Leadership & Management
The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1. Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2. Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3. Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain 4. Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber
Answer: 3 Rationale: A lung contusion (bruised lung) caused by a blunt force to the chest is potentially life-threatening. Clients should be monitored for 24-48 hours after the injury for manifestations of hypoventilation and hypoxemia as these are usually absent initially but develop as the bruise worsens.
A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center
Answer: 4 Rationale: Individuals impacted by natural disasters or emergencies are often in need of mental health services for assistance in coping with a wide range of reactions and emotions including fear, confusion, hopelessness, and anxiety. Outreach strategies in the aftermath of a disaster need to be centrally coordinated by the various community agencies providing services in order to maximize efficiency and avoid duplicative efforts.
Which client should the nurse assess first after receiving the hand-off morning report? 1. Client 1 day postoperative exploratory abdominal laparotomy who has a nasogastric tube and absent bowel sounds in 4 quadrants 2. Client with a peripherally inserted central catheter who has a 5-cm (2-in) increase in external catheter length since yesterday 3. Client with chronic diarrhea from malabsorption syndrome who is receiving 10% dextrose in water via a peripheral IV line 4. Client with type 2 diabetes mellitus who is scheduled for discharge and has a hemoglobin A1C level of 9%
Answer: 2 Rationale: A change in the length of the external portion of a peripherally inserted central catheter (PICC) can indicate migration of the catheter from its original position. If migration is suspected, the nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider immediately for evaluation and x-ray verification of placement of the catheter tip.
The emergency department nurse is triaging clients. Which client is a priority for diagnostic workup and definitive care? 1. Fell, twisting the right knee; heard a "pop" 2. History of glomerulonephritis; has "iced tea"-colored urine 3. Pain 10/10 in reddened eye; wears contact lens 4. Took a handful of amitriptyline tablets after a fight with spouse
Answer: 4 Rationale: Priority is given to clients with overdose, especially those who have taken tricyclic antidepressants (amitriptyline) as they are at risk for lethal cardiovascular arrhythmias.
The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."
Answer: 1 Rationale: COX-2 inhibitors (eg, celecoxib) and nonsteroidal anti-inflammatory drugs (eg, ibuprofen) are associated with increased risk of cardiovascular events. Myocardial infarction in an elderly woman can present with atypical symptoms (eg, shoulder pain, nausea).
After receiving the shift report, the nurse should assess which infant first? 1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min 2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2 mmol/L) 3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago 4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)
Answer: 2 Rationale: A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include - jitters -cyanosis -tremors -pallor -poor feeding -retractions -lethargy -low oxygen saturation -seizures This infant with borderline-low glucose level is symptomatic and should be assessed first.
The nurse has received report on 4 clients at the start of the shift. Which client should the nurse assess first? 1. Client in body cast who reports abdominal pain and bloating 2. Client post mastectomy who reports numbness at the surgical site 3. Client post neck dissection who reports difficulty chewing 4. Client receiving antibiotics who reports new-onset vaginal itching
Answer: 1 Rationale: Large body casts can cause bowel obstruction as a result of cast syndrome or decreased peristalsis. Bowel obstruction symptoms should be addressed immediately due to the potential for bowel ischemia. Note: rest of s&s with other scenarios listed are expected
The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. 1. Avoid infusion devices in confused clients as alarms can be disruptive 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45-degree angle on insertion because older adults have deeper veins that roll
Answer: 2,3,4 Rationale: -The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. -Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance -Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. -Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. -Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. -Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. -Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). -Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5).
An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death
Answer: 4 Rationale: The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess the client's needs and ensure that the plan of care will facilitate the client's life closure activities (eg, legacy building).
The nurse receives a report on 4 clients. Which client should the nurse assess first? 1. A 29-year-old heroin user admitted for arm cellulitis 24 hours ago has abdominal cramps and is restless 2. A 34-year-old admitted with femur fracture 24 hours ago is confused and has SpO2 of 91% 3. A 65-year-old admitted with serum sodium of 125 mEq/L (125 mmol/L) 8 hours ago is confused 4. A 78-year-old admitted for urinary tract infection 6 hours ago is disoriented to time and place
Answer: 2 Rationale: Clients with pelvic or long-bone fractures are at risk for the development of life-threatening fat embolism syndrome. (S&S) -Respiratory distress -mental status changes - petechiae (on chest, axillae, and soft palate)
The registered nurse is working with a licensed practical nurse and unlicensed assistive personnel. A client has just returned to the cardiac unit after a percutaneous coronary intervention. Which actions are most appropriate for the registered nurse to assign to the licensed practical nurse? Select all that apply. 1. Administer oral pain medication for the client's chronic lower back pain 2. Assist the client with the use of a urinal post-procedure 3. Monitor for bleeding at the catheter insertion site every 15 minutes 4. Perform the initial post-procedure vital sign measurements 5. Review the ECG monitor for dysrhythmias
Answer: 1,3 Rationale: Scope of practice RN: Initial client education Discharge education Clinical judgment Initiating blood transfusion LPN/LVN: Monitoring RN findings Reinforcing education Routine procedures (eg, catheterization) Most medication administrations Ostomy care Tube patency & enteral feeding Specific assessments* UAP: Activities of daily living Hygiene Linen change Routine, stable vital signs Documenting input/output Positioning
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime
Answer: 1,4,5 Rationale: The role of the LPN includes: -Administration of enteral feedings (if prescribed) -Administration of medications -Monitoring for safety hazards -Monitoring for behavioral changes The role of UAP includes: -Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care, personal hygiene) -Assisting with feeding -Reporting changes in ability to eat or difficulty swallowing -Reporting changes in behavior -Placing bed alarms to reduce risk of falls
The clinic nurse is teaching a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information? 1. "I will get this notarized as soon as I can." 2. "I will give a copy of this to my daughter, who is listed as my health care proxy." 3. "I'll put this on my refrigerator, so no one will give me cardiopulmonary resuscitation (CPR)." 4. "You and my daughter can witness this for me."
Answer: 2 Rationale: An advance directive is placed in the client's medical record and copies are given to health care proxies. Two witnesses are required for completion of the advance directive, but they should not be the health care proxies listed in the document.
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? Click on the exhibit button for additional information. 1700 Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor. __________RN 1710 Health care provider (HCP) notified of fall. Prescribed CT of head STAT. ___________RN 1740 No change in neurologic status. Client to CT via gurney. Report filed per policy. __________RN 1810 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor. __________RN 1. 1700 2. 1710 3. 1740 4. 1810
Answer: 3 Rationale: The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system, using an electronic form. The nurse SHOULD NOT document that an incident report was filed or refer to the incident report in the medical record.
