Management Delegation Quiz 4

Which medication should the nurse be prepared to administer to lower the patient's potassium level? 1. Furosemide 40 mg IV push 2. Epoetin alfa 300 units/kg subcutaneously 3. Calcium 1 tablet PO 4. Sodium polystyrene sulfonate 15 g PO

4

Based on Ms. J's history, which risk factors indicate increased risk for CKD? SATA 1. GERD 2. HTN 3. Four pregnancies 4. Type 2 diabetes 5. Patient is hispanic 6. Coronary artery disease 7. Cataracts 8. Long-term use of OTC ranitidine

2, 4, 5, 6

The oral temperature of Mr. B, the patient newly admitted from a long-term care facility with decreased urine output and altered LOC, is now 102.6 F. What is the nurse's best action? 1. Notify the HCP 2. Administer acetaminophen 3. Assign the LPN/LVN to give an acetaminophen suppository 4. Remove extra blankets from the patient's bed

1

The results of Ms. J's 24-hour urine collection reveals a creatinine clearance of 65 mL/min (1.09 mL/sec). How does the nurse *best* interpret this finding? 1. Creatinine clearance is lower than normal 2. Creatinine clearance is higher than normal 3. Creatinine clearance is within normal range 4. Creatinine clearance indicates adequate kidney function

1

Which factor does the nurse suspect most likely precipitated Mr. B's elevated temperature? 1. Bladder infection 2. Increased metabolic rate 3. Kidney failure 4. Nosocomial pneumonia

1

The RN is assessing Ms. J's chest pain. Which question would the RN be sure to ask the patient? SATA 1. "When did you first notice the chest pain?" 2. "Did your pain start suddenly or gradually?" 3. "How long has the chest pain lasted?" 4. "Have you experienced confusion or loss of memory with the pain?" 5. "Can you grade you pain on a scale of 0 to 10, with 10 being the worst pain ever?" 6. "What were you doing when the chest pain started?"

1, 2, 3, 5, 6

The nurse reports the morning assessment findings to the HCP. Which prescribed intervention is most directly related to the nurse's assessment findings? 1. Administer furosemide 20 mg IV push now 2. Keep accurate records of intake and output 3. Administer potassium 20 mEq/L orally every morning 4. Weigh the patient every morning

1

Mr. W is to be transferred back to the long-term care facility after lunch. Which nursing care intervention would be best for the RN to assign to the experienced LPN/LVN? 1. Administer the patient's 12:00 pm oral medications 2. Check and record a set of vital signs at 12:00 pm. 3. Pack the patient's personal items to be taken with him. 4. Change Mr. W's incontinence pad before he is transferred.

1

Ms. J states that she feels increasingly short of breath. The nurse team leader is supervising an LPN/LVN and a UAP. Which nursing care action for Ms. J is the most appropriate to assign to the LPN/LVN? 1. Checking for residual urine with the bedside bladder scanner 2. Planning restricted fluid amounts to be given with meals 3. Assessing breath sounds for increased bilateral crackles 4. Discussing renal replacement therapies with the patient

1

Ms. S tells the nurse that she has worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and the nurse notifies the HCP. Which prescribed action takes the highest priority at this time? 1. Administer morphine sulfate 2 mg IV push. 2. Schedule an ECG. 3. Draw blood for coagulation studies. 4. Administer ranitidine 75 mg PO every 12 hours.

1

Ms. S's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs) and short runs of ventricular tachycardia. Which drug should the nurse be prepared to administer first? 1. Amiodarone IV push 2. Nitroglycerin sublingually 3. Morphine sulfate IV push 4. Atenolol IV push

1

Ms. S's daughter asks the nurse why her mother did not receive a "clot-buster" drug. What is the nurse's best response? 1. "Thrombolytic agents, also called clot busters, are most effective when administered within the first 6 hours of a coronary event" 2. "Thromoblytic drugs are much more effective when used for patients who have had a recent stroke" 3. "Thrombolytic drugs work better for patients who have a heart attack at a much younger age" 4. "Contraindications for these drugs include recent surgeries, and your mother had gallbladder surgery a year ago"

1

Six months later, Ms. J is readmitted to the unit. She has just returned from HD. Which nursing care action should the nurse delegate to the AP? 1. Measuring vital signs and postdialysis weight 2. Assessing the HD access site for bruit and thrill 3. Checking the access site dressing for bleeding 4. Instructing the patient to request assistance getting out of bed

1

The AP is delegated that task of measuring morning vital signs for all six patient. Which finding would the nurse instruct the AP to report immediately? 1. Oral temperature higher than 102 F 2. Blood pressure higher than 140/80 mmHg 3. Heart rate lower than 65 bpm 4. Respiratory rate lower than 18 breaths/min

1

The HCP prescribes captopril 12.5 mg orally twice daily and HCTZ 25 mg orally daily. Which information would the nurse be sure to include when teaching Ms. S about these drugs? 1. "Take your HCTZ in the morning" 2. "If you miss a dose of captopril, tale two tablets next time" 3. "Avoid foods that are rich in potassium, such as bananas and oranges" 4. "You should expect an increase in blood pressure with these drugs"

1

The HCP's prescribed actions for this patient include all of the following. Which intervention should the nurse complete first? 1. Send an ABG sample to the lab 2. Schedule pulmonary function tests 3. Repeat chest radiography each morning 4. Administer albuterol via MDI 2 puffs every 4 hours

1

The LPN/LVN reports to the RN that Mr. R was unable to take his oral medications because of difficulty swallowing. The RN assesses Mr. R and finds that he is having dysphagia. What is the RN's best instruction for the LPN/LVN? 1. "Keep Mr. R NPO, and I will contact his HCP" 2. "Try giving his medications with applesauce or pudding" 3. "Check with the pharmacy to find out if they have liquid forms of Mr. R's medications" 4. "Assess Mr. R's ability to speak and move his tongue"

1

The RN administers the patient's first dose of IV cefotaxime. Within 15 minutes, Mr. W develops a rash with fever and chills. What is the nurse's first action at this time? 1. Discontinue the IV infusion 2. Administer two tablets of acetaminophen 3. Measure the area of the rash 4. Check for numbness and tingling

1

The RN is caring for Ms. J on the first day postop after a kidney transplant. On assessment, her temperature is 100.4 F, her blood pressure is 168/92 mmHg, and the patient tells the RN she has pain around the transplant site. What is the best interpretation of these findings? 1. Hyperacute rejection 2. Acute rejection 3. Chronic rejection 4. Transplant site infection

1

The RN is delegating and assigning care for Ms. J related to her type 2 diabetes. Which action by the RN indicates that the team leader needs to intervene? 1. RN delegates fingerstick glucose check to newly hired AP 2. RN assigns administering morning dose of metformin to the LPN/LVN 3. RN refers the patient to a dietician for education about a diabetic diet 4. RN assesses the condition of the patient's feet daily

1

The RN reviews Ms. J's lab results. Which lab finding is of greatest concern? 1. Serum potassium level of 7.1 mEq/L 2. Serum creatinine level of 7.3 mg/dL 3. BUN level of 180 mg/dL 4. Serum calcium level of 7.8 mg/dL

1

Ms. J's care plan includes the nursing concern, excess fluid volume. What interventions are appropriate for this nursing concern? SATA 1. Measure weight daily. 2. Monitor daily intake and output. 3. Restrict sodium intake with meals. 4. Restrict fluid to 1500 mL plus urine output. 5. Assess for crackles in the lungs at least once per shift. 6. Check for peripheral edema and note any increase. 7. Assess level of consciousness and cognition 8. Ask patient about headache or blurred vision

1, 2, 3, 5, 6, 7, 8

Based on the patient's ABG results, what are the nurse's priority actions at this time? SATA 1. Administer oxygen at 2 L/min via nasal cannula 2. Initiate a rapid response 3. Teach the patient how to cough and deep breathe 4. Begin IV normal saline at 100 mL/hr 5. Arrange a transfer to the ICU 6. Remind the patient to practice incentive spirometry every hour while awake

1, 2, 3, 6

Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which postprocedural tasks would be best assigned to the LPN/LVN? SATA 1. Check bilateral pedal pulses every 15 minutes during the first hour 2. Check right groin area for bleeding 15 minutes during the first hour 3. Continue IV fluids normal saline at 50 mL/hr 4. Assist patient to bathroom as needed during first 6 hours after the procedure 5. Administer morphine sulfate 2 mg IV push as needed for pain 6. Give patient's daily multivitamin and stool softener on return to medical unit

1, 2, 3, 6

The RN assesses Mr. W in the ED. Which assessment findings are consistent with a diagnosis of COPD? SATA 1. Enlarged neck muscles 2. Forward bent posture 3. Respiratory rate 15 to 25 breaths/min 4. Inspiratory and expiratory wheezes 5. Blue-tinged dusky appearance 6. Symmetrical lung expansion

1, 2, 4, 5

Which risk factors from Ms. S's history would suggest a possible cardiac problem to the nurse? 1. HTN for 12 years 2. Smoked for 43 years, quit 1 year ago 3. Surgery for gallbladder removal 1 year ago 4. Ms. S's father died at age 42 years from a heart attack 5. Patient's weight is 278 lb 6. Diet includes fast foods three to five times a week 7. Patient is an African-American female 8. History of GERD 9. Report of chest pressure and indigestion associated with nausea

1, 2, 4, 5, 6, 7, 9

Mr. W is receiving an IV dose of potassium 10 mEq/100 mL normal saline to run over 1 hour. The AP asks why it takes so long to infuse such a small amount of fluid. What should the nurse explain to the AP? SATA 1. "IV potassium is very irritating to the veins and can cause phlebitis" 2. "Tissue damaged by potassium can become necrotic" 3. "Oral potassium can cause nausea, so IV potassium is preferred" 4. "The maximum recommended infusion rate for IV potassium if 5 to 10 mEq/hr" 5. "That's a good question, and I will ask the HCP if I can give the drug IV push" 6. "The goal is to prevent infiltration into the tissue" 7."The patient is not taking in sufficient dietary potassium to keep the level within normal limits" 8. "Giving the potassium slowly will give us time to teach the patient about dietary sources of potassium"

1, 2, 4, 6

Which interventions would the acute care RN delegate to an experienced assistive personnel? SATA 1. Changing the patient's incontinence pad as needed 2. Performing pulse oximetry every shift 3. Teaching the patient to cough and deep breathe 4. Reminding the patient to use incentive spirometry every hour while awake 5. Assessing the patient's breath sounds every shift 6. Encouraging the patient to drink adequate oral fluids

1, 2, 4, 6

Which patient admission tasks should the nurse delegate to the experienced assistive personnel? SATA 1. Check vital signs every 4 hours 2. Record accurate intake and output 3. Place a saline lock in left forearm 4. Check oxygen saturation by pulse oximetry 5. Teach the patient the importance of keeping oxygen in place 6. Check and record the fingerstick blood glucose before lunch

1, 2, 4, 6

Because Ms. S continues to experience chest discomfort and has elevated levels of cardiac markers, the following interventions have been prescribed by the HCP. Which interventions should the nurse delegate to an experienced AP? SATA 1. Measuring vital signs every 2 hours 2. Accurately recording intake and output 3. Administering tenecteplase IV push 4. Drawing blood for coagulation studies 5. Assessing the cardiac monitor every 4 hours 6. Assisting the patient to the bedside commode 7. Helping the patient with morning care and partial bed bath 8. Assessing the patient's pain level 9. Reminding the patient to report any episodes of chest discomfort

1, 2, 6, 7

Mr. W has lost 15 lb over the past year. On assessment, he tells the nurse that his appetite is not what it used to be, and he becomes short of breath while eating. Which interventions should be included in his nursing care plan? SATA 1. Initiate a dietary consult 2. Stress that he must eat all of his meals or he'll become malnourished 3. Monitor serum prealbumin levels 4. Suggest four to six small meals per day 5. Instruct the patient to use his bronchodilator 30 minutes before meals 6. Encourage dry foods to avoid coughing

1, 3, 4, 5

Ms. S has returned to the CCU after a cardiac catheterization and a percutaneous coronary intervention procedure. Which follow-up care orders should the nurse assign to an experienced LPN/LVN? SATA 1. Reminding the client to remain on bed rest with the insertion site extremity straight 2. Preparing a teaching plan that includes activity restrictions and risk factor modification 3. Measuring the client's vital signs every 15 minutes for the first hour 4. Assessing the catheter insertion site for bleeding or hematoma formation 5. Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs 6. Administering two tablets of acetaminophen for back pain

1, 3, 4, 5, 6

Which patients should the team leader assign to the LPN/LVN for nursing care under the RN's supervision? SATA 1. Mr.C (unstable angina) 2. Ms. J (chest pain) 3. Mr. R (stroke) 4. Ms. S (heart disease and dementia) 5. Mr. B (decreased urine output, altered LOC) 6. Mr. L (SOB and chronic emphysema)

1, 3, 4, 6

Which activities could the nurse delegate to AP assisting Ms. S during phase 1 of cardiac rehabilitation? SATA 1. Assist with Ms. S's morning bath as needed 2. Refer Ms. S to a monitored cardiac rehab program 3. Ambulate Ms. S to the bathroom 4. Administer Ms. S's morning doses captopril and HCTZ 5. Assist with progressive ambulation in the hall 6. Assess Ms. S for additional chest pain or pressure

1, 3, 5

Based on Ms. S's admission vital signs, which HCP orders would the nurse expect? Vitals: BP 174/92 mmHg, HR 120 to 130 bpm and irregular, O2 sat 91% on RA, RR 30 to 34 breaths/min, Temp 99.8 F. SATA 1. Continuous cardiac monitoring 2. Blood pressure checks every 10 minutes 3. Oxygen at 2 L per nasal cannula 4. Instruct patient to breathe and rebreathe into a paper bag 5. Acetaminophen 650 mg as needed for temperature greater than 99 F 6. Check apical heart rate with each set of vital signs

1, 3, 6

After discussing renal replacement therapies with the HCP and nurse, Ms. J is considering hemodialysis. Which statement indicates that Ms. J needs additional teaching about HD? 1. "I will need surgery to create an access route for HD" 2. "I will be able to eat and drink what I want after I start dialysis" 3. "I will have a temporary dialysis catheter for a few months" 4. "I will be having dialysis three times every week"

2

All of these laboratory values were obtained for Ms. S in the ED. Which value would be of most concern to the nurse and have immediate implications for the care of the patient? 1. Potassium level of 3.5 mEq/L 2. Troponin T level of more than 0.20 ng/mL 3. Glucose level of 123 mg/dL 4. Slight elevation of white blood cell count

2

An LPN/LVN tells the RN that the patient is now receiving oxygen at 2 L/min via nasal cannula and his pulse ox reading is 91%, but he still has crackles in the bases of his lungs. What intervention should the RN assign to the LPN/LVN? 1. Begin creating a plan for discharging the patient 2. Administer furosemide 20 mg orally each morning 3. Get a baseline weight for the patient now 4. Administer cefotaxime IV piggyback every 6 hours

2

During admission assessment, Ms. J has all of these findings. For which finding should the nurse notify the HCP immediately? 1. Bilateral pitting ankle and calf edema rated +2 2. Crackles in both lower and middle lobes 3. Dry and peeling skin on both feet 4. Faint but palpable pedal and post-tibial pulses

2

During the shift change report, the night RN informs the team that Ms. S is to be transferred back to her long-term care facility after lunch. What action should be taken for this patient? (case study 3) 1. Instruct the AP to awaken her for vital signs and breakfast 2. Allow her to sleep for an hour or two while the other patients are assessed 3. Assign the LPN/LVN to immediately pack up the patient's belongings 4. Call the nursing home to find out if the transfer can wait until tomorrow

2

Ms. S's condition is stable, and she has been transferred to the cardiac step-down unit. What should the step-down nurse instruct the AP to report immediately? 1. Temperature 99 F with morning vital sign monitoring 2. Chest pain episode occurring during morning care 3. Systolic blood pressure increase of 8 mmHg after morning care 4. Heart rate increase of 10 bpm after ambulation

2

The AP reports that Mr. L's heart rate, which was 86 bpm in the morning, is now 98 bpm. What would be the most appropriate question for the nurse to ask Mr. L? 1. "Have you just returned from the bathroom?" 2. "Did you recently use you albuterol inhaler?" 3. "Are you feeling short of breath?" 4. "How much do you smoke?"

2

The HCP's prescribed intervention for Mr. R, who had a stroke 4 days ago, include assisting the patient with meals. Which staff member would be best to assign this task? 1. Physical therapist 2. AP 3. LPN/LVN 4. Occupational therapist

2

The RN is working on a care plan for Mr. B. Which care intervention is most appropriate to delegate to the AP? 1. Checking the patient's LOC every shift 2. Assisting the patient with ambulation to the bathroom to urinate 3. Teaching the patient the side effects of antibiotic therapy 4. Administering sulfamethoxazole-trimethoprim orally every 12 hours

2

The patient is scheduled for an emergent cardiac catheterization with possible percutaneous coronary intervention. Ms. S asks the nurse what is involved with this procedure. What is the nurse's best response? 1. "It is a procedure that is usually done on patients who have heart attacks to diagnose blockages in the arteries that feed the heart" 2. "The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open" 3. "Cardiac catheterization is usually performed on an outpatient basis to determine whether or not you have had a heart attack" 4. "After the cardiac catheterization, you will come back to the coronary care unit, where you will be on bed rest for 6 to 8 hours, and we will check your vital signs often"

2

What is the priority nursing concern for this patient (case study 2)? 1. Skin care because of incontinence 2. Clearance of thick secretions 3. Rapid heart rate 4. Elevated temperature

2

Which formation is most important to prevent recurrence of reocclusion of the coronary artery, chest discomfort, or myocardial infarction? 1. Remain on bed rest for the next 24 hours 2. Patient will be prescribed dual antiplatelet therapy 3. Patient should do no heavy lifting for 48 hours 4. HCP will prescribe a beta-blocker

2

Which patient should the RN assess first? 1. Mr. C (unstable angina) 2. Ms. J (chest pain) 3. Mr. B (decreased urine output, altered LOC) 4. Mr. L (SOB and chronic emphysema)

2

The team leader RN observes the AP perform all of these actions for Ms. J. For which actions must the RN intervene? SATA 1. Assisting the patient to replace her oxygen nasal cannula 2. Checking vital signs after the patient has had something cold to drink 3. Ambulating with the patient to the bathroom and back 4. Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min 5. Washing the patient's back, legs, and feet with warm water 6. Reminding Ms. J to perform prescribed incentive spirometry every hour while awake

2, 4

Near the end of the shift, the LPN/LVN reports that the UAP has not totaled clients' intake and output for the past 8 hours. What is the nurse's best action? 1. Confront the UAP and instruct him to complete this assignment at once 2. Assign this task to the LPN/LVN 3. Ask the UAP if he needs assistance completing the intake and output records 4. Notify the nurse manager to include this on the UAP's evaluation.

3

The AP asks the RN why it is important to notify someone whenever a patient with heart problems reports chest pain. What is the RN's best response? 1. "It's important to keep track of the chest pain episodes so we can notify the HCP" 2. "The patient may need morphine to treat the chest pain" 3. "Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment" 4. "Our unit policy includes specific steps to take in the treatment of patients with chest pain"

3

Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates notification of the HCP? 1. Weight decrease of 4.5 lb 2. Systolic blood pressure decrease of 14 mm Hg 3. Decreased level of consciousness 4. Small blood spot near the center of the dressing

3

During morning rounds, the nurse notes all of these assessment findings for Mr. W. Which finding indicates a worsening of the patient's condition? 1. Barrel-shaped chest 2. Clubbed fingers on both hands 3. Crackles bilaterally 4. Frequent productive cough

3

Mr W's ABG results include the following ph 7.37 PaCO2 55.4 PaO2 51.2 HCO3 38 What is your interpretation of these results? 1. compensated metabolic acidosis with hypoxemia 2. compensated metabolic alkalosis with hypoxemia 3. compensated respiratory acidosis with hypoxemia 4. compensated respiratory alkalosis with hypoxemia

3

Mr. W's ED lab values include a serum potassium of 2.8 mg/dL. What is the priority nursing action at this time? 1. Teach the patient about potassium-rich foods 2. Provide the patient with oxygen at 2 L per nasal cannula 3. Contact and notify the HCP immediately 4. Initiate 0.9% saline at 20 mL/hr

3

The AP reports to the RN that Mr. L, the patient with chronic emphysema, says he is feeling short of breath after walking to the bathroom. What action should the RN take first? 1. Notify the HCP 2. Increase oxygen flow to 6 L/min via nasal cannula 3. Assess oxygen saturation by pulse ox 4. Remind the patient to cough and deep breathe

3

The AP tells the nurse that Mr. W is unable to complete his morning care without assistance and wonders if he is being lazy. What is the nurse's best response? 1. "Encourage the patient to do as much as he can as quickly as he can" 2. "If the patient is short of breath, increase his oxygen flow" 3. "Remind the patient to take his time and not to rush his morning care" 4. "He may not need as much help as he is asking for, so try to get him to do more"

3

The HCP prescribed atenolol 50 mg each morning for Ms. S. Which instruction would the nurse provide for the LPN/LVN assigned to give this drug? 1. Hold the drug if the patient's blood pressure is higher than 100/80 mmHg 2. Give the drug if the patient's respiratory rate is greater than 30 breaths/min 3. Hold the drug if the patient's heart rate is less than 55 bpm 4. Give the drug if the patient's blood pressure is less than 90/50 mmHg

3

The HCP's prescribed actions for Ms. J, who is currently experiencing chest pain, are as follows. Which intervention should be completed first? 1. Administer nitroglycerin 0.6 mg sublingually as needed for chest pain 2. Administer morphine 2 mg IV push as needed for chest pain 3. Check blood pressure and heart rate 4. Complete lab tests including cardiac markers and daily ECG

3

The RN is precepting a new nurse orienting to the unit, who is providing care for Ms. J after her return from surgery to create a left forearm access for dialysis. Which action by the orienting nurse requires that the preceptor intervene? 1. Monitoring the patient's operative site dressing for evidence of bleeding 2. Obtaining a blood pressure reading by placing the cuff on the right arm 3. Drawing blood for lab studies from the temporary dialysis line 4. Administering acetaminophen when codeine PO for moderate postop pain

3

The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT). What is the nurse's best action? 1. Instruct the UAP to put the client in a wheelchair and take her to the lab 2. Call the cardiac lab and ask to delay the test until later in the day 3. Contact the HCP to ask if the client should still have the GXT 4. Ask the client if she is continuing to have chest pain

3

Which action prescribed by the HCP for Ms. S tale first priority at this time? 1. Measure vital signs every 2 hours 2. Obtain a 12-lead ECG every 6 hours 3. Place the patient on a cardiac monitor 4. Check levels of cardiac markers every 6 hours

3

Which assessment finding would the nurse instruct the AP to report immediately? 1. Incontinence of urine and stool 2. 1-lb weight loss since admission 3. Patient cough productive of greenish-yellow sputum 4. Eating only half of breakfast and lunch

3

Which key point would the nurse be sure to include when teaching Mr. C about the postprocedural care for cardiac catheterization? 1. "There are no restrictions after the procedure" 2. "You will be able to get out of bed within 2 hours after the procedure" 3. ""You will have to stay almost flat in bed with limited position changes for 4 to 6 hours" 4. "Family visitors will be restricted until the next day"

3

Which task associated with the patient's 24-hour urine collection is appropriate for the nurse to delegate to the UAP? 1. Instructing Ms. J to collect all urine with each voiding 2. Teaching Ms. J the purpose of collecting urine for 24 hours 3. Ensuring that all of Ms. J's urine collected for the test is kept on ice 4. Assessing Ms. J's urine for color, odor, and sediment

3

While making the rounds, the RN finds Ms. J in tears and sobbing. She states, "I just don't want to have to go back to dialysis 3 days a week!" What is the nurse's best response? 1. "Would you like me to call someone to come in and sit with you?" 2. "You can always get on the list for another kidney transplant" 3. "Tell me some more about how you are feeling" 4. "Let me call your HCP to come in and speak with you"

3

Which tasks should the nurse delegate to the newly hired AP? SATA 1. Asking Ms. S memory-testing questions 2. Teaching Ms. J about treadmill exercise testing 3. Checking vital signs on all six patients 4. Recording oral intake and urine output for Mr. B 5. Assisting Mr. L to walk to the bathroom 6. Helping Mr. R with morning care

3, 4, 5, 6

The nurse delegates to the AP the task of taking Ms. S's vital signs every 4 hours and recording the vital sign values in the electronic chart. Later the nurse checks the patient's chart and discovers that vital sign measurements have not been recorded. What is the nurse's best action? 1. Take the vital signs because the AP is not competent to complete this task 2. Notify the nurse manager immediately 3. Reprimand the AP at the nurse's station 4. Speak to the AP privately to determine why the values were not recorded

4

What intervention is required at this time? 1. Increased doses of immunosuppressive drugs 2. IV antibiotics 3. Conservative management including dialysis 4. Immediate removal of the transplanted kidney

4

Which action is best for the nurse to delegate to a new assistive personnel orienting to the CCU when caring for Ms. S? 1. Placing the patient on a cardiac telemetry monitor 2. Drawing blood to test cardiac marker levels and sending it to the laboratory 3. Obtaining a 12-lead ECG 4. Checking and recording the patient's intake and output

4

Before discharging Ms. S, the HCP orders an ECG. This reveals normal sinus rhythm with a heart rate of 87 bpm. What is the nurse's best action at this time? 1. Delay the patient's discharge until she is seen by the HCP 2. Administer the patient's next dose of atenolol 3 hours early before she goes home 3. Contact the HCP and ask about drawing an additional set of cardiac markers 4. Document this finding as the only action and prepare for discharge

4

Ms. J is preparing for discharge. The RN is supervising a student nurse, who is teaching the patient about her discharge medications. For which statement by the student nurse will the RN intervene? 1. "Sevelamer prevents your body from absorbing phosphorus." 2. "Take your folic acid after dialysis on dialysis days." 3. "The docusate is to prevent constipation that may be caused by ferrous sulfate." 4. "You must take the epoetin alfa three times a week by mouth to treat anemia."

4

The AP checks morning vital signs and immediately reports the following values to the nurse. Which takes priority when notifying the HCP? 1. Heart rate of 96 bpm 2. Blood pressure of 160/90 mmHg 3. Respiratory rate of 34 breaths/min 4. Oral temperature of 103.5 F

4

The HCP orders dual antiplatelet therapy for Ms. S. What is the nurse's highest priority concern for this patient? 1. Reminding the patient to do no heavy lifting while hospitalized 2. Assessing the progression of walking in the halls 3. Teaching the patient to apply oxygen for any shortness of breath 4. Monitoring the patient for any form of bleeding

4

The LPN/LVN rechecks Ms. J's O2 saturation after she has been on oxygen at 2 L/min per nasal cannula and finds the reading is now 93%. What is the LPN/LVN's best action? 1. Increase the oxygen to 3 L/min per nasal cannula 2. Ask the respiratory therapist to start Ms. J on incentive spirometry 3. Teach Ms. J to take 10 deep breaths every hour while awake 4. Notify the team leader RN and record the finding

4

The LPN/LVN reports to the RN that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if the patient can be restrained. What is the RN's best response? 1. "Yes, this patient had a heart attack, and we must keep her on the cardiac monitor" 2. "Yes, but be sure to use soft restraints so that the patient's circulation is not compromised" 3. "No, we must have an HCP's order before we can apply restraints in any situation" 4. "No, but try covering the lead wires with the sheet so that the patient does not see them"

4

The RN observes the patient's use of the albuterol MDI. The patient takes two puffs from the inhaler in rapid succession. Which intervention takes priority at this time? 1. Call the pharmacy to request a spacer for the patient 2. Notify the provider that the patient will need to continue receiving nebulizer treatments 3. Ask the AP to help get the patient into a chair 4. Instruct the patient about proper techniques for using an MDI

4

The RN team leader assigns the LPN/LVN to give Ms. J's 9:00 AM oral medications. Which key instruction or action will be most important regarding the action of Ms. J's atenolol 50 mg tablet? 1. Give this drug with just a few swallows of water 2. Ask the patient if she has been taking a diuretic at home 3. Instruct the patient to use the bedside commode 4. Check the patient's heart rate and blood pressure

4

Which intervention would the RN assign to an experienced LPN/ LVN? 1. Drawing a sample for ABG determination 2. Administering albuterol by handheld nebulizer 3. Measuring vital signs every 2 hours 4. Increasing oxygen flow rate from 1 to 2 L/min by nasal cannula

4