed client (eg, on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly). Every client in the hospital is on universal precautions; therefore, there should be no concern about placing a vulnerable post-operative client in the same room where standard precautions are being taken for another client. In a disaster setting, clients of different age groups can be placed in the same room together so long as both are stable and noninfectious (even if this is not socially acceptable). (Option 1) Though both clients are on contact isolation, they are infected with different organisms and this places them at risk for cross-infection. (Option 3) By around age 4, clients with sickle cell disease have some level of immunosuppression as their spleens are dysfunctional due to infarctions from the sickling episodes. The spleen then fails to carry out protective phagocytosis, especially to encapsulated bacteria (eg, streptococcus pneumoniae). Educational objective:Clients infected with different organisms cannot be placed together in the same room (due to risk of cross-infection). An infectious client should not be housed with an immunocompromised one.

The nurse in a women's health clinic is returning client phone calls. Which client would be the priority to call first? 1. Client 4 days post cesarean delivery who has not had a bowel movement since surgery 2. Client who gave birth vaginally a few days ago who states, "They want to hurt my baby." 3. Client who gave birth vaginally recently who states, "I think I am experiencing incontinence." 4. Client's spouse who is concerned that the client wants to sleep instead of care for the baby

2. Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate? 1. "I don't know because I am off duty right now." 2. "Let's step away from the crowd to discuss it." 3. "Mrs. Jones was fine when I last checked on her during rounds." 4. "You will have to talk with the nurse caring for her while I am on break."

2. he nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately (Option 2). (Option 1) This response is neither accurate nor helpful because the nurse knows how the client was earlier in the day. It is best to make the conversation private so that the nurse can respond to the question appropriately. (Option 3) Although vague, this response in a public area (ie, cafeteria) violates the client's privacy by acknowledging the client's presence in the hospital, where the response may be overheard by others. In addition, it does not provide accurate information. (Option 4) It is appropriate to direct questions about the client to the currently assigned nurse; however, this response violates the client's privacy by confirming the client's presence in the hospital. It is best to make the conversation private before sharing any information.

The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain 4. 75-year-old with nausea, fever, and left lower quadrant pain

3. Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. (Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than AAA. (Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis. Educational objective:

The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the priority? 1. Student who feels well but is concerned about possible exposure to viral meningitis at an off-campus party 2 weeks ago 2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain 3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain 4. Student with itchy, cottage-cheese-like vaginal discharge who is sexually active and worried about having a sexually transmitted infection

3. Sexual assault is a medical emergency requiring a thorough head-to-toe physical examination by a specially trained health care provider (eg, sexual assault nurse examiner) to identify and treat injuries. A student reporting potential sexual assault (eg, waking in a strange room, signs of physical assault) should be instructed to seek immediate medical attention and not to bathe, brush teeth, urinate, douche, or change clothes. These activities can delay a medical-forensic examination and interfere with evidence retrieval and preservation. Many college and university health centers have providers for this specialized physical and emotional care, but if they do not, the student should be referred to a local hospital emergency department.

The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate? 1. Assisting the parents in signing Against Medical Advice (AMA) papers 2. Discharging the child if parents have power of attorney papers 3. Notifying the hospital administration about the situation 4. Reassuring the parents that their decision will be respected under the principle of autonomy

3. A competent adult has the right to make any decision regarding the client's health care even if the provider does not believe it is in the client's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents have legal authority to make choices about their child's health care, but not when they do not permit life-saving treatment or when there is a potential conflict of interest, such as child abuse or neglect. The hospital will seek court-appointed custody to treat this child who is seriously ill with dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential. (Option 1) The parents will not be allowed to take this child out of the hospital against medical advice as it will endanger the child's life. It does not matter that it is a religious reason for the desired AMA. (Option 2) Durable power of attorney for health care (health care proxy) is something a competent adult establishes when that adult can no longer self-advocate. Parents are automatically the legal guardians and decision makers for their minor children as long as the decisions do not put any of their children in danger. (Option 4) The ethical principle of autonomy is deciding for oneself. In this case, the child's best interest is priority and the legal authority takes precedent. Educational objective:Hospital administration will obtain legal protective custody of a minor child if the parents are deciding against life-saving measures for their child or when there is child abuse/neglect. Additional Information Management of Care NCSBN Client Need

The nurse receives report on 4 clients. Which client conditions require priority assessment? 1. 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations 2. 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain 3. 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea 4. 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg

3. Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot. (Option 1) Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is evidenced by jugular venous distension, hypotension, and muffled heart sounds. (Option 2) This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if flow is not restored. However, loss of life is a priority over loss of limb. (Option 4) Atrial fibrillation requires assessment but is not immediately life-threatening in most situations. This client has stable blood pressure and is not the priority.

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? 1. 2-year-old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy 2. 5-year-old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus 3. 9-year-old client with parvovirus B-19 infection admitted for observation after a febrile seizure 4. 14-year-old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

3. Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus.

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first?After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first? 1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago 2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate (TURP) 3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing 4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake all night

4 The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery. For this reason, it is important to identify and listen to the client's concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well.

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1. A client diagnosed with varicella and a client with pertussis 2. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis

4,5 PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option 4). Clients with the same organism can room together (Option 5). (Option 1) Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact precautions also if open lesions are present). Pertussis requires droplet precautions. Both the precautions and the organisms are different, and the clients could cross-infect each other. (Option 2) An AIIR (formerly negative-airflow room) is indicated when the client has an organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. (Option 3) Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation (eg, when absolute neutrophil count is ≤500/mm3), an infectious client should not be placed with this client. Yellow sputum typically indicates bacterial infection. COPD clients can have chronic colored sputum, but infection (bacterial or viral) is the primary cause of exacerbations (the most likely reason the client is in the hospital). This is not a safe option. Educational objective:For infection control, clients with same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed or at-risk clients.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit 1. Client newly admitted for an evolving ischemic stroke 2. Client newly diagnosed with diabetes mellitus who needs insulin administration teaching 3. Client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy 4. Client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

4. Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as-needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion (blood loss with surgery/trauma). The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility. (Option 1) The client newly admitted for an evolving ischemic stroke is best assigned to an experienced nurse who regularly works on the unit. The nurse will perform baseline and frequent follow-up neurologic assessments to determine if the client's condition is worsening. (Option 2) The client newly diagnosed with diabetes mellitus who needs insulin administration teaching is best assigned to a nurse who regularly works on the unit. The nurse would be familiar with the location of diabetic teaching materials, documentation procedure, and referral resources, and would be better able to evaluate the client's understanding and performance of insulin administration the next day. (Option 3) The client with exacerbation of COPD with a new tracheostomy is best assigned to an experienced nurse who regularly works on the unit. Care of a new tracheostomy requires the nurse to be familiar with assessment (eg, appearance, bleeding) and care (eg, suctioning). Educational objective:A stable client with the least complex problems and the most clearly defined outcomes is the most appropriate assignment for a float nurse.

A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call to say that a culture shows that the client needs an antibiotic. The client's spouse answers the phone, says that the client is at work and doing fine, and that the client does not need the antibiotic. Which is a priority action for the nurse? 1. Call the prescription into the client's pharmacy 2. Document the spouse's statement in the client's chart 3. Notify the emergency department physician 4. Request that the spouse tell the client to call back

4. The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decision-making capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client. (Option 1) The prescription can be called into the pharmacy, but there is no guarantee that the client will pick it up and take it in light of the spouse's response. Speaking to the client is the priority. (Option 2) The statement and attempts for contact should be documented, but the first priority is client care. (Option 3) The emergency department physician should be notified of the conversation, but the priority is to speak to the client and explain the importance of the new follow-up treatment. If the client has a primary care provider, the nurse could also communicate with that office to aid follow-up. Educational objective:A competent adult with decision-making capacity can refuse essential treatment; the client's spouse does not have that legal authority. Treatment refusal must include awareness of the risks and benefits.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with cellulitis of the right foot, medicated with hydromorphone IV 1 hour ago, reports pain as 6 on a scale of 0-10 2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit 24% (0.24) reports shortness of breath with activity 3. Client with heart failure exacerbation and a large pleural effusion with serum sodium of 132 mEq/L (132 mmol/L) reports headache 4. Client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing

4. After receiving report, the nurse should assess clients with airway and respiratory problems first (eg, airway, breathing, circulation). The client with asthma may have silent chest (sudden decrease in wheezing related to severe decrease in airflow) and require immediate attention.

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond? 1. Ask about liver disease and give acetaminophen from the nurse's personal supply 2. Assess the employee's blood pressure 3. Check for allergies to drugs before giving acetaminophen from hospital stock 4. Refer employee to the employee health provider

4. Although acetaminophen is an over-the-counter drug, the nurse should not give it without a prescription. By doing so, the nurse would be functioning outside the job description. There has not been a proper assessment (eg, allergies, liver disease), and a legal caregiving relationship will be established by administering the medication. If the employee does not want to go to the employee health provider, the nurse can suggest that the employee purchase acetaminophen in the gift shop.

A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims arrive at the triage area. Which client should the nurse care for first? 1. Client with charred, leathery skin over entire back, chest, and legs 2. Client with cool skin, shivering from sitting in water until rescued 3. Client with diabetes who was unable to take prescribed insulin today 4. Client with high-pitched, crowing inspiratory respirations

4. Disaster triage is based on the principle of providing the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system to categorize them from highest medical priority (emergent) to lowest (expectant). The client with stridor (eg, high-pitched, crowing inspiratory respirations), which typically occurs from constricted or blocked upper airways, is at risk for impending respiratory failure due to a compromised airway. This client should be classified as emergent, requiring immediate treatment and possibly prophylactic intubation (Option 4). (Option 1) Using the rule of nines, clients with full-thickness burns to the chest, back, and legs are suspected to have at least 72% total body surface area burns and should be classified as expectant (black tag). (Option 2) Clients with wet clothing or cold water immersion are at risk for hypothermia but can be easily self-managed by provision of warm, dry blankets; this client should be classified as nonurgent (green tag). Untreated hypothermia may lead to decreased cerebral metabolism, dysrhythmias, and coagulopathies. (Option 3) Clients with diabetes mellitus who are unable to receive insulin may develop hyperglycemia, which is unlikely to cause rapid deterioration.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see first? 1. A 1-day post tubal myringotomy client with purulent tympanic drainage [1%] 2. A 4-day post valve replacement client with a temperature of 102 F (38.8 C) and petechiae [25%] 3. A 10-day-old client with a patent ductus arteriosus who has a continuous murmur [0%] 4. A 6-year-old client with epiglottitis who is drooling and has a severe sore throat [71%]

4. Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenzae type b (Hib) was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress (Option 4). (Option 1) Purulent drainage is expected in a 1-day post tubal myringotomy client. The drainage shows the procedure was successful. (Option 2) A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client would need to be seen second, as this is a circulation disorder. (Option 3) A murmur is expected in a client with a patent ductus arteriosus. It is best heard at the left infraclavicular area and has a continuous "machinery" quality. Educational objective:

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? 1. Ask a client if the UAP has performed the test 2. Discuss the importance of task completion and accurate documentation in a staff meeting 3. Give the UAP a verbal warning not to falsify data 4. Take a client's capillary glucose personally and compare it to the recorded result

4. The best initial result is to assess and validate the charge nurse's perception. Doing the test and comparing results randomly/intermittently will give data to prove/disprove this concern. (Option 1) It could cause concern to involve a client when there may be an issue about inadequate provider care. The nurse should handle it independently. (Option 2) It is good to reinforce policies in general announcements to the entire staff, especially if wide-spread compliance is a concern. However, there is only one person that is suspected of not adhering in this case. Speaking out is often a general step taken, but the intended individuals usually don't hear the information. In addition, this is information that the staff has known/heard before. (Option 3) The normal discipline process is a verbal warning, a written warning, suspension, and termination. To initiate the process, there has to be evidence of wrong doing. However, it is only a suspicion at this point. Educational objective:When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented. Additional Information Management of Care NCSBN Client Need

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L) 3. Client undergoing ultrafiltration for congestive heart failure 4. Client with a prescription for routine hemodialysis who has chronic renal failure

4. The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse.

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1-day postoperative client with lower abdominal pain and no urine output for 6 hours 2. An elderly client with blood pressure 190/88 mm Hg who is asymptomatic 3. Client with hepatitis C virus who has alanine aminotransferase/aspartate aminotransferase (ALT/AST) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

4. The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias. Assessing this client is a priority over pain or expected findings. (Option 1) This client likely has postoperative urinary retention and needs to be evaluated as soon as possible (second in priority). Although, this condition is painful and could result in kidney injury, it is not immediately life-threatening. (Option 2) This client has isolated systolic hypertension, which is common in elderly clients and they are often asymptomatic. Systolic blood pressure is usually >160 mm Hg but diastolic blood pressure is <90 mm Hg. Treatment might benefit these clients, but this is not a priority. (Option 3) ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are ≥2-3 times the normal value. The hepatitis C virus usually causes chronic infection. The client's acuity is not directly related to the level of enzymes; this client is not more seriously ill because the enzymes are higher than a client whose labs results are twice the normal value. This is an expected finding and is not a priority. Educational objective:Acute hypocalcemia can be life-threatening due to seizures, tetany (laryngeal stridor), and cardiac arrhythmias. Inadvertent removal of the parathyroid gland can result in rapid development of severe hypocalcemia. Additional Information Management of Care NCSBN Client Need

The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage

4. The registered nurse makes assignments according to staff members' experience, knowledge, and skill level. The more experienced nurse is assigned to clients who are less stable and require more in-depth analysis of assessment data to implement and plan care. The less experienced graduate nurse is assigned to more stable clients who require basic nursing care.

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client? 1. Clinical psychologist 2. Occupational therapist 3. Physical therapist 4. Social worker

4. The case manager and social worker on the interdisciplinary team have expertise in discharge planning and health care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe, effective discharge planning.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply. 1. Client develops right-sided upper and lower extremity drift 2. Client found lying unconscious on the floor 3. Client has order for heparin with surgery planned for the morning 4. Client has serum sodium of 124 mEq/L (124 mmol/L) 5. Client refuses a prescribed, routine pain medication

1,2,3,4 The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: Falls Deteriorates significantly or dies Has critical laboratory results Needs a prescription that requires clarification Leaves against medical advice or runs away Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall ) (Options 1 and 2).

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply. 1. Facilitating communication between health care providers (HCPs) 2. Obtaining health information from the client's nursing home 3. Reconciliation of home medications 4. Referral for home health after discharge 5. Visiting the client daily while hospitalized

1,2,4 Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases fragmentation of care (Option 2), helps to coordinate care and communication between HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge (Option 4). (Option 3) Case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP. (Option 5) Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally.

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1. Accepting a birthday gift of a gold bracelet from a client 2. Making a visit to the hospital after a client has surgery 3. Offering to pray together if a client so wishes 4. Sending a sympathy card to family after a client dies 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client

1,5,6

The nurse receives the change of shift report for assigned clients at 7 AM. Which client should the nurse assess first? 1. Client with change in level of consciousness who fell in the nursing home 2. Client with chronic headaches who is scheduled for an MRI at 9 AM 3. Client with chronic obstructive pulmonary disease (COPD) and pulse oximeter reading of 90% 4. Client with heart failure and 3+ pitting edema of the lower extremities

1. Change in level of consciousness is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment (eg, pupil size and response, level of consciousness (LOC), mentation, speech, hand grasps). This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased intracranial pressure (eg, change in LOC, Cushing's triad, pupillary changes).

The nurse has just received shift report. Which client should be seen first? The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

2. The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics.

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 1. Client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain 2. Client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing 3. Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg 4. Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

3 e nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema, warmth, redness, tenderness on palpation). DVT is a postoperative complication related to venous stasis and subsequent thrombosis. If a DVT is suspected, early diagnostic testing (eg, venous ultrasound) and treatment with anticoagulant therapy (eg, heparin, enoxaparin) are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism.

The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber

3. lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary.

The nurse calls the health care provider at midnight and states, "Client X in room 212 had a colectomy yesterday and is now lethargic. The client currently has a rising pulse at 130/min and a falling systolic blood pressure at 80 mm Hg. I am concerned that the client is going into shock." With regard to the SBAR (Situation, Background, Assessment, and Recommendation/Request) communication technique, what is the most important information excluded by the nurse? 1. Basic demographic information 2. Current temperature and trend 3. Requesting action by the health care provider 4. Significant past medical history and allergies

3. BAR (or I-SBAR-R [Introduction, Situation, Background, Assessment, Recommendation/Request, and Read-back]) is used to communicate pertinent information regarding changes in a client's condition in an organized fashion. The content should include the situation (why the nurse is calling), background, assessment, and a recommendation/request of the health care provider.

The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation? 1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives 2. Tape-record a report and leave a cell phone number to call if there are any questions 3. Tell the charge nurse of the impending need to leave and that client coverage is required 4. Write out a report about the clients for the incoming nurse prior to leaving

3. he off-going nurse must ensure that there is another registered nurse responsible for the care of the clients, if this is not done then abandonment has occurred. A deliberate report must be given using standardized format for continuity of care. During the hand-off, objective data should be provided about the clients' current status and response to treatment to enable planning care. The off-going nurse should let the charge nurse know as this individual is responsible for the staffing of the unit and would have the authority to try different options, such as asking another nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit. In addition, there is no established time frame for the incoming nurse's actual arrival; a significant amount of time could pass before this inadequate staffing issue is resolved. (Option 1) This general vague oversight is an inadequate report and transfer of responsibility to the other nurse. (Option 2) Tape recording a report is a legitimate method of communication as long as there is an opportunity to ask questions. However, this does not resolve the issue of procuring a nurse to take over responsibility for the clients' care. (Option 4) Although this would help transmit essential information, it does not accomplish procurement of another nurse to be responsible for the clients' current care. Educational objective:

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate? 1. Autonomy 2. Nonmaleficence 3. Paternalism 4. Veracity

2

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition

4. The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP). (Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP. (Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum glucose. This increases insulin requirements but would not affect the current HbA1c level, as it reflects glucose control over a 2-3 month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP. (Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP. Educational objective:The recommended target serum glucose range for clients receiving nutritional support is 140-180 mg/dL (7.8-10.0 mmol/L). The nurse should monitor a client receiving TPN for hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) and hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]). Hypoglycemia places the client at risk for life-threatening complications (eg, seizures, nervous system damage).

There has been a major community disaster. Stable clients need to be discharged to make more beds available for the victims. Which clients could be discharged safely? Select all that apply. 1. Diagnosed with endocarditis on antibiotics with a peripherally inserted central catheter (PICC) line 2. History of multiple sclerosis with ataxia and diplopia 3. One day postoperative from a hemicolectomy 4. Reporting abdominal pain with coffee ground emesis 5. Taking warfarin with prothrombin time/International Normalized Ratio of 2x control value

1,2,5

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply. 1. Before liver biopsy, pulse is 80/min and blood pressure (BP) is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg 2. Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg 3. Client with coronary artery disease on metoprolol; pulse is 62/min 4. Elderly client with black stools; pulse is 112/min 5. Neonate crying inconsolably at feeding time; pulse is 160/min

1,4

The charge nurse on a telemetry unit is training a new registered nurse (RN). The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an International Normalized Ratio of 4.0 who has a warfarin dose due 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99 F (37.2 C), and has a dose of vancomycin due 3. A client who is 48 hours post myocardial infarction, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids

3 Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP). (Option 1) The client with atrial fibrillation (AF) should be seen after the MI client. Vital signs are stable, but the International Normalized Ratio (INR) should be lower (therapeutic range of 2.0-3.0 for AF). The nurse should assess for signs of bleeding and notify the HCP; the scheduled dose of warfarin should likely be held. (Option 2) A temperature of 99 F (37.2 C) is not uncommon in the days immediately following surgery. The nurse should assess surgical incisions and respiratory status and give the scheduled antibiotic. (Option 4) After NPO status is discontinued, the client should be offered fluids. This task can be delegated to unlicensed assistive personnel and is not the priority.

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply. 1. Client in sickle cell crisis receiving oxygen via face mask 2. Client who drank a 1 L bottle of vodka 2 hours ago 3. Client who hears voice commands to kill a coworker 4. Client with mania who has not eaten in 5 days 5. Client with ST elevation on ECG monitoring

2,3,4 To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol).

A client with terminal cancer arrives in the emergency department unresponsive and in respiratory distress. The client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes 2. Get directions about care from the client's sister 3. Prepare for emergency intubation 4. Request that the sister provide a living will

2.

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? 1. Client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain [63%] 2. Client who is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath [15%] 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago [19%] 4. Client with a kidney stone who is requesting pain medication for severe flank pain [1%]

1.

The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? 1. 2-year-old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy 2. 5-year-old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus 3. 9-year-old client with parvovirus B-19 infection admitted for observation after a febrile seizure 4. 14-year-old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion

3. Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions.

Which client is most appropriate for the 7:00 AM-7:00 PM charge nurse on a cardiac step-down unit to assign to a float registered nurse from a medical-surgical unit? 1. Client who just returned to the unit after coronary angioplasty and placement of a stent 2. Client with atrial fibrillation scheduled for electrical cardioversion this afternoon 3. Client with heart block scheduled for pacemaker placement this afternoon 4. Client with heart failure and deep vein thrombosis receiving an IV infusion of heparin

4.

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply. 1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery

1,2,4,5

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime

1,4,5

The nurse in a pulmonary clinic triages telephone messages left by several clients. Which client should the nurse call back first? 1. Client with a history of asthma who reports scoring a peak flow of 45% of personal best 2. Client with a pneumothorax who reports scant, clear drainage from the Heimlich valve 3. Client with active tuberculosis reporting dark red-orange urine after starting rifampin 4. Client with chronic obstructive pulmonary disease with an oxygen saturation of 90%

1. anything under 50% is an emergyency (Option 2) Clients with small, uncomplicated pneumothoraxes may have a flutter (Heimlich) valve placed but can be safely discharged home. Scant, clear pleural drainage is expected.

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

2

Which issue would a unit quality improvement committee address? 1. A 10% decrease in client satisfaction in the registration process 2. A nurse who made 3 medication errors in the past quarter 3. An increase in catheter-associated urinary tract infections 4. Staff perception of hospital laboratory personnel incivility

3. unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met. Examples requiring unit quality improvement include the following: Medications prescribed STAT are not available in a timely manner Catheter-associated bacterial infections are increasing within the unit (Option 3)

The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? 1. Fell, twisting the right knee; heard a "pop" 2. History of glomerulonephritis; has "iced tea"-colored urine 3. Pain 10/10 in reddened eye; wears contact lens 4. Took a handful of amitriptyline tablets after a fight with spouse

4. Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline (Elavil) is lethal if taken in overdose, especially if consumed with alcohol. It is estimated that 70%-80% of clients with tricyclic antidepressant overdose die before reaching the hospital. Amitriptyline was historically used for depression; it is now used for insomnia and neuropathic pain. Death results from serious cardiac arrhythmias.

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

2 \

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney to provide consent for the additional procedure 3. Document that an additional hernia was found and that it will require surgery at a later time 4. Witness an additional consent after both procedures are complete and the client is awake

2. nformed consent is required before any nonemergency procedure. The 3 principles of informed consent include: The surgeon explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and prognosis without surgery. The client indicates understanding of the information. The client is competent and gives voluntary consent. The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's medical power of attorney, legal guardian, or next of kin should be contacted so that the surgeon can explain the situation and obtain consent (Option 2).

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent is required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

3.

The nurse receives handoff report on 4 clients. Which client should the nurse assess first? 1. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth 2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up 3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache 4. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea

3. onoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option 3).

antibiotics can cause what type of infection

candida this is white curd or cheeslike discharge. this client needs antifungal treatment such as fluconazole

A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first? 1. A client who underwent a colon resection 3 hours ago and is bleeding 2. A client who was rescued from a burning building and shows evidence of smoke inhalation 3. A client with gastroenteritis who is throwing up large amounts of vomit 4. A client with peritonitis who has pain level of "8" on a scale from 1-10

2. A nurse on a medical surgical unit receives a report on multiple clients. Based on this report, which client should the nurse assess first? 1. A client who underwent a colon resection 3 hours ago and is bleeding [13%] 2. A client who was rescued from a burning building and shows evidence of smoke inhalation [81%] 3. A client with gastroenteritis who is throwing up large amounts of vomit [2%] 4. A client with peritonitis who has pain level of "8" on a scale from 1-10 [2%]

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? Select all that apply. 1. Cleaning the skin surrounding the gastrostomy tube stoma 2. Crushing and administering metoprolol through the gastrostomy tube 3. Programming the feeding pump to administer a prescribed bolus feeding 4. Teaching the client about home enteral feeding and gastrostomy tube care 5. Weighing the client using the bed scale

1,2,3

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding 3. Client with purulent drainage and crusting of the eyelid with vision unaffected 4. New parent who is crying and overwhelmed, and denies suicidal ideation

1. nfants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate.

The emergency department nurse is obligated to make a report for which situations? Select all that apply. 1. To a client's employer that the client had a car crash while intoxicated 2. To the authorities that an elderly client has suspicious bruising but denies caregiver abuse 3. To the medical examiner of a death following trauma, even if the family refuses autopsy 4. To the spouse of a client that the client has a reportable sexually transmitted disease 5. To the supervisor that an oncoming health care provider has the smell of alcohol on the breath

2,3,5 The nurse is required to report an impaired coworker, a suspicious death, and elder abuse to appropriate authorities. The nurse is legally prohibited from sharing health information with employers or family members without the client's permission.

The nurse is preparing to administer a unit of packed red blood cells to a client whose hemoglobin is 7 g/dL (70 g/L). What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Assist with checking identification of the client and the blood product 2. Measure vital signs at the end of the transfusion 3. Measure vital signs prior to starting the transfusion 4. Measure vital signs within the first 10 minutes of starting the transfusion 5. Pick up blood from the blood bank

2,3,5 uaps can take vitals before and after blood transfusions and they can also pick up blood from the bank/ they can also measures vitals after 15 mins of transfusion the nurse must verify product with client

The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? 1. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

2. The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances (eg, orthostatic hypotension, acid loss, hypokalemia, hyponatremia), and potential cardiac dysrthythmias. The client is exhibiting manifestations of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias (Option 2).

The office nurse receives 4 telephone messages from clients. Which client should the nurse call back first? 1. 20-year-old college student who reports getting a ringlike, red bull's eye-shaped, itchy leg rash after hiking in the woods 2 days ago 2. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching 3. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago 4. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well

3 A chronic subdural hematoma involves bleeding into the subdural space that can occur several weeks to months following a mild head trauma. Elderly clients and those taking anticoagulants are at high risk. Older individuals are vulnerable due to age-related changes in the brain and increased risks for falls. Manifestations indicating a chronic subdural hematoma (eg, headache, gait disturbance, memory loss, decreased level of consciousness) should be investigated immediately as the condition can lead to increased intracranial pressure and death

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply. 1. Client with a malignancy prescribed filgrastim has neutropenia 2. Client with acute osteomyelitis prescribed vancomycin has leukocytosis 3. Client with acute pancreatitis prescribed hydromorphone has an elevated lipase level 4. Client with hypertension prescribed candesartan has hyperkalemia 5. Client with peritonitis prescribed tobramycin has an elevated creatinine level

4,5 Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia (Option 4). Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required (Option 5). (Option 1) Neutropenia (decreased neutrophil count) increases a client's susceptibility to infection. Filgrastim (Neupogen) is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemotherapy. Neutropenia is expected in this client and is not the most important result to report. (Option 2) Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection (eg, leukocytosis - white blood cell count >11,000/mm3 [11.0 x 109/L], increased erythrocyte sedimentation rate, fever) and involves long-term antibiotic therapy. This is expected and is not the most important result to report. (Option 3) Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl). Morphine can also be used; worsening pancreatitis due to an increase in sphincter of Oddi pressure has not been proven in studies. Elevated lipase level is expected and is not the most important result to report. Educational objective:ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin, gentamicin, amikacin) can cause nephrotoxicity.

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords)

4. his client's abnormally high blood pressure increases the risk for complications such as stroke. The nurse should assess this client and recheck the blood pressure with a manual cuff to verify the accuracy of the previous measurement taken by the unlicensed assistive personnel (UAP). The nurse will need to assess the client further before making additional nursing judgments and taking actio

A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first? 1. Client 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F (38 C) 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours

4. Low urine output in the first 24 hours after surgery is expected due to fluid restriction before surgery, hormonal responses to the physiological stress of surgery, and fluid losses during surgery. Urine output should increase by the second postoperative day. The total intravenous intake for this client for the last 24 hours is 3000 mL (125 mL x 24 hours). The urine output for an adult of average weight (154 lb [70 kg]) should be at least 0.5 mL/kg/hr (ie, 70 kg x 0.5 mL/hr = 35 mL/hr x 8 hours = 280 mL in 8 hours). This client is becoming oliguric (100 mL in 8 hours). The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distension and Foley catheter patency before notifying the health care provider (HCP). This assessment takes priority due to the potential for prerenal failure and acute kidney injury. (Option 1) Auscultating fine crackles in the base of the lungs is common 1 day postoperative and is usually related to atelectasis caused by hypoventilation, especially in a client who has not yet ambulated. This assessment does not take priority. (Option 2) A surgical dressing with serosanguineous drainage and a low-grade temperature related to the inflammatory response due to stress of surgery are expected findings 1 day postoperative. This assessment does not take priority. (Option 3) Epidural analgesia (eg, continual, intermittent bolus, patient-controlled) provides excellent long-lasting postoperative pain control as it distributes the opioid medication directly to the opioid receptors in the spinal cord through a catheter placed in the epidural space. The nurse will perform a pain assessment and report to the anesthesia HCP, as a bolus of pain medication through the catheter may be needed. This assessment does not take priority. Educational objective:

INFANT NORMAL glucose levels

40-60 Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures

The nurse receives report on 4 clients. Which client should be seen first?The nurse receives report on 4 clients. Which client should be seen first? 1. Client with amyotrophic lateral sclerosis experiencing increased dysarthria 2. Client with chronic obstructive pulmonary disease reporting increasing leg edema 3. Client with strep throat and fever of 102 F (38.9 C) on antibiotics for 12 hours 4. Client with urolithiasis reporting wavelike flank pain and nausea

1 Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involved in swallowing and respiratory function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis.

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. Which tasks would be appropriate to delegate to the unlicensed assistive personnel? Select all that apply. 1. Document output from the urinary collection bag 2. Hold adipose tissue out of the way during catheter insertion 3. Monitor color of the urine after the nurse has assessed it 4. Reinforce education about the purpose of the urinary catheter 5. Secure the catheter to the client's thigh with an anchor

1,2,5 It is within the unlicensed assistive personnel (UAP) scope of practice to document output from a urinary collection bag (Option 1). The UAP can assist the nurse during a procedure by helping to position a client or holding part of the client's body (Option 2). The UAP may also perform routine tasks, such as securing a catheter to the client's thigh with an anchor device (Option 5). (Option 3) A licensed practical nurse (LPN) may monitor for changes after an initial assessment has been performed by a registered nurse (RN), but this is not within the UAP scope of practice. (Option 4) Education should be provided by the RN. Reinforcement of education may be performed by the LPN, but it is not within the UAP scope of practice.

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? 1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy 2. 6-year-old girl with varicella and 7-year-old girl with measles 3. 9-month-old boy with rotavirus infection and 8-month-old boy with salmonella infection 4. 14-year-old girl with sickle cell anemia and 13-year-old girl with periorbital cellulitis

1. Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given the options above, this is the safest room assignment. (Option 2) Children with infections requiring airborne precautions (eg, varicella, tuberculosis, measles) should be placed in a private, airborne infection isolation room (eg, negative airflow room). If required, clients infected with the same organism can be roomed together, but a private room is preferred. (Option 3) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The risk for cross contamination is high, especially with caregivers sharing the facilities.

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting? 1. A 2-month-old who rolled off the changing table and is now lethargic 2. A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth 3. A 3-year-old with forehead bruises that the mother says come from running into a table 4. A 4-year-old who pulled boiling water off the stove and has splattered burns on the arms

1. Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out.

The nurse is reviewing new laboratory values. Which client would be the priority to report to the health care provider? 1. Client 2 days after a hip arthroplasty with a white blood cell count of 12,000/mm3 (12x109/L) 2. Client admitted for cocaine overdose with a creatine kinase of 30,000 U/L (501 µkat/L) 3. Client admitted for end-stage renal disease with a creatinine of 3.6 mg/dL (274.5 mmol/L) 4. Client in heart failure exacerbation with a brain natriuretic peptide of 600 pg/mL (600 pmol/L)

2 Rhabdomyolysis occurs when muscle tissue is damaged and myoglobin (protein found in muscle tissue) is released into the blood, usually after an injury from overexertion, dehydration, severe vasoconstriction (eg, cocaine use), heat stroke, or trauma. Acute kidney injury can occur when myoglobin overwhelms the kidneys' filtration ability. As myoglobin is excreted, the urine becomes very dark and is described as being a cola-brown color. Severely elevated creatine kinase levels, typically >15,000 U/L (>250 µkat/L), are observed with severe muscle damage and can be a precursor to kidney injury (Option 2). Forced saline diuresis with intravenous fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent permanent kidney damage. (Option 1) Postoperative leukocytosis (leukocytes >11,000 mm3 [>11X109/L]) is common in the first 48 hours after orthopedic surgery from normal inflammatory immune responses. (Option 3) Clients with end-stage renal disease commonly have elevated creatinine and blood urea nitrogen levels. These are expected findings. (Option 4) Increased brain natriuretic peptide levels can indicate stretching of the chambers of the heart in heart failure. Levels >100 pg/mL (>100 pmol/L) can indicate heart failure and would be expected in this client.

The nurse is caring for a hospitalized client with a diagnosis of thyrotoxicosis. Which of the following actions can be delegated to unlicensed assistive personnel? Select all that apply. 1. Administer artificial tears if the client reports eye dryness 2. Assist the client to bathe and change the bed linens to maintain client comfort 3. Lower the room temperature and provide cool cloths on request 4. Reinforce to the client that fever is expected with thyrotoxicosis 5. Return a call to the client's family telling them the client's condition is unchanged

2,3

The nurse is discharging a client with emphysema who is on continuous oxygen. The case manager alerts the nurse that the home oxygen will not be delivered until 2 hours later. What action should the nurse take? 1. Ask if the client can go without the oxygen for 2 hours 2. Delay discharge until the oxygen is delivered 3. Notify the health care provider (HCP) to see what action should be taken 4. Send a hospital oxygen tank home with the client

2.

he registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Alert the x-ray department about maintaining airborne isolation precautions 2. Explain to the client why the client must wear a mask during transport to another department 3. Post signs for airborne isolation precautions on the client's door and stock necessary equipment 4. Remind visitors to wear a respirator mask and keep the door closed while in the client's room 5. Talk with the family about the reasons for airborne isolation precautions in the client

3,4

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever

3. Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production. It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia.

the nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1. 28-year-old with infective endocarditis and heart rate of 105/min 2. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3. 65-year-old with tachycardia of 110/min after liver biopsy 4. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

3. The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center

4. Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts.

Which are appropriate examples of cost-effective care? Select all that apply. Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1,2 Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying a new dressing, when sterile technique is commonly used). The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it wet, do not reach over it).

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct? 1. Stop all resuscitation activity immediately 2. Continue resuscitation until DNR status is verified with health care provider 3. If client shows any signs of life, follow advanced cardiovascular support protocol until stable 4. Once resuscitation has begun, complete it regardless of client code status

1. Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error (Option 1).

A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation? 1. Ask a client if the UAP has performed the test 2. Discuss the importance of task completion and accurate documentation in a staff meeting 3. Give the UAP a verbal warning not to falsify data 4. Take a client's capillary glucose personally and compare it to the recorded result

4.

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? 1. A 25-year-old client with multiple sclerosis who had bladder incontinence last night 2. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes 3. A 58-year-old client with Parkinson disease who is drooling 4. A 78-year-old client with dementia who has new-onset agitation and confusion

4. New-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. (Option 2) Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the diaphragm.

Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural practices of the clients on their assigned unit. Which leadership strategy is best for the nurse manager to implement to assist the graduate nurses in developing cultural competency? 1 Assign the graduate nurses to a unit without cultural diversity until cultural competency is achieved [2%] 2. Provide the graduate nurses with a workshop designed to teach about cultures encountered at work [67%] 3. Request that the charge nurse assign the graduate nurses 2 culturally diverse clients each shift [9%] 4. Suggest that the graduate nurses research various cultures and provide an in-service to the staff [21%]

2. The transformational nurse manager provides a supportive culture in which learning is valued and best practices are implemented to ensure the appropriate skill level and experience of each staff member. A workshop would provide the graduate nurses with an opportunity to learn and ask questions about the cultures represented on their unit. It would also help develop cultural awareness and sensitivity, leading to respect for the diverse cultures represented on the unit.

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly? 1. Ranitidine 150 mcg daily by mouth 2. Ranitidine 150 mg per os qhs 3. Ranitidine 150 mcg po qd nightly 4. Ranitidine 150 mg PO at bedtime

4

A nurse is assigned to multiple clients. Which client should the nurse reassess as a priority after administering IV morphine for pain relief? 1. 22-year-old with sickle cell anemia admitted for acute pain crisis 2. 26-year-old with pneumonia reporting sharp right side chest pain on deep inspiration 3. 55-year-old who is 1-day postoperative bowel resection reporting pain at the incision site 4. 67-year-old with obstructive sleep apnea reporting pain at the fractured right tibia

4 Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% of normal ventilation), resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, especially during sleep. The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours. (Option 1) This 22-year-old with sickle cell crisis will likely need large doses of narcotics due to increased tolerance from prior use. The nurse needs to assess the pain and any complications from narcotic use. However, this is not the first priority. (Option 2) This 26-year-old has pneumonia and right side pain on deep inspiration, which indicate pleuritic pain (inflammation of the 2 layers of pleura). Pleuritic pain is an expected finding associated with pneumonia and is not the priority assessment. (Option 3) Moderate to severe postoperative pain and lack of audible bowel sounds (due to general anesthesia, bowel manipulation, and opioid drugs) are expected findings 1 day after major abdominal surgery. This client is not the priority.

he registered nurse (RN) is planning care to prevent venous thromboembolism in several clients. Which tasks can the RN delegate to the licensed practical nurse? Select all that apply. 1. Administering enoxaparin subcutaneously to a client in skeletal traction 2. Applying sequential compression devices to a client with limited mobility 3. Evaluating partial thromboplastin time in a client receiving heparin 4. Measuring a client with chronic heart failure for compression stockings 5. Teaching a client with a new prescription for warfarin about bleeding precautions

1,2,4

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8-year-old with sickle cell crisis who has sudden-onset unilateral arm weakness 2. 11-year-old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intussusception who has reddish mucoid stool 4. Male child with hemophilia who has hemarthrosis and is receiving desmopressin

1. Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening.

The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place

2 A fat embolism is life-threatening; therefore, the client with the femur fracture is the priority. There is a risk for the formation of fat emboli following certain fractures, typically those of the long bones and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they cause damage by occluding small vessels. Altered mental status will result from blocked blood vessels in the brain. An embolism to the lung would result in respiratory distress. A hallmark sign of fat emboli is the presence of petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate. (Option 1) This hospitalized heroin user is likely experiencing heroin withdrawal, which manifests with vomiting, abdominal cramping, and diarrhea; restlessness and diaphoresis; frequent yawning; rhinorrhea and lacrimation; and myalgias and arthralgias. This client needs treatment, but this condition is not life-threatening. (Option 3) Moderate hyponatremia (normal sodium 135-145 mEq/L [135-145 mmol/L]) can cause altered mental status and can lead to seizures if it becomes severe. This client needs treatment and should be the second priority after the client with fat embolism. (Option 4) Infections can cause altered mental status, especially in elderly clients. As the infection resolves, mental status improves.

Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%

2 A peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement. (Option 1) After abdominal surgery, placement of a nasogastric tube to decompress the stomach and the absence of bowel sounds for 24-72 hours due to postoperative paralytic ileus would be expected. (Option 3) The client with malabsorption syndrome is unable to digest and absorb nutrients by the gastrointestinal tract. Peripheral parenteral nutrition with 10% dextrose is an expected treatment. (Option 4) The hemoglobin A1C level of 9% is above the recommended level (ie, <7%) and reflects inadequate glycemic control, which can be expected in a client with diabetes mellitus.

A nurse is providing anticipatory guidance to a client with early Alzheimer disease and osteoarthritis. Current symptoms include mild forgetfulness and cognition changes. Which is the best example of an educational goal for anticipatory guidance? 1. The client will demonstrate proper organization of medications in a weekly pill box by the end of the teaching session. 2. The client will identify and attend a support group meeting for clients with dementia by the end of the month. 3. The client will verbalize 2 home safety changes that can prevent falls during disease progression by the end of the session. 4. The client will verbalize 3 examples of easy, nutritious meals that can be prepared independently by the end of the clinic visit.

3 Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to disease processes. This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future (Option 3). (Option 1) Memory aids (eg, pill organizers, alarms) should be used now, while the client has only mild cognition changes. As the disease progresses, a caregiver should take over medication management. (Option 2) Support groups are an appropriate intervention for current psychosocial needs (eg, depression). (Option 4) Clients with osteoarthritis are at risk for nutritional deficits due to functional decline (eg, inability to open jars), and clients with Alzheimer disease can forget to eat. The nurse should address this current need by teaching simple meal planning. Educational objective:Anticipatory guidance addresses expected changes related to growth and development or disease progression. Educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client.

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1. Room 1 - Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL (14.7 mmol/L) 2. Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 (0.2 x 109/L) 3. Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4. Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/L)

4 The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery.

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply. 1. Do not continue the handoff report with the oncoming nurse 2. Document the incident according to facility policy 3. Notify the charge nurse 4. Say nothing but watch for impaired behavior 5. Tell the oncoming nurse that he/she is not fit for duty

1,2,3 An impaired nurse cannot safely give care regardless of the reason for impairment. If impairment is suspected, the nurse has a duty to take action that will both protect the client and ensure that the impaired individual receives assistance. The charge nurse/nurse supervisor should be notified (so the nurse can be replaced and sent home safely), the incident documented, and the nurse not allowed to give care while impaired (Options 1, 2, and 3)

The nurse reads a journal article about a study using a new pain management protocol for clients with terminal cancer. What should the nurse first consider in determining whether the protocol is appropriate to implement on the unit? 1. Did the study have institutional review board approval? 2. Do the characteristics of the sample population match those of the nurse's unit? 3. What are the credentials of the study's researcher? 4. What was the financial support provided for the study?

2. When evaluating research for practice changes, the nurse must first determine if there is reasonable similarity between the nurse's unit population and the study population to expect equivocal results. This should be the initial consideration to ensure that the research is appropriate for a given setting. For instance, if the nurse cares for pediatric clients with acute pain, the protocol for adult clients with terminal cancer might not translate effectively or safely to those clients.

A licensed practical nurse is discussing assessment findings for several older adult clients with the registered nurse (RN). Which client is priority for the RN to assess? 1. Client taking metoprolol who has a pulse of 54/min and blood pressure of 154/82 mm Hg [16%] 2. Client who has chronic obstructive pulmonary disease with an oxygen saturation of 92% [0%] 3. Client with 345 mL gastric residual volume aspirated from a PEG tube before an enteral feed [17%] 4. Client with pneumonia who is receiving IV fluids and has a new S3 heart sound [64%]

4 An S3 sound can be an expected finding in young adults. However, a new S3 sound in older adults requires prompt evaluation as it is often a sign of volume overload or heart failure. Additional Information Management of Care NCSBN Client Need

The nurse assesses and reviews the laboratory results for 4 clients. Which client's fever is of highest priority and should be reported to the health care provider immediately? 1. Client newly diagnosed with Hodgkin lymphoma scheduled for chemotherapy who has a fever of 100.9 F (38.3 C) and white blood cell count of 6,000/mm3 (6.0 × 109/L) 2. Client with acute cholecystitis scheduled for laparoscopic surgery who has a fever of 102 F (38.9 C) and white blood cell count of 13,000/mm3 (13.0 × 109/L) 3. Client with Clostridium difficile infection receiving metronidazole who has a fever of 101 F (38.3 C) and white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Client with colon cancer receiving chemotherapy who has a fever of 100.4 F (38 C) and white blood cell count of 1,500/mm3 (1.5 × 109/L)

4. Common adverse effects of chemotherapy are bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression. Even a low-grade fever should be taken seriously in clients who are immunosuppressed or have neutropenia. Additional Information Management of Care NCSBN Client Need

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially? 1. Ask the spouse to further describe the client's symptoms 2. Indicate that privacy rules prevent discussion of concerns with the spouse 3. Offer a same-day appointment to the client 4. Tell the spouse to have the client call the nurse

1.

Which tasks can the registered nurse safely delegate to unlicensed assistive personnel? Select all that apply. 1. Ambulate an oxygen-dependent client to the bathroom 2. Assist client with dentures to perform oral suctioning after the client's meal 3. Document pulse oximetry of a client with chronic obstructive pulmonary disease 4. Instruct a client with pneumonia on use of the incentive spirometer 5. Turn and reposition a client with pneumonia

1,2,3,5 Unlicensed assistive personnel (UAP) may assist stable clients with activities of daily living, hygiene needs, ambulation, and turning and repositioning. UAP may also collect and record vital signs (eg, pulse oximetry); obtain and set up equipment; and take precautions to prevent aspiration (eg, oral care and suctioning).

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output volume 2. Emptying and verifying the patency of an accordion drain 3. Escorting a disgruntled family member off the unit 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices

1,4,5 To delegate a task appropriately, the nurse must observe the 5 rights of delegation to ensure that the skills and experience required for performing the task are adequate and are within the delegatee's scope of practice. Unlicensed assistive personnel (UAP) can perform basic tasks that require little assessment and are unlikely to cause harm to the client. Obtaining a clean-catch urine specimen, emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices are all routine tasks that can be safely performed by UAP (Options 1, 4, and 5). (Option 2) UAP can measure, empty, and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color, and odor of drainage. (Option 3) With a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer. Educational objective:Emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices can be performed safely by unlicensed assistive personnel. Assessing the patency of a wound drain is the responsibility of the registered nurse, and disgruntled visitors should be escorted off the unit by security.

While caring for a client in skeletal traction, which tasks can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion (ROM) exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Remind the client to use the incentive spirometer 5. Reapply pneumatic compression device after bathing the client

1,4,5 To prevent immobility hazards for a client in skeletal traction, the RN can delegate the following tasks to the UAP: Assist with active and passive ROM exercises Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer Maintain proper use of pneumatic compression devices

An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? 1. Administer care until the parents or guardians can be reached 2. Admit the client but without giving care until the parents or guardians can be reached 3. Perform a pregnancy test to see if the client qualifies as an emancipated minor 4. Provide health care and follow-up advice but do not give any direct care

1.

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

1. Celecoxib (Celebrex), a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing (ie, ECG, cardiac enzymes) would be warranted. (Option 2) This client's nutritional status is concerning and needs to be addressed but would not be a priority over a client experiencing a possible acute myocardial infarction. (Option 3) This client needs cleaning as soon as possible to prevent fecal matter from entering into wounds. Cleaning the client can be delegated to a licensed practical nurse or unlicensed assistive personnel and would not be a priority over a client experiencing a possible acute myocardial infarction. The registered nurse can assess the wounds and dressings later. (Option 4) This client's nausea and pain medication need to be addressed; they would not be a priority over a client experiencing a possible acute myocardial infarction.

The night nurse receives a call at 4 AM from the laboratory regarding a client's blood cultures that have tested positive for bacteria. Which action by the nurse is appropriate at this time? 1. Call the answering service and speak to the health care provider now 2. Document the results of the culture in the client's medical record 3. Leave a message on the health care provider's office phone 4. Speak to the health care provider on rounds in the morning

1. Critical laboratory results (eg, positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications (eg, septic shock) (Option 1).

A nurse on the medical surgical unit has just received report. Which client should be seen first? 1. Client 1 day post femoral-popliteal bypass grafting who has an intravenous (IV) antibiotic due now 2. Client diagnosed with deep venous thrombosis (DVT) yesterday who reports some chest discomfort and cough 3. Client with hypertension and blood pressure of 180/92 mm Hg who reports a headache 4. Client on fall precautions who just called the nurses' station for assistance in using the bathroom immediately

2. The client with DVT who is experiencing chest discomfort and cough should be seen first. This client is exhibiting possible signs of pulmonary embolism (PE), which can be a life-threatening complication. Signs and symptoms of PE include dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability. The nurse should elevate the head of the bed, administer oxygen, and assess the client. The health care provider should be notified of these findings. (Option 1) The administration of an IV antibiotic is important but should be done after the nurse has assessed the client with DVT. (Option 3) This client is hypertensive and most likely has a headache due to the high blood pressure. The nurse should assess this client after the client with DVT and administer any antihypertensives needed. (Option 4) This client can be delegated to unlicensed assistive personnel who can go to the room immediately.

The nurse receives the following information in the hand-off report. Which client should the nurse assess first? 1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea 2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min 3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F (38.3 C) 4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

2. The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities (eg, thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (eg, hypotension, decreased urine output, peripheral vasoconstriction, pallor) and notify the health care provider of any significant changes from baseline as immediate esophagogastroduodenoscopy is necessary to determine the bleeding site. Treatment to stop the bleeding (eg, heat probe, sclerotherapy) may be indicated.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1

3 The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions. (Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored." (Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given. (Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present. Educational objective:Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

A pediatric nurse is floated to an adult medical surgical unit. Which client assignment would be most appropriate for the pediatric nurse? 1. Client with alcohol withdrawal who needs IV lorazepam every 2 hours 2. Client with emphysema and an oxygen saturation of 89% on room air 3. Client with sickle cell crisis requiring IV morphine every 2 hours 4. Client with type 2 diabetes mellitus who needs discharge teaching

3 The most appropriate assignment for the pediatric nurse is the client with sickle cell anemia requiring IV morphine every 2 hours. Sickle cell anemia is a common disorder in children and the pediatric nurse would be familiar with the assessment, plan of care, and treatment of clients with sickle cell crisis.

Which of the following are examples of medical battery? Select all that apply .1. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 2. Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 4. The nurse inserts a needed urinary catheter even though a competent client refuses it 5. The nurse threatens to put a client in restraints if the client does not stay in bed

3,4

The nurse is triaging clients in the emergency department. Which client needs to be seen first? The nurse is triaging clients in the emergency department. Which client needs to be seen first? 1. 18-year-old female with fever, suprapubic pain, and dysuria [3%] 2. 21-year-old male with diffuse abdominal pain and a rigid abdomen [41%] 3. 64-year-old male with a pulsatile mass in the periumbilical area and back pain [45%] 4. 75-year-old with nausea, fever, and left lower quadrant pain [9%]

3. Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. (Option 1) Fever, suprapubic pain, and dysuria in a young female client indicate urinary tract infection, a much lower priority than AAA. (Option 2) Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. (Option 4) Fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis. The client needs bowel rest, antibiotics, and IV fluids. This is a lower priority than AAA and peritonitis.

Which of these clients should the nurse assess first? 1. A client who has shortness of breath from moderate pleural effusion and is waiting for thoracentesis 2. A client who just had a long leg cast applied and has severe pain despite a dose of morphine 3. A client with cellulitis who is receiving a first dose of IV antibiotics and has throat tightness 4. A sickle cell crisis client who has severe bone pain despite a dose of morphine

3. First-level priorities include issues of airway, breathing, cardiac and circulation, and vital signs, respectively. A client receiving the first dose of an antibiotic is at risk for allergic reactions, including anaphylaxis. Signs and symptoms of anaphylaxis include itching, flushing, hives, wheezing, bronchospasm, swelling of the oral mucosa, and hypotension. This is a potentially fatal complication that requires immediate intervention (Option 3).

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client? 1. Room A: Client with multiple myeloma who is being treated with corticosteroids 2. Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics 3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube 4. Room D: Client with influenza with a high fever who is receiving oseltamivir

3. Surgical debridement of an unstageable pressure injury involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A and B (Option 3). (Option 1) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells (monoclonal antibodies), which are ineffective in providing protection against infection and suppress normal bone marrow cell production (eg, erythrocytes, platelets, leukocytes). This client in Room A is especially vulnerable to infection due to immunosuppression related to the disease process and to drug therapy with corticosteroids. (Option 2) The postoperative client should not be assigned to Room B with a client who has osteomyelitis, an infection of bone. (Option 4) The client with influenza requires droplet precautions and would likely require a private room (Room D). Clients with severe disease (ie, requiring hospitalization) should receive antiviral medication (eg, zanamivir, oseltamivir) as they are at high risk for complications.

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with cellulitis of the right foot, medicated with hydromorphone IV 1 hour ago, reports pain as 6 on a scale of 0-10 2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit 24% (0.24) reports shortness of breath with activity 3. Client with heart failure exacerbation and a large pleural effusion with serum sodium of 132 mEq/L (132 mmol/L) reports headache 4. Client with pneumonia and asthma, who just received nebulized albuterol, now appears to be resting after a sudden decrease in wheezing

4. After receiving report, the nurse should assess clients with airway and respiratory problems first (eg, airway, breathing, circulation). The client with asthma may have silent chest (sudden decrease in wheezing related to severe decrease in airflow) and require immediate attention.

The nurse in the emergency department receives report on 4 clients. Which client should be seen first? 1. 5-year-old with an accidental epinephrine auto-injector stick and a heart rate of 124/min 2. 7-year-old who is crying, has vaginal lacerations and bruising, and has a heart rate of 118/min 3. 10-year-old with a large, draining abscess on the left buttock and a temperature of 101.2 F (38.4 C) 4. 14-year-old who is lethargic after playing a football game and has a temperature of 104.1 F (40.1 C)

4. Heatstroke is a medical emergency characterized by a body temperature ≥104 F (40 C); hot, dry skin; tachycardia and hypotension; altered mental status; and neurological dysfunction. Clients require rapid cooling interventions to decrease the risk of permanent neurological injury or death

Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1. Client experiencing fever and pain with mastitis 2. Client preparing for discharge after cesarean birth 3. Client showing disinterest in caring for the newborn 4. Client with hysterectomy after postpartum hemorrhage

4. The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues. Educational objective:

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you."

4. A power of attorney (POA) designates a representative to act on a person's behalf in the event that the individual becomes incapacitated. There are different types of POAs, including medical and financial. An advance directive or living will describes the client's health care decisions (eg, do not resuscitate). As part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (Canada). This client's statement requires further clarification regarding what type of POA is in place (Option 4).

Which client in the emergency department should the nurse see first? 1. 2-year-old with fever and sore throat who is restless and drooling 2. 7-year-old with appendicitis who has right lower quadrant pain and vomiting 3. 9-year-old with immune thrombocytopenia who has generalized petechiae 4. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum

1 Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus influenzae type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency. Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia. The nurse should prepare to assist with emergent endotracheal intubation. (Option 2) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately. (Option 3) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of ITP. Acute ITP usually resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids, IV immunoglobulin). (Option 4) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated but is not a priority. Educational objective: Acute epiglottitis is a life-threatening emergency due to possible airway obstruction from severe swelling of the epiglottis. Symptoms include fever, sore throat, stridor, drooling, restlessness, and tripod positioning. The nurse should prepare to assist with emergent endotracheal intubation.

what kind of murmur do you hear witha patent ductus arteriousis and where do you hear it

left infraclavicular area and has continous machinery quality

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

1 Celecoxib (Celebrex), a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing (ie, ECG, cardiac enzymes) would be warranted.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply. 1. Nurse floated from another medical-surgical floor 2. Nurse who is 24 weeks pregnant 3. Nurse with erythematous rash and honey-color crusts on the hand 4. Unlicensed assistive personnel who just received the yearly injectable flu vaccination 5. Unlicensed assistive personnel with a cold

1,2,4 A client who has recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. Infectious contacts include staff members with a cold or impetigo, a common, highly contagious bacterial skin infection (Options 3 and 5). Impetigo vesicles rupture and form erosions, and the fluid creates a honey-colored crust. Common sites include the mouth and hands. The nurse should be referred to occupational health and must cover the site while working.

The registered nurse is working with a licensed practical nurse and unlicensed assistive personnel. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the registered nurse to assign to the licensed practical nurse? Select all that apply. 1. Administer oral pain medication for the client's chronic lower back pain 2. Assist the client with the use of a urinal post-procedure 3. Monitor for bleeding at the catheter insertion site every 15 minutes 4. Perform the initial post-procedure vital sign measurements 5. Review the ECG monitor for dysrhythmias

1,3 (Option 2) Unlicensed assistive personnel (UAP) possess appropriate skills and knowledge to meet clients' elimination, hygiene, and comfort needs. Although these tasks could be performed safely by an LPN, underutilizing UAP would be an ineffective use of resources. (Options 4 and 5) The RN should perform initial assessments (including vital signs), review the ECG for any dysrhythmias, monitor the client for chest pain, and monitor any infusions of anticoagulants or antiplatelet drugs. If the client is stable after the initial assessment, the RN may delegate routine vital sign measurements to the UAP.

A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related tasks should the RN delegate to the LPN? Select all that apply. 1. Administering oral pain medication 2. Assessing characteristics of pain 3. Measuring vital signs before and after analgesic administration 4. Monitoring pain level using a numeric scale 5. Providing discharge teaching about pain management

1,4 Everyone on the health care team contributes to the client's pain management. The registered nurse (RN) is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain (ie, P - provocation/palliation, Q - quality, R - region/radiation, S - severity, T - timing); performing initial client and caregiver teaching, including discharge instructions; and evaluating the effectiveness of the care plan (Options 2 and 5). The nurse should always consider the 5 rights of delegation prior to delegating a task. In this case, the RN may delegate the following tasks to the licensed practical nurse (LPN): Administering oral pain medication; individual practice region and facility policy will determine which of the various routes of medication the LPN is permitted to use (Option 1) Monitoring current objective pain level (numeric scale) (Option 4)

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply. 1. Emptying a urinary drainage bag and recording output volume 2. Emptying and verifying the patency of an accordion drain 3. Escorting a disgruntled family member off the unit 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices

1,4,5 To delegate a task appropriately, the nurse must observe the 5 rights of delegation to ensure that the skills and experience required for performing the task are adequate and are within the delegatee's scope of practice. Unlicensed assistive personnel (UAP) can perform basic tasks that require little assessment and are unlikely to cause harm to the client. Obtaining a clean-catch urine specimen, emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices are all routine tasks that can be safely performed by UAP (Options 1, 4, and 5). (Option 2) UAP can measure, empty, and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color, and odor of drainage. (Option 3) With a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer.

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg/dL." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1,4,5 cceptable abbreviations include "ac," "pc," "QID," and "cm." Unacceptable abbreviations include "qd," "q1d," and "qod"; "SSRI" for insulin; and "u" for units. There must be a zero before a decimal dose and no trailing zero after a decimal point. Additional Information Management of Care NCSBN Client Need Copyright © UWorld. All rights reserved.

The registered nurse (RN) is working with unlicensed assistive personnel (UAP). Which task can the RN safely delegate to the UAP? 1. Assisting a 2-day postoperative hip arthroplasty client with morning care [74%] 2. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter [21%] 3. Initial change of colostomy bag for a client who is 1-day postoperative colostomy [0%] 4. Refilling the empty enteral feeding container with tube feeding [3%]

1. (Option 2) Specimen collection from a Foley catheter is considered a sterile procedure. It involves accessing a sterile collection port, but there is a risk of introducing bacteria into the closed drainage system if done improperly. However, the UAP or even the client may collect a clean-catch or midstream urine specimen when appropriate instructions are given. (Option 3) Changing the colostomy bag for a client with an established stoma (not fresh) can be delegated by the RN to the UAP. However, the RN must first assess the appearance and function of the new colostomy stoma during the initial bag change. This requires nursing knowledge and judgment. The RN is also responsible for providing both initial client education regarding the new colostomy and emotional support as many clients have difficulty adjusting to the change in body image. (Option 4) The RN does not delegate care related to enteral feedings to the UAP as this requires professional nursing skills regarding abdominal and placement assessment, aspiration of residual volumes, and irrigation.

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

1. Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit. (Option 2) Mild oozing of blood from the surgical site is normal during the postoperative period. The nurse will note the amount and appearance of the drainage, reinforce the dressings, and continue to monitor the client. This client would be seen third. (Option 3) Pain control after surgery is important for client recovery. Because short-acting pain medications are given to minimize respiratory depression, a client's pain can increase quickly. This client would be seen second. (Option 4) After transurethral resection of the prostate, continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period. This client would be seen last.

A nurse delegates a task to the unlicensed assistive personnel (UAP). The UAP states, "I can't do that." Which is the best initial response for the nurse to make? 1. Ask the UAP the reason for the response 2. Do the task, but discuss the UAP's response with the manager 3. Ignore the UAP's initial response and repeat the delegation request 4. Remind the UAP of the importance of teamwork

1. Just as in clinical situations, the nurse should first assess in management situations. The UAP may not have the skills or abilities to do the task or the availability if doing something else. The nurse may need to reprioritize the tasks that the UAP has been delegated or provide additional instructions/education. However, finding out the reason for the response is the first step.

An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? 1. Call the telemetry unit manager 2. Notify the nursing supervisor 3. Send the client to ICU to "hold" the client in the hallway 4. Wait until the resident has time to request the transfer

2

The nursing team consists of a registered nurse (RN), licensed practical nurse (LPN), and 2 unlicensed assistive personnel (UAP). The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric client? 1. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today 2. A 6-month-old who had diaphragmatic hernia repair 5 days ago 3. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm3 4. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing

2 The LPN should be assigned stable clients with expected outcomes. A 5-day post-diaphragmatic hernia client is stable at this time. The LPN cannot perform initial teaching, assessments, or evaluate a client condition (Option 2). (Option 1) This client is scheduled for surgery today and will require education and evaluation. (Option 3) This client is newly admitted to the unit and will need to be assessed by an RN. (Option 4) This client is not stable. The client is exhibiting signs of diabetic ketoacidosis and will require care provided by an RN.

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the registered nurse (RN) delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Assisting the client in completing a health history form 2. Collecting a urine specimen for culture and sensitivity 3. Instructing the client to strain urine when voiding 4. Measuring and documenting urine output 5. Monitoring the color and characteristics of urine output

2,4 Measuring intake and output and obtaining a urine specimen for culture and sensitivity are both appropriate duties to delegate to the UAP. Objective measurements (eg, vital signs, intake and output) do not require assessment skills and are therefore appropriate for delegation (Option 4). Nursing actions that require assessment, teaching, evaluation, or clinical judgment must be performed by the RN. Collecting a urine specimen is a routine task with a predictable outcome and is therefore appropriate for delegation to the experienced UAP under the instruction and supervision of the RN (Option 2). The RN should always observe the five rights of delegation by verifying that the UAP have the skills and experience necessary to collect a urine specimen without contamination. If this client had a Foley catheter, specimen collection would be inappropriate for delegation to the UAP. Collecting a specimen from a Foley catheter is considered a sterile procedure as it involves accessing a sterile collection port and risks introducing bacteria into the closed drainage system if done improperly. However, when provided with the appropriate instructions, the UAP and even clients themselves may collect a clean-catch or midstream urine specimen.

he office nurse receives 4 telephone messages. Which client should the nurse call back first? 1. 32-year-old woman with a temperature of 100.4 F (38 C) who reports feeling achy following a flu shot yesterday [1%] 2. 50-year-old man who reports right shoulder pain and difficulty raising the arm above the head after playing baseball 2 days ago [4%] 3. 68-year-old woman with left-sided jaw pain, dizziness, and nausea who thinks it is an infection related to routine teeth cleaning yesterday [87%] 4. 72-year-old woman with urge incontinence who started taking solifenacin 2 days ago and reports constipation and very dry mouth [7%]

3 Older individuals, diabetic clients, and women may have atypical angina symptoms rather than the characteristic crushing, substernal type of chest pain. These symptoms include atypical pain (jaw or arm), shortness of breath, indigestion, nausea, dizziness, and cold sweats. This client reports symptoms thought to be related to a dental problem, but the nurse needs to gather more information. The symptoms can indicate a cardiac medical emergency (myocardial ischemia or acute myocardial infarction) that requires immediate evaluation and intervention.

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident." What is the best response by the nurse? 1. "A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then." 2. "Did you ask the HCP why it is being reported?" 3. "Reporting your child's injuries is required by law. It is for your child's safety and protection." 4. "Your explanation of your child's injuries does not seem plausible."

3 In discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has actually harmed or abused the child, the parent needs to know that a report will be made, why it is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The nurse should emphasize that the primary concerns are for the safety and well-being of the child and that reporting is mandatory for the types of injuries sustained by the child. It is not unusual for a parent to react to this information with denial and/or anger. The nurse needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and nonaccusatory approach.

The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? Select all that apply. 1. "Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation." 2. "Client reports that IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified." 3. "Heparin infusion running at 15 units/kg/hr at 7:15 AM; infusion rate adjusted to prescription of 12 units/kg/hr. Labs drawn at 7:20 AM, aPTT 65 sec. HCP notified; will draw labs again at 1:20 PM." 4. "IV site in right hand is red and swollen at 9:30 AM. IV removed, bleeding controlled, and warm compress administered at 9:40 AM. Will reassess for swelling and pain every hour." 5. "Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings."

3,4 when charting a situation or symptom nurse should chart interventions taken and client response.

The emergency department nurse receives report on 4 clients. Which client should the nurse assess first? 1. Client with acute cholecystitis who reports right shoulder pain 2. Client with gastroparesis who reports persistent nausea and vomiting 3. Client with intractable lower back pain who reports new urinary incontinence 4. Client with Ménière disease who reports increasing tinnitus

3. Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equine syndrome (ie, incontinence); therefore, the nurse should assess this client first. (Option 1) Clients with acute cholecystitis may experience referred pain to the right shoulder due to irritation of the diaphragm from the inflamed gallbladder. Although the client's pain should be addressed, this client is not the priority. (Option 2) Clients with gastroparesis have delayed gastric emptying and often report persistent nausea and vomiting. Treatment includes antiemetics, but this client is not the priority. (Option 4) Ménière disease is an inner ear disorder. Expected symptoms include episodic vertigo, tinnitus, and muffled hearing. Treatment during an acute attack includes antihistamines, anticholinergics, and benzodiazepines. As long as the client is safe from falling, treatment is not emergent. Educational objective:Signs and symptoms of cauda equina syndrome (eg, acute spinal/back pain, inability to walk, saddle anesthesia, bowel/bladder incontinence) require emergency attention to prevent permanent damage

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give? 1. Encourage the night nurse to provide the UAP with additional training [33%] 2. Indicate that it is the night nurse's job to deal with staff problems [1%] 3. Remind the night nurse that the UAP is doing the best job the UAP can [1%] 4. Suggest that the night nurse discuss concerns with the nurse manager [64%]

4

The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate registered nurse (RN) during orientation. The LPN states, "The only difference between you and me is the size of our paychecks." What would be the best response for the new graduate RN to make initially? 1. Assert being the manager of the client team 2. Emphasize the additional education received 3. Explain the legal difference in the scope of practice 4. Focus on the need to work together for quality client care

4

The nurse is performing beginning of shift assessments on 4 clients. Which client's assessment findings should the nurse immediately report to the health care provider? 1. 36-year-old client with alcohol withdrawal who is receiving IV lorazepam every 3 hours for agitation and has a blood pressure of 190/98 mm Hg 2. 56-year-old client with stable angina who has chest and jaw pain relieved with nitroglycerin, blood pressure of 98/70 mm Hg, and dizziness when getting up 3. 60-year-old client with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching 4. 82-year-old client with a pressure injury who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg

4 Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury), that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response (ie, immunosenescence). Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality (Option 4). (Option 1) Chronic use of central nervous system depressants (eg, alcohol) causes a reflexive increase in catecholamine production (eg, epinephrine). During alcohol withdrawal, hypertension, agitation, and anxiety occur because catecholamine production is no longer inhibited. (Option 2) Clients with stable angina (ie, chest and jaw pain relieved with sublingual nitroglycerin) often experience orthostatic hypotension, an adverse effect of nitrate drugs. (Option 3) Clients with chronic kidney disease (CKD) commonly experience nausea and pruritus due to buildup of nitrogenous wastes in the blood (ie, azotemia). Elevated creatinine is an expected finding in CKD. Hypertension does require intervention by the nurse after management of infection and sepsis. Educational objective:Immunosenescence is an age-related decrease in the immune and inflammatory responses that increases older adult clients' risk of infection and sepsis and causes atypical signs of infection (eg, hypothermia, altered mental status, leukopenia). Atypical signs of infection should be immediately reported to increase the client's chance of survival. Additional Information Management of Care NCSBN Client Need

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

1. The nurse should assess the postoperative client first by monitoring vital signs, examining the dressing and amount and appearance of the drainage, and performing a neurovascular assessment (eg, pulses, skin color and temperature, sensation, movement). Serosanguineous (pink) drainage would be expected 2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality (Option 1).

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply. 1. Client in sickle cell crisis receiving oxygen via face mask 2. Client who drank a 1 L bottle of vodka 2 hours ago 3. Client who hears voice commands to kill a coworker 4. Client with mania who has not eaten in 5 days 5. Client with ST elevation on ECG monitoring

2,3,4 To leave against medical advice (AMA), the client must be legally competent to make an educated decision to stop treatment. Disqualifications for legal competency include altered consciousness, mental illness (ie, a danger to self or others), and being under chemical influence (eg, drugs or alcohol). The client who drank a 1 L bottle of vodka is intoxicated (Option 2). The client who hears voices has psychotic symptoms and is potentially homicidal (Option 3). The manic client who has not eaten in 5 days is a potential danger to self and cannot leave AMA (Option 4). For a competent client to leave AMA, the health care provider must explain the risks of discontinuing treatment. The nurse must witness and document the discussion on risks of leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving AMA can, and should, receive discharge instructions and the option to return at any time. (Options 1 and 5) Clients have the right to leave AMA, even if it is not in their best interests to leave (eg, even if potentially life-threatening). Not allowing a competent client to leave AMA is a form of false imprisonment, a legally liable action by the nurse.

The registered nurse is caring for multiple clients on a medical-surgical unit and has finished the morning assessment. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel? 1. Apply a collagenase dressing to a client's pressure ulcer for wound debridement 2. Assist a client 1 day postoperative hip fracture repair to the bathroom 3. Feed a client through a gastrostomy tube after elevating the head of the bed 4. Offer orange juice to a client if the blood glucose level is <70 mg/dL (<3.9 mmol/L)

2 Delegation is the process of transferring responsibility of performing a task while maintaining the ultimate responsibility for the action and its outcome. The registered nurse (RN) should take into account the five rights of delegation (right task, right person, right circumstances, right communication/direction, and right supervision/evaluation) and the scope of practice when deciding which tasks to delegate. The unlicensed assistive personnel (UAP) can assist clients out of bed or to the bathroom, assist with activities of daily living, and position clients. The RN is responsible for assessing the client and adhering to the nursing process. (Option 1) Debridement of a wound involves removing debris or dead tissue to convert contaminated wounds into clean wounds so that normal healing can take place. Dressing (eg, collagenase) changes for debridement require sterile technique; UAP can change dressings only for chronic wounds using clean technique. (Option 3) The UAP can elevate the head of the bed when a client receives enteral nutrition to prevent aspiration. However, feeding through a gastrostomy tube cannot be delegated to the UAP as it requires assessment of tube placement and aspiration of gastric residual volume.

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply. 1. Client has a row of 3-inch circles down the back from "cupping" 2. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA) 3. RN thinks a teenage client's signs are from abuse, but the health care provider does not 4. RN thinks an elderly client's signs are from abuse but the client denies this 5. Syphilis is diagnosed in an 11-year-old who denies sexual activity

2,3,4,5 The RN is required to report suspected abuse of vulnerable clients (eg, underage, elderly, mentally ill) to appropriate authorities, regardless of what other practitioners think. A proper investigation, rather than conflicting opinions, will determine whether abuse has occurred (Option 3). The RN should report suspected abuse of vulnerable clients even if the client denies it because other factors (eg, dependence on the abuser, dementia) could be the reason for denial (Option 4). Sexually transmitted infection (STI) in a child is sexual abuse and must be reported and investigated (Option 5). The greater good of society outweighs an individual's right to confidentiality. Gonorrhea is an STI; the client should be informed that public health will be notified and partners will be contacted to receive treatment (Option 2).

Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV [2%] 2. A client with Cushing syndrome who needs intermittent urinary catheterization [92%] 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion [3%] 4. A client with thyrotoxicosis and new-onset atrial fibrillation [1%]

2. Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching.

A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dL (38.3 mmol/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days

3 The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation (normal reference is ≥95%) indicates mild-to-moderate status asthmaticus. This client needs to be treated immediately.

client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the charge nurse choose as the best option for this client? 1. Room 1—client with Clostridium difficile 2. Room 2—client with fever of unknown origin 3. Room 3—client with bacterial pneumonia 4. Room 4—client with upper gastrointestinal bleed

4

The charge nurse is reviewing clients' medical records on the cardiovascular care unit. Which client care outcomes are appropriate? Select all that apply. 1. Client receiving a continuous heparin infusion for a deep venous thrombosis remains free of petechiae or purpura 2. Client who had a carotid endarterectomy maintains a heart rate <100/min and blood pressure >90/60 mm Hg with no neurological changes 3. Client who had a percutaneous coronary intervention maintains a chest pain level of <4 on a scale of 0-10 while at rest 4. Client with hypertension receiving IV furosemide remains free from muscle cramping in the extremities 5. Client with peripheral arterial disease following a femoral-popliteal angioplasty remains free of leg pain during ambulation

1,2,4,5 Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg, petechiae, purpura) (Option 1). Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status) (Option 2). Clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac arrhythmia) (Option 4). A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia (eg, leg pain) (Option 5). (Option 3) A percutaneous coronary intervention (PCI) is a procedure used to restore coronary perfusion to prevent or treat ischemia or infarction. Clients having undergone a PCI would be expected to have no chest pain at rest. Chest pain at rest indicates myocardial ischemia.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1. 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 C) and 6 wet diapers today 2. Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding 3. Client with purulent drainage and crusting of the eyelid with vision unaffected 4. New parent who is crying and overwhelmed, and denies suicidal ideation

1. Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate. (Option 2) The client receiving radiation therapy is stable, and there is 6- to 8-hour window in which to safely close the wound. This is not a high-risk client. (Option 3) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted" eyelids. The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. Pink eye is highly contagious but not emergent. (Option 4) The parent has postpartum blues/depression and is not emergent. This client can be counseled or provided resources later after the infant with fever is seen.

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting

2. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (Option 2). (Option 1) Clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy are required. (Option 3) Clients with diabetes may develop diabetic ketoacidosis (DKA) during illness or infection. Features of DKA (eg, lethargy, abdominal pain, hyperglycemia, urine ketones) are a medical emergency. Untreated DKA may progress to loss of consciousness and coma. Treatment includes frequent laboratory monitoring and IV insulin, fluids, and potassium. (Option 4) Clients with ulcerative colitis are at risk for developing toxic megacolon (ie, severe inflammatory colon distension). Symptoms include fever, nausea, vomiting, pain, and abdominal distension. Clients require close monitoring, nasogastric tube for decompression, IV fluids, and antibiotics. Emergency surgery may be required. Educational objective:

A nurse is admitting a child who has leukemia. Several rooms are available on the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever

3. Leukemia is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production. It would be appropriate for this client with leukemia to share a room with a client with minimal change nephrotic syndrome (MCNS). MCNS is a non-infectious condition of the glomeruli and poses no risk to a client with leukemia. (Option 1) Appendicitis is a result of viral or infectious processes and can lead to rupture of the appendix. A client recovering from a ruptured appendix poses a threat of infection to the child who has leukemia. (Option 2) A client with cystic fibrosis has pulmonary complications due to thick mucus that traps bacteria. The tracheobronchial tree is colonized with bacteria and respiratory infections are a lifelong problem. This client poses a threat of infection to the child with leukemia. (Option 4) Rheumatic fever occurs following pharyngitis caused by group A β-hemolytic Streptococcus. A client with this condition poses a threat of infection to the child with leukemia. Educational objective:Leukemia is a cancer of the blood and organs involved in hematologic function. Due to myelosuppression, clients are at risk for problems related to infection, anemia, and bleeding.

The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1. Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours 2. Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms 3. Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria 4. Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea

4. A client with a spinal cord injury at or above T6 is at risk for autonomic dysreflexia, a medical emergency that can lead to hypertensive emergency (eg, stroke, myocardial infarction) and death. Common triggers include bladder or rectum distention and pressure ulcers.

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gestures 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

1. An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The role does not include personally editorializing or embellishing with advice beyond what the health care provider (HCP) said. It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about other topics (eg, social). The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no additional questions that the interpreter personally answered. The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line.

During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first? 1. Administer the correct medication and obtain current vital signs 2. Alert the graduate nurse and complete an incident report 3. Assess the client and notify the health care provider 4. Discontinue the dopamine and inform the nursing supervisor

3 When a medication error occurs, client safety is the nurse's first priority. The nurse should assess the client immediately for any adverse effects and inform the healthcare provider (HCP) (Option 3). Before taking any other actions, the nurse must ensure that the client is stable. Following client stabilization, the error should be reported to the appropriate nursing authority (eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours.

When caring for a client with pneumonia, which nursing activities are most appropriate for the registered nurse (RN) to delegate to the licensed practical nurse (LPN) working under RN supervision? Select all that apply. 1. Administering metered-dose inhaled medications 2. Monitoring lung sounds 3. Evaluating use of the incentive spirometer 4. Nasotracheal suctioning to collect a sputum specimen 5. Teaching the importance of fluid intake

1,2,4 The RN can safely delegate certain aspects of nursing care for stable clients to the LPN. The scope of nursing practice for the LPN includes routine procedures, such as administering most medications, completing basic assessment tasks (eg, auscultating lung or bowel sounds after initial assessment by RN), and performing sterile procedures (eg, suctioning, catheterization). The RN can delegate these tasks to the LPN because they do not involve the functions of higher-level assessment, planning, evaluation, or clinical nursing judgment.

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply. 1. Assist the registered nurse with ambulating a client 1-day post chest tube placement 2. Measure wound drainage from a bulb drain and document it on the output flow sheet 3. Monitor for redness and swelling at the IV insertion site and report back to the nurse 4. Return an unused unit of packed red blood cells to the blood bank 5. Take family members to the waiting room after the client goes into surgery

1,2,4,5 Unlicensed assistive personnel (UAP) may perform routine tasks for stable clients under the direction of the registered nurse (RN). Tasks related to the nursing process (eg, assessment, planning, evaluation) require trained knowledge, critical thinking, and individualized application by the RN and cannot be delegated. A client 1-day post chest tube placement must be assessed by the RN to establish safety and readiness for ambulation. However, the UAP can assist the RN in ambulating if appropriate (Option 1). UAP can empty, measure, and record output from a surgical drain. However, the RN is responsible for assessing the drainage (eg, type, amount, odor, color) and maintaining the wound drainage device (Option 2). As directed by the RN, UAP can courier blood products to and from the blood bank (Option 4). However, verification of any blood products must be performed by 2 RNs prior to transfusion. UAP can carry out comfort measures such as escorting family members to the waiting area (Option 5

Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply.Which actions by a registered nurse are reportable to the state board of nursing? Select all that apply. 1. Administering hydromorphone without a prescription 2. Being habitually tardy to work 3. Documenting an intervention that was not performed 4. Stealing narcotics 5. Walking off duty in the middle of a shift

1,3,4,5 The National Council of State Boards of Nursing advises any individual who has knowledge of a potential violation of a nursing law or rule to file a complaint with the appropriate state board of nursing. A nurse should be knowledgeable concerning the presiding board's stance on mandatory reporting and which actions are considered reportable. In general, reportable actions may include any behavior by a licensed nurse that is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical condition), or in violation of nursing law. Practicing outside of the scope of the license is reportable even if the practice meets quality standards (Option 1). Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action (Option 3). Stealing narcotics is a criminal offense (a violation punishable by the state that can result in prison or a fine) and is reportable in all states. Many states offer an alternate rehabilitation program to nurses who diverted or abused drugs (Option 4). Abandonment (eg, leaving without proper replacement of personnel and transfer of responsibility for client care) is reportable in all states (Option 5). (Option 2) Work habits are handled under the facility's management policies and are often part of the criteria for discipline and/or termination. If the facility has 24-hour care, the off-going nurse cannot leave without someone assuming responsibility for the clients or waiting for the tardy nurse. Educational objective:Nurse offenses reportable to the state board of nursing include criminal acts (such as theft), practicing outside of the scope, falsification of records, and client abandonment. Any individual may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or in violation of nursing law.

The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action? 1. A 3-month-old with fever, vomiting, high-pitched cry, and irritability 2. A 9-month-old with diarrhea who is refusing fluids and cries without tears 3. An 11-month-old with cold symptoms and an abdominal breathing pattern 4. An 18-month-old who cries when the caregiver leaves

1. Infants with underlying infection and increased intracranial pressure (ICP) will be very irritable and have fever and a high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3-month-old needs to be seen first due to the potential for bacterial meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated with antibiotics immediately. (Option 2) The absence of tears when crying indicates moderate dehydration. This infant needs evaluation but is not the priority. (Option 3) In children under age 6 years, the diaphragm is the major respiratory muscle. This infant is displaying normal respiratory effort. Furthermore, cold symptoms are common in children. (Option 4) Separation anxiety (distress when the primary caregiver is absent) is common in this age group (age 8 months to 2 years).

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with blood pressure of 90/70 mm Hg and deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg 4. Client with pain at the thoracic spine and complete paralysis of both legs

1. Tension pneumothorax causes marked compression and shifting of mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-threatening emergency. The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures. (Option 2) Clients who have a head injury and lose consciousness are at high risk of intracranial injury (bleed). This client would likely need a head CT scan to assess for further damage, but the client with pneumothorax is the priority. (Option 3) A grossly swollen upper thigh likely represents a femur fracture with extensive bleeding. It requires intervention, especially IV fluids and surgical correction. However, this is a second priority after the client with pneumothorax. (Option 4) Thoracic spine pain and leg paralysis likely represent injury to the spinal cord. Precautions such as a hard cervical collar and backboard should be used to prevent further injury. This client requires further testing and treatment but is not a priority over the client with pneumothorax.

The health care provider (HCP) remarks that the staff nurse has a great body and that it would be worthwhile for them to have sex. The staff nurse does not want a relationship with the HCP and finds the remarks offensive. What action should the receiving nurse take initially? 1. Report the statement to the nurse manager 2. Tell the HCP to stop the comments 3. Walk away and say nothing 4. Write up an incident report

2 Sexual harassment, including soliciting sexual favors in exchange for favorable job benefits, is prohibited. Other behaviors that could be defined as sexual harassment include asking someone for a date after the other person expressed disinterest or making remarks about a person's gender or body. The receiving nurse should first immediately and clearly indicate that the attention is unwanted and the offending HCP should stop. The offending HCP may have erroneously perceived a mutual attraction. If that is not effective, additional action should be taken. The American Nurses Association cites 4 tactics to fight workplace sexual harassment: confront, report, document, and support.

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply. 1. Orient the client to the bedside unit and explain the call bell system on admission 2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately 5. Report whether client is using correct gait and balance while ambulating with walker

2,3,4 The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords)

The emergency department nurse is obligated to make a report for which situations? Select all that apply. 1. To a client's employer that the client had a car crash while intoxicated 2. To the authorities that an elderly client has suspicious bruising but denies caregiver abuse 3. To the medical examiner of a death following trauma, even if the family refuses autopsy 4. To the spouse of a client that the client has a reportable sexually transmitted disease 5. To the supervisor that an oncoming health care provider has the smell of alcohol on the breath

2,3,5 There are several circumstances in which the nurse is legally required to report to appropriate civil authorities: Suspected elder abuse must be reported to the appropriate authorities for investigation. The nurse has a legal obligation to report signs of abuse regardless of clients' ability or willingness to advocate for themselves (Option 2). The nurse should report deaths that meet medical examiner reporting guidelines (eg, suspected to be the result of a crime, trauma, or suicide) to the authorities for investigation. The local medical examiner has the legal authority and obligation to perform an autopsy independent of the family's wishes (Option 3). For the sake of client safety, nurses should immediately report impaired or intoxicated health care workers, regardless of their position (Option 5). Under the Health Insurance Portability and Accountability Act, a client's reason for an emergency department visit cannot be communicated to employers without the client's permission (Option 1). Health authorities must be notified of a reportable sexually transmitted disease regardless of client wishes. Depending on the condition, authorities may report findings to sexual contacts, but it is a violation of client privacy for the nurse to share this information with the client's family or spouse (Option 4).

An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? An admitted emergency department (ED) client is waiting for an intensive care unit (ICU) bed to be available for transfer to the inpatient unit. The ED is very crowded today. The ICU resident is currently too busy to request that an ICU client be transferred to telemetry so the bed can be available; the resident will be able to do so in about 6 hours. What action should the ED charge nurse take first? 1. Call the telemetry unit manager 2. Notify the nursing supervisor 3. Send the client to ICU to "hold" the client in the hallway 4. Wait until the resident has time to request the transfer

2. It is important to move the client to the ICU and for the ED to continue to care for incoming clients. The nursing supervisor, who serves as an "officer" of the facility, can help resolve interdepartmental issues when it is necessary for a higher authority to intervene and expedite processes (Option 2). (Option 1) The telemetry unit manager would not have the authority to transfer a client. Although the manager could suggest other transfers, prescriptions for the transfers would still be necessary. The nursing supervisor can work with the telemetry manager as needed. (Option 3) The client needs appropriate monitoring equipment and staff, not just a physical bed. A high-acuity client is not held in a hallway without adequate caregiving support. (Option 4) The client will be held until a bed and staff are available in the appropriate unit. However, the charge nurse should at least try to facilitate a timely transfer.

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine

2. Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option 1) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room

Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)? 1. Assisting a client in ambulating to the bathroom for the first time following surgery 2. Explaining why using the incentive spirometer is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar of 70 mg/dL (3.9 mmol/L) 4. Taking vital signs every 15 minutes on a client who was just transferred from the post- anesthesia recovery unit

3 he RN can delegate routine tasks such as taking vital signs, supervising ambulation, making beds, assisting with hygiene, and activities of daily living to the experienced UAP. Assessment, analysis of data, planning, teaching, and evaluation are the responsibilities of the RN.

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L)

3 Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is the most life-threatening condition listed. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) 3. Administered warfarin to a client with International Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

3. A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4.

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 3. Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 4. Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

1. Serosanguineous (pink) drainage is expected after a surgical procedure, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. Treatment with a pressure dressing to provide hemostasis, cauterization of a bleeding vessel, or fluid replacement may be necessary.

Four clients enter the emergency department at the same time. Which should the triage nurse see first? 1. 25-year-old client with sudden-onset chest pain and heart rate of 110/min 2. 45-year-old client with type 2 diabetes who is traveling and has lost insulin glargine 3. 60-year-old client with pain, swelling, erythema, and warmth in the right leg 4. 70-year-old client with left lower abdominal pain and diarrhea for 2 days

1. An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by the health care provider before the other 3 clients. (Option 2) This client will need a prescription renewal. Glargine (Lantus) is given once a day, typically in the evening, as basal insulin. The consequence of late administration is hyperglycemia. A single temporary rise in glucose will not have a significant negative impact. The damage to vessels in a diabetic client comes from long-term uncontrolled diabetes. The other clients are a higher priority. (Option 3) This client may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen after the higher-risk client with chest pain. (Option 4) This client may have acute diverticulitis and should be seen urgently, but after the client with chest pain. Prioritization should be based on which client is most ill and not on advanced age. Educational objective:Chest pain in an adult, regardless of age, is a priority. It is important to not make assumptions based on client age, race, or nationality.

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? 1. Assess for copious secretions to determine exposure 2. Assist the victims farthest from the source first 3. Assist the victims with the most severe symptoms first 4. Monitor for diplopia to determine extent of exposure

2. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. (Option 1) Nerve agents used as biological weapons (eg, sarin) inhibit acetyl-cholinesterase, and their effects are caused by the resulting excess acetylcholine. Common symptoms are miosis, rhinorrhea, copious secretions, shortness of breath, and flaccid paralysis. Treatment is with suction and support ventilation and circulation. However, these symptoms are not related to radiation contamination. (Option 3) Damage from radiation affects the most radiosensitive cells first; these are the hematopoietic, digestive, central nervous system, and cutaneous cells. The presence of severe symptoms indicates extensive internal damage and that the victims are less salvageable in the long term. (Option 4) Neurologic symptoms such as symmetrical descending flaccid paralysis with cranial nerve palsies (ptosis, diplopia, dysphagia, dysphonia) are classic of botulism, which is caused by toxins from the spore-forming anaerobic bacillus Clostridium botulinum. Treatment includes ventilator assistance and the heptavalent botulism antitoxin. Educational objective:In triaging victims from a radiation contamination disaster, nurses should assist clients who are farthest away from the source and have the least symptoms as most damage is internal and will not be apparent initially. Nerve agents (eg, sarin) cause excess acetylcholine with copious secretions. Neurologic symptoms are classic for biological threats such as botulinum toxin. Additional Information Safety and Infection Control NCSBN Client Need

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first?The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis 2. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine 3. Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL (27.8 mmol/L) who is to receive subcutaneous regular insulin and insulin glargine

3 Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome. (Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually prescribed once every 24 hours, so administration is not urgent. (Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy and need to be treated emergently. (Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis. Educational objective:Sepsis is a serious condition involving an infection in the bloodstream that can lead to organ dysfunction and death. IV antibiotics should be administered to a client with sepsis as soon as possible after obtaining blood and other cultures to help prevent progression to septic shock and multiorgan dysfunction syndrome.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? 1. Room 1 - client in skeletal traction following a fracture of the femur, who has erythema at the pin sites [10%] 2. Room 2 - client with cellulitis and osteomyelitis following blunt trauma of the tibia [2%] 3. Room 3 - client with compartment syndrome following a crush injury, who is 1 day post fasciotomy [12%] 4. Room 4 - client with a long leg cast following open reduction of a fractured tibia [75%]

4 A client who is postoperative total knee replacement is at risk for infection. No postoperative client should be assigned to a room with a client who has an actual infection or the potential for infection. This client should be assigned to room 4 as the client with the cast has the lowest potential risk for infection (Option 4). (Option 1) This client has erythema at the pin sites; this can be a sign of infection, a complication of skeletal traction. (Option 2) This client has cellulitis, a bacterial infection of the skin, and osteomyelitis, an infection of the bone. (Option 3) This client has a fasciotomy wound, which is usually kept open for several days to relieve the pressure in the myofascial compartment. This client is a potential source of infection and is susceptible to infection as well. Educational objective: A client who is postoperative total knee replacement is at increased risk for infection. This client should not be assigned to a room with a client who has an actual (eg, cellulitis, osteomyelitis) or potential (eg, skeletal traction, fasciotomy) infection.

The nurse receives report on 4 clients. Which client should be seen first? 1. 10-month-old with audible congestion and mucus-producing cough 2. 10-year-old with an active nose bleed who is applying pressure 3. 12-year-old with urinary frequency and burning, and fever 4. 15-year-old with painful right hip, fever, and limited range of motion

4. his client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition

4. should be 140-180 glucose under 70 for pt receving tpn is considered hypoglycemia hyperglycemia is over 180 hypoglycemia causes risk for seizures nervous system damage

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? 1. Albumin of 3.0 g/dL (30 g/L) in a client with chronic hepatitis 2. B-type natriuretic peptide of 400 pg/mL (400 pmol/L) in a client with heart failure 3. Magnesium of 1.7 mEq/L (0.85 mmol/L) in a client with alcohol withdrawal 4. Sodium of 120 mEq/L (120 mmol/L) in a client with small cell lung cancer

4 Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH. 135-145

The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene? 1. UAP applies the anti-embolism stockings while maintaining the client in supine position [5%] 2. UAP carefully smoothes out any wrinkles over the length of the stockings [1%] 3. UAP checks that the toe opening of the stockings is located on the plantar side of the foot [10%] 4. UAP rolls down and folds over the excess material at the top of the stockings [82%]

4.

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first? The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first? 1. 9-year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer [1%] 2. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy [61%] 3. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine [20%] 4. 72-year-old who is incontinent with acute altered mental status and is yelling at staff [15%]

2. remember ABCS. Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation. These complications have a high priority due to potential interference with airway patency. The nurse should assess for signs and symptoms of airway compromise (eg, stridor, use of accessory muscles, restlessness). Suction equipment should be available to clear the airway of secretions, and a tracheostomy tray should be at the bedside in case an emergency tracheotomy is required

The primary care provider's office nurse must return telephone calls concerning 4 clients. Which client has the most emergent situation and requires an immediate call back? 1. 28-year-old woman is requesting antibiotic to be called to pharmacy due to another bladder infection [1%] 2. 55-year-old man who takes trazodone is reporting a painful erection of 3 hours duration [79%] 3. 78-year-old man with sinusitis who takes pseudoephedrine is having difficulty voiding [14%] 4. 84-year-old man with prostate cancer and spine metastasis is requesting increased pain medication [4%]

2. priapism is a medical emergency Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department.

The clinic nurse receives phone calls about the following 4 clients. Which call should the nurse return first?1. A 6-month-old who received the diphtheria, tetanus, acellular pertussis vaccine 18 hours ago and developed fever of 102 F (38.9 C) and injection site redness 2. An 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen 3. A 4-year-old diagnosed with right lung pneumonia 2 days ago who has chest pain when breathing deeply 4. A 15-year-old whose eyes are red and itchy and have a yellow discharge

2. Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation. (Option 1) Mild to moderate fever and local reactions are common after diphtheria, tetanus, acellular pertussis (DTaP) injections. Severe allergic reaction (eg, anaphylaxis) and encephalopathy (eg, decreased level of consciousness, prolonged seizures) are the most serious reactions that require priority attention. (Option 3) Pneumonia is often accompanied by chest and side pain that worsens with deep breathing due to rubbing of the nearby inflamed pleura (pleuritis). This would not be the priority phone call. (Option 4) These symptoms are consistent with bacterial conjunctivitis, or inflammation of the clear membrane (conjunctiva) that covers the eye. This client is second in priority. Educational objective:Intussusception occurs when one section of bowel telescopes over another. Inconsolable crying, drawing up of the legs toward the abdomen, and "currant jelly" stools (mixed with blood and mucus) are the classic findings. It is an

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence 2. The parent is in the process of a divorce and will soon be a single parent 3. The parent is witnessed stealing food and drinks from the cafeteria 4. The parent leaves the client's younger sibling to care for the client's newborn sibling

4. hild neglect occurs when a caregiver purposely withholds or does not adequately provide necessary resources to fulfill the basic needs of a child (eg, adequate nutrition, security, hygiene). Supervisory neglect, leaving children without adequate guardianship to ensure safety, is one form of child neglect (Option 4). Children age <12 lack formal operational reasoning and cannot anticipate safety risks or respond appropriately to emergencies, and should therefore not be left to supervise other children. It is a priority for the nurse to intervene, as this is an unsafe situation for the young children. The nurse, or social services, should report the situation to an appropriate government child protective service and/or law enforcement.

After receiving the hand-off nurse-to-nurse evening shift report, which client should the nurse assess first? 1. Client who is 3-days postoperative bowel resection, now reports shortness of breath and chest pain 2. Client who is 3-days postoperative right knee surgery, now reports fever, cough, and shortness of breath 3. Client who was transferred from the post-anesthesia care unit (PACU) 15 minutes ago 4. Client with a kidney stone who is requesting pain medication for severe flank pain

1. The nurse should assess the postoperative client who had the bowel resection and is currently reporting shortness of breath and chest pain first. Abdominal surgery can cause engorgement of the large vessels in the pelvis leading to venous stasis and increased risk for a pulmonary embolism (PE). Therefore, this client's problem poses the greatest threat to survival and requires immediate attention. (Option 2) This client likely developed postoperative pneumonia. Though pneumonia needs to be assessed and treated as soon possible, it is not as life-threatening as acute PE. Pneumonia is fatal to clients within a period of days (rarely hours), but PE can lead to death in minutes to hours, depending on its severity. (Option 3) This client requires a thorough respiratory assessment. However, this client arrived 15 minutes ago, vital signs, including pulse oximetry, were already measured; and the day shift nurse who received the report from the PACU nurse assessed the client. (Option 4) Flank pain is expected in a client who is hospitalized for a kidney stone. Providing pain relief and comfort are priorities, but this client does not have the most urgent problem. Educational objective:

Which client should the charge nurse assign to the room closest to the nurses' station? 1. Client with a Salem sump tube to continuous suction who is deaf 2. Client with gastroenteritis and dementia who wanders 3. Client with herpes zoster under airborne isolation precautions 4. Client with sickle cell crisis who requires frequent intravenous opioids

2 The client with dementia and gastroenteritis presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalance. This client should be assigned to the room closest to the nurses' station as a confused client requires frequent checks and this allows the staff to respond quickly if necessary

The nurse is providing handoff-of-care report to the oncoming nurse for a client admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during handoff report? 1. Chest x-ray showed lung infiltrates; WBC count is 14,000/mm3 (14 x 109 /L) [32%] 2. Client's spouse was acting rudely toward the nurse earlier [2%] 3. Current respirations are 24/min; pulse oximetry is 93% on 2 L/min [62%] 4. Intravenous line is infusing with no signs of infiltration [2%]

3 andoff report should include objective information related to the client's current condition. It is especially important to include baseline measurements that may not be documented in the medical record (eg, current respiratory status) so that the oncoming nurse can prioritize care.

The registered nurse (RN) delegates to the unlicensed assistive personnel (UAP) the ambulation of a client. The RN observes the UAP placing the client's Foley bag on the IV pole at the level of the client's chest during the ambulation down the length of the hallway. What action should the RN take initially? 1.Discuss the need for UAP inservice education with the nurse manager 2. Give praise to the UAP for encouraging the client to walk the entire hall 3. Immediately lower the bag and speak privately to the UAP 4. Let the UAP complete assigned tasks and speak to the UAP at the end of the shift

3 The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client. (Option 1) Future inservice education is not a timely solution to this immediate need. It is appropriate to carry out teaching first rather than initiate disciplinary actions. According to the Federal Drug Administration's (FDA's) mandate, as no serious harm was caused, the incident does not need to be reported. (Option 2) The most important issue needing intervention is the improper positioning (too high) of the Foley catheter bag. Positive reinforcement for appropriate actions can also be included (and is beneficial), but the error should first be corrected to prevent harm. (Option 4) It is important to attend to the error right away to help ensure that the UAP does not repeat it. Letting this UAP complete assigned tasks first does not immediately deal with the incorrect position of the Foley bag and may not effectively teach (aid retention of) the correct positioning to the UAP. Educational objective:When observing a provider making an error, correct it immediately to stop any potential harm to the client. Correct the provider privately and as soon as possible