Lacharity Chapters 1-21 (3rd Edition), Lacharity Chapter 21: Psychiatric & Mental Health, Lacharity Chapter 19: Pediatric Problems, Lacharity Chapter 20: Emergencies & Disasters, Lacharity Chapter 18: Problems in Pregnancy and Childbearing, Lacharity...

9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free. 3. Titrate downward to prevent toxicity. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.

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In the care of a client with acute viral hepatitis, which task should be delegated to the UAP? 1. emptying the bed pan wearing gloves 2. playing games or engaging the client in diversional activities 3. monitoring dietary preferences 4. reporting signs and symptoms of jaundice

1. emptying the bedpan wearing gloves

13. A client is crying and grimacing but denies pain and refuses pain medication, because "my sibling is a drug addict and has ruined our lives." What is the priority intervention for this client? 1. Encourage expression of fears and past experiences. 2. Provide accurate information about the use of pain medication. 3. Explain that addiction is unlikely among acute care clients. 4. Seek family assistance in resolving this problem.

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15. In the care of clients with pain and discomfort, which task is most appropriate to delegate to the UAP? 1. Assisting the client with preparation of a sitz bath 2. Monitoring the client for signs of discomfort while ambulating 3. Coaching the client to deep breathe during painful procedures 4. Evaluating relief after applying a cold compress

1

Your caring for a client with cirrhosis importantly retention which statement by the client can send you the most and very constipating and I've been straining during bowel movements I can put my pants anymore because my belly is so swollen I have a tight sensation in my lower legs and I forgot to put my feet up when I sleep I had to sit in a recliner so that I can breathe more easily

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6. Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1,3,5,6

14. You are monitoring your patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. "Last night my back really hurt, and I had trouble sleeping." 2. "My leg has been giving out when I try to stand." 3. "My bowels are just not moving like they usually do." 4. "When I try to pass urine, I have difficulty starting the stream."

1. Back pain is an early sign of spinal cord compression occurring in 95% of patients. The other symptoms are later signs.

17. A patient with SLE is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission laboratory testing concerns you most? 1. Elevated blood urea nitrogen level 2. Increased C-reactive protein level 3. Positive antinuclear antibody test result 4. Positive lupus erythematosus cell preparation

1. A high number of patients with SLE develop nephropathy, so an increase in blood urea nitrogen level may indicate a need for a change in therapy or for further diagnostic testing such as a creatinine clearance test or renal biopsy. The other laboratory results are expected in patients with SLE.

A client underwent an exploratory laparotomy two days ago. The dr. should be called immediately for which physical assessment finding? 1. Abdominal distension and rigidity 2. Displacement of NG tube by client 3. Absent or hypoactive bowel sounds 4. n/v

1. Abdominal distension and rigidity

28. You are checking medication orders that were received by telephone for a client with rheumatoid arthritis who was admitted with methotrexate toxicity. Which order is most important to clarify with the physician? 1. Administer chlorambucil (Leukeran) 4 mg PO daily 2. Infuse normal saline at 250 mL/hr for 4 hours 3. Administer folic acid (Folacin) 2000 mcg PO daily 4. Give cyanocobalamin (vitamin B12) 10,000 mcg PO

1. Administer chlorambucil (Leukeran) 4 mg PO daily Leukeran is an antineoplastic drug used to treat cancer. The medication used to treat methotrexate toxicity is leucovorin (Wellcovorin), a reduced form of folic acid. Leukeran and leucovorin are "look-alike, sound-alike" drugs that have been identified by the ISMP as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the Leukeran order, which is likely an error. Focus: Prioritization

6. A client's potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising? 1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. 2. Administer spironolactone (Aldactone) 25 mg orally. 3. Assess the electrocardiogram (ECG) strip for tall T waves. 4. Administer potassium 10 mEq orally.

1. Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally. The client's potassium level is high (normal range is 3.5 to 5 mEq/L). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client's potassium level to go even higher. The beginning nursing student does not have the skill to assess ECG strips.

13. A hospitalized patient with AIDS has a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to nausea and anorexia. Which nursing action is most appropriate to delegate to an LPN/LVN who is providing care to this patient? 1. Administering oxandrolone (Oxandrin) 5 mg daily 2. Assessing the patient for other nutritional risk factors 3. Developing a plan of care to improve the patient's appetite 4. Providing instructions about a high-calorie, high-protein diet

1. Administration of oral medication is included in LPN/LVN education and scope of practice. Assessment, planning of care, and teaching are more complex RN-level interventions.

16. Which members of the health care team (advanced practice nurse, MD, RN, LPN/LVN) should perform the tasks related to care of patients who are at risk for breast cancer? (There may be more than one professional who could complete the task.) 1. Perform the clinical breast examination. _________________________________________ 2. Teach about breast self-examination. _________________________________________ 3. Make a nursing diagnosis based on the assessment data. _________________________________________ 4. Assess the patient's belief about and use of complementary and alternative therapies. _________________________________________ 5. Reinforce the importance of a baseline screening mammogram starting at age 40. _________________________________________ 6. Explain the results of the mammogram to the patient. _________________________________________

1. Advanced practice nurse, MD, 2. Advanced practice nurse, MD, RN, 3. Advanced practice nurse, RN, 4. Advanced practice nurse, MD, RN, 5. Advanced practice nurse, MD, RN, LPN/LVN, 6. MD Advanced practice nurses could do any of the tasks; however, explaining results of a mammogram may be handled by the supervising physician, especially if complex follow-up is needed (e.g., surgery). Physicians could do any of the tasks except they do not make nursing diagnoses. RNs could do tasks 2, 3, 4, and 5 but usually do not do clinical breast examination, unless specially trained, and do not interpret results of diagnostic tests for patients. LPNs/LVNs could reinforce standard information about screening recommendations. The RN should make the nursing diagnoses, and the LPN/LVN assists in planning and implementing the interventions.

1. What is the priority nursing diagnosis for a client experiencing a migraine headache? 1. Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or threat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk for Injury related to side effects of medical therapy

1. Ans: 1 Acute Pain related to biologic and chemical factors The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating. Focus: Prioritization

1. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

1. Ans: 2. Troponin I level Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization

1. You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first? 1. "Please call your physician" (i.e., refuse to advise). 2. "Apply a cool compress to your eyes." 3. "If you are wearing contact lenses, remove them." 4. "Take an over-the-counter antihistamine."

1. Ans: 3 If you are wearing contact lenses, remove them." If the client is wearing contact lenses, the lenses may be causing the symptoms, and removing them will prevent further eye irritation or damage. Policies on giving telephone advice vary among institutions, and knowledge of your facility policy is essential. The other options may be appropriate, but you should gather additional information before suggesting anything else. Focus: Prioritization

1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

1. Ans: 4 As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

1. You are initiating a nursing care plan for a patient with osteoporosis. All of these nursing interventions apply to the nursing diagnosis Risk for Falls. Which intervention should you delegate to the UAP? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist (PT) to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls

1. Ans: 4 Assisting the patient with ambulation to the bathroom and in the halls Assisting with activities of daily living (ADLs) is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses. Focus: Delegation, supervision

1. You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery? 1. Hematocrit of 33% 2. Hemoglobin level of 10.9 g/dL 3. Platelet count of 426,000/mm3 4. White blood cell count of 16,000/mm3

1. Ans: 4. White blood cell count of 16,000/mm3 Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infections indicate that surgery should be postponed when there is evidence of a pre-existing infection such as an elevation in white blood cell count. The other values are slightly abnormal, but would not be likely to cause postoperative problems for knee arthroscopy. Focus: Prioritization

12. When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. During preparation, drugs may be absorbed through the skin or inhaled. 2. Many chemotherapeutic drugs are vesicants. 3. Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common.

1. Chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves and others from exposure. The other options express concerns, but the general principles of drug administration apply.

In the work setting, what is your primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? 1. Knowing the agency's emergency response plan 2. Being aware of the signs and symptoms of potential agents of bioterrorism 3. Knowing how and what to report to the Centers for Disease Control and Prevention (CDC) 4. Making ethical decisions about exposing self to potentially lethal substances

1. gives guidance that includes the roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of exposure to many agents will mimic common complaints, such as flulike symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self. Focus: Prioritization

11. A 22-year-old with stage I Hodgkin disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the patient tells you, "Sometimes I'm afraid of dying." Which response is most appropriate at this time? 1. "Many individuals with this diagnosis have some fears." 2. "Perhaps you should ask the doctor about medication." 3. "Tell me a little bit more about your fear of dying." 4. "Most people with stage I Hodgkin disease survive."

11. Ans: 3 Tell me a little bit more about your fear of dying." More assessment about what the patient means is needed before any interventions can be planned or implemented. All of the other statements indicate an assumption that the patient is afraid of dying of Hodgkin disease, which may not be the case. Focus: Prioritization PCC

10. A patient with chronic hepatitis C has been receiving interferon alfa-2a (Roferon-A) injections for the last month. Which information gathered during a home visit is most important to communicate to the physician? 1. The patient has persistent nausea and vomiting. 2. The patient injects the medication into the thigh by the intramuscular route. 3. The patient's temperature is 99.7° F (37.6° C) orally. 4. The patient reports chronic fatigue, muscle aches, and anorexia.

1. Nausea and vomiting are common adverse effects of interferon alfa-2a, but continued vomiting should be reported to the physician, because dehydration may occur. The medication may be given by either the subcutaneous or intramuscular route. Flulike symptoms such as a mild temperature elevation, headache, muscle aches, and anorexia are common after initiation of therapy but tend to decrease over time.

10. For a patient who is receiving chemotherapy, which laboratory result is of particular importance? 1. White blood cell (WBC) count 2. Prothrombin time and partial thromboplastin time 3. Electrolyte levels 4. Blood urea nitrogen level

1. WBC count is especially important, because chemotherapy can cause decreases in WBCs, particularly neutrophils (known as neutropenia), which leave the patient vulnerable to infection. The other tests are important in the total management but are less directly specific to chemotherapy in general.

24. Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration? 1. Warfarin (Coumadin) 1.0 mg by mouth (PO) 2. Morphine sulfate 2 to 4 mg IV 3. Cephalexin (Keflex) 250 mg PO 4. Heparin infusion at 900 units/hr

1. Warfarin (Coumadin) 1.0 mg by mouth (PO) The Institute for Safe Medication Practices (ISMP) guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate, based on the client's diagnosis. Focus: Prioritization

You are the pediatric unit charge nurse working with a new RN. Which action by the new RN requires the most immediate action on your part? 1. Placing a child who has chemotherapy-induced neutropenia into a negative-pressure room 2. Wearing goggles to change the linens of a patient who has diarrhea caused by Clostridium difficile 3. Instructing UAPs to use an N95 respirator mask when caring for a child who has pertussis 4. Admitting a new patient with respiratory syncytial virus (RSV) infection to a room with another child who has RSV

1. child in a negative-airflow room will increase the likelihood of infection for this patient. Although private rooms are preferred for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients who are infected with the same microorganism. The use of an N95 respirator is not necessary for pertussis, and goggles are not needed for changing the linens of patients infected with C. difficile; however, these precautions do not increase risk to the patients. Focus: Prioritization

A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per night with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. what is the priority nursing diagnosis? 1. diarrhea 2. imbalanced nutrition 3. acute pain 4. ineffective self-health management

1. diarrhea

You're providing postop care for a client who had fundoplication to reinforce the lower esophageal sphincter for the purpose of a hiatal hernia repair. what is the priority action for the care of this client? 1. elevate the head of bed at least 30° 2. assess the NG tube for yellowish green drainage 3. assist the client to start taking a clear liquid diet 4. assess the client for gas bloat syndrome

1. elevate the head of bed at least 30°

2. The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation

1. Flattened neck veins when the client is in the supine position. Providing straws and offering fluids between meals Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume.

3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)

1. Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant nedication. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

25. A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells you, "I feel really dizzy." Which action should you take first? 1. Help the client to sit down. 2. Check the client's apical pulse. 3. Take the client's blood pressure. 4. Have the client breathe deeply.

1. Help the client to sit down. The first priority for an ambulating client who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority. Focus: Prioritization

14. The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should you expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%

1. Increase in ventilator rate from 6 to 10 breaths/min The blood gas component responsible for respiratory acidosis is carbon dioxide. Increasing the ventilator rate will blow off more carbon dioxide and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

16. In your role as the hospital infection control nurse, which policy will you implement to most effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? 1. Limit the use of indwelling urinary catheters in all hospitalized clients. 2. Ensure that clients with catheters have at least a 1500-mL fluid intake daily. 3. Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria. 4. Require the use of antimicrobial/antiseptic impregnated catheters for catheterization.

1. Limit the use of indwelling urinary catheters in all hospitalized clients. According to the CDC, CAUTIs are the most common health care-acquired infection in the United States. Primary CDC recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some clients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing CAUTI incidence. Focus: Prioritization

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

1. Monitor for peripheral edema, crackles in the lungs, and JVD

25. You are providing end-of-life-care for a patient with terminal liver cancer. The patient is weak and restless. Her skin is cool and mottled. Dyspnea develops and the patient appears anxious and frightened. What should you do? 1. Obtain an order for morphine elixir. 2. Alert the rapid response team and call the physician for orders. 3. Deliver breaths at 20/min with a bag-valve mask and prepare for intubation. 4. Sit quietly with the patient and offer emotional support and comfort.

1. Morphine elixir is the therapy of choice because it is thought to reduce anxiety and the subjective sensation of air hunger. It also increases venous capacitance.End-of-life-care should not include aggressive measures such as intubation or resuscitation. Support and comfort are always welcome, but in this case you should not sit quietly because there is an option that would offer some physical relief for the patient.

6. A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional (RN, LPN/LVN, nurse practitioner,nutritionist) should be assigned responsibility for the following tasks? 1. Explain screening examinations and diagnostic testing for common cancers. ___________________________ 2. Discuss how to plan a balanced diet and reduce fats and preservatives. ___________________________ 3. Prepare a poster on the seven warning signs of cancer. ___________________________ 4. Discuss how to perform breast or testicular self-examinations. ___________________________ 5. Describe strategies for reducing risk factors such as smoking and obesity. ___________________________

1. Nurse practitioner, 2. Nutritionist, 3. LPN/LVN, 4. Nurse practitioner, 5. RN The nurse practitioner is often the provider who performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs. The RN has primary responsibility for educating people about risk factors.

1. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings

1. Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement.

3. Which patient is at greatest risk for pancreatic cancer? 1. An elderly African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis

1. Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation.

6. A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a negative result on a skin test for tuberculosis (TB). Which action will you anticipate taking next? 1. Obtain a chest radiograph and sputum smear. 2. Tell the patient that the TB test results are negative. 3. Teach the patient about the anti-TB drug isoniazid. 4. Schedule TB testing again in 12 months.

1. Patients with severe immunodeficiency may be unable to produce an immune response, so a negative TB skin test result does not completely rule out a TB diagnosis for this patient. The next steps in diagnosis are chest radiography and sputum culture. Teaching about isoniazid and follow-up TB testing may be required, depending on the radiographic findings and sputum culture results.

8. The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP? 1. Providing oral care every 3 to 4 hours 2. Monitoring for indications of dehydration 3. Administering 0.45% saline by IV line 4. Assessing daily weights for trends

1. Providing oral care every 3 to 4 hours Providing oral care is within the scope of practice of the UAP. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skills of the RN.

19. A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report? 1. Repeated episodes of nausea and vomiting 2. Reports of pain associated with exertion 3. Failure to eat all the food on the breakfast tray 4. Client hair loss during the morning bath

1. Repeated episodes of nausea and vomiting Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed, but are not related to acid-base imbalances.

17. A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min 2. Decrease in pain level from 6 to 2 (on a scale of 10) 3. Request by the client that the room door be closed 4. Heart rate of 90 to 100 beats/min

1. Respiratory rate of 8 to 10 breaths/min A decreased respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. All of the other findings are important and should be reported to the RN, but the respiratory rate demands urgent attention.

2. You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer first dose of oseltamivir (Tamiflu). 4. Obtain blood and sputum specimens for testing.

1. Start oxygen using a nonrebreather mask. Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems.

2. As the nurse manager in a public health department, you are implementing a plan to reduce the incidence of infection with human immunodeficiency virus (HIV) in the community. Which nursing action will you delegate to health assistants working for the agency? 1. Supplying injection drug users with sterile injection equipment such as needles and syringes 2. Interviewing patients about behaviors that indicate a need for annual HIV testing 3. Teaching high-risk community members about the use of condoms in preventing HIV infection 4. Assessing the community to determine which population groups to target for education

1. Supplying sterile injection supplies to patients who are at risk for HIV infection can be done by staff members with health assistant education. Assessing for high-risk behaviors, education, and community assessment are RN-level skills.

14. A patient has a fractured femur. Which finding would you instruct the UAP to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.

14. Ans: 2 The patient appears confused. Fat embolism syndrome is a serious complication that often results from fractures of long bones. Its earliest manifestation is altered mental status caused by a low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and the patient's voiding; however, this information is not urgent to report. Focus: Prioritization, delegation, supervision

12. Before giving a beta-adrenergic blocking glaucoma agent, you would make additional assessments and notify the physician if the client makes which statement? 1. "My blood pressure runs a little high if I gain too much weight." 2. "Occasionally I have palpitations, but they pass very quickly." 3. "My joints feel stiff today, but that's just my arthritis." 4. "My pulse rate is a little low today because I take digoxin."

12. Ans: 4. "My pulse rate is a little low today because I take digoxin." Excerpt From: LaCharity, Linda A. "Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam." Elsevier Health Sciences, 2013-11-22T00:00:00+00:00. iBooks. This material may be protected by copyright.All beta-adrenergic blockers are contraindicated in bradycardia. Alpha-adrenergic agents can cause tachycardia and hypertension. Carbonic anhydrase inhibitors should not be given to clients with rheumatoid arthritis who are taking high dosages of aspirin. Focus: Prioritization

15. After you receive the change-of-shift report, which patient should you assess first? 1. 42-year-old with CTS who reports pain 2. 64-year-old with osteoporosis awaiting discharge 3. 28-year-old with a fracture who reports that the cast is tight 4. 56-year-old with a left leg amputation who reports phantom pain

15. Ans: 3 28-year-old with a fracture who reports that the cast is tight The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. Although all of the other patients' concerns are important and the nurse will want to see them as soon as possible, none of their complaints is urgent. Focus: Prioritization

16. At 10:00 AM, a hospitalized client receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

16. Ans: 1. Put the client on "nothing by mouth" (NPO) status. Because TEE is performed after the throat is numbed using a topical anesthetic and possibly after IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the TEE but do not need to be implemented immediately. Focus: Prioritization

12. You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

12. Ans: 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute MI is to completely eliminate the pain. Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time. Focus: Prioritization

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

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

10. In discharge teaching after cataract surgery, the client and family should be told to immediately report which symptom to the physician? 1. A scratchy sensation in the operative eye 2. Loss of depth perception with the patch in place 3. Poor vision 6-8 hours after patch removal 4. Pain not relieved by prescribed medications

10. Ans: 4 Pain not relieved by prescribed medications Pain may signal hemorrhage, infection, or increased ocular pressure. A scratchy sensation and loss of depth perception with the patch in place are not uncommon. Adequate vision may not return for 24 hours. Focus: Prioritization

11. As charge nurse, you assign the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would you provide for the LPN/LVN? (Select all that apply.) 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour.

11. Ans: 1, 2, 3, 5 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 5. Check the neurovascular status of the fingers every hour. Postoperatively, patients undergoing open carpal tunnel release surgery experience pain and numbness, and their discomfort may last for weeks to months. All of the other directions are appropriate for the postoperative care of this patient. It is important to monitor for drainage, tightness, and neurovascular changes. Raising the hand and wrist above the heart reduces the swelling from surgery, and this is often done for several days. Focus: Assignment, delegation, supervision

11. You are floated from the ED to the neurologic floor. Which action should you delegate to the UAP when providing nursing care for a client with an SCI? 1. Assessing the client's respiratory status every 4 hours 2. Taking the client's vital signs and recording every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

11. Ans: 2 Taking the client's vital signs and recording every 4 hours The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision

10. You are preparing to discharge four clients from the hospital and are planning their discharge teaching. Which client will it be most important to instruct about the need to use sunscreen? 1. 32-year-old with a urinary tract infection who is being discharged with a prescription for tetracycline (Sumycin) 2. Fair-skinned 55-year-old who has just had neck surgery and who plans to walk in the yard for 15 minutes twice daily 3. Dark-skinned 62-year-old who has had keloids injected with hydrocortisone (Solu-Cortef) 4. 78-year-old with a red, pruritic rash caused by an allergic reaction to penicillin (Bicillin)

10. Ans: 1 32-year-old with a urinary tract infection who is being discharged with a prescription for tetracycline (Sumycin) Systemic use of tetracycline is associated with severe photosensitivity reactions to ultraviolet light. All individuals should be taught about the potential risks of overexposure to sunlight or other ultraviolet light, but the client taking tetracycline is at the most immediate risk for severe adverse effects. Focus: Prioritization

10. A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would you be sure to teach the patient? 1. Pain and numbness will be experienced for several days to weeks. 2. Immediately after surgery, the patient will no longer need assistance. 3. After surgery, the dressing will be large and there will be lots of drainage. 4. The patient's pain and paresthesia will no longer be present.

10. Ans: 1 Pain and numbness will be experienced for several days to weeks. Postoperative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with an open procedure. Patients often need assistance postoperatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small, and there should not be a lot of drainage. Focus: Prioritization

10. A patient is admitted to the intensive care unit with disseminated intravascular coagulation associated with a gram-negative infection. Which assessment information has the most immediate implications for the patient's care? 1. There is no palpable radial or pedal pulse. 2. The patient reports chest pain. 3. The patient's oxygen saturation is 87%. 4. There is mottling of the hands and feet.

10. Ans: 3 The patient's oxygen saturation is 87%. Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need. Focus: Prioritization

10. You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

10. Ans: 3. Administer sublingual nitroglycerin. The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority. Focus: Prioritization

11. A client reports a sudden excruciating pain in the left eye with the visual change of colored halos around lights and blurred vision. Which interventions should you anticipate and perform for this emergency condition? (Select all that apply.) 1. Prepare the client for photodynamic therapy. 2. Instill a mydriatic agent, such as phenylephrine (Neo-Synephrine). 3. Instill a miotic agent, such as pilocarpine (Isopto Carpine). 4. Administer an oral hyperosmotic agent, such as isosorbide (Ismotic). 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client.

11. Ans: 3, 4, 5, 6 3. Instill a miotic agent, such as pilocarpine (Isopto Carpine). 4. Administer an oral hyperosmotic agent, such as isosorbide (Ismotic). 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client. The client's symptoms are suggestive of angle-closure glaucoma. Immediate inventions include instillation of miotics, which open the trabecular network and facilitate aqueous outflow, and intravenous or oral administration of hyperosmotic agents to move fluid from the intracellular space to the extracellular space. Applying cool compresses and providing a dark, quiet space are appropriate comfort measures. Photodynamic therapy is a treatment for age-related macular degeneration. Use of mydriatics is contraindicated because dilation of the pupil will further block the outflow. Focus: Prioritization

11. An 80-year-old client on the coronary step-down unit tells you that he does not want to take the ordered docusate (Colace) because he does not have any problems with constipation. Which action is most appropriate? 1. Document the medication on the client's chart as "refused." 2. Mix the medication with food and administer it to the client. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

11. Ans: 3. Explain that his decreased activity level may cause constipation. The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as "refused" or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it, unless someone else has health care power of attorney and has authorized use of the medication. Focus: Prioritization

12. You are the charge nurse in an LTC facility that employs RNs, LPNs/LVNs, and UAPs as staff members. An 80-year-old client has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to delegate to an LPN/LVN? 1. Applying nystatin (Mycostatin) powder to the area three times daily 2. Cleaning the skinfolds every 8 hours with mild soap and drying thoroughly 3. Evaluating the need for further antifungal treatment at least weekly 4. Assessing for ongoing risk factors for skin breakdown and infection

12. Ans: 1 Applying nystatin (Mycostatin) powder to the area three times daily Medication administration is included in LPN/LVN education and scope of practice. Bathing and cleaning clients require the least education and would be better delegated to a UAP. Assessment and evaluation of outcomes of care are more complex skills best performed by RNs. Focus: Delegation

12. You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (Select all that apply.) 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle

12. Ans: 1, 2, 4, 5 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. Focus: Prioritization

12. You are preparing the patient who had carpal tunnel release surgery for discharge. Which information is important to provide to this patient? 1. The surgical procedure is a cure for CTS. 2. Hand movements will be restricted for 4 to 6 weeks after surgery. 3. Frequent doses of pain medication will no longer be necessary. 4. The health care provider should be notified immediately if there is any pain or discomfort.

12. Ans: 2 Hand movements will be restricted for 4 to 6 weeks after surgery. Hand movements, including heavy lifting, may be restricted for 4 to 6 weeks after surgery. Patients experience discomfort for weeks to months after surgery. The surgery is not always a cure; in some cases, CTS may recur months to years after surgery. Focus: Prioritization

12. You receive a change-of-shift report about the following patients. Which one will you assess first? 1. 26-year-old with thalassemia who has a hemoglobin level of 8 g/L and orders for a PRBC transfusion 2. 44-year-old who was admitted 3 days previously in a sickle cell crisis and has orders for a computed tomographic scan 3. 50-year-old with stage IV non-Hodgkin lymphoma who is crying and saying, "I'm not ready to die" 4. 69-year-old with chemotherapy-induced neutropenia who has an oral temperature of 100.1° F (37.8° C)

12. Ans: 4 69-year-old with chemotherapy-induced neutropenia who has an oral temperature of 100.1° F (37.8° C) Any temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection, so actions such as drawing blood for culture and administering antibiotics should be initiated quickly. The other patients need to be assessed as soon as possible but are not critically ill. Focus: Prioritization

13. When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to you that the patient needs additional teaching? 1. "I take my ibuprofen every morning as soon as I get up." 2. "My daughter removed all of the throw rugs in my home." 3. "My husband helps me every afternoon with range-of-motion exercises." 4. "I rest in my reclining chair every day for at least an hour."

13. Ans: 1 "I take my ibuprofen every morning as soon as I get up." Ibuprofen can cause abdominal discomfort or pain and ulceration of the gastrointestinal tract. In such cases, it should be taken with meals or milk. Removal of throw rugs helps prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis. Focus: Prioritization

13. A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client

13. Ans: 1, 3, 4 1. Checking the client's skin for pressure from the device 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Delegation, supervision

13. You are supervising a new nurse who has just finished assessing a client who came to the clinic for redness and discomfort to the right eye. You review her documentation, which includes "visual acuity N/A." What should you do next? 1. Do nothing; the documentation is minimal but acceptable. 2. Ask her to explain her rationale for the documentation. 3. Reassess the client yourself to validate her findings. 4. Suggest that she contact the clinical educator for documentation tips.

13. Ans: 2 Ask her to explain her rationale for the documentation. Asking the nurse to explain the documentation is a way of assessing her knowledge of documentation, how the client's complaint contributes to what should be assessed, and her understanding of the use of abbreviations. The nurse may have a good reason for charting "N/A," but you should explain how a reader could misunderstand. For example, "visual acuity N/A" could be interpreted as the nurse making a clinical judgment that assessing vision was not important for this client. The documentation is not acceptable, because the client's chief complaint indicates that vision should be tested if at all possible. Redoing the assessment yourself does not help the nurse to correct mistakes. Contacting the educator for assistance is an option that is based on your assessment of her rationale. Focus: Supervision, prioritization

13. A patient in a long-term care (LTC) facility who has chronic lymphocytic leukemia has a nursing diagnosis of Activity Intolerance related to weakness and anemia. Which nursing activity will you delegate to the UAP? 1. Evaluating the patient's response to normal activities of daily living 2. Checking the patient's blood pressure and pulse rate after ambulation 3. Determining which self-care activities the patient can do independently 4. Assisting the patient in choosing a diet that will improve strength

13. Ans: 2 Checking the patient's blood pressure and pulse rate after ambulation UAP education covers routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of patient abilities, and nutrition planning are activities appropriate to RN practice. Focus: Delegation

13. You are preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had an MI and her husband. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

13. Ans: 2. "Can you tell me why you don't feel that you need to make any changes?" For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give you more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle. Focus: Prioritization

14. Which tasks are appropriate to delegate to an LPN/LVN who is functioning under the supervision of a team leader or RN? (Select all that apply.) 1. Irrigating the ear canal to loosen impacted cerumen 2. Administering amoxicillin to a child with otitis media 3. Reminding the client not to blow the nose after tympanoplasty 4. Counseling a client with Ménière disease 5. Suggesting communication techniques for the family of a hearing-impaired elder 6. Assessing a client with labyrinthitis for headache and level of consciousness

14. Ans: 1, 2, 3 1. Irrigating the ear canal to loosen impacted cerumen 2. Administering amoxicillin to a child with otitis media 3. Reminding the client not to blow the nose after tympanoplasty Irrigating the ear, giving medication, and reminding the client about postoperative instructions that were given by an RN are within the scope of practice of the LPN/LVN. Counseling clients and families and assessing for meningitis signs in a client with labyrinthitis are the responsibilities of the RN. Focus: Delegation

14. You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The client tells you, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing diagnosis takes priority? 1. Risk for Injury related to altered mobility 2. Imbalanced Nutrition: Less than Body Requirements 3. Impaired Individual Resilience related to spinal cord injury 4. Disturbed Body Image related to immobilization

14. Ans: 3 Impaired Individual Resilience related to spinal cord injury The client's statement indicates impaired individual resilience in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate for a client with SCI but are not related to the client's statement. Focus: Prioritization

14. A transfusion of PRBCs has been infusing for 5 minutes when the patient becomes flushed and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should you take first? 1. Obtain a warm blanket for the patient. 2. Check the patient's oral temperature. 3. Stop the transfusion. 4. Administer oxygen.

14. Ans: 3 Stop the transfusion. The patient's symptoms indicate that a transfusion reaction may be occurring, so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the patient may not be appropriate. Checking the patient's temperature and administering oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority. Focus: Prioritization

14. You are caring for a hospitalized client with heart failure who is receiving captopril (Capoten) and spironolactone (Aldactone). Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood urea nitrogen level 3. Potassium level 4. Alkaline phosphatase level

14. Ans: 3. Potassium level Hyperkalemia is a common adverse effect of both ACE inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening. Focus: Prioritization

15. A group of patients is assigned to an RN-LPN/LVN team. The LPN/LVN should be assigned to provide patient care and administer medications to which patient? 1. 36-year-old with chronic kidney failure who will need a subcutaneous injection of epoetin alfa (Procrit) 2. 39-year-old with hemophilia B who has been admitted to receive a transfusion of PRBCs 3. 50-year-old with newly diagnosed polycythemia vera who will require phlebotomy 4. 55-year-old with a history of stem cell transplantation who has a bone marrow aspiration scheduled

15. Ans: 1 36-year-old with chronic kidney failure who will need a subcutaneous injection of epoetin alfa (Procrit) LPNs/LVNs should be assigned to care for stable patients. Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. Blood transfusions should be administered by RNs, because evaluation for and management of transfusion reactions require RN-level education and scope of practice. The other patients will require teaching about phlebotomy and bone marrow aspiration that should be implemented by the RN. Focus: Assignment

15. You are interviewing an elderly client who reports that "lately there has been a roaring sound in my ears." What additional assessments should you include? (Select all that apply.) 1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. 5. Ask about frequency of ear hygiene.

15. Ans: 1, 2, 3, 4 1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. Medications such as aspirin or diuretics (and many others) can cause tinnitus (ringing in the ears). Loud noises, impacted earwax or foreign bodies in the ear canal, or ear infections can also cause tinnitus. Asking about frequency of hygiene is less relevant than asking about the method the client uses to clean the ears. For example, the insertion of cotton-tipped swabs may be contributing to the impaction of earwax. Focus: Prioritization

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

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

15. The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel (Plavix). Which medication is most important to clarify further with the health care provider? 1. Aspirin (Ecotrin) 162 mg daily 2. Omeprazole (Prilosec) 20 mg daily 3. Metoprolol (Lopressor) 50 mg daily 4. Nitroglycerin patch (Nitrodur) 0.4 mg/hr

15. Ans: 2. Omeprazole (Prilosec) 20 mg daily Since proton pump inhibitors such as omeprazole affect the metabolism of clopidogrel and decrease its effectiveness, the health care provider may want to discontinue the omeprazole in this client with unstable angina. The other medications should also be verified, but current national guidelines for clients with unstable angina indicate that providers should consider avoiding proton pump inhibitors in those who require clopidogrel. Focus: Prioritization

16. A cheerful elderly widow comes to the community clinic for her annual checkup. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, "I don't get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing." What is the priority nursing diagnosis? 1. Risk for Situational Low Self-Esteem related to perceived inability to interact 2. Impaired Social Interaction related to progressive hearing loss 3. Deficient Knowledge related to pathophysiologic processes 4. Ineffective Coping related to change in sensory abilities

16. Ans: 2 Impaired Social Interaction related to progressive hearing loss This client has a hearing loss, and it seems likely that a referral for a hearing aid or rehabilitation program will allow her to participate in her baseline social habits. The other diagnoses are pertinent if the hearing loss continues to interfere with her quality of life. Focus: Prioritization

16. A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would you instruct the UAP to report immediately? 1. The patient wants to change position in bed. 2. There is a small amount of clear fluid at the pin sites. 3. The traction weights are resting on the floor. 4. The patient reports pain and muscle spasm.

16. Ans: 3 The traction weights are resting on the floor. When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient's pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position, because position changes may alter the traction. Focus: Delegation, supervision, prioritization

16. A client with MS tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing diagnosis at this time? 1. Fatigue related to disease state 2. Activity Intolerance due to generalized weakness 3. Impaired Physical Mobility related to neuromuscular impairment 4. Bathing Self-Care Deficit related to fatigue and neuromuscular weakness

16. Ans: 4 Bathing Self-Care Deficit related to fatigue and neuromuscular weakness At this time, based on the client's statement, the priority is Bathing Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patent with MS but are not related to the client's statement. Focus: Prioritization

16. You obtain the following data about a patient admitted with multiple myeloma. Which information has the most immediate implications for the patient's care? 1. The patient reports chronic bone pain. 2. The blood uric acid level is very elevated. 3. The 24-hour urine test shows Bence Jones proteins. 4. The patient reports new-onset leg numbness.

16. Ans: 4 The patient reports new-onset leg numbness. The leg numbness may indicate spinal cord compression, which should be evaluated and treated immediately by the health care provider to prevent further loss of function. Chronic bone pain, hyperuricemia, and the presence of Bence Jones proteins in the urine all are typical of multiple myeloma and do require assessment and/or treatment; the loss of motor or sensory function is an emergency. Focus: Prioritization

17. The nursing diagnosis for a patient with a fracture of the right ankle is Impaired Physical Mobility. As charge nurse, you observe a newly-graduated RN perform all of these interventions. For which action should you intervene? 1. Encouraging the patient to go from a lying to a standing position 2. Administering pain medication before the patient begins exercises 3. Explaining to the patient and family the purpose of the exercise program 4. Reminding the patient about the correct use of crutches

17. Ans: 1 Encouraging the patient to go from a lying to a standing position Moving from a lying position first to a sitting position and then to a standing position allows the patient to establish balance before standing. Administering pain medication before the patient begins exercising decreases pain with exercise. Explanations about the purpose of the exercise program and proper use of crutches are appropriate interventions with this patient. Focus: Delegation, supervision

17. The nurse in the outpatient clinic is assessing a 22-year-old who required a splenectomy after a recent motor vehicle accident. Which information obtained during the assessment will be of most immediate concern to the nurse? 1. The patient engages in unprotected sex. 2. The oral temperature is 100° F (37.8° C). 3. There is abdominal pain with light palpation. 4. The patient admits to occasional marijuana use.

17. Ans: 2 The oral temperature is 100° F (37.8° C). Because the spleen has an important role in the phagocytosis of microorganisms, the patient is at higher risk for severe infection after a splenectomy. Medical therapy, such as antibiotic administration, is usually indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this patient. Focus: Prioritization

17. Which physical assessment findings should be reported to the physician? 1. Pearly gray or pink tympanic membrane 2. Dense whitish ring at the circumference of the tympanum 3. Bulging red or blue tympanic membrane 4. Cone of light at the innermost part of the tympanum

17. Ans: 3 Bulging red or blue tympanic membrane A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation. The other signs are considered normal anatomy. Focus: Prioritization

17. An LPN/LVN, under your supervision, is providing nursing care for a client with GBS. What observation should you instruct the LPN/LVN to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

17. Ans: 4 Shallow respirations and decreased breath sounds The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening. Focus: Prioritization, delegation, supervision

17. You assess a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 144/78 mm Hg 2. Pedal pulses are palpable at +1 3. Left groin has a 3-cm bruised area 4. Apical pulse is 122 beats/min and regular

17. Ans: 4. Apical pulse is 122 beats/min and regular The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern. Focus: Prioritization

18. You are working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to an experienced UAP? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

18. Ans: 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated Measurement of ankle and brachial blood pressures for ankle-brachial index calculation is within the UAP's scope of practice. Calculating the ankle-brachial index and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN. Focus: Delegation

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

18. Ans: 2 Notify the physician immediately. The changes that the UAP is reporting are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation. Focus: Prioritization

18. The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under your supervision. What will you tell the LPN/LVN is the major focus for the patient's care today? 1. To attain pain control over phantom pain 2. To monitor for signs of sufficient tissue perfusion 3. To assist the patient to ambulate as soon as possible 4. To elevate the residual limb when the patient is supine

18. Ans: 2 To monitor for signs of sufficient tissue perfusion Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial, because it may promote knee flexion contracture. Focus: Delegation, supervision

18. A patient with graft-versus-host disease (GVHD) after bone marrow transplantation is being cared for on the medical unit. Which nursing activity is best delegated to a travel RN? 1. Administering oral cyclosporine (Sandimmune) to the patient 2. Assessing the patient for signs of infection caused by GVHD 3. Infusing 5% dextrose in 0.45% saline at 125 mL/hr into the patient 4. Educating the patient about ways to prevent and detect infection

18. Ans: 3 Infusing 5% dextrose in 0.45% saline at 125 mL/hr into the patient The infusion of IV fluids is a common intervention that can be implemented by RNs who do not have experience in caring for patients who are severely immunosuppressed. Administering cyclosporine, assessing for subtle indications of infection, and patient teaching are more complex tasks that should be done by RN staff members who have experience caring for immunosuppressed patients. Focus: Delegation

18. Which description by a client reporting vertigo would concern you the most? 1. Dizziness with hearing loss 2. Episodic vertigo 3. Vertigo without hearing loss 4. "Merry-go-round" vertigo

18. Ans: 3 Vertigo without hearing loss The client reporting vertigo without hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic. The other descriptions are more commonly associated with inner ear or labyrinthine causes. Focus: Prioritization

19. In assisting clients with vertigo and balance problems, which team member (RN, LPN/LVN, MD, physical therapist, UAP), working under appropriate supervision, should be assigned to complete each task? 1. Assess and identify the cause of the vertigo. 2. Assist the client in routine position change and ambulation. 3. Administer antivertigo agents such as meclizine (Antivert). 4. Obtain informed consent for a labyrinthectomy. 5. Assess situations that lead to or exacerbate vertigo. 6. Review the need for adaptive aids such as a walker or cane.

19. Ans: 1. Assess and identify the cause of the vertigo. --MD, 2. Assist the client in routine position change and ambulation. --UAP, 3. Administer antivertigo agents such as meclizine (Antivert). --LPN/LVN or RN, 4. Obtain informed consent for a labyrinthectomy. --MD, 5. Assess situations that lead to or exacerbate vertigo.--RN, 6. Review the need for adaptive aids such as a walker or cane. --Physical therapist The physician is responsible for determining the medical diagnosis and for explaining the outcomes and risks of surgical procedures. A physical therapist evaluates movement and the need for adaptive equipment and teaches ambulation techniques; however, the UAP (under supervision) is able to help clients with routine ambulation and position changes. The LPN/LVN and RN are qualified to give medications. The RN should assess the client to identify situations associated with vertigo. Focus: Assignment

19. A patient with a right above-the-knee amputation asks you why he has phantom limb pain. What is your best response? 1. "Phantom limb pain is not explained or predicted by any one theory." 2. "Phantom limb pain occurs because your body thinks your leg is still present." 3. "Phantom limb pain will not interfere with your activities of daily living." 4. "Phantom limb pain is not real pain but is remembered pain."

19. Ans: 1 Phantom limb pain is not explained or predicted by any one theory." Three theories are being researched with regard to phantom limb pain. The peripheral nervous system theory holds that sensations remain as a result of the severing of peripheral nerves during the amputation. The central nervous system theory states that phantom limb pain results from a loss of inhibitory signals that were generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain phantom limb pain because stress, anxiety, and depression often trigger or worsen a pain episode. Focus: Prioritization

19. While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. 19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV 3. 50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care 4. 75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

19. Ans: 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses. Focus: Assignment

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

19. Ans: 3 "Alteplase dissolves clots and may cause more bleeding into your wife's brain." Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug such as alteplase can worsen the bleeding. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis. Focus: Prioritization

19. You are the charge nurse on an oncology unit when a patient with an absolute neutrophil count of 300/μL is admitted. Which staff member should you assign to provide care for this patient, under the supervision of an experienced oncology RN? 1. LPN/LVN who has floated from the same-day surgery unit 2. RN from a staffing agency who is being oriented to the oncology unit 3. LPN/LVN with 2 years of experience on the oncology unit 4. RN who recently transferred to the oncology unit from the ED

19. Ans: 3 LPN/LVN with 2 years of experience on the oncology unit Because many aspects of nursing care need to be modified to prevent infection when a patient has a low absolute neutrophil count, care should be provided by the staff member with the most experience with neutropenic patients. The other staff members have the education required to care for this patient but are not as clinically experienced. When LPN/LVN staff members are given acute care patient assignments, they must work under the supervision of an RN. The LPN/LVN in this case would report to the RN assigned to the patient. Focus: Assignment

10. For client education about nonpharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function with your continued support and supervision? 1. Therapeutic touch 2. Application of heat and cold 3. Meditation 4. Transcutaneous electrical nerve stimulation (TENS)

2

11. A client received "as needed" (PRN) morphine, lorazepam (Ativan), and cyclobenzaprine (Flexeril). The UAP reports that the client has a respiratory rate of 10/min. What is the priority action? 1. Call the physician to obtain an order for naloxone (Narcan). 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and deliver breaths at 20/min. 4. Double-check the drug order to see what the client should have received.

2

17. For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take? 1. Closely assess for nonverbal signs such as grimacing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Look at the MAR and chart to note the time of the last dose of analgesic and the client's response. 4. Give the maximum PRN dose within the minimum time frame for relief.

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26. Pain disorder and depression have been diagnosed for a client. Hereports chronic low back pain and states, "None of these doctors hasdone anything to help." Which client statement concerns you the most? 1. "I twisted my back last night, and now the pain is a lot worse." 2. "I'm so sick of this pain. I think I'm going to find a way to end it." 3. "Occasionally I buy pain killers from a guy in my neighborhood." 4. "I'm going to sue you and the doctor; you aren't doing anything forme."

2

29. You are caring for a young client with diabetes who has sustainedinjuries when she tried to commit suicide by crashing her car. Her bloodglucose level is 650 mg/dL, but she refuses insulin; however, she wantsthe pain medication. What is the best action? 1. Notify the charge nurse and obtain an order for a transfer to intensivecare. 2. Explain that insulin is a priority and inform the health care provider. 3. Withhold the pain medication until she agrees to accept the insulin. 4. Give her the pain medication and document the refusal of the insulin.Answer Key for this chapter begins onp. 167.61

2

22. Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

2,3,6

24. Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically- implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication

2,5,6

20. The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate has decreased. What is your best response? 1. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." 2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." 3. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." 4. "The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."

2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client's decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. The first response may be true, but it does not address all the components of the question. The third and fourth answers are inaccurate.

5. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

2. Administering enemas and antibiotics is within the scope of practice of LPNs/LVNs. Although some states an facilities may allow the LPN/LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the RN.

24. A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to delegate to an LPN/LVN? 1. Development of a "quit plan" 2. Explanation of how to apply a nicotine patch 3. Discussion of strategies to avoid relapse 4. Suggestion of ways to deal with urges for tobacco

2. An LPN/LVN is versed in medication administration and able to teach patients standardized information. The other options require more in-depth assessment, planning, and teaching, which should be performed by the RN. Helping patients with smoking cessation is a Core Measure.

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months At this time, what is the primary collaborative goal for the treatment of Ms. C? A. Assist her to increase feelings of control B. Decrease power struggles over eating C. Resolve dysfunctional family roles D. Restore normal nutrition and weight

D. Restore normal nutrition and weight

You must rearrange the room assignments for several clients. Who could you put together? 1. 35-year-old woman with diarrhea and vomiting 2. 43 year old woman who underwent a cholecystectomy 2 days ago 3. a 52 year old woman with pain related to alcohol associated pancreatitis 4. .62 year old woman with colon cancer receiving chemo

2. 43 year old woman who underwent a cholecystectomy 2 days ago 3. a 52 year old woman with pain related to alcohol associated pancreatitis

5. You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection? 1. 3-year-old who has paroxysmal coughing and whose sibling has pertussis 2. 5-year-old who has a new pruritic rash and a possible chickenpox infection 3. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. 5-year-old who has a new pruritic rash and a possible chickenpox infection Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization

13. As the charge nurse, you would assign which client to the step-down unit nurse floated to the intensive care unit for the day? 1. 68-year-old on a ventilator with acute respiratory failure and respiratory acidosis 2. 72-year-old with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent 3. Newly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip 4. 38-year-old on a ventilator with narcotic overdose and respiratory alkalosis

2. 72-year-old with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent The client with COPD, although ventilator dependent, is in the most stable condition of the clients in this group. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with diabetic ketoacidosis is a new admission and will require an in-depth admission assessment. All three of these clients need care from an experienced critical care

18. As the hospital employee health nurse, you are completing a health history for a newly-hired staff member. Which information given by the new employee most indicates the need for further nursing action before he or she begins orientation to patient care? 1. The employee takes enalapril (Vasotec) for hypertension. 2. The employee has an allergy to bananas, avocados, and papayas. 3. The employee received a tetanus vaccination 3 years ago. 4. TB skin test site has a 5-mm induration at 48 hours.

2. A high incidence of latex allergy in seen in individuals with allergic reactions to these fruits. More information and/or testing is needed to determine whether the new employee has a latex allergy, which might affect his or her ability to provide direct patient care. The other findings are important to include in documenting the employee's health history but do not affect the ability to provide patient care.

2. You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by your physician.

2. Ans: 1, 2, 3, 4, 5 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization

2. You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all that apply.) 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired.

2. Ans: 1, 2, 3, 5 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 5. Rest when you are tired. The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk of falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles and improve coordination. Focus: Prioritization

2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?"

2. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization 3. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

2. You are providing orientation for a new RN who is preparing to administer packed red blood cells (PRBCs) to a patient who had blood loss during surgery. Which action by the new RN requires that you intervene immediately? 1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion 2. Starting an IV line for the transfusion using a 22-gauge catheter 3. Priming the transfusion set using 5% dextrose in lactated Ringer's solution 4. Telling the patient that the PRBCs may cause a serious transfusion reaction

2. Ans: 3 Priming the transfusion set using 5% dextrose in lactated Ringer's solution Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-bore IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although the new RN should avoid increasing patient anxiety by indicating that a serious transfusion reaction may occur, this action is not as high a concern as using an inappropriate fluid for priming the IV tubing. Focus: Prioritization

2. At a community health clinic, you are teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress? 1. Workplace policies for handling chemicals should be followed. 2. Children and parents should be cautious about aggressive play. 3. Protective eyewear should be worn during sports or hazardous work. 4. Emergency eyewash stations should be established in the workplace.

2. Ans: 3 Protective eyewear should be worn during sports or hazardous work. Most accidental eye injuries (90%) could be prevented by wearing protective eyewear for sports and hazardous work. Other options should be considered in the overall prevention of injuries, but these have less impact. Focus: Prioritization

2. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)

2. Ans: 4. Chest pain level of 3 (on a scale of 10) Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization

18. Which information about a client who has meningococcal meningitis is the best indicator that you can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100° F (37.8° C).

2. Appropriate antibiotics have been given for 24 hours. Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued. Focus: Prioritization

The ED is calling to report on a patient who will be admitted to your acute psychiatric unit. HE has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions and minor lacerations. What is the priority question that you should ask? A. When will the patient be transferred? B. Will a police officer be with him while he is on the unit? C. Why isn't the patient being admitted to the trauma unit? D. What is the patient's current mood and behavior?

D. What is the patient's current mood and behavior?

19. A patient who is HIV-positive and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient states, "I'm afraid I'm going to die right here!" 2. The patient has an order for midazolam (Versed) 2 mg IV immediately (STAT). 3. The patient is diaphoretic and tremulous, and reports dizziness. 4. The patient's symptoms occurred suddenly while she was driving to work.

2. Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient's diagnosis of panic attack and do not indicate an urgent need to communicate with the provider.

16. A patient with wheezing and coughing caused by an allergic reaction to penicillin is admitted to the emergency department. Which medication do you anticipate administering first? 1. Methylprednisolone (Solu-Medrol) 100 mg IV 2. Cromolyn (Intal) 20 mg via nebulizer 3. Albuterol (Proventil) 3 mL via nebulizer 4. Aminophylline (Theophylline) 500 mg IV

3. Albuterol is the most rapidly acting of the medications listed. Corticosteroids are helpful in preventing allergic reactions but are not rapidly acting. Cromolyn is used as a prophylactic medication to prevent asthma attacks but not to treat acute attacks. Aminophylline is not a first-line treatment for bronchospasm.

3. You are working with a student nurse to care for an HIV-positive patient with severe esophagitis caused by Candida albicans. Which action by the student indicates that you need to intervene most quickly? 1. Putting on a mask and gown before entering the patient's room 2. Giving the patient a glass of water after administering the ordered oral nystatin (Mycostatin) suspension 3. Suggesting that the patient should order chile con carne or chicken soup for the next meal 4. Placing a "No Visitors" sign on the door of the patient's room

2. Nystatin should be in contact with the oral and esophageal tissues as long as possible for maximum effect. The other actions are also inappropriate and should be discussed with the student but do not require action as quickly. HIV-positive patients do not require droplet/contact precautions or visitor restrictions to prevent opportunistic infections. Hot or spicy foods are not usually well tolerated by patients with oral or esophageal fungal infections.

5. You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

2. Potassium Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block.

22. Which blood test result would you be sure to monitor for the client taking HCTZ (hydrochlorothiazide , Microzide)? 1. Sodium level 2. Potassium level 3. Chloride level 4. Calcium level

2. Potassium level Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly.

17. For a patient with osteogenic sarcoma, which laboratory value causes you the most concern? 1. Sodium level of 135 mEq/L 2. Calcium level of 13 mg/dL 3. Potassium level of 4.9 mEq/L 4. Hematocrit of 40%

2. Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers.

1. The client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake

2. Providing straws and offering fluids between meals UAPs can reinforce additional fluid intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN.

18. The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Respiratory alkalosis The client is most likely hyperventilating and blowing off carbon dioxide. This decrease in carbon dioxide will lead to an increase in pH and cause respiratory alkalosis.

9. An experienced LPN/LVN reports to you that a client's blood pressure and heart rate have decreased, and when his face is assessed, one side twitches. What action should you take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.

2. Review the client's morning calcium level. A positive Chvostek sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to accurately measure vital signs.

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

D. Whenever you are concerned or nervous, talk to me or any of the nurses

14. You assess a 24-year-old patient with RA who is considering using methotrexate (Rheumatrex) for treatment. Which patient information is most important to communicate to the health care provider? 1. The patient has many concerns about the safety of the drug. 2. The patient has been trying to get pregnant. 3. The patient takes a daily multivitamin tablet. 4. The patient says that she has taken methotrexate in the past.

2. Methotrexate is teratogenic and should not be used by patients who are pregnant. The physician will need to discuss the use of contraception during the time the patient is taking methotrexate. The other patient information may require further patient assessment or teaching, but does not indicate that methotrexate may be contraindicated for the patient.

19. You are administering vancomycin (Vancocin) 500 mg IV to a client with a MRSA wound infection when you notice that the client's neck and face are becoming flushed. Which action should you take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2. Slow the rate of the vancomycin infusion. "Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, the vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing. Focus: Prioritization

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

623541 6. Don a pair of clean gloves and remove the old pouch 2. assess the color and appearance of the stoma 3. wash the skin with mild soap and rinse with warm water 5. Dry the skin carefully 4. Apply a skin barrier to protect the peristomal skin 1. Fit the pouch snugly around the stoma

7. You are working in an AIDS hospice facility that is also staffed with LPNs/LVNs and UAPs. Which nursing action will you delegate to the LPN/LVN you are supervising? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Teaching the UAPs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed

2. The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and teaching are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP.

22. A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would you clarify with the health care provider? 1. Give fluoxetine (Prozac) 40 mg once a day. 2. Administer acetaminophen with codeine (Tylenol-Codeine) 1 or 2 tablets every 4 hours as needed. 3. Assist the patient to the bedside chair every shift. 4. Reinforce the dressing to the right residual limb as needed.

22. Ans: 1 Give fluoxetine (Prozac) 40 mg once a day. Doses of fluoxetine, a drug used to treat depression, that are greater than 20 mg should be given in two divided doses, not once a day. The other three orders are appropriate for a patient who underwent amputation 4 days earlier. Focus: Prioritization

5. After interviewing an HIV-positive patient who is considering starting highly active antiretroviral therapy (HAART), which patient information concerns you the most? 1. The patient has been HIV positive for 8 years and has never taken any drug therapy for the HIV infection. 2. The patient tells you, "I have never been very consistent about taking medications." 3. The patient is sexually active with multiple partners and says "I always use a condom." 4. The patient has many questions and concerns regarding the effectiveness and safety of the medications.

2. Drug therapy for HIV infection requires taking medications very consistently. Failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus. Although the other data indicate the need for further assessments or interventions, they will not affect the decision to initiate antiretroviral therapy for this patient.

15. As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health care-associated infections? 1. Require nursing staff to don gowns to change wound dressings for all clients. 2. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. 3. Screen all newly admitted clients for colonization or infection with MRSA. 4. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms.

2. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for clients who are not on contact precautions is not necessary. Although some hospitals have started screening newly-admitted clients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection. Focus: Prioritization

9. A client who states that he may have been contaminated by anthrax arrives at the ED. Which action included in the ED protocol for possible anthrax exposure will you take first? 1. Notify hospital security personnel about the client. 2. Escort the client to a decontamination room. 3. Give ciprofloxacin (Cipro) 500 mg by mouth (PO). 4. Assess the client for signs of infection.

2. Escort the client to a decontamination room. To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure. Assessment of the client for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the client. According to the CDC guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax. Focus: Prioritization

For clients coming to the ambulatory care G.I. clinic, which task would be most appropriate to have the LPN do? 1. Teaching a client self care for an ulcer 2. Helping the dr. in i/d of a pilonidal cyst 3. Evaluate a client's response to sitz baths for an anorectal abscess. 4. Describing the basic pathophysiology of an anal fistula

2. Helping the dr. in i/d of a pilonidal cyst

22. A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient? 1. A fluid bolus 2. Fluid restrictions 3. Urinalysis 4. Sodium-restricted diet

2. Hyponatremia is a concern; therefore, fluid restrictions would be ordered. Urinalysis is less pertinent; however, the nurse should monitor for changes in urine specific gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely to be ordered for patients with SIADH; however, IV normal saline or hypertonic saline solutions may be given very cautiously.

27. You are caring for a patient with uterine cancer who is being treated with intracavitary radiation therapy. The UAP reports that the patient insisted on ambulating to the bathroom and now "something feels like it is coming out." What is the priority action? 1. Assess the UAP's knowledge; explain the rationale for strict bed rest. 2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. 3. Assess the patient's knowledge of the treatment plan and her willingness to participate. 4. Notify the physician about the potential or confirmed dislodgment of the radiation implant.

2. If the radiation implant has obviously been expelled (i.e., is on the bed linens), use a pair of forceps to place the radiation source in a lead container. The other options would be appropriate after safety of the patient and personnel are ensured.

15. An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone (Deltasone) 20 mg daily for 4 days. Which medical order should you question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen (Advil) 800 mg PO.

2. The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical orders are appropriate. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of NSAIDs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with SLE exacerbations.

20. Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory value requires particular attention? 1. Platelet count 2. Electrolyte levels 3. Hemoglobin level 4. Hematocrit

2. Tumor lysis syndrome can result in severe electrolyte imbalances and potential kidney failure. The other laboratory values are important to monitor to identify general chemotherapy side effects but are less pertinent to tumor lysis syndrome.

27. You are caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can you delegate to an LPN/LVN? 1. Determining whether the client's mental status justifies the continued use of restraints 2. Undoing and retying the restraints in order to improve client comfort 3. Reporting the client's status and continued need for restraints to the health care provider 4. Explaining the purpose of the restraints to the client's family members

2. Undoing and retying the restraints in order to improve client comfort Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the client's status, and teaching of the family require RN-level education and scope of practice. Focus: Delegation

You're taking initial history for a client seeking surgical treatment for obesity. Which finding should be reported to the surgeon before continuing? 1. obesity for approximately five years 2. history of counseling for body dysmorphic disorder 3. Failure to reduce weight with other therapies 4. Body weight 100% above the ideal

2. history of counseling for body dysmorphic disorder

When the client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to a UAP? 1. explaining the need for a clear liquid diet 1 to 3 days before the procedure 2. reinforcing NPO status 8 hours before the procedure 3. administering laxatives 1 to 3 days before the procedure 4. administering in enema the night before the procedure

2. reinforcing NPO status 8 hours before the procedure

You are caring for an obese postop client who had a bowel resection. His wound eviscerated. What do you do? (in order). 1. Cover the intestine with sterile moistened gauze 2. Stay calm and stay with the client 3. Check the VS especially BP and HR 4. Have a colleague gather sterile supplies and contact the dr. 5. Put the client into semi-fowler's position with knees slightly flexed 6. Prep the client for surgery as ordered

253416 2. Stay calm and stay with the client 5. Put the client into semi-fowler's position with knees slightly flexed 3. Check the VS especially BP and HR 4. Have a colleague gather sterile supplies and contact the dr. 1. Cover the intestine with sterile moistened gauze 6. Prep the client for surgery as ordered

22. A client who had a stroke needs to be fed. What instruction should you give to the UAP who will feed the client? 1. Position the client sitting up in bed before you feed him. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly, because there are three more you must feed. 4. Suction the client's secretions between bites of food.

22. Ans: 1 Position the client sitting up in bed before you feed him. Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding. Focus: Delegation, supervision

28. A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for you to delegate to the UAP? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

28. Ans: 4. Assisting the client in cleaning around the Unna boot Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members. Focus: Delegation

14. A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps

3

25. A client's family member says to you, "He needs more pain medicine. He is still having a lot of pain." What is your best response? 1. "The physician ordered the medicine to be given every 4 hours." 2. "If the medication is given too frequently, he could experience ill effects." 3. "Please tell him that I will be right there to check on him." 4. "Let's wait about 30 to 40 minutes. If there is no relief, I'll call the physician."

3

22. A patient who has been receiving cyclosporine (Sandimmune) following an organ transplantation is experiencing the following symptoms. Which one is of most concern? 1. Bleeding of the gums while brushing the teeth 2. Nontender lump in the right groin 3. Occasional nausea after taking the medication 4. Numbness and tingling of the feet

22. Ans: 2 Nontender lump in the right groin A nontender lump in this area (or near any lymph node) may indicate that the patient has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The patient should receive further evaluation immediately. The other symptoms may also indicate side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia), but do not indicate the need for immediate action. Focus: Prioritization

21. A patient with acute myelogenous leukemia is receiving induction-phase chemotherapy. Which assessment finding requires the most rapid action? 1. Serum potassium level of 7.8 mEq/L 2. Urine output less than intake by 400 mL 3. Inflammation and redness of the oral mucosa 4. Ecchymoses present on the anterior trunk

21. Ans: 1 Serum potassium level of 7.8 mEq/L Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia. The other symptoms also indicate a need for further assessment or interventions but are not as critical as the elevated potassium level. Focus: Prioritization

21. During assessment of a patient with fractures of the medial ulna and radius, you find all of these data. Which assessment finding should you report to the health care provider immediately? 1. The patient reports pressure and pain. 2. The cast is in place and is dry and intact. 3. The skin is pink and warm to the touch. 4. The patient can move all the fingers and the thumb.

21. Ans: 1 The patient reports pressure and pain. Pressure and pain may be due to increased compartment pressure and can indicate the serious complication of acute compartment syndrome. This situation is urgent. If it is not treated, cyanosis, tingling, numbness, paresis, and severe pain can occur. Focus: Prioritization

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

20. Ans: 1 Instructing the client to sit up straight, and the client responding with a puzzled expression Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions. Focus: Delegation, supervision

20. You performed postoperative stapedectomy teaching several days ago for a client. Which comment by the client concerns you the most? 1. "I'm going to take swimming lessons in a couple of months." 2. "I have to take a long overseas flight in several weeks." 3. "I can't wait to get back to my regular weightlifting class." 4. "I have been coughing a lot with my mouth open."

20. Ans: 3 "I can't wait to get back to my regular weightlifting class." Heavy lifting should be strictly avoided for at least 3 weeks after stapedectomy. Water in the ear and air travel should be avoided for at least 1 week. Coughing and sneezing should be performed with the mouth open to prevent increased pressure in the ear. Focus: Prioritization

20. You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min

20. Ans: 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of MI. Focus: Prioritization

20. During morning care, a patient with a below-the-knee amputation asks the UAP about prostheses. How will you instruct the UAP to respond? 1. "You should get a prosthesis so that you can walk again." 2. "Wait and ask your doctor that question the next time he comes in." 3. "It's too soon to be worrying about getting a prosthesis." 4. "I'll ask the nurse to come in and discuss this with you."

20. Ans: 4 "I'll ask the nurse to come in and discuss this with you." The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly the health care provider can also discuss prostheses with the patient, but the patient's wish to learn should receive a quick response. The nurse can then notify the health care provider about the patient's request. Focus: Delegation, supervision

20. You are transferring a patient with newly-diagnosed chronic myeloid leukemia to an LTC facility. Which information is most important to communicate to the LTC charge nurse before transferring the patient? 1. Philadelphia chromosome is present in the patient's blood smear. 2. Glucose level is elevated as a result of prednisone (Deltasone) therapy. 3. There has been a 20-lb weight loss over the last year. 4. The patient's chemotherapy has resulted in neutropenia.

20. Ans: 4 The patient's chemotherapy has resulted in neutropenia A patient with neutropenia is at increased risk for infection, so the LTC charge nurse needs to know about the neutropenia to make decisions about the patient's room assignment and to plan care. The other information also will impact planning for patient care, but the charge nurse needs the information about neutropenia before the patient is transferred. Focus: Prioritization

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

21. Ans: 1, 2, 3, 5 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active ROM exercises 5. Setting up meal trays and assisting with feeding An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. Assessing for redness and swelling (signs of deep venous thrombosis) requires additional education and skill, appropriate to the professional nurse. Focus: Delegation, supervision

21. Place the following steps for ear irrigation in the correct order. 1. Use an otoscope to ascertain that the eardrum is intact and that there is no evidence of infection. 2. Place the tip of the syringe at an angle in the external canal. 3. Watch for fluid return and signs of cerumen. 4. If cerumen does not appear, wait 10 minutes and repeat the irrigation. 5. Fill a syringe with warm irrigating solution. 6. After completion of the irrigation, have the client turn the head to the side to facilitate drainage. 7. Apply gentle but continuous pressure to the syringe plunger.

21. Ans: 1, 5, 2, 7, 3, 4, 6 1. Use an otoscope to ascertain that the eardrum is intact and that there is no evidence of infection. 5. Fill a syringe with warm irrigating solution. 2. Place the tip of the syringe at an angle in the external canal. 7. Apply gentle but continuous pressure to the syringe plunger. 3. Watch for fluid return and signs of cerumen. 4. If cerumen does not appear, wait 10 minutes and repeat the irrigation. 6. After completion of the irrigation, have the client turn the head to the side to facilitate drainage. Use an otoscope to assess the ear first and then fill the syringe with warm fluid. Angle the syringe to allow the fluid to flow along the side of the ear canal, not directly at the eardrum. Flush with continuous pressure, rather than a pumping action. You should see fluid return with cerumen. If not, then wait at least 10 minutes and repeat. Tipping the head allows gravity drainage of fluid left in the ear canal. Focus: Prioritization

21. Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate.

21. Ans: 1. Defibrillate at 200 J. Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available. Focus: Prioritization

22. Two weeks ago, a 63-year-old client with heart failure received a new prescription for carvedilol (Coreg) 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

22. Ans: 3. Sinus bradycardia at a rate of 48 beats/min Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, the slow heart rate does require further follow-up, because bradycardia may progress to more serious dysrhythmias such as heart block. Focus: Prioritization

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

23. Ans: 2 Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible, but are not as important as starting antibiotic therapy. Focus: Prioritization

23. You have just received a change-of-shift report about these clients on the coronary step-down unit. Which one will you assess first? 1. 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. 56-year-old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. 77-year-old who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6° F (38.1° C)

23. Ans: 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change The client's symptoms indicate acute hypoxia, so immediate further assessments (such as assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon, because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client. Focus: Prioritization

23. A patient with Hodgkin lymphoma who is receiving radiation therapy to the groin area has skin redness and tenderness in the area being irradiated. Which nursing activity should you delegate to the UAP caring for the patient? 1. Checking the skin for signs of redness or peeling 2. Assisting the patient in choosing appropriate clothing 3. Explaining good skin care to the patient and family 4. Cleaning the skin over the area daily with a mild soap

23. Ans: 4 Cleaning the skin over the area daily with a mild soap Skin care is included in UAP education and job description. Assessment and patient teaching are more complex tasks that should be delegated to RNs. Because the patient's clothes need to be carefully chosen to prevent irritation or damage to the skin, the RN should assist the patient with this. Focus: Delegation

24. After you receive the change-of-shift report, which patient will you assess first? 1. 20-year-old with possible acute myelogenous leukemia who has just arrived on the medical unit 2. 38-year-old with aplastic anemia who needs teaching about decreasing infection risk before discharge 3. 40-year-old with lymphedema who requests help in putting on compression stockings before getting out of bed 4. 60-year-old with non-Hodgkin lymphoma who is refusing the prescribed chemotherapy regimen

24. Ans: 1 20-year-old with possible acute myelogenous leukemia who has just arrived on the medical unit The newly-admitted patient should be assessed first, because the baseline assessment and plan of care need to be completed. The other patients also need assessments or interventions but do not need immediate nursing care. Focus: Prioritization

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

24. Ans: 1 Entering the room without putting on a mask and gown Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may not be appropriate but do not require intervention as rapidly. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia. Focus: Prioritization

24. As the charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and UAPs, you have developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to delegate to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

24. Ans: 2. Listening to lung sounds and checking for edema each week LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice. Focus: Delegation

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

25. Ans: 1, 2 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin (Dilantin) 200 mg by mouth (PO) three times a day Any nursing staff member who is involved in caring for the client should observe for the onset and duration of any seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice. Focus: Delegation

25. During a home visit to an 88-year-old client who is taking digoxin (Lanoxin) 0.25 mg daily to treat heart failure and atrial fibrillation, you obtain this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse of 68 beats/min and irregularly irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

25. Ans: 3. Vision that is becoming "fuzzy" The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregularly irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure. Focus: Prioritization

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

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

26. You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

26. Ans: 2, 4, 3, 1 2. Have the client sit down. 4. Administer PRN oxygen by nasal cannula. 3. Check the client's blood pressure. 1. Call the client's physician. The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization

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

27. Ans: 2 The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment and/or client teaching but will not require a change in medical treatment for the seizures. Focus: Prioritization

27. A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the client's physician about the change in status. 4. Reassure the client that embolization is common in endocarditis.

27. Ans: 3. Notify the client's physician about the change in status. The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the physician should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain. Focus: Prioritization

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

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

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

29. Ans: 1, 3, 5 1. Checking for orthostatic changes in pulse and blood pressure 3. Reminding the client to allow adequate time for meals 5. Assisting the client with prescribed strengthening exercises UAP education and scope of practice include taking pulse and blood pressure measurements. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation

29. During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, you obtain these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

29. Ans: 1. Arterial line indicates a blood pressure of 190/112 mm Hg. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and/or hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability. Focus: Prioritization

28. You are caring for a young man with a history of substance abuse whohad exploratory abdominal surgery 4 days ago for a knife wound. There isan order to discontinue the PCA-delivered morphine and to start oralpain medication. The client begs, "Please don't stop the morphine. Mypain is really a lot worse today than it was yesterday." What is the bestresponse? 1. "Let me stop the pump and we can try oral pain medication to see if itrelieves the pain." 2. "I realize that you are scared of the pain, but we must try to wean youoff the pump." 3. "Show me where your pain is and describe how it feels compared toyesterday." 4. "Let me take your vital signs, and then I will call the physician andexplain your concerns."

3

7. In application of the principles of pain treatment, what is the first consideration? 1. Treatment is based on client goals. 2. A multidisciplinary approach is needed. 3. The client's perception of pain must be accepted. 4. Drug side effects must be prevented and managed.

3

2. Family members are encouraging your client to "tough out the pain" rather than risk drug addiction to narcotics. The client is stoically abiding. You recognize that the sociocultural dimension of pain is the current priority for the client. Which question will you ask? 1. " Where is the pain located, and does it radiate to other parts of your body?" 2. " How would you describe the pain, and how is it affecting you?" 3. " What do you believe about pain medication and drug addiction?" 4. " How is the pain affecting your activity level and your ability to function?" 5. " What information do you need about pain, healing, and addiction?"

3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the behavioral dimension. Asking about knowledge addresses the cognitive dimension. Focus: Prioritization 3. LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

22. You are preparing to insert a PICC line in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion? 1. 70% isopropyl alcohol 2. Povidone-iodine (Betadine) 3. 0.5% chlorhexidine in alcohol (Hibistat) 4. Betadine followed by 70% isopropyl alcohol

3. 0.5% chlorhexidine in alcohol (Hibistat) The current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections (CLABSIs). The other solutions provide some decrease in the number of microorganisms on the skin, but are not as effective as chlorhexidine. Focus: Prioritization

11. The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

3. "The client's skeletal muscles are weak because of the low phosphorus." A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of ATP, and when not produced, leads to generalized muscle weakness. Although the other statements are true, they do not answer the UAP's question.

14. A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN? 1. Performing ongoing assessments to determine the client's hydration status 2. Explaining the purpose of ordered stool cultures to the client and family 3. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client 4. Reviewing the client's medical history for any risk factors for diarrhea

3. Administering the ordered metronidazole (Flagyl) 500 mg PO to the client LPN/LVN scope of practice and education include administration of medications. Assessment of hydration status, client and family education, and assessment of client risk factors for diarrhea should be done by the RN. Focus: Delegation

3. A client with diabetic neuropathy reports a burning, electrical-type pain in the lower extremities that is worse at night and not responding to nonsteroidal anti-inflammatory drugs. Which medication will you advocate for first? 1. Gabapentin (Neurontin) 2. Corticosteroids 3. Hydromorphone (Dilaudid) 4. Lorazepam (Ativan)

3. Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolytic that may be ordered as an adjuvant nedication. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

3. Which clients would be best to assign to the most experienced nurse in an ambulatory care center that specializes in vision problems and eye surgery? (Select all that apply.) 1. Client who requires postoperative instructions after cataract surgery 2. Client who needs an eye pad and a metal shield applied 3. Client who requests a home health referral for dressing changes and eyedrop instillation 4. Client who needs teaching about self-administration of eyedrops 5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty

3. Ans: 1, 3, 5, 6 1. Client who requires postoperative instructions after cataract surgery 3. Client who requests a home health referral for dressing changes and eyedrop instillation 5. Client who requires an assessment for recent and sudden loss of sight 6. Client who requires preoperative teaching for laser trabeculoplasty Providing postoperative and preoperative instructions, making home health referrals, and assessing for needs related to loss of vision should be done by an experienced nurse who can give specific details and specialized information about follow-up eye care and adjustment to loss. The principles of applying an eye pad and shield and teaching the administration of eyedrops are basic procedures that should be familiar to all nurses. Focus: Assignment

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

3. Ans: 1, 4, 6 1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation

3. A 32-year-old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first? 1. Give morphine sulfate 4 to 8 mg IV every hour as needed. 2. Administer 100% oxygen using a nonrebreather mask. 3. Start a 14-gauge IV line and infuse normal saline at 200 mL/hr. 4. Give pneumococcal (Pneumovax) and Haemophilus influenzae (ActHIB) vaccines.

3. Ans: 2 Administer 100% oxygen using a nonrebreather mask. Hypoxia and deoxygenation of the RBCs are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this patient and should be accomplished rapidly. Vaccination may help prevent future sickling episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization

3. Your assessment reveals all of these data when you are admitting a patient with Paget disease. Which finding should you notify the physician about first? 1. There is a bowing of both legs and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.

3. Ans: 2 The base of the skull is invaginated (platybasia). Platybasia (basilar skull invagination) causes brainstem manifestations that threaten life. Patients with Paget disease are usually short and often have bowing of the long bones that results in asymmetrical knees or elbow deformities. The skull is typically soft, thick, and enlarged. Focus: Prioritization

3. After a client has a seizure, which action can you delegate to the UAP? 1. Documenting the seizure 2. Performing neurologic checks 3. Taking the client's vital signs 4. Restraining the client for protection

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

11. A 23-year-old client comes to the outpatient clinic reporting increasing shortness of breath, diarrhea, abdominal pain, and epistaxis. Which action should you take first? 1. Assist the client to pinch the anterior nares firmly for 5 minutes. 2. Call an ambulance to take the client immediately to the hospital. 3. Ask the client about any recent travel to Asia or the Middle East. 4. Determine whether the client has had recommended immunizations.

3. Ask the client about any recent travel to Asia or the Middle East. The client's clinical manifestations suggest possible avian influenza ("bird flu"). If the client has traveled recently in Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. The other actions may also be appropriate but are not the initial action to take for this client, who may transmit the infection to other clients or staff members. Focus: Prioritization

6. You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infection? 1. Client with an implanted port in the right subclavian vein 2. Client who has a midline IV catheter in the left antecubital fossa 3. Client who has a nontunneled central line in the left internal jugular vein 4. Client with a peripherally inserted central catheter (PICC) line in the right upper arm

3. Client who has a nontunneled central line in the left internal jugular vein According to CDC guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection. Focus: Prioritization

17. You are admitting four clients with infections to the medical unit, but only one private room is available. Which client is it most appropriate to assign to the private room? 1. Client with diarrhea caused by C. difficile 2. Client with a wound infected with VRE 3. Client with a cough who may have TB 4. Client with toxic shock syndrome and fever

3. Client with a cough who may have TB Clients with infections that require airborne precautions (such as TB) need to be in private rooms. Clients with infections that require contact precautions (such as those with C. difficile and VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with toxic shock syndrome. Focus: Prioritization

19. An athletic young man was recently diagnosed with Ewing sarcoma. He has pain, lowgrade fever, and anemia. The surgeon recommends amputation of the right lower leg for an operable tumor. The patient tells you he is leaving the hospital to go on a long hiking trip. What is the priority nursing diagnosis? 1. Acute Pain related to tumor invasion of soft tissue 2. Fatigue related to anemia 3. Ineffective Coping related to loss of body image 4. Noncompliance related to personal values

3. The patient is not coping with the recent diagnosis of cancer and prospect of losing his leg. His decision to go hiking may be a form of denial, or possibly a veiled suicide threat. It is also possible that he has decided not to have any treatment; however, you need to make additional assessment about his decision and actions and help him to discuss alternatives and consequences. The other diagnoses may also apply, but if he leaves the hospital there will be no chance to address any other issues.

You're caring for a client was admitted for cirrhosis. The client has ascites, peripheral dependent edema, nausea, vomiting, and dyspnea. What is the best way to track for fluid retention? 1. Lung sounds 2. Abdominal girth measurement 3. Daily weights 4. Check for edema

3. Daily weights

1. A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first? 1. Start oxygen at 4 L/min using a nasal cannula. 2. Obtain IV access with a large-bore IV catheter. 3. Give epinephrine (Adrenalin) 0.3 mL intramuscularly. 4. Administer 3 mL of nebulized albuterol (Proventil) 0.083%.

3. Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention.

26. You are asked to float to a different nursing unit. During report, you are told that the patient is receiving IV administration of vincristine (Oncovin) that should be completed within the next 15 minutes. The IV site is intact, and the patient is not having any problems with the infusion. You are not certified in chemotherapy administration. What is your priority action? 1. Ask the nurse to stay until the infusion is finished, because you are not certified. 2. Assess the IV site; check the progress of the infusion and the patient's condition. 3. Contact the charge nurse and explain that you are not chemotherapy certified. 4. Look up drug side effects and monitor, because the infusion is almost complete.

3. Explain that you are not chemotherapy certified so that the charge nurse can quickly rearrange the patient assignments. You can assess the patient, site, and infusion; however, you do not have the expertise to recognize the side effects of the medication or to give specialized care that may be needed. Asking the nurse to stay is not the best solution, because the care of the patient and the effects of the medication continue after the infusion has been completed. Looking up the side effects of the drug is okay for your own information, but you are still not qualified to deal with this situation. In addition, knowing how to properly discontinue the infusion and dispose of the equipment are essential for your own safety and the safety of others.

7. The physician tells the patient with cancer that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. Which patient statement would concern you the most? 1. "My symptoms will eventually be cured; I'm so happy that I don't have to worry any longer." 2. "My doctor is trying to help me control the symptoms; I am grateful for the extension of time with my family." 3. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death." 4. "Initially, I may have to take some time off of work for my treatments; I can probably work full time in the future."

3. Further assess what the patient means by having "control over my own life and death." This could be an indirect statement of suicidal intent. A patient who believes he will be cured should also be assessed for misunderstanding what the physician said; however, the patient may need to use denial as a temporary defense mechanism. The patient's acknowledgment that the treatments are for control of symptoms or plans for the immediate future suggest an understanding of what the physician said.

You are supervising a nursing student who is caring for a client who had a cholecystectomy. There is a t-tube in place. when would you intervene? 1. Maintains the client in semi-fowlers 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation

3. Gently aspirates the drainage from the tube

11. For care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? 1. Assisting the patient to brush and floss 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes

3. Giving medications is within the scope of practice of the LPN/LVN. Assisting the patient in brushing and flossing should be delegated to the UAP. Explaining contraindications is the responsibility of the RN. Recommendations for saliva substitutes should come from the physician or pharmacist.

7. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia

3. Hyponatremia SIADH causes a relative sodium deficit due to excessive retention of water.

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

3. I'm going to cut down on my drinking very soon

10. A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the UAP who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 2. Communicating with other departments when the client is transported for ordered tests 3. Implementing contact precautions when providing care for the client 4. Monitoring the results of ordered laboratory culture and sensitivity tests

3. Implementing contact precautions when providing care for the client All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data. Focus: Delegation

7. You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which nursing action can you delegate to an LPN/LVN? 1. Planning ways to improve the client's oral protein intake 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown

3. Obtaining wound cultures during dressing changes LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN. Focus: Delegation

9. For a patient receiving the chemotherapeutic drug vincristine (Oncovin), which side effects should be reported to the physician? 1. Fatigue 2. Nausea and vomiting 3. Paresthesia 4. Anorexia

3. Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine. The physician can modify the dosage or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects of many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals containing high-protein and highcalorie foods.

11. A patient with a history of liver transplantation is receiving cyclosporine (Sandimmune), prednisone (Deltasone), and mycophenolate (CellCept). Which finding is of most concern? 1. Gums that appear very pink and swollen 2. A blood glucose level that is increased to 162 mg/dL 3. A nontender lump above the clavicle 4. Grade 1+ pitting edema in the feet and ankles

3. Patients taking immunosuppressive medications are at increased risk for development of cancer. A nontender swelling or lump may signify that the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications.

While tansferring the dirty laundry bag, a UAP sustains a puncture wound from a contaminated needle. The unit has several clients with hepatitis and AIDS. The needle source is unknown. Place in order of priority what to do. 1. Have blood tests performed per protocol 2. complete and file an incident report 3. Perform a thorough aseptic hand washing 4. Report to the occupational health nurse 5. follow up for results and counseling 6. Begin prophylactic drug therapy

3. Perform a thorough aseptic hand washing 4. Report to the occupational health nurse 1. Have blood tests performed per protocol 2. complete and file an incident report 6. Begin prophylactic drug therapy 5. follow up for results and counseling

1. A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? 1. Infuse normal saline at 75 mL/hr. 2. Obtain blood, urine, and sputum for cultures. 3. Place the client on airborne and contact precautions. 4. Give methylprednisolone (Solu-Medrol) 1 g IV.

3. Place the client on airborne and contact precautions. Current Centers for Disease Control and Prevention (CDC) guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS in order to protect other clients and health care workers. If an airborne-agent isolation (negative-pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room. The other actions should also be taken rapidly but are not as important as preventing transmission of the disease.

You're providing postop care for a client who underwent laparoscopic colycystectomy. What should be reported immediately to the physician? 1. the client hasn't voided five hours postop 2. the client reports shoulder pain 3. the client reports right upper quadrant pain 4. input does not equal output for the first few hours

3. RUQ pain

8. For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the UAP? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3. The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue and skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the physician.

23. You have received a needlestick injury after giving a client an intramuscular injection, but you have no information about the client's HIV status. What is the most appropriate method of obtaining this information about the client? 1. You should personally ask the client to authorize HIV testing as soon as possible. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The occupational health nurse should discuss HIV status with the client. The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about obtaining a client's HIV status and/or ordering HIV testing is the occupational health nurse. Performing unauthorized HIV testing or asking the client yourself would be unethical. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health). Focus: Prioritization

8. A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine (Sandimmune) and methylprednisolone (Solu-Medrol). Which staff member is best to assign to care for this patient? 1. RN who floated to the medical unit from the coronary care unit for the day 2. RN with 3 years of experience in the operating room who is orienting to the medical unit 3. RN who has worked on the medical unit for 5 years and is working a double shift today 4. Newly graduated RN who needs experience with IV medication administration

3. To be most effective, cyclosporine must be mixed and administered in accordance with the manufacturer's instructions, so the RN who is likely to have the most experience with the medication should care for this patient or monitor the new graduate carefully during medication preparation and administration. The coronary care unit float nurse and the nurse who is new to the unit would not have experience with this medication.

28. You are the charge nurse. Two hours into the shift you discover that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should you take first? 1. Insist that they switch back to the original patient assignments and talk to each of them at the end of the shift. 2. Allow them this flexibility; as long as the patients are well cared for it doesn't matter if the assignments are changed. 3. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues. 4. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings.

3. You must try to find out what Nurse A is thinking and feeling. If you can discover the underlying issue, there is a better chance that you can help her (e.g., referral to counseling or in-service training). You should try to avoid being too draconian with your staff by insisting that they switch back to the original assignments, or too condescending by lecturing them about patients' rights. Nurses frequently can and do switch patients to help each other out, but the charge nurse should always be informed prior to making the switch.

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

3. assist the client to the bedpan or toilet 30 minutes after meals

Postop care of the morbidly obese client is being planned. Which task best best utilizes the expertise of the LPN? 1. obtaining an oversize blood pressure cuff and an extra large bed 2. setting up a trapeze bar 3. assisting in the planning of toileting, turning, and ambulation 4. assigning tasks to UAPs

3. assisting in the planning of toileting, turning, and ambulation

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

3. check vital signs every hour

You are caring for a client with an NG tube. What task can you delegate the UAP? 1. removing the NG tube 2. securing the tape if the client accidentally dislodges the tube 3. disconnecting the section to allow ambulation to the toilet 4. reconnecting the suction after the client has ambulated

3. disconnecting the section to allow ambulation to the toilet

8. Which client has the most immediate need for IV access to deliver immediate analgesia with rapid titration? 1. Client who has sharp chest pain that increases with cough and shortness of breath 2. Client who reports excruciating lower back pain with hematuria 3. Client who is having an acute myocardial infarction with severe chest pain 4. Client who is having a severe migraine with an elevated blood pressure

3. morphine can be used in this instance

In the care of a client with GERD, which task would be appropriate to assign to the UAP? 1. sharing successful strategies for weight reduction 2. encouraging the client to express concerns about lifestyle modification 3. reminding client not to lie down for 2 to 3 hours after eating 4. explaining the rationale for eating small frequent meals

3. reminding client not to lie down for 2 to 3 hours after eating

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

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

30. You are developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. Which nursing activity included in the care plan will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

30. Ans: 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously-taught information are activities that can be delegated to other nursing personnel under the supervision of the RN. Focus: Delegation

31. A client who has Alzheimer disease is hospitalized with new-onset angina. Her husband tells you he does not sleep well because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give the client to be sure they are "the same pills she takes at home." Based on this information, which nursing diagnosis is most appropriate for this client? 1. Decreased Cardiac Output related to poor myocardial contractility 2. Caregiver Role Strain related to continuous need for providing care 3. Risk for Falls related to client wandering behavior during the night 4. Ineffective Family Therapeutic Regimen Management related to poor client memory

31. Ans: 2 Caregiver Role Strain related to continuous need for providing care The husband's statement about lack of sleep and anxiety about whether his wife is receiving the correct medications are behaviors that support this diagnosis. There is no evidence that the client's cardiac output is decreased. The husband's statements about how he monitors the client and his concern with medication administration indicate that the risk for ineffective family therapeutic regimen management and falls are not priority diagnoses at this time. Focus: Prioritization

31. You are preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine (Pepcid) 20 mg IV 2. Furosemide (Lasix) 40 mg IV 3. Digoxin (Lanoxin) 0.25 mg PO 4. Warfarin (Coumadin) 2.5 mg PO

31. Ans: 4. Warfarin (Coumadin) 2.5 mg PO Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed. Focus: Prioritization

32. You are caring for a client with a glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information will concern you the most? 1. The client no longer recognizes family members. 2. The blood glucose level is 234 mg/dL. 3. The client reports a continuing headache. 4. The daily weight has increased 1 kg.

32. Ans: 1 The client no longer recognizes family members. The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies. Focus: Prioritization

32. A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

32. Ans: 2. B-type natriuretic peptide Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored, but do not indicate whether the client has heart failure. Focus: Prioritization

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

33. Ans: 2 Transport the client to the radiology department for a computed tomographic (CT) scan. The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion. Focus: Prioritization

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

34. Ans: 3 46-year-old who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due Of the clients listed, the client with bacterial meningitis is in the most stable condition. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses. Focus: Assignment

16. The physician has ordered a placebo for a client with chronic pain. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take? 1. Prepare the medication and hand it to the physician. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice.

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19. On the first day after surgery, a client receiving an analgesic via PCA pump reports that the pain control is inadequate. What is the first action you should take? 1. Deliver the bolus dose per standing order. 2. Contact the physician to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity.

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20. The team is providing emergency care to a client who received an excessive dose of narcotic pain medication. Which task is best to delegate to the LPN/LVN? 1. Calling the physician and reporting the situation using the SBAR (situation, background, assessment, recommendation) format 2. Giving the ordered dose of Narcan and evaluating the response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered

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21. What is the best way to schedule medication for a client with constant pain? 1. PRN at the client's request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around the clock

4

27. A client has severe pain and bladder distention related to urinaryretention and possible obstruction. An experienced UAP states that shereceived training in Foley catheter insertion at a previous job. What taskcan be delegated to this UAP? 1. Assessing the bladder distention and the pain associated with urinaryretention 2. Inserting the Foley catheter, once you ascertain that she knows steriletechnique 3. Evaluating the relief of pain and bladder distention after the catheter isinserted60 4. Measuring the urine output after the catheter is inserted and obtaininga urine specimen

4

20. A patient seen in the sexually-transmitted disease clinic has just tested positive for HIV with a rapid HIV test. Which action will you take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

4. A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection. According to current national guidelines, the other actions are also appropriate. Rapid HIV testing must be confirmed by another test, usually the Western blot test. Antiretroviral therapy is recommended for all HIV-positive patients. Risk factor information will be used in tracking patient contacts and in teaching the patient how to reduce the risk for transmission to others.

4. The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weigh the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide (Lasix) 40 mg IV push.

4. Administer furosemide (Lasix) 40 mg IV push. Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important, but are not urgent.

4. These activities are included in the care plan for a 78-year-old patient admitted to the hospital with anemia caused by possible gastrointestinal bleeding. Which activity can you delegate to an experienced UAP? 1. Obtaining stool specimens for fecal blood test (Hemoccult) slides 2. Having the patient sign a colonoscopy consent form 3. Giving the prescribed polyethylene glycol electrolyte solution (GoLYTELY) 4. Checking for allergies to contrast dye or shellfish

4. Ans: 1. Obtaining stool specimens for fecal blood test (Hemoccult) slides An experienced UAP will have been taught how to obtain a stool specimen for the Hemoccult slide test, because this is a common screening test for hospitalized patients. Having the patient sign an informed consent form should be done by the physician who will be performing the colonoscopy. Administering medications and checking for allergies are within the scope of practice of licensed nursing staff. Focus: Delegation

10. You are preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates to you the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. "I will make sure to take my vitamin D with my calcium each day." 3. "I will take my calcium citrate pill every morning before breakfast." 4. "I will avoid dairy products, broccoli, and spinach when I eat."

4. "I will avoid dairy products, broccoli, and spinach when I eat." Clients with low calcium levels should be encouraged to eat dairy products, seafood, nuts, broccoli, and spinach, which are all good sources of dietary calcium.

4. You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

4. Ans: 2 Setting up oxygen and suction equipment The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins. Focus: Delegation, supervision

4. The charge nurse observes an LPN/LVN providing all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen (Advil) to the patient 2. Encouraging the patient to perform PT-recommended exercises 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese

4. Ans: 3 Applying ice and gentle massage to the patient's lower extremities Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation, supervision

4. Which client is most likely to receive opioids for extended periods of time? 1. A client with fibromyalgia 2. A client with phantom limb pain in the leg 3. A client with progressive pancreatic cancer 4. A client with trigeminal neuralgia

4. Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with nonopioid and adjuvant medications. Trigeminal neuralgia is treated with antiseizure medications such as carbamazepine (Tegretol). Phantom limb pain usually subsides after ambulation begins. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

4. Based on this information in a client's medical record, which topic will you plan on including in the initial teaching plan for a client who has a new diagnosis of stage 1 hypertension? Health History- Denies any chronic health problems, currently takes no medications. Physical Exam- 5'6" , 115lbs, BMI 18.6. Social and Diet HX- Accountant, 1 glass of wine 1-2 times week, Eats fast food frequently. 1. Benefits and adverse effects of beta-blockers 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4. Ans: 4. Low-sodium food choices when eating out Research indicates that reducing sodium intake will lower blood pressure. Lifestyle management is appropriate initial therapy for this client with stage 1 hypertension and no cardiovascular disease or risk factors. Antihypertensive medications would not be prescribed unless lifestyle changes were attempted for several months without a decrease in blood pressure. This client's assessment data indicate that she is not overweight and does not drink alcohol excessively, so discussing changes in these risk factors would not be appropriate. Focus: Prioritization

4. Place the following steps for eyedrop administration in the correct order. 1. Gently press on the lacrimal duct for 1 minute. 2. Gently pull the tissue underneath the eye downward to expose the lower conjunctival sac. 3. Have the client gently close the eye and move it around. 4. Have the client look up while you instill the number of prescribed drops. 5. Hold the dropper and stabilize your hand on the client's forehead. 6. Have the client sit down and tilt his or her head slightly backward.

4. Ans: 6, 2, 5, 4, 3, 1 6. Have the client sit down and tilt his or her head slightly backward. 2. Gently pull the tissue underneath the eye downward to expose the lower conjunctival sac. 5. Hold the dropper and stabilize your hand on the client's forehead. 4. Have the client look up while you instill the number of prescribed drops. 3. Have the client gently close the eye and move it around. 1. Gently press on the lacrimal duct for 1 minute. Have the client sit with the head tilted back. Pulling down the lower conjunctival sac creates a small pocket for the drops. Stabilizing the hand prevents accidentally poking the client's eye. Having the client look up prevents the drops from falling on the cornea and stimulating the blink reflex. When the client gently moves the eye, the medication is distributed. Pressing on the lacrimal duct prevents systemic absorption. Focus: Prioritization

1. You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your initial action? 1. Check the medication administration records (MARs) for the past several days. 2. Ask the nurse educator to provide in-service training about pain management. 3. Perform a complete pain assessment on the client and take a pain history. 4. Have a conference with the nurses responsible for the care of this client.

4. As charge nurse, you must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the records and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem. Focus: Supervision, prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

9. Your patient with rheumatoid arthritis (RA) is taking prednisone (Deltasone) and naproxen (Aleve) to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? 1. RA symptoms are worst in the morning 2. Dry eyes 3. Round and moveable nodules just under the skin 4. Dark-colored stools

4. Both naproxen (a nonsteroidal anti-inflammatory drug [NSAID]) and prednisone (a corticosteroid) can cause gastrointestinal bleeding, and the stool appearance indicates that blood may be present in the stool. The health care provider should be notified so that actions such as testing a stool specimen for occult blood and administering proton pump inhibitors can be prescribed. The other symptoms are common in patients with RA and will require further assessment or intervention, but do not indicate that the patient is experiencing adverse effects from the medications.

16. You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalances? 1. History of myocardial infarction 1 year ago 2. Antacid use for occasional indigestion 3. Shortness of breath with extreme exertion 4. Chronic renal insufficiency

4. Chronic renal insufficiency Risk factors for acid-base imbalances in the older adult include chronic kidney disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis.

2. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrhea/Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process and diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anxiety related to unknown outcomes and perceived threats to body integrity

4. The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored.

12. An HIV-positive patient who has been started on HAART is seen in the clinic for follow-up. Which test will be most helpful in determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

4. Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the HAART is effective. The CD4 level, total lymphocytes, and complete blood count will also be used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy.

Which client is the most appropriate to sign to an LPN?1. client with oral cancer who is scheduled in the morning for glossectomy 2. obese client returning from surgery after a gastroplasty 3. client with anorexia nervosa who has muscle weakness and decreased urine output 4. a client with nausea and vomiting related to chemo

4. a client with nausea and vomiting related to chemo

Your caring for a client with a peptic ulcer disease, which assessment findings and most serious? 1. projectile vomiting 2. burning sensation two hours after eating 3. coffee ground emesis 4. board like abdomen with shoulder pain

4. board like abdomen with shoulder pain

Which assessment of a dementia patient is of most concern? 1. flat affect and rambling and repetitive speech 2. The client has memory impairments and thinks the year is 1948 3. the client lacks motivation and demonstrates early-morning wakening 4. the client has a fluctuating level of consciousness and mood swings

4. the client has a fluctuating level of consciousness and mood swings

You would be most concerned about an order for a TPN fat emulsion for a client with which conditoin? 1. G.I. obstruction 2. anorexia nervosa 3. chronic diarrhea and vomiting 4. fractured femur

4. fractured femur (fat embolism risk)

You are caring for a client was recently admitted for severe diverticulitis. Which is proper delegation? 1. Have the secretary call radiology and schedule a barium enema 2. Instruct the LPN to give prn laxatives 3. Advise the nursing student to help the client ambulate 4. Tell the UAP that a stool specimen must be saved to test for occult blood

4. Tell the UAP that a stool specimen must be saved to test for occult blood

20. A healthy 65-year-old woman who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations, but tells you, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4. Tetanus, diphtheria, pertussis Individuals who have contact with infants should be immunized against pertussis in order to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, prior to the influenza season. The herpes zoster vaccine is important, but does not need to be administered today. Focus: Prioritization

12. You are the charge nurse on the medical unit. Which infection control activity should you delegate to an experienced UAP? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses. Focus: Delegation

12. Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? 1. Elderly client with chronic pain who has a hip fracture 2. Client with a heroin addiction and back pain 3. Young female client with advanced multiple myeloma 4. Child with an arm fracture and cystic fibrosis

4. Greatest risks are elderly, opiod naive clients and underlying pulmonary disease. The child has two of those risks

4. You are evaluating an HIV-positive patient who is receiving IV pentamidine (Pentam) as a treatment for Pneumocystis jiroveci (PCP) pneumonia. Which information is most important to communicate to the physician? 1. The patient is reporting pain at the site of the infusion. 2. The patient is not taking in an adequate amount of oral fluids. 3. Blood pressure is 104/76 mm Hg after pentamidine administration. 4. Blood glucose level is 55 mg/dL after medication administration.

4. Pentamidine can cause fatal hypoglycemia, so the low blood glucose level indicates a need for a change in therapy. The low blood pressure suggests that the pentamidine infusion rate may need to be slowed. The other responses indicate a need for independent nursing actions (such as establishing a new IV site and encouraging oral intake) but are not associated with pentamidine infusion.

8. A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first? 1. Notify the physician about the loose stools. 2. Obtain stool specimens for culture. 3. Instruct the client about correct hand washing. 4. Place the client on contact precautions.

4. Place the client on contact precautions. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients. The other actions are also needed and should be taken after placing the client on contact precautions. Focus: Prioritization

12. You are reviewing the client's morning laboratory results. Which of these results is of most concern to you? 1. Serum potassium level of 5.2 mEq/L 2. Serum sodium level of 134 mEq/L 3. Serum calcium level of 10.6 mg/dL 4. Serum magnesium level of 0.8 mEq/L

4. Serum magnesium level of 0.8 mEq/L Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

A client with proctitis needs a rectal suppository. a senior nursing student is assigned to care for this client. she tells you that she's afraid to insert a suppository because she's never done it. what is the most appropriate action? 1. give the medication yourself 2. ask the student to leave the clinical area because she's unprepared 3. reassign the client to an LPN and send a student to observe 4. show the student had insert the suppository and talk to the instructor

44. show the student had insert the suppository and talk to the instructor

23. You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" 5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain."_____, _____, _____, _____, _____

5,2,1,3,4

18. You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. _____, _____, _____, _____, _____

5,3,1,2,4

5. Which tasks are appropriate to delegate to an LPN/LVN who is functioning under the supervision of an RN? (Select all that apply.) 1. Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 5. Assessing nutritional factors for a client with age-related macular degeneration 6. Reviewing the health history of a client to identify risk for ocular manifestations 7. Performing a routine check of a client's visual acuity using the Snellen eye chart

5. Ans: 2, 3, 4, 7 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 7. Performing a routine check of a client's visual acuity using the Snellen eye chart Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation

5. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which patient is best assigned to a float nurse who has come from the postanesthesia care unit (PACU)? 1. 30-year-old patient with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) 2. 43-year-old patient with multiple myeloma who requires discharge teaching 3. 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy 4. 65-year-old patient with pernicious anemia who has just been admitted to the unit

5. Ans: 3 52-year-old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy A nurse who works in the PACU will be familiar with the monitoring needed for a patient who has just returned from a procedure such as a colonoscopy, which requires conscious sedation. Care of the other patients requires staff with more experience with various types of hematologic disorders and would be better to assign to nursing personnel who regularly work on the medical-surgical unit. Focus: Assignment

5. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client coughs often during the visit. 4. Client says, "I get dizzy sometimes."

5. Ans: 3. Client coughs often during the visit. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization

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

5. Ans: 4 . "It's OK to take over-the-counter medications." A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families. Focus: Delegation, supervision

5. As charge nurse, you are making assignments for the day shift. Which patient would you assign to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. 35-year-old with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. 62-year-old with osteomalacia who is being discharged to a long-term care facility 3. 68-year-old with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. 72-year-old with Paget disease who has just returned from surgery for total knee replacement

5. Ans: 4 72-year-old with Paget disease who has just returned from surgery for total knee replacement The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system-related nursing care are needed to provide teaching and assessment, and prepare a report to the long-term care facility. Focus: Assignment

5. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.

5. Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision, delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 3). Elsevier Health Sciences. Kindle Edition.

6. You are making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia. Which patient will be the best roommate for the new patient? 1. Patient with digoxin toxicity 2. Patient with viral pneumonia 3. Patient with shingles 4. Patient with cellulitis

6. Ans: 1 Patient with digoxin toxicity Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes. Focus: Prioritization

6. You delegate the measurement of vital signs to an experienced UAP. Osteomyelitis has been diagnosed in a patient. Which vital sign value would you instruct the UAP to report immediately? 1. Temperature of 101° F (38.3° C) 2. Blood pressure of 136/80 mm Hg 3. Heart rate of 96 beats/min 4. Respiratory rate of 24 breaths/min

6. Ans: 1 Temperature of 101° F (38.3° C) An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital sign values are normal or high normal. Focus: Delegation, supervision

6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

6. Ans: 1, 2 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization

6. You are interviewing an elderly woman and discover that she has been taking her glaucoma eyedrops by mouth for the past week. What should you do first? 1. Call to obtain an order for tonometry so that her intraocular pressure can be checked. 2. Try to determine how frequently and how much she has been ingesting. 3. Ask her how she decided to take the drops orally instead of instilling them as eyedrops. 4. Call the Poison Control Center and be prepared to describe untoward side effects.

6. Ans: 2 Try to determine how frequently and how much she has been ingesting. Try to find out how much and how frequently she has been taking the drops by mouth. This information will be needed if you call the ophthalmologist for an order or if you call Poison Control. A good follow-up question is to try to find out why she is taking the drops by mouth. She may be very confused, or there may have been an error of omission in client education by all health care team members who were involved in the initial prescription. Focus: Prioritization

6. A client with Parkinson disease has received a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe the UAP performing all of these actions. For which action must you intervene? 1. Helping the client ambulate to the bathroom and back to bed 2. Reminding the client not to look at his feet when he is walking 3. Performing the client's complete bathing and oral care 4. Setting up the client's tray and encouraging the client to feed himself

6. Ans: 3 Performing the client's complete bathing and oral care The UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence. Focus: Delegation, supervision

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

7 3 1 5 2 8 4 6 7. put on a pair of clean gloves 3. put 500 to 1000 mL of lukewarm water in the container 1. hang the container at about shoulder height 5. lubricate the stoma cone and gently insert the tubing tip into the stoma 2. allow the solution to flow slowly and steadily for 5 to 10 minutes 8. allow 15 to 20 minutes for the initial evacuation 4. clip the irrigation sleeve and have the client walk 30 to 45 minutes for secondary evacuation 6. clean, rinse, and dry the skin and apply new drainage pouch

You're preparing to administer TPN on a central line. Place the following steps in the correct order. 1. use aseptic technique when handling the injection cap 2. Thread the IV tubing through an infusion pump 3. check the solution for cloudiness or turbidity 4. connect the tubing to the central line 5. select and flush the correct tubing and filter 6. Set the infusion pump at the prescribed rate 7. Confirm the order for TPN

7 3 5 2 1 46 7. Confirm the order for TPN 3. check the solution for cloudiness or turbidity 5. select and flush the correct tubing and filter 2. Thread the IV tubing through an infusion pump 1. use aseptic technique when handling the injection cap 4. connect the tubing to the central line 6. Set the infusion pump at the prescribed rate

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

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

7. You are working in a community health clinic and a client needs instructions for the care of a hordeolum (sty) on the right upper eyelid. What is the first treatment that the client should try? 1. Apply warm compresses four times per day. 2. Gently perform hygienic eyelid scrubs. 3. Obtain a prescription for antibiotic drops. 4. Contact the ophthalmologist.

7. Ans: 1 Apply warm compresses four times per day. Warm compresses will usually provide relief. If the problem persists, eyelid scrubs and antibiotic drops would be appropriate. The ophthalmologist could be consulted, but other providers such as the family physician or the nurse practitioner could give a prescription for antibiotics. Focus: Prioritization

7. You are the charge nurse for the coronary care step-down unit. Which client is best to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

7. Ans: 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have ACS and with collaborative treatments such as coronary angioplasty and coronary artery stenting. Focus: Assignment

7. A 67-year-old who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which statement made by the patient when you are obtaining the admission history is of most concern? 1. "I've noticed that I bruise more easily since the chemotherapy started." 2. "My bowel movements are soft and dark brown." 3. "I take one aspirin every morning because of my history of angina." 4. "My appetite has decreased since the chemotherapy started."

7. Ans: 3. "I take one aspirin every morning because of my history of angina." Because aspirin will decrease platelet aggregation, patients with thrombocytopenia should not use aspirin routinely. Patient teaching about this should be included in the care plan. Bruising is consistent with the patient's admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank blood in the bowel movements. Although the patient's decreased appetite requires further assessment by the nurse, this is a common complication of chemotherapy. Focus: Prioritization

7. You are working with a UAP to provide care for six patients. At the beginning of the shift, you carefully tell the UAP what patient interventions and tasks she is expected to perform. To be sure that your communication is appropriate, you refer to the "Four Cs." List the "Four Cs"

7. Ans: Clear, Concise, Correct, Complete Implementing the Four Cs of communication helps the nurse ensure that the UAP understands what is being said; that the UAP does not confuse the nurse's directions; that the directions comply with policies, procedures, job descriptions, and the law; and that the UAP has all the information necessary to complete the tasks assigned. Focus: Delegation, supervision

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

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

8. After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency department (ED). Which action prescribed by the health care provider will you implement first? 1. Transport to the radiology department for cervical spine radiography. 2. Transfuse factor VII concentrate. 3. Type and cross-match for 4 units of packed red blood cells (PRBCs). 4. Infuse normal saline at 250 mL/hr.

8. Ans: 2 Transfuse factor VII concentrate. When a hemophiliac patient is at high risk for bleeding, the priority intervention is to maximize the availability of clotting factors. The other orders also should be implemented rapidly but do not have as high a priority as administering clotting factors. Focus: Prioritization

8. You are caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should you delegate to the UAP? 1. Initiating placement of a splint for immobilization during the day 2. Assessing the patient's wrist and hand for discoloration and brittle nails 3. Assisting the patient with daily self-care measures such as bathing and eating 4. Testing the patient for painful tingling in the four digits of the hand

8. Ans: 3 Assisting the patient with daily self-care measures such as bathing and eating Helping with ADLs is within the scope of practice of UAPs. Placing a splint for the first time is appropriate to the scope of practice of PTs. Assessing and testing for paresthesia are not within the scope of practice of UAPs. Focus: Delegation, supervision

8. Which finding should be immediately reported to the physician? 1. A change in color vision 2. Crusty yellow drainage on the eyelashes 3. Increased lacrimation 4. A curtainlike shadow across the visual field

8. Ans: 4 A curtainlike shadow across the visual field A curtainlike shadow is a symptom of retinal detachment, which is an emergency situation. A change in color vision is a symptom of cataract. Crusty drainage is associated with conjunctivitis. Increased lacrimation is associated with many eye irritants, such as allergies, contact lenses, or foreign bodies. Focus: Prioritization

8. At 9:00 pm, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine (Pepcid) for esophageal reflux. 3. The client has ST-segment elevations on the 12-lead ECG. 4. The client has had continuous chest pain since 8:00 AM.

8. Ans: 4. The client has had continuous chest pain since 8:00 AM. Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. Focus: Prioritization

9. As a home health nurse, you are obtaining an admission history for a patient who has deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the patient is the best indicator that additional teaching about warfarin may be needed? 1. "I have started to eat more healthy foods like green salads and fruit." 2. "The doctor said that it is important to avoid becoming constipated." 3. "Coumadin makes me feel a little nauseated unless I take it with food." 4. "I will need to have some blood testing done once or twice a week."

9. Ans: 1. "I have started to eat more healthy foods like green salads and fruit." Patients taking warfarin are advised to avoid making sudden dietary changes, because changing the oral intake of foods high in vitamin K (such as green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is required first. Focus: Prioritization

9. You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN? 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

9. Ans: 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice. Focus: Delegation

9. Which client should you, as charge nurse, assign to a new RN graduate who is on orientation to the neurologic unit? 1. 28-year-old newly-admitted client with an SCI 2. 67-year-old who had a stroke 3 days ago and has left-sided weakness 3. 85-year-old with dementia who is to be transferred to long-term care today 4. 54-year-old with Parkinson disease who needs assistance with bathing

9. Ans: 2 67-year-old who had a stroke 3 days ago and has left-sided weakness The new RN graduate who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the UAP. The client being transferred to the nursing home and the newly-admitted client with SCI should be assigned to experienced nurses. Focus: Assignment

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

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

9. In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to a UAP? (Select all that apply.) 1. Counseling the client to express grief or loss 2. Assisting the client with ambulating in the hall 3. Orienting the client to the surroundings 4. Encouraging independence 5. Obtaining supplies for hygienic care 6. Storing personal items to reduce clutter 7. Rearranging furniture to prevent falls

9. Ans: 2, 5 2. Assisting the client with ambulating in the hall 5. Obtaining supplies for hygienic care Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and encouraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearranging furniture are inappropriate actions, because the client needs be able to consistently locate objects in the immediate environment. Focus: Delegation

9. You observe a UAP performing all of these interventions for a patient with CTS. Which action requires that you intervene immediately? 1. Arranging the patient's lunch tray and cutting his meat 2. Providing warm water and assisting the patient with his bath 3. Replacing the patient's splint in hyperextension position 4. Reminding the patient not to lift very heavy objects

9. Ans: 3 Replacing the patient's splint in hyperextension position When a patient with CTS has a splint to immobilize the wrist, the wrist is placed either in the neutral position or in slight extension. The other interventions are correct and are within the scope of practice of a UAP. UAPs may remind patients about elements of their care plans such as avoiding heavy lifting. Focus: Delegation, supervision

A nursing student reports to you that he has observed several types of behavior among the patients. Which patient needs priority assessment? A. A patient who is having command hallucinations B. A patient who is demonstrating clang associations C. A patient who is verbalizing ideas of reference D. A patient who is using neologisms

A. A patient who is having command hallucinations

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months In caring for this patient with anorexia nervosa, which task can be delegated to the UAP? A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals B. Observing for the reporting ritualistic behaviors related to food C. Obtaining special food for the patient when she requests it D. Weighting the patient daily and reinforcing that she is underweight

A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals

A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task should be delegated to the mental health assistant? A. Wiping the patient's body with cool moist towels B. Monitoring VS every 15 minutes C. Attaching ECG monitor D. Assigns the RN to transfer the patient to the ICU

A. Wiping the patient's body with cool moist towels

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

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

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

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

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

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

8. A 22-year-old woman who has been taking isotretinoin (Claravis) to treat severe cystic acne makes all these statements while being seen for a follow-up examination. Which statement is of most concern? 1. "My husband and I are thinking of starting a family soon." 2. "I don't think there has been much improvement in my skin." 3. "Sometimes I get nauseated after taking the medication." 4. "I have been having problems driving when it gets dark."

Ans: 1 "My husband and I are thinking of starting a family soon." Because isotretinoin is associated with a high incidence of birth defects, it is important that the client stop using the medication at least a month before attempting to become pregnant. Nausea and poor night vision are possible adverse effects of isotretinoin that would require further assessment but are not as urgent as discussing the fetal risks associated with this medication. The client's concern about whether treatment is effective should be addressed, but this is a lower-priority intervention. Focus: Prioritization

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

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

You are caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse

Ans: 1 A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not corrected. All of the other symptoms need to be addressed, but are of lower priority. Focus: Prioritization

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

Ans: 1 A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Focus: Prioritization

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

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

A 30-year-old G6P5 woman at 12 weeks has just begun prenatal care, and her initial laboratory work reveals that she has tested positive for human immunodeficiency virus (HIV) infection. What would be priority evidence-based nursing education for this patient today? 1. Medication for HIV infection is safe and can greatly reduce transmission of HIV to the infant. 2. Breast feeding is still recommended due to the great benefits to the infant. 3. Pregnancy is known to accelerate the course of HIV disease in the mother. 4. Cesarean section is not recommended because of the increased risk of HIV transmission with the bleeding at surgery.

Ans: 1 Administration of antiviral medications to the pregnant woman and the newborn, cesarean birth, and avoidance of breast feeding have reduced the incidence of perinatal transmission of HIV from approximately 26% to 1% to 2%. Pregnancy is not known to accelerate HIV disease in the mother. The most important nursing action is to engage the mother in prenatal care and educate her as to the great benefits of medication for HIV during pregnancy. Focus: Prioritization

After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit (PACU). Which nursing action is best to delegate to an experienced LPN/LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed

Ans: 1 An LPN/LVN working in a PACU would be expected to check dressings for bleeding and alert RN staff members if bleeding occurs. The other tasks are more appropriate for nursing staff with RN-level education and licensure. Focus: Delegation

You are working as a telephone triage nurse in the prenatal clinic. Which telephone call would require immediate notification of the provider? 1. Patient reports leaking vaginal fluid at 34 weeks' gestation 2. Patient reports nausea and vomiting at 8 weeks' gestation 3. Patient reports pedal edema at 39 weeks' gestation 4. Patient reports vaginal itching at 20 weeks' gestation

Ans: 1 An RN in a prenatal clinic can safely give telephone advice regarding nausea, vomiting, and pedal edema, which can be considered normal in pregnancy. The RN would assess the complaint, give the patient evidence-based advice, and define the circumstances under which the patient should call back. Vaginal itching at 20 weeks could be a yeast infection. Depending on clinic protocols, the RN could, after phone assessment, safely recommend an over-the-counter medication or arrange an office visit for the patient. Leaking vaginal fluid at 34 weeks requires immediate attention, however, because it could indicate premature rupture of membranes with the risk of premature birth. Focus: Prioritization

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

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

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

Ans: 1 Assisting patients with positioning and activities of daily living (ADLs) is within the educational preparation and scope of practice of UAPs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses. Focus: Delegation, supervision

You have just received a change-of-shift report about these pediatric patients. Which patient will you assess first? 1. 1-year-old with hemophilia B who was admitted because of decreased responsiveness 2. 3-year-old with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled 3. 7-year-old with acute lymphocytic leukemia who has chemotherapy-induced thrombocytopenia 4. 16-year-old with sickle cell disease who reports acute right lower quadrant abdominal pain

Ans: 1 Because decreased responsiveness in a 1-year-old with a clotting disorder may indicate intracerebral bleeding, this patient should be assessed immediately. The other patients also require assessments or interventions but are not at immediate risk for life-threatening or disabling complications. Focus: Prioritization

You are working in the ED when a client with possible toxic shock syndrome is admitted. Which prescribed intervention will you implement first? 1. Remove the client's tampon. 2. Obtain blood specimens for culture. 3. Give acetaminophen (Tylenol) 650 mg. 4. Infuse nafcillin (Unipen) 1000 mg IV.

Ans: 1 Because the most likely source of the bacteria causing the toxic shock syndrome is the client's tampon, it is essential to remove it first. The other actions should be implemented in the following order: obtain blood culture samples (best done before initiating antibiotic therapy to ensure accurate culture and sensitivity results), infuse nafcillin (rapid initiation of antibiotic therapy will decrease bacterial release of toxins), and administer acetaminophen (fever reduction may be necessary, but treating the infection has the highest priority). Focus: Prioritization

7. Which assessment finding calls for the most immediate further assessment or intervention? 1. Bluish color around the lips and earlobes 2. Yellow color of the skin and sclera 3. Bilateral erythema of the face and neck 4. Dark brown spotting on the chest and back

Ans: 1 Bluish color around the lips and earlobes A blue color or cyanosis may indicate that the client has significant problems with circulation or ventilation. More detailed assessments are needed immediately. The other data may also indicate health problems in major body systems, but potential respiratory or circulatory abnormalities are the priority. Focus: Prioritization

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

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

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

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

You are assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. Which is the priority nursing diagnosis? 1. Risk for Infection related to organisms specific to cat bites 2. Impaired Skin Integrity related to puncture wounds 3. Ineffective Health Maintenance related to immunization status 4. Risk for Impaired Physical Mobility related to potential tendon damage

Ans: 1 Cats' mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Appropriate first aid would include rigorous washing of the wound site with soap and water to combat infection. There is also a risk for tendon damage due to deep puncture wounds, but this is usually evaluated by an orthopedic surgeon after initial emergency care is started. A tetanus shot can be given before discharge. Focus: Prioritization

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

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

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

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

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

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

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN/LVN under your supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

Ans: 1 Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice. Focus: Delegation, supervision

You have obtained this assessment information about a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? 1. Frequent swallowing 2. Hypotonic bowel sounds 3. Reports of a sore throat 4. Heart rate of 112 beats/min

Ans: 1 Frequent swallowing after tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are expected in a 3-year-old after surgery. Focus: Prioritization

You are the charge nurse in the labor and delivery unit. Which action by a newly graduated RN during a delivery complicated by shoulder dystocia would require your immediate intervention? 1. Applying fundal pressure 2. Applying suprapubic pressure 3. Requesting immediate presence of the neonatologist 4. Flexing the maternal legs back across the maternal abdomen

Ans: 1 Fundal pressure should never be applied in a case of shoulder dystocia, because it may worsen the problem by impacting the fetal shoulder even more firmly into the symphysis pubis. This issue of patient safety would require the supervising RN to intervene immediately. The other responses are appropriate actions in a case of shoulder dystocia. Focus: Assignment

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

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

You are teaching a group of day-care workers about how to avoid transmission of hepatitis A in day-care settings. What is the single most effective measure to emphasize? 1. Hand hygiene should be performed often to prevent and control the spread of infection. 2. Children in whom hepatitis has been diagnosed should not share toys with others. 3. Children with episodes of fecal incontinence should be isolated from others. 4. Immunizations are recommended before children are admitted into day-care settings.

Ans: 1 Hand washing is the most important aspect to emphasize. Addressing fecal incontinence and sharing of personal items may be recommended when the disease is in an infectious stage. Immunizations are recommended, but this would be emphasized to parents rather than day-care providers. Focus: Prioritization

A tearful parent brings a child to the ED after the child takes an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? 1. The ingested children's chewable vitamins contain iron. 2. The child has been treated previously for ingestion of toxic substances. 3. The child has been treated several times before for accidental injuries. 4. The child was nauseated and vomited once at home.

Ans: 1 Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. The other information needs additional investigation but will not change the immediate diagnostic testing or treatment plan. Focus: Prioritization

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

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

You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

Ans: 1 Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for deep vein thrombosis and pulmonary embolus, but this period of bed rest was very short. Focus: Prioritization

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

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

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

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

After a radical prostatectomy, a client is ready to be discharged. Which nursing action included in the discharge plan should be delegated to an experienced LPN/LVN? 1. Reinforcing the client's need to check his temperature daily 2. Teaching the client how to care for his retention catheter 3. Documenting a discharge assessment in the client's chart 4. Instructing the client about the prescribed narcotic analgesic

Ans: 1 Reinforcement of previous teaching is an expected role of the LPN/LVN. Planning and implementing client initial teaching and documentation of a client's discharge assessment should be performed by experienced RN staff members. Focus: Delegation

Which intervention for the 5-year-old child who still wets the bed would be best assigned to the UAP? 1. Reminding the child to use the bathroom before going to bed 2. Teaching the mother about moisture alarm devices 3. Administering the prescribed dose of imipramine (Tofranil) 4. Discussing research related to the use of hypnosis with the mother

Ans: 1 Reminding the child about something that has already been taught is within the scope of practice for a UAP. An LPN/LVN could administer the oral medication. Teaching and discussion of other strategies for dealing with bed-wetting require additional education and are more appropriate to the scope of practice of the professional RN. Focus: Delegation

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

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

You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this client? 1. Arrange transportation to a safe house. 2. Make a referral to a counselor. 3. Advise the client about contacting the police. 4. Make an appointment to follow up on the injuries.

Ans: 1 Safety is a priority for this client, and she should not return to a place where violence could recur. The other options are important for the long-term management of this case. Focus: Prioritization

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

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

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

Ans: 1 Temperature elevation to 100.2° F When caring for a patient with hyperthyroidism, even after a partial thyroidectomy, a temperature elevation of 1° must be reported immediately because it may indicate an impending thyroid crisis. The other changes should be monitored, but none is urgent. Focus: Prioritization

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

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

Which task could be appropriately assigned to the UAP working with you at the obstetric clinic? 1. Checking the blood pressure of a patient who is 36 weeks pregnant and reports a headache 2. Removing the adhesive skin closure strips of a patient who had a cesarean section 2 weeks ago 3. Giving community resource information and emergency numbers to a prenatal patient whom you suspect is experiencing domestic violence 4. Dispensing a breast pump with instruction to a lactating patient having trouble with milk supply 4 weeks postpartum

Ans: 1 The UAP can check the blood pressure of this patient and report it to the RN. The RN would include this information in her full assessment of the patient, who may be showing signs of preeclampsia. The other tasks listed require nursing assessment, analysis, and planning, and should be performed by the RN. Provision of accurate and supportive education about breastfeeding and breast pumping supports the Perinatal Core Measure of increasing the percentage of women who exclusively breast-feed. Focus: Delegation

While working in the pediatric clinic, you receive a telephone call from the parent of a 13-year-old who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (varicella). Which action will you anticipate taking next? 1. Administer varicella-zoster immune globulin to the patient. 2. Teach the parent about the correct use of acyclovir (Zovirax). 3. Educate the parent about contact and airborne precautions. 4. Prepare to admit the patient to a private room in the hospital.

Ans: 1 The administration of varicella-zoster immune globulin can prevent the development of varicella in immunosuppressed patients and will typically be prescribed. Acyclovir therapy and hospitalization may be required if the child develops a varicella-zoster virus infection. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. Focus: Prioritization

What would be the appropriate first nursing action when caring for a 20-year-old G1P0 woman at 39 weeks' gestation who is in active labor and for whom an assessment reveals mild variable fetal heart rate decelerations? 1. Change the maternal position. 2. Notify the provider. 3. Prepare for delivery. 4. Readjust the fetal monitor.

Ans: 1 The cause of variable fetal heart decelerations is compression of the umbilical cord, which can often be corrected by a change in maternal position. Focus: Prioritization

A man, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? 1. Risk for Injury related to seizures 2. Risk for Other-Directed Violence related to hallucinations 3. Risk for Situational Low Self-Esteem related to police custody 4. Risk for Imbalanced Nutrition: Less than Body Requirements related to chronic alcohol abuse

Ans: 1 The client demonstrates neurologic hyperreactivity and is on the verge of a seizure. Client safety is the priority. The client needs medications such as chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to address the other problems. The other diagnoses are pertinent but less urgent. Focus: Prioritization

A client who underwent an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temperature is 101.3° F (38.5° C). Which of these actions prescribed by the health care provider will you implement first? 1. Insert a straight catheter PRN for output of less than 300 mL/8 hr. 2. Administer acetaminophen (Tylenol) 650 mg orally. 3. Send a urine specimen to the laboratory for culture and sensitivity testing. 4. Administer ceftizoxime (Cefizox) 1 g IV every 12 hours.

Ans: 1 The client has symptoms of a urinary tract infection. Inserting a straight catheter will enable you to obtain an uncontaminated urine specimen for culture and sensitivity testing before the antibiotic is started. In addition, the client is probably not emptying her bladder fully because of the painful urination. The antibiotic therapy should be initiated as rapidly as possible once the urine specimen is obtained. Administration of acetaminophen is the lowest priority, because the client's temperature is not dangerously elevated. Focus: Prioritization

After arriving for your shift in the emergency department (ED), you receive a change-of-shift report about all of these clients. Which one do you need to assess first? 1. 19-year-old with scrotal swelling and severe pain that has not decreased with elevation of the scrotum 2. 25-year-old who has a painless indurated lesion on the glans penis 3. 44-year-old with an elevated temperature, chills, and back pain associated with recurrent prostatitis 4. 77-year-old with abdominal pain and acute bladder distention

Ans: 1 This client has symptoms of testicular torsion, an emergency that needs immediate assessment and intervention, because it can lead to testicular ischemia and necrosis within a few hours. The other clients also have symptoms of acute problems (primary syphilis, acute bacterial prostatitis, and prostatic hyperplasia and urinary retention), which also need rapid assessment and intervention, but these are not as urgent as the possible testicular torsion. Focus: Prioritization

As the pediatric unit charge nurse, you are working with a newly-graduated RN who has been on orientation in the unit for 2 months. Which patient should you assign to the new RN? 1. 2-year-old with a ventricular septal defect for whom digoxin (Lanoxin) 90 mcg by mouth has been prescribed 2. 4-year-old who had a pulmonary artery banding and has just been transferred in from the intensive care unit 3. 9-year-old with mitral valve endocarditis whose parents need teaching about IV antibiotic administration 4. 16-year-old with a heart transplant who was admitted with a low-grade fever and tachycardia

Ans: 1 This patient requires the least complex assessments and interventions of the four patients. Safe administration of oral medications such as digoxin would have been included in the orientation of the new RN graduate. The conditions of the other patients are more complex, and they require assessments and/or interventions (such as teaching) that should be carried out by an RN with more experience. Focus: Assignment

Which information obtained when taking a client's health history will be most important in determining whether the client should receive the human papillomavirus (HPV) immunization? 1. Client is 19 years old 2. Client is sexually active 3. Client has a positive pregnancy test 4. Client has tested positive for HPV previously

Ans: 3 Centers for Disease Control and Prevention guidelines indicate that the HPV immunization should not be given during pregnancy. Ideally, the immunization series should start at age 11 or 12 for females and males, but it may be started up through age 26. HPV immunization is most effective in preventing HPV infection and cervical cancer when it is started before the individual is sexually active and prior to any HPV infection, but these are not contraindications for vaccination. Focus: Prioritization

The emergency medical service team has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the UAP? 1. Performing chest compressions 2. Initiating bag-valve mask ventilation 3. Assisting with oral intubation 4. Placing the defibrillator pads

Ans: 1 UAPs are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice, and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide assistance as needed during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Focus: Delegation

The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

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

13. You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? (Select all that apply.) 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

Ans: 1, 2 1. Gown 2. Gloves A gown and gloves should be used when coming in contact with linens that may be contaminated by the client's wound secretions. The other PPE items are not necessary, because transmission by splashes, droplets, or airborne means will not occur when the bed is changed. Focus: Prioritization

You have received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions will you give the student nurse who is assisting in the care of the infant? (Select all that apply.) 1. Cover the infant's eyes with a mask. 2. Monitor the infant's temperature closely. 3. Keep the infant "nothing by mouth" (NPO) during the treatment. 4. Apply ointment to the infant's skin prior to light exposure. 5. Offer the infant sterile water feedings during the treatment.

Ans: 1, 2 During phototherapy, the infant's eyes must be protected and the temperature carefully monitored to avoid both hypothermia and hyperthermia. Breastfeeding should be continued to avoid dehydration and to increase passage of meconium, which helps to excrete bilirubin. Ointments or lotions should not be applied to the skin during phototherapy as they may cause burns. Encouraging continued breast feeding and teaching the family the benefits of breast feeding in this scenario supports the Perinatal Core Measure of increasing the percentage of infants who are fed breast milk only. Focus: Assignment

You are acting as preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? (Select all that apply.) 1. 38-year-old with moderate persistent asthma awaiting discharge 2. 63-year-old with a tracheostomy needing tracheostomy care every shift 3. 56-year-old with lung cancer who has just undergone left lower lobectomy 4. 49-year-old just admitted with a new diagnosis of esophageal cancer 5. 76-year-old newly diagnosed with type 2 diabetes

Ans: 1, 2 The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly-diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with him or her in providing care for these patients with more complex needs. The newly-diagnosed diabetic patient will need much teaching as well as careful monitoring. Focus: Assignment, delegation, supervision

3. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays

Ans: 1, 2, 3, 4 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.

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

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

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

Ans: 1, 2, 3, 5 While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Focus: Delegation, supervision

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

Ans: 1, 2, 3, 6 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 6. Record intake and output. Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring also. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses. Focus: Delegation

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

Ans: 1, 2, 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN. Focus: Delegation, supervision

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

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

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

Ans: 1, 2, 4, 5 Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma. Focus: Prioritization

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. Which actions would require immediate intervention by the supervising RN? (Select all that apply.) 1. Gently cleansing the amputated digits and the hand with a povidone-iodine (Betadine)/normal saline solution 2. Cleansing the amputated digits and placing them directly into an ice slurry 3. Wrapping the cleansed digits in saline-moistened gauze, sealing them in a plastic bag, and placing them in an ice slurry 4. Cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline 5. Placing the amputated digits in the correct anatomic position and then wrapping the hand and digits with sterile gauze.

Ans: 1, 2, 4, 5 The only correct intervention is to gently cleanse the digits with normal saline, wrap them in sterile gauze moistened with saline, and place them in a plastic bag or container. The container is then placed on ice. Focus: Supervision, knowledge

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

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

23. In the care of a patient with neutropenia, what tasks can be delegated to a UAP? (Select all that apply.) 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4° F (38° C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

Ans: 1, 2, 4, 6 Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

13. After reviewing the medical record for a client who has an oral herpes simplex infection following chemotherapy, which nursing diagnosis will you address as the priority? 1. Social Isolation related to anxiety about herpes infection 2. Acute Pain related to the presence of extensive herpes simplex lesions 3. Imbalanced Nutrition: Less than Body Requirements related to decreased oral intake 4. Disturbed Body Image related to the appearance of oral lesions

Ans: 2 Acute Pain related to the presence of extensive herpes simplex lesions The highest priority diagnoses for this client are Acute Pain and Imbalanced Nutrition. The Acute Pain diagnosis takes precedence, because the client's acute oral pain will need to be controlled to increase the ability to eat and to improve nutrition. Disturbed Body Image and Social Isolation are major concerns for the client but are not as high a priority as the need for pain control and improved nutrition. Focus: Prioritization

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

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

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

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

21. You are caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

Ans: 1, 2, 5 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily. The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential in preventing VAP. Focus: Prioritization

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

Ans: 1, 2, 6 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort Assessment, auscultation, and reminding patients about information that has been taught to them are within the scope of practice of the LPN/LVN. Certainly the LPN/LVN could check the patient's vital signs, but this would be more appropriately delegated to the UAP. Creating nursing care plans falls within the scope of practice of the RN. The use of sedation is discouraged for patients with hypothyroidism because it may make respiratory problems more difficult. If sedation is used, dosage is reduced and it is not given around the clock. Focus: Delegation, supervision

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

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

13. You have just received the morning report from the night shift nurse. List the order of priority for assessing and caring for the following patients. 1. A patient who developed tumor lysis syndrome around 5:00 AM 2. A patient with frequent reports of breakthrough pain over the past 24 hours 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours _______,_______, _______, _______

Ans: 1, 3, 2, 4 Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment, and the physician may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics.

You are caring for a 21-year-old client who had a left orchiectomy for testicular cancer on the previous day. Which nursing activity will you delegate to an LPN/LVN? 1. Educating the client about post-orchiectomy chemotherapy and radiation 2. Administering the prescribed "as needed" (PRN) oxycodone (Roxicodone) to the client 3. Teaching the client how to perform testicular self-examination on the remaining testicle 4. Assessing the client's knowledge level about post-orchiectomy fertility

Ans: 2 Administration of narcotics and the associated client monitoring are included in LPN/LVN education and scope of practice. Assessments and teaching are more complex skills that require RN-level education and are best accomplished by an RN with experience in caring for clients with this diagnosis. Focus: Delegation

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

Ans: 1, 3, 2, 5, 4, 6 Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler. Focus: Prioritization

You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environmental isolation. Which nursing tasks will you delegate to the UAP? (Select all that apply.) 1. Stocking the patient's room with the needed personal protective equipment items 2. Teaching the patient to perform thorough hand washing after using the bathroom 3. Reminding visitors to wear a respirator mask, gloves, and gown 4. Posting the precautions for protective isolation on the door of the patient's room 5. Talking to the family members about the reasons for the isolation

Ans: 1, 3, 4 Because all patient care staff members should be familiar with the various types of isolation, a UAP will be able to stock the room and post the precautions on the patient's door. Reminding visitors about previously taught information is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Patient teaching and discussion of the reasons for the protective isolation fall within the RN-level scope of practice. Focus: Delegation

Which statements by a new father indicate that additional discharge teaching is needed for this family, who had their first baby 24 hours ago? (Select all that apply.) 1. "We have a crib ready for our baby with lots of stuffed animals and two quilts that my mother made." 2. "My wife wants to receive the flu shot before she goes home." 3. "We will bring our baby to the pediatrician in 3 weeks." 4. "I will give the baby formula at night so my wife can rest. She will breast-feed in the daytime." 5. "We will always put our baby to sleep in a face-up position."

Ans: 1, 3, 4 It is recommended that a newborn be placed on the back in a crib with a firm mattress with no toys and a minimum of blankets as a safety measure for prevention of sudden infant death syndrome. A newborn discharged before 72 hours of life should be seen by an RN or MD within 2 days of discharge. Breast-feeding women should breast-feed at all feedings, especially in these early weeks of establishing breast feeding. This supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. A more appropriate response would be for the father to help with household chores to allow breast feeding to be established successfully. A flu shot in flu season is a recommended intervention for a new mother. Focus: Prioritization

A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.) 1. Check deep tendon reflexes. 2. Observe for vaginal bleeding. 3. Check the respiratory rate. 4. Note the urine output. 5. Monitor for calf pain

Ans: 1, 3, 4 Magnesium sulfate toxicity can cause fatal cardiovascular events and/or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis, but is not associated with magnesium sulfate therapy. Focus: Prioritization

The ED receives multiple individuals, mostly children, who were injured when the roof of a day-care center collapsed because of a heavy snowfall. Based on physiologic differences in children compared with adults, for which injuries and complications will the nurse assess first? (Select all that apply.) 1. Head injuries 2. Bradycardia or junctional arrhythmias 3. Hypoxemia 4. Liver and spleen contusions 5. Hypothermia 6. Fractures of the long bones 7. Lumbar spines injuries

Ans: 1, 3, 4, 5 Children have proportionately larger heads that predispose them to head injuries. Hypoxemia is more likely because of their higher oxygen demand. Liver and spleen injuries are more likely because the thoracic cage of children offers less protection. Hypothermia is more likely because of children's thinner skin and proportionately larger body surface area. They have strong hearts; therefore pulse rate will increase to compensate, but other arrhythmias are less likely to occur. Children have relatively flexible bones compared with those of adults. The most likely spinal injury in children is injury to the cervical area. Focus: Prioritization

21. People at risk are the target populations for cancer screening programs. Which of these asymptomatic patients need extra encouragement to participate in cancer screening? (Select all that apply.) 1. A 21-year-old white American woman who is sexually inactive, for a Pap test 2. A 30-year-old Asian-American woman, for an annual mammogram 3. A 45-year-old African-American man, for a prostate-specific antigen test 4. A 50-year-old African-American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy 6. A 70-year-old Asian-American woman with normal results on three previous Pap tests, for a Pap test

Ans: 1, 3, 4, 5 Women age 21 or over should have annual Pap smears, regardless of sexual activity. African-American men should begin prostate-specific antigen testing at age 45. Colonoscopy and annual fecal occult blood testing are recommended for those with average risk starting at age 50. Annual mammograms are recommended for women over the age of 40. Women age 65 or older who have normal results on previous Pap tests may forego additional screenings for cervical cancer.

A new nurse is caring for a child with a foreign body in the ear canal who has not yet been evaluated by the health care provider. You would intervene if the new nurse performs which action? 1. Inspects the pinna for trauma 2. Obtains history for type of object 3. Prepares to irrigate the canal with warm water 4. Uses an otoscope to check for perforation

Ans: 3 Vegetable or insect matter will swell if water is used for irrigation. Tightly wedged objects such as beads are difficult to flush. If perforation is suspected or if the object is not easily removed, the nurse should not attempt irrigation or instillation. Focus: Prioritization

A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization

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

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

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

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

A 24-year-old G1P0 patient, who is receiving oxytocin (Pitocin), is in labor at 41 weeks' gestation. Which are appropriate nursing actions in the presence of late fetal heart rate decelerations? (Select all that apply.) 1. Discontinue the oxytocin. 2. Decrease the maintenance IV fluid rate. 3. Administer oxygen to the mother by mask. 4. Place the woman in high Fowler position. 5. Notify the provider.

Ans: 1, 3, 5 Late fetal heart rate decelerations can be an ominous sign of fetal hypoxemia, especially if repetitive and accompanied by decreased variability. Notification of the provider is indicated. Turning off the oxytocin and administering oxygen to the mother are recommended nursing interventions to improve fetal oxygenation. An increase in the IV rate can improve hydration, correct hypovolemia, and increase blood flow to the uterus. Putting the woman in a lateral position can increase blood flow to the uterus and increase oxygenation to the fetus. Promptly addressing fetal heart rate changes may allow intrauterine resuscitation and may decrease the need for cesarean section if those measures are effective. This supports the Perinatal Core Measure of reducing of cesarean section rates. Focus: Prioritization

A 26-year-old G1P1 patient who underwent cesarean section 24 hours ago tells the nurse that she is having some trouble breast-feeding. Which tasks could be appropriately delegated to the UAP on the postpartum floor? (Select all that apply.) 1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast-feeding 3. Taking the mother's vital signs 4. Checking the amount of lochia present 5. Assisting the mother with ambulation

Ans: 1, 3, 5 The UAP could provide an abdominal binder, measure the vital signs of the patient, and assist her to ambulate. The RN would be responsible for evaluating the normality of the vital sign values. The UAP should be given parameter limits for vital signs and told to report values outside these limits to the RN. Assisting in breast feeding for a first-time mother is a very important nursing function, because the RN needs to give consistent, evidence-based advice to enhance success at breast feeding. A common complaint of postpartum patients is inconsistent help with and advice on breast feeding. The RN should also be the one to check the amount of lochia, because the evaluation requires nursing judgment. The use of the professionally educated RN to provide evidence-based and consistent information and assistance with breast feeding supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Delegation

As the charge nurse in the labor and delivery unit, you need to assign two patients to one of the RNs because of a staffing shortage. Normally on your unit the nurse-patient ratio is 1:1. Which two patients would you assign to the RN? 1. 30-year-old G1P0 woman, 40 weeks, 2 cm/90% effaced/-1 station 2. 25-year-old G3P2 woman, 38 weeks, 8 cm/100% effaced/0 station 3. 26-year-old G1P1 woman who delivered via normal vaginal delivery 15 minutes ago 4. 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks 5. 40-year-old G6P5 woman with contractions at 28 weeks who has not yet been evaluated by the provider _____, _____

Ans: 1, 4 Patient 1 is in the latent phase of labor with her first child; she typically will cope well at this point and will have many hours before labor becomes more active. Patient 4 would most likely be managed expectantly at this point and require observation and assessment for labor or signs of infection. Patient 2 can be expected to deliver soon and so requires intensive nursing care. Patient 3 is in the first hour of recovery and therefore requires frequent assessments, newborn assessments, and help with initiation of breast feeding if this is her chosen feeding method. Breast feeding in the first hour of life supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Patient 5 could be in premature labor and require administration of tocolytic medications to stop contractions or preparation for a preterm delivery if dilation is advanced. Focus: Assignment

26. The LPN/LVN whom you are supervising comes to you and says, "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the physician of the incorrect medication dose.

Ans: 1, 4, 3, 2 1. Assess the client's heart rate. 4. Notify the physician of the incorrect medication dose. 3. Ask the LPN/LVN to explain how the error occurred. 2. Complete a medication error report. The first action after a medication error should be to assess the client for adverse outcomes. You should evaluate this client for symptoms such as bradycardia and excessive salivation. These may indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The physician should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report. Focus: Prioritization

21. The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? (Select all that apply.) 1. "Take this medication in the morning." 2. "This medication should be taken in 2 divided doses when you get up and when you go to bed." 3. "Eat foods with extra sodium every day." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase."

Ans: 1, 4, 5 1. "Take this medication in the morning." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so you should teach the client about eating foods rich in potassium. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the prescriber.

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

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

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

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

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

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

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

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

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

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

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

Ans: 2 "Patients with Cushing disease have very fragile capillaries." A key cardiovascular feature seen in patients with Cushing disease is capillary fragility, which results in bruising and petechiae. Bleeding disorders are not a sign of Cushing disease, and although these patients have delicate skin, this is not the cause of the bruising. You may want to investigate whether the patient fell, but these patients have bruising and petechiae despite falls. Focus: Supervision, prioritization

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

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

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

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

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

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

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

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

You are working in the obstetric triage area, and several patients have just come in. Which patient should you assess first? 1. A 17-year-old gravida 1, para 0 (G1P0) woman at 40 weeks' gestation with contractions every 6 minutes who is crying loudly and is surrounded by anxious family members 2. A 22-year-old G3P2 woman at 38 weeks' gestation with contractions every 3 minutes who is requesting to go to the bathroom to have a bowel movement 3. A 32-year-old G4P3 woman at 27 weeks' gestation who noted vaginal bleeding today following intercourse 4. A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels no contractions

Ans: 2 A multiparous patient in active labor with an urge to have a bowel movement will probably give birth imminently. She needs to be the first assessed, the provider must be notified immediately, and she must be moved to a safe location for the birth. She should not be allowed up to the bathroom at this time. The other patients all have needs requiring prompt assessment, but the imminent birth takes priority. Vaginal bleeding after intercourse could be due to cervical irritation or a vaginal infection, or could have a more serious cause such as placenta previa. This patient should be the second one assessed. Focus: Prioritization

An 86-year-old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly? 1. The oral temperature is 100.7° F (38.2° C). 2. The abdomen is firm and tender to palpation above the symphysis pubis. 3. Breath sounds are decreased, with fine crackles audible at both bases. 4. The apical pulse is 86 beats/min and slightly irregular.

Ans: 2 After an A & P repair, it is essential that the bladder be empty to avoid putting pressure on the suture lines. The abdominal firmness and tenderness indicate that the client's bladder is distended. The physician should be notified and an order for catheterization obtained. The other data also indicate a need for further assessment of her cardiac status and actions such as having the client cough and deep breathe, but these are not such immediate concerns. Focus: Prioritization

A teenager arrives in the triage area alert and ambulatory, but his clothes are covered with blood. His friends are yelling, "We were goofing around and he got poked in the abdomen with a stick!" Which comment would be of most concern? 1. "There was a lot of blood and we used three bandages." 2. "He pulled the stick out, just now, because it was hurting him." 3. "The stick was really dirty and covered with mud." 4. "He's a diabetic, so he needs attention right away."

Ans: 2 An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history, including a more definitive description of the blood loss, depth of penetration, and medical history, should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan but can be addressed later. Focus: Prioritization

You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which factor is of most concern in determining whether to admit the child to your unit? 1. The unit is staffed with fewer RNs than usual. 2. No negative-airflow rooms are available. 3. The infection control nurse liaison is not present today. 4. There are several children receiving chemotherapy.

Ans: 2 Because patients with rubeola require implementation of airborne precautions, which include placement in a negative-airflow room, this child cannot be admitted to the pediatric unit. The other circumstances may require actions such as staff reassignments but would not prevent the admission of a patient with rubeola. Focus: Prioritization

3. You have just received a change-of-shift report for the burn unit. Which client should you assess first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the postanesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

Ans: 2 Client who has just arrived from the emergency department with facial burns sustained in a house fire Facial burns are frequently associated with airway inflammation and swelling, so this client requires the most immediate assessment. The other clients also require rapid assessment or interventions, but not as urgently as the client with facial burns. Focus: Prioritization

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

Ans: 2 Continuous bubbling indicates an air leak that must be identified. With the physician's order, you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak. Focus: Delegation, supervision

A group of people arrive at the ED by private car reporting extreme periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the priority action? 1. Measure vital signs and listen to lung sounds. 2. Direct the clients to the decontamination area. 3. Instruct clients to don personal protective equipment. 4. Direct the clients to the cold or clean zone for immediate treatment.

Ans: 2 Decontamination in a specified area is the priority. Performing assessments delays decontamination and does not protect the total environment. These clients do not need to don personal protective equipment (PPE); however, personnel should don PPE before assisting with decontamination or assessing the clients. The clients must undergo decontamination before entering cold or clean areas. Focus: Prioritization

An excited mother calls you for advice. "My child got cleaning solution in her eyes and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What do you instruct the caller to do first? 1. Comfort the child and check her vision. 2. Continue to irrigate the eyes with water. 3. Call the Poison Control Center. 4. Call 911 to request an ambulance.

Ans: 2 Despite the fact that the child is screaming, the mother must continue to irrigate the eyes for at least 20 minutes. Another adult, if present, should call the Poison Control Center and 911. Focus: Prioritization

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

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

You notify the ED physician about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later you see an order for discharge and a follow-up appointment in the morning. You reexamine the client and the symptoms seem worse. What should you do first? 1. Contact the nursing supervisor and express your concerns. 2. Express your findings and concerns to the physician. 3. Discharge the client, but stress the importance of follow-up. 4. Follow the physician's orders and write an incident report.

Ans: 2 First try to express your concerns to the physician. The ED can be very hectic, and the ED staff should work as a team and watch out for each other as well as the clients. If the physician refuses to consider your concerns, then you may have to contact the nursing supervisor or write an incident report. This client has the signs of peritonitis. If the client dies or suffers a poor outcome, you are as liable as the physician if you fail to intervene. Focus: Prioritization

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

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

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

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

20. As charge nurse, you are providing orientation for a newly-hired RN. Which action by the new RN requires the most immediate action? 1. Obtaining an anaerobic culture specimen from a superficial burn wound 2. Giving doxycycline (Vibramycin) with a glass of milk to a client with cellulitis 3. Discussing the use of herpes zoster vaccine with a 25-year-old client 4. Teaching a newly admitted burn client about the use of pressure garments

Ans: 2 Giving doxycycline (Vibramycin) with a glass of milk to a client with cellulitis Dairy products inhibit the absorption of doxycycline, so this action would decrease the effectiveness of the antibiotic. The other activities are not appropriate but would not cause as much potential harm as the administration of doxycycline with milk. Anaerobic bacteria would not be likely to grow in a superficial wound. The herpes zoster vaccine is recommended for clients who are 60 years or older. Pressure garments may be used after graft wounds heal and during the rehabilitation period after a burn injury, but this should be discussed when the client is ready for rehabilitation, not when the client is admitted. Focus: Prioritization

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

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

25. You admit a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone do you suspect is elevated? 1. Thyroid-stimulating hormone 2. Growth hormone 3. Adrenocorticotropic hormone 4. Vasopressin antidiuretic hormone

Ans: 2 Growth hormone These assessment findings are classic initial manifestations for growth hormone excess. Focus: Prioritization

You are caring for a client who has just returned to the surgical unit after a TURP. Which assessment finding will require the most immediate action? 1. Blood pressure reading of 153/88 mm Hg 2. Catheter that is draining deep red blood 3. Client not wearing antiembolism hose 4. Client reports of abdominal cramping

Ans: 2 Hemorrhage is a major complication after TURP and should be reported to the surgeon immediately. The other assessment data also indicate a need for nursing action, but not as urgently. Focus: Prioritization

Which action would best demonstrate evidence-based nursing practice in the care of a patient who is 1 day postpartum and reporting nipple soreness while breast-feeding? 1. Give the baby a bottle after 5 minutes of nursing to allow soreness to resolve. 2. Assess the mother-baby couplet for nursing position and latch, and correct as indicated. 3. Advise the use of a breast pump until nipple soreness resolves. 4. Advise alternating breast and bottle feedings to avoid excess sucking at the nipple.

Ans: 2 It is recommended to avoid artificial nipples and pacifiers while establishing breast feeding unless medically indicated. Improper latch and position are common causes of nipple soreness and can be corrected with assessment and assistance to the mother. This practice supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Prioritization

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

Ans: 2 Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia. Focus: Prioritization

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

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

You are the charge nurse on the pediatric neurologic unit when the health care provider calls with new medication prescriptions for several patients with seizure disorders. Which prescription is most important to verify with the provider? 1. Ibuprofen (Motrin) 10 mg/kg for a 2-year-old having a febrile seizure 2. Phenytoin (Dilantin) 300 mg/day for a 6-year-old with tonic-clonic seizures 3. Valproic acid (Depakote) 15 mg/kg/day for an 11-year-old with absence seizures 4. Carbamazepine (Tegretol) 100 mg every 8 hours for a 70-kg 17-year-old with complex seizures

Ans: 2 National guidelines indicate that medication dosing for pediatric patients should be based on the child's weight. The weight for the 6-year-old is not provided. For phenytoin, the dose for children is prescribed as 5 mg/kg in 2 or 3 divided doses; 300 mg is a typical maintenance dose for an adult, but would be an unusual dose for a 6-year-old. All telephone orders should be verified; however, the dosages for the other three prescriptions are appropriately based on the child's weight. Focus: Prioritization

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

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

A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed, and the health care provider has informed the parents that surgery is the next step. Which finding should be reported immediately before surgery proceeds? 1. Palpable sausage-shaped abdominal mass 2. Passage of normal brown stool 3. Passage of currant jelly-like stools 4. Frequent nausea and vomiting

Ans: 2 Passage of brown stool indicates resolution of the intussusception, so surgery may not be necessary. The other findings are part of the clinical presentation of this disorder. Focus: Prioritization

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

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

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

Ans: 2 Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing tissues in plastic bags, help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB. Focus: Prioritization

You are working with a UAP to care for a client who has had a right breast lumpectomy and axillary lymph node dissection. Which nursing action can you delegate to the UAP? 1. Teaching the client why blood pressure measurements are taken on the left arm 2. Elevating the client's arm on two pillows to promote lymphatic drainage 3. Assessing the client's right arm for lymphedema 4. Reinforcing the dressing if it becomes saturated

Ans: 2 Positioning the client's arm is a task within the scope of practice for UAP working on a surgical unit. Client teaching and assessment are RN-level skills. The RN should reinforce dressings as necessary, because this requires assessment of the surgical site and possible communication with the surgeon. Focus: Delegation

You are caring for a 3-year-old who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is most important to communicate to the surgeon? 1. The child is crying and says, "It hurts!" 2. The right pupil is 1 mm larger than the left pupil. 3. The cardiac monitor shows a heart rate of 130 beats/min. 4. The head dressing has a 2-cm area of bloody drainage.

Ans: 2 Pupil dilation may indicate increased intracranial pressure and should be reported immediately to the surgeon. The other data are not unusual in a 3-year-old after surgery, although they indicate the need for ongoing assessments or interventions. Focus: Prioritization

As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? A. Male LVN assigned to a male patient with chronic depression and excessive rumination B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa C. Female RN assigned to a newly admitted female patient who has command hallucination sand delusions of persecution D. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa

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

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

You are assisting with the delivery of a 31-week gestational age premature newborn who requires intubation for RDS. Which medication will you anticipate will be needed first for this infant? 1. Theophylline (Theolair, Theochron) 2. Surfactant (Exosurf) 3. Dexamethasone (Decadron) 4. Albuterol (Proventil)

Ans: 2 Research indicates that the administration of synthetic surfactant improves respiratory status and decreases the incidence of pneumothorax in premature infants with RDS. The other medications may be used if respiratory distress persists, but the first medication administered will be the surfactant. Focus: Prioritization

When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning of the client's care? 1. Fine crackles are audible at the lung bases. 2. The client's right calf is swollen, and she reports calf tenderness. 3. The client uses the patient-controlled analgesia device every 30 minutes. 4. Urine in the collection bag is amber and clear.

Ans: 2 Right calf swelling and tenderness indicate the possible presence of deep vein thrombosis. This will change the plan of care, because the client should be placed on bed rest, whereas the usual plan is to ambulate the client as soon as possible after surgery. The other data indicate the need for common postoperative nursing actions such as having the client cough, assessing her pain, and increasing her fluid intake. Focus: Prioritization

15. A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is admitted to the ED. Which ordered intervention will you implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

Ans: 2 Rinse the back and legs with 4 L of sterile normal saline. With chemical injuries, it is important to remove the chemical from contact with the skin to prevent ongoing damage. The other actions also should be accomplished rapidly; however, rinsing the chemical off is the priority for this client. Focus: Prioritization

The health care provider has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which task will you delegate to the UAP? 1. Providing explanations of nursing actions to the family 2. Assisting the child in removing outer clothing 3. Advising the parent to use acetaminophen (Tylenol) instead of aspirin 4. Monitoring the child's level of consciousness and orientation level

Ans: 2 The UAP can help with the removal of outer clothing, which allows the heat to dissipate from the child's skin. Assessments, advising, and explaining require RN-level education and scope of practice. Focus: Delegation

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

Ans: 2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN. Focus: Delegation, supervision

You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

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

You are a public school nurse. Which action will you take to have the most impact on the incidence of infectious diseases in the school? 1. Make soap and water readily available in the classrooms. 2. Ensure that students are immunized according to national recommendations. 3. Provide written information about infection control to all parents. 4. Teach students how to cover their mouths when they cough or sneeze.

Ans: 2 The incidence of once-common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by the immunization of all school-age children. The other actions are also helpful but will not have as great an impact as immunization. Focus: Prioritization

A 23-year-old G1P0 patient at 10 weeks states that she exercises 5 days a week. You have discussed exercise in pregnancy with her. Which statement by the patient indicates that more teaching of evidence-based principles is needed? 1. "I will continue to exercise 5 days a week." 2. "I will reduce my exercise at this time in my pregnancy to reduce the risk of miscarriage but will increase it in the second trimester." 3. "I will drink more fluid before and after exercising." 4. "I will stop playing football while I am pregnant."

Ans: 2 There is no evidence that exercise should be avoided in the first trimester of pregnancy in a healthy woman without medical or obstetric complications. The American College of Obstetricians and Gynecologists recommends 30 minutes or more of exercise on most if not all days of the week for pregnant women. Exercise in which injury is more likely to occur should be avoided. Focus: Prioritization

Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you take first? 1. Notify the surgeon that wound evisceration has occurred. 2. Cover the wound with saline-soaked dressings. 3. Use swabs to obtain aerobic and anaerobic wound cultures. 4. Call for assistance from the Rapid Response Team.

Ans: 2 The initial action should be to ensure that the abdominal contents remain moist by covering the wound and loops of intestine with dressings soaked with sterile normal saline. Since national guidelines addressing the use of Rapid Response Teams (RRTs) indicate that the role of the RRT is immediate assessment and stabilization of the client, the nurse's next action should be to activate the RRT. The surgeon should be notified once further assessments of the client (i.e., pulse and blood pressure) are obtained. Wound cultures may be obtained, but protection of the wound, further assessment of the client, then notification of the surgeon so that other actions can be taken are the priority. Focus: Prioritization

You are working with an LPN/LVN who is caring for a 10-year-old who has severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires that you intervene immediately? 1. Suggesting genetic counseling to the patient 2. Positioning cold packs on the patient's knees 3. Placing a "No Visitors" sign on the patient's door 4. Checking the patient's temperature every 2 hours

Ans: 2 The joint pain that occurs in sickle cell crisis is caused by obstruction of blood flow by the red blood cells. Cold packs will further decrease blood flow to the patient's knees and increase sickling. The appropriate therapy for this patient is application of moist heat to the joints to cause vasodilation and improve circulation. Genetic counseling may be provided to patients with sickle cell disease but is not appropriate to suggest to a 10-year-old. Although infection control is important in preventing and treating sickle cell crisis, there is no need to restrict all visitors or to check the patient's temperature every 2 hours. Focus: Prioritization

You are reviewing the complete blood count for a 3-year-old who has been diagnosed with idiopathic thrombocytopenic purpura. Which information should you report immediately to the health care provider? 1. Increased eosinophil level 2. Hemoglobin level of 6.1 g/dL 3. Platelet count of 40,000/mm3 4. Elevated reticulocyte count

Ans: 2 The low hemoglobin level suggests that the child may have active bleeding, and rapid actions such as diagnostic testing and transfusions are indicated. The other laboratory data are expected in a child with idiopathic thrombocytopenic purpura. Focus: Prioritization

A 24-year-old G2P1 woman is being admitted in active labor at 39 weeks' gestation. What prenatal data would be most important to know in your care of this patient at this time? 1. Hemoglobin level of 11 g/dL at 28 weeks' gestation 2. Positive result on test for group B streptococci at 36 weeks' gestation 3. Urinary tract infection with Escherichia coli treated at 20 weeks' gestation 4. Elevated level on glucose screening test at 28 weeks' gestation followed by normal 3-hour glucose tolerance test results at 29 weeks' gestation

Ans: 2 The positive group B streptococci result requires immediate action. The provider must be notified and orders obtained for prompt antibiotic prophylaxis during labor to reduce the risk of mother-to-newborn transmission of group B streptococci. The other data are not as significant in the care of the patient at this moment. Intrapartum-appropriate antibiotic treatment of the mother with group B streptococci supports the Perinatal Core Measure of reducing health care-acquired bloodstream infections in newborns. Focus: Prioritization

Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

Ans: 2 The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management. Focus: Delegation

You receive the following shift report on an adolescent with anorexia: The patient is 5 kg under her target weight. Her self-esteem has improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize a diet and exercise plan. What is the priority nursing diagnosis? 1. Imbalanced Nutrition: Less than Body Requirements 2. Disturbed Body Image 3. Risk for Situational Low Self-Esteem 4. Ineffective Health Maintenance

Ans: 2 The shift report indicates that the patient still has a disturbed body image; however, she is actively working on gaining weight and improving self-esteem, and has appropriate knowledge that she can use to maintain her health. Focus: Prioritization

You are assigned to telephone triage. A client who was just stung by a common honeybee calls for advice. The client reports pain and localized swelling but has no respiratory distress or other systemic signs of anaphylaxis. What is the first action that you should direct the caller to perform? 1. Call 911. 2. Remove the stinger by scraping. 3. Apply a cool compress. 4. Take an oral antihistamine.

Ans: 2 The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance. Focus: Prioritization

18. Which two cancer patients could potentially be placed together as roommates? 1. A patient with a neutrophil count of 1000/mm3 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who has undergone laminectomy for spinal cord compression _______,_______

Ans: 2, 4 Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with a low neutrophil count and the patient who has had a bone marrow transplantation need protective isolation.

A 79-year-old who has just returned to the surgical unit following a TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? 1. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. 2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL daily. _____, _____, _____, _____

Ans: 2, 1, 3, 4 Bladder spasms after a TURP are usually caused by the presence of clots that obstruct the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate postoperative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged once you are sure that the client is not nauseated and has adequate bowel tone. Focus: Prioritization

You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization

15. Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply.) 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level

Ans: 2, 3 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes The UAP's training and education includes how to measure vital signs and record intake and output. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP.

A 36-year-old G1P0 patient has received an epidural anesthetic. Her cervix is 6 cm dilated. Her blood pressure is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? (Select all that apply.) 1. Place the patient in high Fowler position. 2. Turn the patient to a lateral position. 3. Notify the anesthesiologist. 4. Prepare for emergency cesarean section. 5. Decrease the IV fluid rate.

Ans: 2, 3 The patient may be experiencing supine hypotension caused by the pressure of the uterus on the vena cava and the effects of epidural medication. Maternal hypotension can cause uteroplacental insufficiency leading to fetal hypoxia. Placing the woman in lateral position can relieve the pressure on the vena cava. The anesthesiologist should be notified and may need to treat the patient with ephedrine to correct the hypotension. IV fluids are increased per protocol when supine hypotension occurs. The correction of common problems in labor supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization

4. A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

Ans: 2, 3, 4 2. N95 respirator 3. Gown 4. Gloves Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and will not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization

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

Ans: 2, 3, 4, 5 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Delegation, supervision, assignment

Identify the five most critical elements in performing disaster triage for multiple victims. 1. Obtain past medical and surgical histories. 2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note color, presence of moisture, and temperature of the skin. 6. Obtain a history of allergies to food or medicine. 7. Check vital signs, including pulse and respirations. 8. Obtain a list of current medications. 9. Inquire about the last tetanus shot. _____, _____, _____, _____, _____

Ans: 2, 3, 4, 5, 7 These would be appropriate for disaster triage. The other items are important and would be addressed when the staff has time and resources to collect the additional information. (Note: During nondisaster situations, it would be appropriate to include all items.) Focus: Prioritization

4. Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? (Select all that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.

Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.

A 22-year-old G1P0 woman is being given an epidural anesthetic for pain control during labor and birth. Which are appropriate nursing actions when epidural anesthesia is used during labor? (Select all that apply.) 1. Request the anesthesiologist to discontinue the epidural anesthetic when the patient's cervix is completely dilated to allow the patient to sense the urge to push. 2. Insert a Foley catheter, because the woman is likely to be unable to void. 3. Encourage pushing efforts when the cervix is completely dilated in the absence of an urge to push. 4. Encourage the patient to turn from side to side during the course of labor.

Ans: 2, 4 Insertion of a Foley catheter is indicated because the woman will usually be unable to void due to the effect of the anesthetic in the bladder area. Positioning the patient on her side enhances blood flow and helps to prevent hypotension. Changing maternal position encourages progress in labor. In management of the second stage of labor when epidural anesthesia is used, laboring down as opposed to immediately pushing without the urge to push is advocated. It is not recommended to routinely discontinue an epidural anesthetic at complete dilation. A continuous epidural infusion provides pain relief throughout labor and birth. Use of evidence-based practices with a laboring woman supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization

You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a UAP to get the crash cart. _____, _____, _____, _____, _____

Ans: 2, 4, 1, 3, 5 Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. (Use a pocket mask or bag-valve mask.) CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team is present. Focus: Prioritization

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

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

When you are developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will you delegate to the home health aide? (Select all that apply.) 1. Monitoring the client for symptoms of urinary tract infection 2. Helping the client to connect the catheter to the leg bag 3. Checking the client's incision for appropriate wound healing 4. Assisting the client in ambulating for increasing distances 5. Helping the client shower at least every other day

Ans: 2, 4, 5 Assisting with catheter care, ambulation, and hygiene are included in home health aide education and would be expected activities for this staff member. Client assessments are the responsibility of RN members of the home health care team. Focus: Delegation

A 30-year-old G1P0 woman at 39 weeks experienced a fetal demise and has just delivered a female infant. Her husband is at the bedside. Which are appropriate nursing actions at this time? (Select all that apply.) 1. Offer the option of autopsy to the parents. 2. Stay with the parents and offer supportive care. 3. Place the infant on the maternal abdomen. 4. Clean and wrap the baby and offer the infant to the parents to view or hold when desired. 5. Ask the parents if there are any special rituals in their religion or culture for a baby who has died that they would like to have done.

Ans: 2, 4, 5 Staying with the parents at this moment and offering physical and emotional support is appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and respect for the baby and to offer the parents the opportunity to view and/or hold the infant as they desire. The RN must ask the parents if there are cultural or religious rituals they would like for their child to ensure that they feel their infant has been treated properly with respect to their religion or culture. Autopsy should be discussed, but not at the very moments after birth. The infant should not be placed on the maternal abdomen until the nurse assesses the parents' wishes of when and how to view the infant. Focus: Prioritization

16. You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. 22-year-old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. 34-year-old who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. 45-year-old with partial-thickness leg burns who has a temperature of 102.6° F (39.2° C) and a blood pressure of 98/46 mm Hg 4. 57-year-old who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

Ans: 3 45-year-old with partial-thickness leg burns who has a temperature of 102.6° F (39.2° C) and a blood pressure of 98/46 mm Hg This client's vital signs indicate that the life-threatening complications of sepsis and septic shock may be developing. The other clients also need rapid assessment and/or nursing interventions, but their symptoms do not indicate that they need care as urgently as the febrile and hypotensive client. Focus: Prioritization

15. You are caring for an older woman with hepatic cancer. The UAP informs you that the patient's level of consciousness is diminished compared to earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. 1. Take vital signs, including pulse, respirations, blood pressure, and temperature. 2. Check responsiveness and level of consciousness. 3. Obtain a blood glucose reading. 4. Check electrolyte values. 5. Check ammonia level. 6. Check the patency of existing IV lines. 7. Administer oxygen if needed and check pulse oximeter readings. _______, _______,_______, _______, _______, _______, _______

Ans: 2, 7, 1, 3, 6, 4, 5 Determine level of consciousness and responsiveness, and changes from baseline. Oxygen should be administered immediately in the presence of respiratory distress or risk for decreased oxygenation and perfusion. Pulse oximetry can be used for continuous monitoring. Adequate pulse, blood pressure, and respirations are required for cerebral perfusion. Increased temperature may signal infection or sepsis. Blood glucose levels should be checked even if the patient is not diabetic. Severe hypoglycemia should be immediately treated per protocol. A patent IV line may be needed for delivery of emergency drugs. Electrolyte and ammonia levels are relevant data for this patient, and abnormalities in these parameters may be contributing to change in mental status. (Note: Laboratory results [i.e., electrolytes and ammonia levels] may be concurrently available; however, you should train yourself to systematically look at data. Look at electrolytes first because these are more commonly ordered. In some cases, you may actually have to remind the physician to order the ammonia level if the patient with a hepatic disorder is having a change in mental status.)

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

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

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

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

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

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

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

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

5. You are the nurse manager in the burn unit. Which client is best to assign to an RN who has floated from the oncology unit? 1. 23-year-old who has just been admitted with burns over 30% of the body after a warehouse fire 2. 36-year-old who requires discharge teaching about nutrition and wound care after having skin grafts 3. 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled 4. 57-year-old with full-thickness burns on both arms who needs assistance in positioning hand splints

Ans: 3 45-year-old with infected partial-thickness back and chest burns who has a dressing change scheduled A nurse from the oncology unit would be familiar with dressing changes and sterile technique. The charge RN in the burn unit would work closely with the float RN to provide partners to assist in providing care and to answer any questions. Admission assessment and development of the initial care plan, discharge teaching, and splint positioning in burn clients all require expertise in caring for clients with burns. These clients should be assigned to RNs who regularly work on the burn unit. Focus: Assignment

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

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

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

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

18. You are the charge nurse on a medical-surgical unit and are working with a newly-graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. 34-year-old who was just admitted to the unit with periorbital cellulitis 2. 40-year-old who needs discharge instructions after having skin grafts to the thigh 3. 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer 4. 78-year-old who needs teaching before a punch biopsy of a facial lesion

Ans: 3 67-year-old who requires a dressing change after hydrotherapy for a pressure ulcer A new graduate would be familiar with the procedure for a sterile dressing change, especially after working for 3 weeks on the unit. Clients whose care requires more complex skills such as admission assessments, preprocedure teaching, and discharge teaching should be assigned to more experienced RN staff members. Focus: Assignment

When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization

1. You are assessing a long-term-care client with a history of benign prostatic hyperplasia (BPH). Which information will require the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago.

Ans: 3 A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization

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

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

A client has had a needle biopsy of the prostate gland using the transrectal approach. Which statement is most important to include in the client teaching plan? 1. "The doctor will call you about the test results in a day or two." 2. "Serious infections may occur as a complication of this test." 3. "You will need to call the doctor if you develop a fever or chills." 4. "It is normal to have a small amount of rectal bleeding after the test."

Ans: 3 Although infection occurs only rarely as a complication of transrectal prostate biopsy, it is important that the client receive teaching about checking his temperature and calling the physician if there is any fever or other signs of systemic infection. The client should understand that the test results will not be available immediately but that he will be notified about the results. Transient rectal bleeding may occur after the biopsy, but bleeding that lasts for more than a few hours indicates that there may have been rectal trauma. Focus: Prioritization

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform? 1. Assessing immediate emotional state and physical injuries 2. Collecting hair samples, saliva specimens, and scrapings beneath fingernails 3. Providing emotional support and supportive communication 4. Ensuring that the chain of custody of evidence is maintained

Ans: 3 An LPN/LVN is able to listen and provide emotional support for clients. The other tasks are the responsibility of an RN or, if available, a sexual assault nurse examiner who has received training in assessing, collecting, and safeguarding evidence, and caring for assault victims. Focus: Delegation

You are the charge nurse on the oncology unit. Which client is best to assign to an RN who has floated from the ED? 1. Client who needs doxorubicin (Adriamycin) to treat metastatic breast cancer 2. Client who needs discharge teaching after surgery for stage II ovarian cancer 3. Client with metastatic prostate cancer who requires frequent assessment and treatment for breakthrough pain 4. Client with testicular cancer who requires preoperative teaching about orchiectomy and lymph node resection

Ans: 3 An RN from the ED would be experienced in assessment and management of pain. Because of their diagnoses and treatments, the other clients should be assigned to RNs who are experienced in caring for clients with cancer. Focus: Assignment

You observe a student nurse who is caring for a client who has an intracavitary radioactive implant in place to treat cervical cancer. Which action by the student requires that you intervene immediately? 1. Standing next to the client for 5 minutes while assisting with her bath 2. Asking the client how she feels about losing her childbearing ability 3. Assisting the client to the bedside commode for a bowel movement 4. Offering to get the client whatever she would like to eat or drink

Ans: 3 Clients with intracavitary implants are kept in bed during the treatment to avoid dislodgement of the implant. The other actions may also require you to intervene by providing guidance to the student. Minimal time should be spent close to clients who are receiving internal irradiation. Asking the client about her reaction to losing childbearing abilities may be inappropriate at this time. Clients are frequently placed on low-residue diets to decrease bowel distention while implants are in place. Focus: Prioritization

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

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

After receiving the change-of-shift report, which patient should you assess first? 1. 18-month-old with coarctation of the aorta who has decreased pedal pulses 2. 3-year-old with rheumatic fever who reports severe knee pain 3. 5-year-old with endocarditis who has crackles audible throughout both lungs 4. 8-year-old with Kawasaki disease who has a temperature of 102.2° F (39° C)

Ans: 3 Crackles throughout both lungs indicate that the child has severe left ventricular failure as a complication of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administration of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life-threatening complications of their medical diagnoses. Focus: Prioritization

19. When you are evaluating a client who has been taking prednisone (Deltasone) 30 mg daily to treat contact dermatitis, which finding is most important to report to the health care provider? 1. The blood glucose level is 136 mg/dL. 2. The client states, "I am eating all the time." 3. The client reports epigastric pain. 4. The blood pressure is 148/84 mm Hg.

Ans: 3 Epigastric pain may indicate that the client is developing peptic ulcers, which require collaborative interventions such as the use of antacids, histamine2 receptor blockers (e.g., famotidine [Pepcid]), or proton pump inhibitors (e.g., esomeprazole [Nexium]). The elevation in blood glucose level, increased appetite, and slight elevation in blood pressure may be related to prednisone use but are not clinically significant when steroids are used for limited periods and do not require treatment. Focus: Prioritization

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

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

While assessing a 29-year-old G2P2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, you note a large amount of red vaginal bleeding. What would be your first priority nursing action? 1. Check vital signs. 2. Notify the provider. 3. Firmly massage the uterine fundus. 4. Put the baby to breast.

Ans: 3 Fundal massage would be the priority nursing action because it helps the uterus to contract firmly and thus reduces bleeding. The first two Answer choices are appropriate nursing actions, but do nothing to stop the immediate bleeding. Putting the baby to the breast does release oxytocin, which causes uterine contraction, but it will be slower to do so than fundal massage. Focus: Prioritization

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

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

You are working on a medical unit staffed with LPNs/LVNs and UAPs when a client with stage IV ovarian cancer and recurrent ascites is admitted for paracentesis. Which activity is best to delegate to an experienced LPN/LVN? 1. Obtaining a paracentesis tray from the central supply area 2. Completing the short-stay client admission form 3. Measuring vital signs every 15 minutes after the procedure 4. Providing discharge instructions after the procedure

Ans: 3 LPN/LVN education includes vital sign monitoring; an experienced LPN/LVN would recognize and report significant changes in vital signs to the RN. The paracentesis tray could be obtained by a UAP. Client admission assessment and teaching require RN-level education and experience, although part of the data gathering may be done by an LPN/LVN. Focus: Delegation

As the pediatric unit charge nurse, you are making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN/LVN? 1. 1-year-old with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant 2. 2-year-old with Wiskott-Aldrich syndrome who has orders for a platelet transfusion 3. 3-year-old who has chronic graft-versus-host disease and is incontinent of loose stools 4. 6-year-old who received chemotherapy a week ago and is admitted with increasing lethargy and a temperature of 101° F (38.3° C)

Ans: 3 LPN/LVN scope of practice includes care of patients with chronic and stable health problems, such as the patient with chronic graft-versus-host disease. Chemotherapy medications are considered high-alert medications and should be given by RNs who have received additional education in chemotherapy administration. Platelets and other blood products should be given by RNs. The 6-year-old patient has a history and clinical manifestations consistent with neutropenia and sepsis and should be assessed by an RN as quickly as possible. Focus: Assignment

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

Ans: 3 Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses. Focus: Assignment

A 4-year-old with acute lymphocytic leukemia has these medications ordered. Which one is most important to double-check with another licensed nurse? 1. Prednisone (Deltasone) 1 mg by mouth (PO) 2. Amoxicillin (Amoxil) 250 mg PO 3. Methotrexate (Rheumatrex) 10 mg PO 4. Filgrastim (Neupogen) 5 mcg subcutaneously

Ans: 3 Methotrexate is a high-alert drug, and extra precautions, such as double-checking with another nurse, should be taken when administering this medication. Although many pediatric units have a policy requiring that all medication administration to children be double-checked, the other medications listed are not on the high-alert list published by the Institute for Safe Medication Practices. Focus: Prioritization

1. You are caring for a client who has just had a squamous cell carcinoma removed from the face. Which activity can you delegate to an experienced LPN/LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery

Ans: 3 Monitoring the surgical site for swelling, bleeding, or pain An LPN/LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation

A 16-year-old with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? 1. Allowing the patient to decide whether she needs aerosolized medications 2. Placing the patient in a private room to decrease the risk of further infection 3. Scheduling postural drainage and chest physiotherapy (CPT) every 4 hours 4. Planning activities to allow for at least 8 hours of uninterrupted sleep

Ans: 3 National guidelines indicate that airway clearance techniques are critical for patients with cystic fibrosis; CPT should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep. Focus: Prioritization

You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L 2. A nosebleed with a platelet count of 100,000/mm3 3. Fever with an absolute neutrophil count of 450/mm3 4. Fatigue with a hemoglobin level of 8 g/dL

Ans: 3 National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3. Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. Focus: Prioritization

These medications have been prescribed for a 9-year-old with deep partial- and full-thickness burns. Which medication is most important to double-check with another licensed nurse before administration? 1. Silver sulfadiazine (Silvadene) ointment 2. Famotidine (Pepcid) 20 mg IV 3. Lorazepam (Ativan) 0.5 mg PO 4. Multivitamin (Centrum Kids) 1 tablet PO

Ans: 3 Oral sedation agents such as the benzodiazepines are considered high-alert medications when ordered for children, and extra precautions should be taken before administration. Many facilities require that all medications administered to pediatric patients be double-checked before administration, but the lorazepam is the most important to double-check with another nurse. Focus: Prioritization

6. You perform a skin assessment on a 70-year-old new resident in an LTC facility. Which finding is of most concern? 1. Numerous striae are noted across the abdomen and buttocks. 2. All the toenails are thickened and yellow. 3. Silver scaling is present on the elbows and knees. 4. An irregular border is seen on a black mole on the scalp.

Ans: 4 An irregular border is seen on a black mole on the scalp. Irregular borders and a black or variegated color are characteristics associated with malignant skin lesions. Striae and toenail thickening or yellowing are common in elderly individuals. Silver scaling is associated with psoriasis, which may need treatment but is not as urgent a concern as the appearance of the mole. Focus: Prioritization

In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. "Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. "If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. "The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. "One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?"

Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization

A 25-year-old G2P1 patient has come to the obstetric triage room at 32 weeks reporting painless vaginal bleeding. You are providing orientation for a new RN on the unit. Which statement by the new RN to the patient would require your prompt intervention? 1. "I'm going to check your vital signs." 2. "I'm going to apply a fetal monitor to check the baby's heart rate and to see if you are having contractions." 3. "I'm going to perform a vaginal examination to see if your cervix is dilated." 4. "I'm going to feel your abdomen to check the position of the baby."

Ans: 3 Painless vaginal bleeding can be a symptom of placenta previa. A digital vaginal examination is contraindicated until ultrasound can be performed to rule out placenta previa. If a digital examination is performed when placenta previa is present, it can cause increased bleeding. The other statements reflect appropriate assessment of an incoming patient with vaginal bleeding. Focus: Assignment

You are preparing a child for IV conscious sedation before repair of a facial laceration. What information should you immediately report to the health care provider? 1. The parent is unsure about the child's tetanus immunization status. 2. The child is upset and pulls out the IV. 3. The parent declines the IV conscious sedation. 4. The parent wants information about the IV conscious sedation.

Ans: 3 Parental refusal is an absolute contraindication; therefore, the provider must be notified. Tetanus status can be addressed later. The RN can reestablish the IV access and provide information about conscious sedation; if the parent is still not satisfied, the provider can give more information. Focus: Prioritization

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

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

When an unexpected death occurs in the ED, which task is most appropriate to delegate to the UAP? 1. Escorting the family to a place of privacy 2. Going with the organ donor specialist to talk to the family 3. Assisting with postmortem care 4. Helping the family to collect belongings

Ans: 3 Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Focus: Delegation

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

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

11. As a home health nurse, you are caring for a 72-year-old client who has a nursing diagnosis of Impaired Skin Integrity related to poor nutrition, bladder incontinence, and immobility. Which nursing actions should you delegate to the UAP? 1. Telling the client and family to apply the skin barrier cream in a smooth, even layer 2. Completing a diet assessment and suggesting changes in diet to improve the client's nutrition 3. Reminding the family to help the client to the commode every 2 hours during the day 4. Evaluating the client for improvement in documented areas of skin breakdown or damage

Ans: 3 Reminding the family to help the client to the commode every 2 hours during the day Although it is not appropriate for UAPs to plan or implement initial client or family teaching, reinforcement of previous teaching is an important function of UAPs (who are likely to be in the home on a daily basis). Teaching about medication use, nutritional assessment and planning, and evaluation for improvement are included in the RN scope of practice. Focus: Delegation

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

Ans: 3 Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure. Focus: Prioritization

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

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

9. A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should you delegate to a medical assistant working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing

Ans: 3 Scheduling a follow-up appointment for the client in 2 days Scheduling a follow-up appointment for the client is within the legal scope of practice and training for the medical assistant role. Client teaching, assessment for positive skin reactions to the test, and monitoring for serious allergic reactions are appropriate to the education and practice role of licensed nursing staff. Focus: Delegation

A 68-year-old client who is ready for discharge from the ED has a new prescription for nitroglycerin (Nitrostat) 0.4 mg sublingual as needed for angina. Which client information has the most immediate implications for teaching? 1. The client has BPH and some urinary hesitancy. 2. The client's father and two brothers all have had myocardial infarctions. 3. The client uses sildenafil (Viagra) several times weekly for erectile dysfunction. 4. The client is unable to remember when he first experienced chest pain.

Ans: 3 Sildenafil is a potent vasodilator and has caused cardiac arrest in clients who were also taking nitrates such as nitroglycerin. The other client data indicate the need for further assessment and/or teaching, but it is essential for the client who uses nitrates to avoid concurrent use of sildenafil. Focus: Prioritization

A 27-year-old patient underwent a primary cesarean section because of breech presentation 24 hours ago. Which assessment finding would be of the most concern? 1. Small amount of lochia rubra 2. Temperature of 99° F (37.2° C) 3. Slight redness of the left calf 4. Pain rated as 3 of 10 in the incisional area

Ans: 3 Slight redness in the left calf could be suggestive of thrombophlebitis and requires further investigation. The other findings are within normal limits. Focus: Prioritization

A 17-year-old G1P0 woman at 40 weeks is in labor. She has chosen natural childbirth with assistance from a doula. Her mother and her boyfriend are at the bedside. What nursing action can help the patient achieve her goal of an unmedicated labor and birth? 1. Encourage the patient to stay in bed. 2. Allow the patient's support people to provide labor support and minimize nursing presence. 3. Assess the effectiveness of the labor support team and offer suggestions as indicated. 4. Offer pain medication on a regular basis so the patient knows it is available if desired.

Ans: 3 The RN remains an important part of the labor and birth in this scenario. Even with a good support team present, the RN needs to observe and assess the patient's comfort and safety as part of essential nursing care during labor. The RN's expertise allows the RN to make helpful suggestions to the support people and patient. The patient should be encouraged to utilize positions and activities that are most comfortable to her. It is appropriate to let the patient and support people know of all pain control options, but it would not be appropriate to continually offer pain medication to a patient who has chosen natural childbirth. Expert nursing care in labor supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization

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

Ans: 3 The UAP can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate medication administration to an LPN/LVN. Focus: Delegation, supervision

A pregnant woman at 12 weeks' gestation tells you that she is a vegetarian. What would be the first appropriate nursing action? 1. Recommend vitamin B12 and iron supplementation. 2. Recommend consumption of protein drinks daily. 3. Obtain a 24-hour diet recall history. 4. Determine the reason for her vegetarian diet.

Ans: 3 The care of a vegetarian woman who is pregnant should begin with assessment of her diet, because vegetarian practices vary widely. The RN must first assess exactly what the woman's diet consists of and then determine any deficiencies. The reason for the diet is less important than what the diet actually contains. It is probable that the woman will need a vitamin B12 supplement, but the assessment comes first. Vegetarian diets can be completely adequate in protein, and therefore protein supplementation is not routinely recommended. Focus: Prioritization

An anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? 1. Notify the physician immediately. 2. Administer supplemental oxygen. 3. Have the student breathe into a paper bag. 4. Obtain an order for an anxiolytic medication.

Ans: 3 The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified. Focus: Prioritization

You are providing orientation for a new RN on the medical-surgical unit. The new RN takes the following actions while caring for a client with severe pelvic inflammatory disease (PID). Which action by the new RN is most important to correct quickly? 1. Telling the client that she should avoid using tampons in the future 2. Offering the client an ice pack to decrease her abdominal pain 3. Positioning the client flat in bed while helping her take a bath 4. Teaching the client that she should not have intercourse for 2 months

Ans: 3 The client should be positioned in a semi-Fowler position to minimize the risk of abscess development higher in the abdomen. The other actions also require correction, but not as rapidly. Tampon use is not contraindicated after an episode of PID, although some sources recommend not using tampons during the acute infection. Heat application to the abdomen and pelvis is used for pain relief. Intercourse is safe a few weeks after effective treatment for PID. Focus: Prioritization

You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? 1. Assessing for bilateral breath sounds and symmetrical chest movement 2. Auscultating over the stomach to rule out esophageal intubation 3. Marking the tube 1 cm from where it touches the incisor tooth or nares 4. Ordering a chest radiograph to verify that tube placement is correct

Ans: 3 The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed. Focus: Delegation, supervision, prioritization

An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse? 1. Trauma team 2. Triage 3. Ambulatory or fast-track clinic 4. Pediatric medicine team

Ans: 3 The fast-track clinic deals with clients in relatively stable condition. The triage, trauma, and pediatric medicine areas should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. Focus: Assignment

A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access.

Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization

You are caring for a 5-year-old whose mother asks why he still wets the bed. What is your best response? 1. "He is old enough that he should no longer be wetting the bed." 2. "Most children outgrow bed-wetting by the time they start school." 3. "His bed-wetting may be due to an immature bladder or deep sleep pattern." 4. "He will probably stop once he realizes how embarrassing it is to wet the bed."

Ans: 3 Theories about bed-wetting relate it to immature bladder and deep sleep patterns. Although it is true that most children stop bed-wetting by the time they start school, this does not answer the mother's question. Many boys wet the bed until after the age of 5. The fourth response is not accurate, because often bed-wetting is not within the control of a 5-year-old child. Focus: Prioritization

You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is most important to report to the health care provider? 1. Apical pulse rate of 156 beats/min 2. Crackles audible in both lungs 3. Tracheal deviation to the right 4. Oxygen saturation of 93%

Ans: 3 Tracheal deviation suggests tension pneumothorax, a possible complication of positive-pressure ventilation. The nurse will need to communicate rapidly with the health care provider and assist with actions such as chest tube insertion. The heart rate, crackles, and oxygen saturation will be reported to the health care provider, but are expected in RDS and do not require immediate intervention. Focus: Prioritization

You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/LVN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment

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

Ans: 3 UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN. Focus: Delegation, supervision

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

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

A 22-year-old woman is 6 weeks postpartum. In the clinic she admits to crying every day, feeling overwhelmed, and sometimes thinking that she may hurt the baby. What would be the priority nursing action at this time? 1. Advise the patient of community resources, parent groups, and depression hotlines. 2. Counsel the mother that the "baby blues" are common at this time and assess her nutrition, rest, and availability of help at home. 3. Contact the provider to evaluate the patient before allowing her to leave the clinic. 4. Advise the woman that she cannot use medication for depression because she is breast feeding.

Ans: 3 When a patient discloses fear of hurting herself or her baby, the RN must have the woman immediately evaluated before allowing her to leave. Merely informing the patient about community resources is not sufficient. The "baby blues" are typically milder and occur 1 to 2 weeks postpartum. Once the woman has been evaluated, the provider can prescribe antidepressants that can be safely used while breastfeeding. Focus: Prioritization

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

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

3. You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene.

Ans: 3, 2, 4, 1, 5 3. Remove gloves. 2. Take off goggles. 4. Take off gown. 1. Remove N95 respirator. 5. Perform hand hygiene. This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration. Focus: Prioritization

You are caring for a client with frostbite to the feet. Place the following interventions in the correct order. 1. Apply a loose, sterile, bulky dressing. 2. Give pain medication. 3. Remove the client from the cold environment. 4. Immerse the feet in warm water of 105° F to 115° F (40.6° C to 46.1° C). 5. Monitor for compartment syndrome. _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5 The client should be removed from the cold environment first, then the rewarming process can be initiated. It will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment. Focus: Prioritization

A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing. 7. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5, 6, 7 For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization

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

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

4. You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Debride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 1, 5 3. Administer morphine sulfate 10 mg IV. 4. Debride the wound of eschar using gauze sponges. 2. Obtain specimens for aerobic and anaerobic wound cultures. 1. Apply silver sulfadiazine (Silvadene) ointment. 5. Cover the wound with a sterile gauze dressing. Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be debrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 5, 1 The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available. Focus: Prioritization

14. A client admitted to the emergency department (ED) reports itching of the trunk and groin. You note multiple reddened wheals on the chest, back, and groin. Which question is most appropriate to ask next? 1. "Do you have a family history of eczema?" 2. "Have you been using sunscreen regularly?" 3. "How do you usually manage stress?" 4. "Are you taking any new medications?"

Ans: 4 "Are you taking any new medications?" Wheals are frequently associated with allergic reactions, so asking about exposure to new medications is the most appropriate question for this client. The other questions would be useful in assessing the skin health history but do not directly relate to the client's symptoms. Focus: Prioritization

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

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

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

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

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

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

A 3-day-old breast-fed infant is brought to the clinic by his parents for routine assessment following a normal full-term delivery without complications. Which statement by the parents suggests an abnormal finding on a newborn of this age? 1. "The baby urinated only 3 times yesterday." 2. "The bowel movement of the baby was dark at first, but yesterday it was greenish yellow." 3. "The baby cried for 2 hours last night." 4. "The baby ate four times in the past 24 hours."

Ans: 4 A newborn baby should feed 8 to 12 times in 24 hours. The other findings are normal for an infant of this age. The baby should void 6 to 8 times a day after the fourth day of life. Helpful guidance at this point may help parents understand infant feeding and help support the Perinatal Core Measure of increasing the percentage of infants who are fed breast milk only. Focus: Prioritization

The patient with COPD tells the UAP that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the UAP to report which vital sign value? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2° F (38.4° C)

Ans: 4 A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern. Focus: Delegation, supervision

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

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

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

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

You are talking to a group of people about an industrial explosion in which many people were killed or injured. Which individual has the greatest risk for psychiatric difficulties, such as post-traumatic stress disorder, related to the incident? 1. Individual who repeatedly watched television coverage of the event 2. Person who recently learned that her son was killed in the incident 3. Individual who witnessed the death of a co-worker during the explosion 4. Person who was injured and trapped for several hours before rescue

Ans: 4 Any of these people may need or benefit from psychiatric counseling. Obviously, there will be variations in previous coping skills and support systems; however, a person who experienced a threat to his or her own life is at the greatest risk for psychiatric problems following a disaster incident. Focus: Prioritization

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? 1. ED physicians and charge nurses 2. Experienced RNs and experienced paramedics 3. RNs, LPNs/LVNs, and UAPs 4. At least one representative from each group of ED personnel

Ans: 4 At least one representative from each group should be included, because all employees are potential targets for violence in the ED. Focus: Assignment

A 16-year-old in the adolescent health clinic tells you that she has been sexually active for 6 months, "but only with my boyfriend." Screening for which sexually transmitted disease (STD) will be most important for this patient? 1. Syphilis 2. Genital herpes simplex 3. Human papillomavirus 4. Chlamydia

Ans: 4 Because Chlamydia trachomatis infection is the most prevalent sexually transmitted disease in the United States, national research-based guidelines state that Chlamydia screening is strongly recommended for all sexually active females age 25 or younger. Screening for the other STDs may also be considered, but is recommended only if other risk factors or evidence of disease is present. Focus: Prioritization

A 67-year-old client with BPH has a new prescription for tamsulosin (Flomax). Which statement about tamsulosin is most important to include when teaching this client? 1. "This medication will improve your symptoms by shrinking the prostate." 2. "The force of your urinary stream will probably increase." 3. "Your blood pressure will decrease as a result of taking this medication." 4. "You should avoid sitting up or standing up too quickly."

Ans: 4 Because tamsulosin blocks alpha receptors in the peripheral arterial system, the most significant side effects are orthostatic hypotension and dizziness. To avoid falls, it is important that the client change positions slowly. The other information is also accurate and may be included in client teaching but is not as important as decreasing the risk for falls. Focus: Prioritization

You are obtaining the history and physical information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information about this patient will concern you most? 1. The child attends a day-care center 5 days a week. 2. The child's fingers have areas of peeling skin. 3. The child is very irritable and cries frequently. 4. The child has not received any immunizations.

Ans: 4 Children who receive aspirin therapy are at risk for the development of Reye syndrome if they contract viral illnesses such as varicella or influenza, so the lack of immunization is the greatest concern for this child. Peeling skin on the fingers and toes and irritability are consistent with Kawasaki disease, but do not require any change in therapy. Since Kawasaki disease is not a communicable disease, day care need not be avoided. Focus: Prioritization

You obtain this information when assessing a 3-year-old with uncorrected tetralogy of Fallot who is crying. Which finding requires immediate action? 1. The apical pulse rate is 118 beats/min. 2. A loud systolic murmur is heard in the pulmonic area. 3. There is marked clubbing of all of the child's nail beds. 4. The lips and oral mucosa are dusky in color.

Ans: 4 Circumoral cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee-chest position, administer oxygen, and take steps to calm the child. The other assessment data are expected in a child with congenital heart defects such as tetralogy of Fallot. Focus: Prioritization

2. You are employed as the charge nurse in a long-term care (LTC) facility that employs RNs, LPNs/LVNs, and UAPs. When you are planning care for a resident with a stage III sacral pressure ulcer, which nursing intervention is best to delegate to an LPN/LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Norton scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning

Ans: 4 Cleaning and changing the dressing on the ulcer every morning LPN/LVN education and scope of practice includes sterile and nonsterile wound care. LPNs/LVNs do function as wound care nurses in some LTC facilities, but the choice of dressing type and assessment for risk factors are more complex skills that are appropriate to the RN level of practice. Assisting the client to change position is a task included in UAP education and would be more appropriate to delegate to the UAP. Focus: Delegation

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

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

1. A 30-year-old woman with type 1 diabetes mellitus comes to the clinic for preconception care. What is the priority education for her at this time? 1. Her insulin requirements will likely increase during the second and third trimesters of pregnancy. 2. Infants of diabetic mothers can be macrosomic, which can result in more difficult delivery and higher likelihood of cesarean section. 3. Breast feeding is highly recommended, and insulin use is not a contraindication. 4. Achievement of optimal glycemic control at this time is of utmost importance in preventing congenital anomalies.

Ans: 4 The incidence of congenital anomalies is three times higher in the offspring of diabetic women. Good glycemic control during preconception and early pregnancy significantly reduces this risk and would be the highest priority message to this patient at this point. The other responses are correct but are not of greatest importance at this time. Focus: Prioritization

You are working on the PACU caring for a 32-year-old client who has just arrived after undergoing dilation and curettage to evaluate infertility. Which assessment finding should be immediately communicated to the surgeon? 1. Blood pressure of 162/90 mm Hg 2. Saturation of the perineal pad after the first 30 minutes 3. Oxygen saturation of 91% to 95% 4. Sharp, continuous, level 8 (out of 10) abdominal pain

Ans: 4 Cramping or aching abdominal pain is common after dilation and curettage; however, sharp, continuous pain may indicate uterine perforation, which would require rapid intervention by the surgeon. The other data indicate a need for ongoing assessment or interventions. Transient blood pressure elevation may occur due to the stress response after surgery. Bleeding following the procedure is expected but should decrease over the first 2 hours. And although the oxygen saturation is not at an unsafe level, interventions to improve the saturation should be carried out. Focus: Prioritization

A parent calls the emergency department (ED), saying "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the most essential question to ask the caller? 1. "Has he vomited?" 2. "Have you been checking his stools?" 3. "What do you think he swallowed?" 4. "Has he been coughing?"

Ans: 4 Even though the caller reports that the child is "breathing okay," additional questions about possible airway obstruction are the priority (i.e., coughing, gagging, choking, drooling, refusing to eat or drink). Gastrointestinal symptoms should be assessed but are less urgent. The type of foreign body, in the absence of symptoms, may dictate a wait-and-see approach, in which case the parent would be directed to check the stools for passage of the foreign body. Focus: Prioritization

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

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

. A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.

Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization

An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet

Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if the child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation

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

Ans: 4 Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. Focus: Prioritization

While performing a breast examination on a 22-year-old client, you obtain the following data. Which finding is of most concern? 1. Both breasts have many nodules in the upper outer quadrants. 2. The client reports bilateral breast tenderness with palpation. 3. The breast on the right side is slightly larger than the left breast. 4. An irregularly shaped, nontender lump is palpable in the left breast.

Ans: 4 Irregularly shaped and nontender lumps are consistent with a diagnosis of breast cancer, so this client needs immediate referral for diagnostic tests such as mammography or ultrasound. The other information is not unusual and does not indicate the need for immediate action. Focus: Prioritization

The day after a radical prostatectomy, your client has blood clots in the urinary catheter and reports bladder spasms. The client says that his right calf is sore and that he feels short of breath. Which action will you take first? 1. Irrigate the catheter with 50 mL of sterile saline. 2. Administer oxybutynin (Ditropan) 5 mg orally. 3. Apply warm packs to the client's right calf. 4. Measure oxygen saturation using pulse oximetry.

Ans: 4 It is important to assess oxygenation, because the client's calf tenderness and shortness of breath suggest a possible deep vein thrombosis and pulmonary embolus, serious complications of TURP. The other activities are appropriate but are not as high a priority as ensuring that oxygenation is adequate. Focus: Prioritization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You are the RN in the labor and delivery unit caring for a 25-year-old G3P2 patient in active labor. You have identified late fetal heart decelerations and decreased variability in the fetal heart rate. You have notified the provider on call, who feels that the pattern is acceptable. What would be your priority action at this time? 1. Advise the patient that a different provider will be called because you do not agree with the advice of the first provider. 2. Discuss your concerns with another labor and delivery nurse. 3. Document your conversation with the provider accurately, including the provider's interpretation and recommendation, and continue close observation of the fetal heart rate. 4. Go up the chain of command and communicate your assessment of the fetal heart rate findings clearly to the next appropriate provider.

Ans: 4 The RN must follow through on the findings of a nonreassuring fetal heart rate. Where patient safety is concerned, the nurse is obligated to pursue an appropriate response. Documenting the conversation with the provider and discussing it with a colleague are appropriate, but something must be done to address the immediate safety concern and possible need for intervention at this time. The RN must persist until the safety concern has been addressed appropriately. Focus: Prioritization

You obtain the following assessment data about your client who has had a transurethral resection of the prostate (TURP) and has continuous bladder irrigation. Which finding indicates the most immediate need for nursing intervention? 1. The client states that he feels a continuous urge to void. 2. The catheter drainage is light pink with occasional clots. 3. The catheter is taped to the client's thigh. 4. The client reports painful bladder spasms.

Ans: 4 The bladder spasms may indicate that blood clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of normal saline using a piston syringe. The other data would all be normal after a TURP, but the client may need some teaching about the usual post-TURP symptoms and care. Focus: Prioritization

An intoxicated client comes in with slurred speech, mild confusion, and uncooperative behavior. The client cannot provide a good history but admits to "drinking a few on the weekend." What is the priority nursing action for this client? 1. Obtain an order for determining blood alcohol level. 2. Contact the family to obtain additional history and baseline information. 3. Administer naloxone (Narcan) 2 to 4 mg as ordered. 4. Administer IV fluid with supplemental thiamine as ordered.

Ans: 4 The client has symptoms of alcohol abuse and there is a risk for Wernicke-Korsakoff syndrome, which is caused by a thiamine deficiency. Multiple drug abuse is not uncommon; however, the primary concern with an opiate overdose is respiratory depression, and the client does not show any respiratory distress or alterations in respiratory pattern. Additional information or the results of the blood alcohol testing are part of the total treatment plan but should not delay the immediate treatment. Focus: Prioritization

17. You take the health history of a 60-year-old client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon? 1. The client does not routinely use sunscreen. 2. The client has a family history of melanoma. 3. The client has not eaten anything for 8 hours. 4. The client takes 325 mg of aspirin daily.

Ans: 4 The client takes 325 mg of aspirin daily. Because aspirin affects platelet aggregation, the client is at increased risk for postprocedure bleeding, and the surgeon may need to reschedule the procedure. The other information is also pertinent but will not affect the scheduling of the procedure. Focus: Prioritization

While you are working in the clinic, a healthy 32-year-old woman whose sister is a carrier of the BRCA gene asks you which form of breast cancer screening is the most effective for her. Which response is best? 1. "An annual mammogram is usually sufficient screening for women your age." 2. "Monthly self-breast examination is recommended because of your higher risk." 3. "A yearly breast examination by a health care provider should be scheduled." 4. "Magnetic resonance imaging is recommended in addition to annual mammography."

Ans: 4 The current national guidelines, supported by nonrandomized screening trials and observational data, call for first-degree relatives of clients with the BRCA gene to be screened with both annual mammography and magnetic resonance imaging (MRI). Although annual mammography, breast self-examination, and clinical breast examination by a health care provider may help to detect cancer, the best option for this client is annual mammography and MRI. Focus: Prioritization

You are caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern? 1. Bulging of the sac when the infant cries 2. Oozing of stool from the anal sphincter 3. Flaccid paralysis of both legs 4. Temperature of 101.8° F (38.8° C)

Ans: 4 The elevated temperature indicates possible infection and should be reported immediately to the physician so that treatment can be started. The other data are typical in an infant with this defect. Focus: Prioritization

It is the summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs attention first? 1. Elderly person with reports of dizziness and syncope after standing in the sun for several hours to view a parade 2. Marathon runner who reports severe leg cramps and nausea, and shows tachycardia, diaphoresis, pallor, and weakness 3. Relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests tachypnea, hypotension, fatigue, and profuse diaphoresis 4. Homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

Ans: 4 The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The elderly client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures. Focus: Prioritization

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% FIO2 and call the physician to discuss the patient's status.

Ans: 4 The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an FiO2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. Focus: Prioritization

A full-term newborn is at the clinic with his parents. He is 4 days old. His birth weight was 7 pounds. Which assessment made by the RN is most significant? 1. The infant's weight today is 6 pounds 9 ounces. 2. The infant's skin is peeling. 3. The infant's breast tissue is swollen. 4. There is a yellow discharge from the infant's right eye.

Ans: 4 The yellow eye discharge could be a conjunctivitis related to an infection acquired during birth or afterward. The other findings are normal variants on a newborn of this age. A newborn may normally experience a weight loss of 5% to 10% in the first days of life. Focus: Prioritization

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

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

After you receive the change-of-shift report, in which order will you assess these clients assigned to your care? 1. 22-year-old who has questions about how to care for the drains placed in her breast reconstruction incision 2. Anxious 44-year-old who is scheduled to be discharged today after undergoing a total vaginal hysterectomy 3. 69-year-old who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostatectomy 2 days ago 4. Usually oriented 78-year-old who has new-onset confusion after having a bilateral orchiectomy the previous day _____, _____, _____, _____

Ans: 4, 3, 2, 1 The bilateral orchiectomy client needs immediate assessment, because confusion may be an indicator of serious postoperative complications such as hemorrhage, infection, or pulmonary embolism. The client who had a perineal prostatectomy should be assessed next, because pain medication may be needed to allow him to perform essential postoperative activities such as deep breathing, coughing, and ambulating. The vaginal hysterectomy client's anxiety needs further assessment next. Although the breast implant client has questions about care of the drains at the surgical site, there is nothing in the report indicating that these need to be addressed immediately. Focus: Prioritization

The following clients come to the ED reporting acute abdominal pain. Prioritize them for care in order of the severity of their conditions. 1. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. 40-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week 4. 65-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour 5. 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 6. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night _____, _____, _____, _____, _____, _____

Ans: 4, 5, 2, 3, 1, 6 The client with a pulsating mass has an abdominal aneurysm that may rupture, and he may decompensate suddenly. The woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider. Focus: Prioritization

23. The RN is providing care for a patient diagnosed with dehydration and hypovolemic shock. Which order should the RN question? 1. Blood pressure every 15 minutes 2. Place two 18-gauge IV lines 3. Oxygen at 3 L via nasal cannula 4. D5W to run at 250 mL/hr

Ans: 4. D5W to run at 250 mL/hr To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic. All of the other orders are appropriate for a client with shock.

After emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function. 1. Obtain an order for a chest radiograph to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral. 5. Check exhaled carbon dioxide levels. _____, _____, _____, _____, _____

Ans: 5, 3, 4, 2, 1 Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the midepigastric area, tube placement must be corrected immediately. Securing the tube can be performed after these assessments are performed. Finally, radiographic study will verify and document correct placement. Focus: Prioritization

You are working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 minutes 2. Firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to the hands and forearms 4. Teenager with a crushed leg that is very swollen who is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. 12-year-old with wheezing and very labored respirations unrelieved by an asthma inhaler _____, _____, _____, _____, _____, _____

Ans: 6, 2, 4, 3, 5, 1 Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, because CPR efforts have been prolonged. Focus: Prioritization

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months Ms. C's self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize an appropriate diet and exercise plan. What is the priority nursing diagnosis? A. Imbalanced Nutrition: Less that Body Requirements B. Disturbed Body Image C. Risk for Situational Low Self-Esteem D. Ineffective Health Maintenance

B. Disturbed Body Image

A well-known celebrity is admitted to your unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response? A. Please be discreet and do not interrupt the work flow B. How did you find out that the patient was admitted to this unit? C. Please wait. I need to call the nursing supervisor about this request D I'm sorry; the patient has asked that only family be allowed to visit

B. How did you find out that the patient was admitted to this unit?

The team has to apply restraints to a combative patient in order to prevent harm to others or to self. Which action requires your intervention? A. Mental health assistant uses a quick-release knot B. MD secures the restraint to the side rail C. RN check the pulses distal to restraint D. LPN explains to the patient why he being restrained

B. MD secures the restraint to the side rail

You are interviewing a patient with suicidal ideations and a history of major depression. Which comment concerns you the most? A. I have had problems with depression most of my adult life B. My father and my brother both committed suicide C. My wife is having health problems and she relies on me D. I am afraid to kill myself, and I wished I had more courage

B. My father and my brother both committed suicide

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months For Ms. C, which route for delivery of nutrition and fluids will the health care team try first? A. NG B. PO C. IV D. Hypodermoclysis

B. PO

A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how ti prevent medication errors. A. Advise the pharmacy of any corrections as appropriate B. Recognize the "look-alike, sound-alike" drugs increase the chances of error C. Consult a medication book to verify the purpose of the drugs and generic and brand names D. Check the original medication order to verify what was prescribed E. Write an incident report, as appropriate, if you believe that a system error is occurring F. Call the MD for clarification of the order as appropriate

B. Recognize the "look-alike, sound-alike" drugs increase the chances of error D. Check the original medication order to verify what was prescribed C. Consult a medication book to verify the purpose of the drugs and generic and brand names F. Call the MD for clarification of the order as appropriate A. Advise the pharmacy of any corrections as appropriate E. Write an incident report, as appropriate, if you believe that a system error is occurring

An LPN complains to you that she is always assigned to the same patient with chronic depression. What should you do? A. Look at the assignment sheet and see if there is any way to switch assignments with another LPN B. Tell her to care for the patient today, but that you will remember the request for future assignments C. Remind her that continuity of care and patient-centered care are the primary goals D. Explain that patients with chronic conditions are more likely to fall under the LPN scope of practice

B. Tell her to care for the patient today, but that you will remember the request for future assignments

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions. A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000 B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

Which task can be assigned to a medical-surgical UAP who has been floated to the acute psychiatric unit? A. Performing one-to-one observation of a patient who is suicidal B. Assisting the OT to conduct a craft class C. Accompanying an elderly patient who wanders on a walk outside D. Assisting the medication nurse who is having problems with a patient

C. Accompanying an elderly patient who wanders on a walk outside

An elderly man was admitted for palliative care of terminal pancreatic cancer. The wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis if this sentinel event? (Select all that apply) A. The wife and all immediate family members B. Only the MD who discharged the patient C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient E. Only the RN who discharged the patient F. Any MD who has involved int eh care of this patient

C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient F. Any MD who has involved int eh care of this patient

Mr. J has a panic disorder and it appears that he is having some problems controlling his anxiety. Which symptoms concern you the most? A. His HR is increased and reports chest tightness B. He demonstrates tachypnea and carpopedal spasms C. He is pacing and pounding his fists together D. He is muttering to himself and is easily startled

C. He is pacing and pounding his fists together

There is a patient on the medical-surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you handle the assignment? A. Rotate the assignment schedule so that no one has to care for him more than once or twice a week B. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the patient C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions D. Assign yourself as primary caregiver sot hat you can role-model how patients should be treated

C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions

You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? A. Jane, come and sit in my house until this is over with B. Jane, calm down and let the fireman do his job C. Jane, look at me and hold my hand D. Jane, tell me why you are struggling so hard

C. Jane, look at me and hold my hand

Which behavior would be the most problematic and require vigilance to prevent danger to self or others? A. Avolition B. Echolalia C. Motor agitation D. Stupor

C. Motor agitation

A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He is being prescribed haloperidol. What is the priority action? A. Encourage him to look at you and stay with him until the spasms pass B. Place the patient on aspiration precautions until the spasms subside C. Obtain an order for IM or IV diphenhydramine D. Obtain an order for and administer an anti seizure medication

C. Obtain an order for IM or IV diphenhydramine

A patient comes in to the clinic with nausea, constipation, and "excruciating stomach pain." Over a period of several years, this patient has come in two or three times a month with the same report, but multiple diagnostic tests have consistently yielded negative results for physical disorders. What is the priority nursing intervention for this patient? A. Advocate for the patient to have a psychiatric consultation B. Ensure that the patient sees the same health care provider for continuity C. Perform a physical assessment to identify any physical abnormalities D. Assess for concurrent symptoms of depression or anxiety

C. Perform a physical assessment to identify any physical abnormalities

A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? A. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative." B. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." C. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment." D. Respect the patients wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you."

C. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment."

You are reviewing the principle of "least restrictive" intervention with the staff. Place the following intervention in the correct ascending order from the least restrictive to the most restrictive. A. Escort the patient to a quite room for a time out B. Restrain the patient's arms and legs with soft cloth restraints C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard E. Restrain the patient's upper extremities with wrist restraints F. Place the patient in an isolation room with a mental health assistant observing

C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard A. Escort the patient to a quite room for a time out F. Place the patient in an isolation room with a mental health assistant observing E. Restrain the patient's upper extremities with wrist restraints B. Restrain the patient's arms and legs with soft clothrestraints

A patient comes into the walk-in clinic and tells you that he wants to be admitted to alcohol rehabilitation program. Which question is the most important to ask? A. What made you decide to enter a program at this time? B. How much alcohol do you usually consume in a day? C. When was the last time your had a drink? D. Have you been in a rehabilitation program before?

C. When was the last time your had a drink?

You are caring for a patient in whom a conversation disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? A. Reassure her that her blindness is temporary and will resolve with time B. Gently point out that she seems to be able to see well enough to function independently C. Encourage expression of feelings and link emotional trauma to the blindness D. Teach ways to cope with blindness, such as methodically arranging personal items

D. Teach ways to cope with blindness, such as methodically arranging personal items

Which patient should be assigned to a newly-graduated nurse who has just started on the unit? A. Patient who is frequently admitted for borderline personality disorder and suicidal gesture B. Patient admitted yesterday for disorganized schizophrenia and psychosis C. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium D. Patient newly diagnosed with major depression and rumination about loss and suicide

D. Patient newly diagnosed with major depression and rumination about loss and suicide

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months You find Ms. C in her room jogging in place and doing jumping jacks "for about the last 20 minutes." What is the best response to give at this time? A. You can of for a few more minutes, but then you will tell me why your are exercising B. If you continue to exercise like this, you are just going to have to eat more at mealtimes C. Stop jogging right now. This is unacceptable behavior and you will lose all privileges D. We have talked about exercise, any you agreed to reach your target weight goal first

D. We have talked about exercise, any you agreed to reach your target weight goal first