MedSurg: Prioritization Ch 2 CV management

The nurse is administering medications at 1800 to a client and uses the following medication administration record (MAR). Which intervention should the nurse implement first? 1. Assess the client's potassium and digoxin levels. 2. Monitor the client's partial thromboplastin level. 3. Check the client's International Normalized Ratio (INR). 4. Verify the client's name and identification (ID) number with the MAR.

Answer: 3 1. The day shift nurse should check the client's potassium and digoxin levels prior to administering the digoxin. The digoxin has been administered for the day. 2. A partial thromboplastin time is monitored for IV heparin, not Coumadin. 3. The nurse should monitor the INR prior to administering warfarin (Coumadin). The therapeutic level for warfarin is 2 to 3. 4. This should be done immediately prior to administering the medication at the bedside.

The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first? 1. Place the client on a telemetry monitor and assess the client. 2. Call an ambulance to transfer the client to a charity hospital. 3. Have the client sign a form agreeing to pay the bill. 4. Ask the client why he chose to come to this hospital.

Answer: 1 1. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The nurse should initiate steps to assess the client. 2. The nurse must assess the client. If a transfer is made, it will be after the client has been stabilized and the receiving hospital has accepted the transfer. 3. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The hospital will attempt to recover the costs after the client has been treated. 4. This is irrelevant information.

The female family member of the client experiencing a cardiac arrest refuses to leave the client's room. Which intervention should the administrative supervisor implement? 1. Stay with the family member and explain what the team is doing. 2. Call hospital security to escort the family member out of the room. 3. Ask the healthcare provider (HCP) whether the family member can stay. 4. Ignore the family member unless she becomes hysterical.

Answer: 1 1. If the family is not causing a disruption in the code, the family member should be allowed to stay in the room with the supervisor remaining near the family member and explaining why the interventions are being implemented will help the client to survive. The supervisor should be ready to escort the family member out of the code if the family member becomes disruptive. 2. This will cause ill will on the part of the family and could result in the filing of a needless lawsuit. 3. The HCP is busy with the care of the client. This is not the time to ask an HCP a question the supervisor can handle. 4. Ignoring the family member could cause a problem; the supervisor should be proactive in managing the situation.

The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? 1. Tell the LPN to notify the clinic healthcare provider (HCP). 2. Instruct the LPN to assess the client for abnormal bleeding. 3. Obtain a stat electrocardiogram on the client. 4. Take no action because this INR is within the normal range.

Answer: 1 1. The LPN can contact the HCP and give pertinent information. The INR is high (therapeutic is 2 to 3), and the HCP should be informed. 2. The RN cannot assign assessment to an LPN. 3. The INR is elevated, but this will not affect the client's atrial fibrillation. The client is at risk for abnormal bleeding, not a life-threatening dysrhythmia. 4. The normal INR is 2 to 3; therefore, some action should be implemented.

The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.

Answer: 1 1. The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice. 2. The apical heart rate should be greater than 60 beats/minute before administering the medication; therefore, the nurse would not question administering this medication. 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be taken with foods to prevent gastric upset; therefore, the nurse would not question administering this medication. 4. The INR therapeutic level for warfarin (Coumadin), an anticoagulant, is 2 to 3; therefore, the nurse would not question administering this medication. MAKING NURSING DECISIONS: The test taker must be knowledgeable of medications. In most scenarios, there is no test-taking hint to help the test taker when answering medication questions except common nursing interventions, such as do not administer cardiac medications if client has AP <60 or B/P <90/60, do not administer medications with grapefruit juice or antacids, or most medications are administered with food to prevent GI distress.

The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first? 1. The client diagnosed with angina who is reporting chest pain. 2. The client diagnosed with CHF who has bilateral 4+ peripheral edema. 3. The client diagnosed with endocarditis who has a temperature of 100°F. 4. The client diagnosed with aortic valve stenosis who has syncope.

Answer: 1 1. The client with angina should be asymptomatic; when the client is complaining of chest pain, this is abnormal data. Therefore, this client should be assessed first. Remember Maslow's Hierarchy of Needs identifies physiological needs as priority and pain is priority. 2. In a client diagnosed with CHF, 4+ edema is expected. The nurse would not need to assess this client first. 3. The client diagnosed with endocarditis is expected to have a fever. The nurse would not need to assess this client first. 4. The client diagnosed with aortic valve stenosis has the classic triad of syncope, angina, and exertional dyspnea; therefore, this client would not be assessed first.

The evening nurse in a long-term care facility is preparing to administer medications to a client diagnosed with atrial fibrillation. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant. 2. Metoclopramide (Reglan), a gastric motility medication. 3. Docusate (Colace), a stool softener. 4. Atorvastatin (Lipitor), an antihyperlipidemic.

Answer: 1 1. The client's International Normalized Ratio (INR) is 3.4. The therapeutic range is 2 to 3 for a client diagnosed with atrial fibrillation. This client is at risk for bleeding. The nurse should hold the medication and discuss the warfarin with the HCP. 2. Metoclopramide is used to stimulate gastric emptying. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication. 3. Docusate is a stool softener. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication. 4. Atorvastatin is a lipid-lowering medication. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication.

The nurse is preparing to administer two units of PRBCs to a client diagnosed with congestive heart failure (CHF). Which HCP order should the nurse question? 1. Administer each unit over 2 hours. 2. Administer the loop diuretic furosemide (Lasix) IVP once. 3. Restrict the client's fluids to 1000 mL per 24 hours. 4. Have a complete blood count (CBC) done the following morning.

Answer: 1 1. The nurse should administer a unit of blood over the greatest length of time possible (4 hours) to a client diagnosed with congestive heart failure to prevent fluid volume overload. The nurse should question this order. 2. Administering a diuretic to a client diagnosed with CHF who is receiving blood is an appropriate order. The nurse would not question this HCP order. 3. Restricting fluids to a client diagnosed with CHF is an appropriate order depending on the severity of the client's condition. The nurse would not question this order, especially when administering IV fluids to the client. 4. The HCP should evaluate the effects of the two units of blood. The nurse would not question this HCP order.

The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement? 1. Continue to care for the client's needs as usual. 2. Place notification of the DNR inside the client's chart. 3. Refer the client to a hospice organization. 4. Limit visitors to two at a time, so as not to tire the client.

Answer: 1 1. The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client's heart stops beating. 2. The information about the DNR status is already inside the chart. It may need to be placed on the outside of the chart and a special armband or other notification made to other healthcare personnel. 3. The client has a DNR order, but this does not imply that there may be 6 months or less life expectancy for the client. (Hospice care may be requested for clients with less than a 6-month life expectancy.) An order for hospice must be written by the attending healthcare provider before making this referral. 4. The client should be allowed as many visitors as the hospital policy allows.

The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client's vasoconstrictor, dopamine. 2. Notify the client's healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client's neurological status.

Answer: 1 1. The nurse should first discontinue the medication that is causing the increase in the client's blood pressure prior to doing anything else. 2. The nurse should notify the HCP but not prior to taking care of the client's elevated blood pressure. 3. The client may need a medication to decrease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure. 4. The nurse must first decrease the client's blood pressure prior to assessing the client. MAKING NURSING DECISIONS: The test taker should remember that when the client is in distress, do not assess. The nurse must intervene and take care of the client. If any of the options is assessment data the HCP will need or an intervention that will help the client, then the test taker should not select the option to notify the HCP.

The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first? 1. Assist the client to a sitting position. 2. Assess the client's vital signs. 3. Call 911 for the paramedics. 4. Auscultate the client's lung sounds.

Answer: 1 1. The nurse's first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client's respiratory distress. 2. The nurse should assess the client's vital signs, but the first intervention is to help the client breathe. 3. The nurse should contact the paramedics if the client does not improve after being placed in a sitting position, but this is not the nurse's first intervention. 4. The nurse should auscultate the client's lungs, but the first intervention is to help the client breathe more easily.

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected.

Answer: 1 1. This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first. 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated and the pain was a 3. The nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure and a bilateral pedal pulse indicates the client is stable; therefore, this client does need to be seen first. 4. Psychological issues are important, but not more so than a physiological issue, and the client admitted from the ED may have a physiological problem. MAKING NURSING DECISIONS: The test taker should use some tool as a reference to guide in the decision-making process. In this situation, Maslow's Hierarchy of Needs should be applied. Physiological needs have priority over psychosocial ones.

The nurse on the cardiac unit is discussing case management with a client who asks, "Why do I need a case manager for my heart disease?" Which statements are most appropriate for the nurse to respond? Select all that apply. 1. "Case management helps contain the costs of your healthcare." 2. "It will help enhance your quality of life with a chronic illness." 3. "It decreases the fragmentation of care across many healthcare settings." 4. "Case management is a form of health insurance for clients with chronic illnesses." 5. "We try to provide quality care along the healthcare continuum."

Answer: 1, 2, 3, and 5 1. Case managers help coordinate healthcare between multiple sources of healthcare attempting to contain healthcare cost. 2. The case manager is a client advocate and helps with communication between the client and healthcare providers, which, it is hoped, enhances the client's quality of life. 3. The case manager coordinates outpatient care and in-patient care, and helps with referrals for the client. 4. Case management is not a form of health insurance. 5. The case manager is involved in assessing, planning, facilitating, and advocating for health services for a client, which, it is hoped, provide quality care. Trying to coordinate this is often exhausting and frustrating for the client and family.

The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply. 1. Notify the healthcare provider (HCP) if the client gains more than 2 lb in one day. 2. Keep the head of the bed elevated when sleeping. 3. Take the loop diuretic once a day before going to sleep. 4. Teach the client which foods are high in sodium and should be avoided. 5. Perform isotonic exercises at least once a day.

Answer: 1, 2, 4, and 5 1. A 2-lb weight gain indicates the client is retaining fluid and should contact the HCP. This is an appropriate teaching intervention. 2. Keeping the head of the bed elevated will help the client breathe easier; therefore, this is an appropriate teaching intervention. 3. The loop diuretic should be taken in the morning to prevent nocturia. This is not an appropriate teaching intervention. 4. Sodium retains water. Telling the client to avoid eating foods high in sodium is an appropriate teaching intervention. 5. Isotonic exercise, such as walking or swimming, helps tone the muscles, and discussing this with the client is an appropriate teaching intervention.

While ambulating in the hallway with the nurse, the client diagnosed with myocardial infarction complains of chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer nitroglycerin 0.4 mg sublingual STAT. 2. Have the client walk back to the room. 3. Take the client's vital signs. 4. Place the client on supplemental oxygen. 5. Ask the ward secretary to call the healthcare provider for orders.

Answer: 1, 3, and 4 1. Nitroglycerin tablets are vasodilators that are administered to dilate the coronary vessels and provide oxygen to the heart muscle. 2. The client should be made to sit down immediately. Exercise is the probable cause of the chest pain; therefore, the activity should immediately stop. 3. The nurse should assess the client's vital signs as part of the assessment of the client's current situation. 4. Supplemental oxygen will assist in getting higher concentrations of oxygen to the heart muscle. 5. A ward secretary cannot take orders; only a nurse should discuss the client with the healthcare provider.

The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client's family is at the bedside. Which intervention should the HH nurse implement first? 1. Contact the agency's chaplain. 2. Pronounce the client's death. 3. Ask the family to leave the bedside. 4. Call the client's funeral home.

Answer: 2 1. The HH nurse can contact the agency's chaplain to provide spiritual support for the client's family, but the first intervention is to pronounce the client's death. 2. Nurses in home health have been given the authority to pronounce death for clients who are on service and death is imminent. This intervention should be implemented first. 3. The family should be able to stay at the bedside, but if for some reason they need to leave, the nurse's asking them to leave is not the first intervention. The nurse can assess the apical pulse with the family at the bedside. 4. The client's funeral home needs to be contacted, but it is not the nurse's first action, and often the family will call the funeral home.

The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time (PT) of 14 and an International Normalized Ratio (INR) of 1.6 mg/dL. 2. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L. 3. Atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotransferase (AST) of 18 U/L. 4. Lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL.

Answer: 2 1. The INR is not at a therapeutic level yet; the nurse should administer this medication. 2. This potassium level is very low. Hypokalemia potentiates dysrhythmias in clients receiving digoxin. This nurse should discuss potassium replacement with the HCP before administering this medication. 3. An aspartate aminotransferase (AST) test measures the amount of this enzyme in the blood. The enzyme is part of the liver function panel. The normal is 14-20 U/L for males and 10-36 U/L for females. 4. Creatinine level is reflective of renal status. Normal is 0.6-1.2 mg d/L.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? 1. Feed the client who has an IV in both forearms. 2. Assess the client diagnosed with stage IV heart failure. 3. Discharge the client who had a cardiac catheterization. 4. Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin).

Answer: 2 1. The LPN can feed a client who is stable but unable to feed him or herself because of medical equipment. This is an appropriate task to assign. 2. The nurse cannot assign an assessment. This is the inappropriate task to assign to the LPN. 3. The LPN can discharge a client who had a procedure and who does not require extensive teaching. 4. The LPN can administer a routine IVPB medication.

The surgical nurse is admitting a client having heart surgery to the operating room. Which information would require the nurse to call a time-out? 1. The client is drowsy from the preoperative medication and drifts off to sleep. 2. The consent form states mitral valve replacement and the client states aortic valve replacement. 3. The chart and client's armband states the client is allergic to the narcotic analgesic morphine. 4. The client states his or her name and birth date as it appears on the chart.

Answer: 2 1. The client would be expected to be drowsy after a narcotic preoperative medication. The nurse would not need to call a time-out for this client. 2. Whenever there is a discrepancy on the chart or with what the client says, the nurse should call an immediate time-out until the situation has been resolved. 3. The client's allergy must be documented on the client's chart and identification band; therefore, this would not warrant a time-out. 4. Because this is what is supposed to happen, the nurse would not need to call a time-out.

The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP? 1. Call the healthcare provider (HCP) and report the client's chest pain. 2. Give a client some acetaminophen (Tylenol) while the nurse checks the client. 3. Get the client's medical records and bring them to the client's room. 4. Notify the client's family of the onset of chest pain.

Answer: 3 1. If the HCP is called, the nurse should perform this task, not the UAP. A UAP cannot take a telephone order; only a licensed nurse can take telephone orders. 2. The UAP cannot administer a medication, not even Tylenol. 3. The nurse should immediately go to the client's room and assess the client. Sometimes the nurse may need the client's chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room. 4. The UAP should not be asked to relay such information. This is the nurse's or HCP's responsibility.

The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first? 1. Have the family bring food from home for the client. 2. Check to see what the client has eaten in the past 24 hours. 3. Tell the client that a low-sodium diet is an important part of the diagnosis. 4. Ask the dietician to discuss food preferences with the client.

Answer: 2 1. The family may be allowed to bring in food occasionally from home, but what they bring may not adhere to a low-sodium diet, and the family should not be required to provide three meals per day for the client. This is the facility's responsibility. 2. Assessing the client's intake will help the nurse to determine the extent of the client's complaints. This is the first intervention. 3. This may be true but does not help the client adjust to a lack of sodium in the diet. 4. A referral to the dietician should be made after the nurse fully assesses the situation.

The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)? 1. Have the UAP call the operator and announce the code. 2. Tell the UAP to answer the other call lights on the unit. 3. Send the UAP to the room to start rescue breaths. 4. Ask the family to step out of the room during the code.

Answer: 2 1. The nurse in the client's room notifies the hospital operator of a code situation. 2. Answering the call lights of the other clients on the unit can be delegated to the UAP. 3. In a hospital, the respiratory therapist assumes the responsibility for ventilations. 4. The nursing supervisor is responsible for requesting the family to leave the room. The UAP does not have the authority to make this request.

The elderly client on the cardiac unit was found on the floor by the bed. Which information should the nurse document in the client's chart? 1. Fell. No injuries noted. Incident report completed. HCP notified. 2. Found on floor. No complaints of pain. Able to move all extremities. 3. States no one answered call light, so attempted to get up without help. 4. Got out of bed without assistance and fell by the bedside.

Answer: 2 1. The nurse should not document that the client fell unless the nurse observed the client fall. The nurse should never write "incident report" in a chart. This becomes a red flag to a lawyer. 2. The nurse should document exactly what was observed. This statement is the correct documentation. 3. This statement is not substantiated and should not be placed in the chart. 4. This statement is documenting something the nurse did not observe, a fall.

The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department? 1. The nurse who has 4 years of experience on the cardiac unit. 2. The nurse who just transferred from critical care to the cardiac unit. 3. The nurse with 1 year of experience on the cardiac unit who has been on a week's sick leave. 4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.

Answer: 2 1. The nurse who just has surgical nursing experience would not be the choice to float to the emergency department. 2. The nurse with critical care experience would be the best choice to float to the emergency department. 3. The nurse just returning from sick leave would not be a good choice to send to the emergency department, which may be very busy at times. 4. This nurse has not had experience in critical care; therefore, this nurse would not be the best choice to float to the emergency department.

The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurse's first intervention during the code? 1. Begin to take notes to document the code. 2. Make sure all the jobs are being done. 3. Arrange for an intensive care unit bed. 4. Administer the emergency medications.

Answer: 2 1. The supervisor can take notes documenting the code until relieved, but the supervisor needs to be free to supervise the code and coordinate room assignments and staffing. 2. The first intervention for the supervisor is to ensure that all the jobs in the code are being filled. 3. This is the responsibility of the supervisor, but it is not the first intervention. 4. The supervisor can administer medications, but the supervisor needs to be flexible to complete the duties of the supervisor.

The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client's telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor.

Answer: 2 1. The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested. 2. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable. 3. The UAP can take care of this problem; there is no need for the primary nurse to check the client. 4. The strip indicates an artifact, but there is no indication that the client should be removed from telemetry. MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions requiring nursing judgment.

The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won't go to the hospital. Which action should the nurse implement first? 1. Instruct the wife to call 911 immediately. 2. Tell the wife to have the client chew an aspirin. 3. Ask the wife what the client had to eat recently. 4. Request the husband talk to the clinic nurse.

Answer: 2 1. The wife should call 911, but the American Heart Association recommends chewing a baby aspirin at the onset of chest pain. 2. The AHA recommends the client having chest pain chew an aspirin to help decrease platelet aggregation. This is the first intervention the clinic nurse should tell the wife to do. The client is in distress; therefore, the nurse should have the wife do something. 3. This question could be asked to determine whether the pain is secondary to a gallbladder attack or gastric irritation, but this is not the first intervention. 4. The clinic nurse could possibly talk to the client while the wife is getting an aspirin, but this is not the first intervention. MAKING NURSING DECISIONS: The test taker should apply the nursing process when the question asks the nurse, "Which intervention should be implemented first?" If the client is in distress, do not assess; if the client is in distress, do something.

The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy? 1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit. 2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift. 3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated. 4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team.

Answer: 2 1. This is a win-lose strategy wherein, during the conflict, one party (charge nurse) exerts dominance and the other (staff nurse) submits. 2. This is a win-win strategy that focuses on goals and attempts to meet the needs of both parties. The charge nurse keeps an experienced nurse and the staff nurse keeps her position. Both parties win. 3. This is negotiation in which the conflicting parties give and take on the issue. The staff nurse gets one more chance and the charge nurse's authority is still intact. 4. This is not an example of a win-win strategy and is not an appropriate action for the staff nurse to take. The opinion of the staff should not influence the charge nurse's action.

The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse's best response? 1. "I am so excited for you; he seems like a very nice young man." 2. "You should not go out with him as long as she is a client of our agency." 3. "I think you should tell the director of the HH care agency about this date." 4. "You should never date someone you meet while taking care of a client."

Answer: 2 1. This is professional boundary crossing. Even though the grandson is not the client, he is related to the client. The HH aide should not go out with him 2. This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service. 3. The nurse's best response is to tell the HH aide the facts about dating relatives of clients. The director would tell the HH aide the same information. 4. The HH aide could date the grandson when the client is no longer on service. So this statement is not the nurse's best response.

The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? 1. Discuss personal information the client shared with the nurse in confidence. 2. Provide the case manager with any information that is required for continuity of care. 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the case manager to get the client's permission before sharing information.

Answer: 2 1. Unless the information shared is directly connected to healthcare issues, the nurse should not share confidential information with anyone else. The nurse should inform clients that information directly affecting the client's healthcare will be shared on a need-to-know basis only. 2. The case manager's job is to ensure continuity and adequacy of care for the client. This individual has a "need to know." 3. The case manager is part of the healthcare team; therefore, information should be shared. 4. The client gave permission when being admitted to the hospital for information to be shared among those providing care. The case manager does not need to obtain further consent.

The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client's drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should the nurse set the pump?

Answer: 24 mL per hour 25,000 divided by 500 mL = 50 units of heparin per mL. 26 (current rate) 50 = 1300 units of heparin currently infusing. 1300 100 = 1200 units of heparin needed as new infusion rate. 1200 divided by 50 = 24 mL per hour to infuse

The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first? 1. Tell the UAP to change it immediately. 2. Ask the UAP why the sharps container has not been changed. 3. Change the sharps container as per clinic policy. 4. Document the situation and place a copy of the documentation in the employee file.

Answer: 3 1. A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations, and because the UAP has not done it after being asked twice, a third request is not necessary. 2. The nurse should discuss why the sharps container has not been changed, but it is not the first intervention. 3. A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behaviour. 4. The situation should be documented because the UAP was told twice, but documentation is not the first intervention.

The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? 1. Assign an RN to perform all sterile procedures. 2. Assign an LPN to give all IV medications. 3. Assign an UAP to complete the a.m. care. 4. Assign an LPN to write the care plans.

Answer: 3 1. An LPN can perform sterile procedures such as inserting indwelling catheters and IV catheters. An RN should perform the functions that require nursing judgment, such as planning and evaluating the care of the clients. 2. Although an LPN could administer most intravenous piggyback (IVPB) medications, only qualified RNs may administer intravenous push (IVP) medications and chemotherapy. 3. A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate. 4. Writing a care plan for a client requires nursing judgment; therefore, an RN should be assigned this function. MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions that require nursing judgment. Remember that in most instances, options with the word "all" (options 1 and 2) can be eliminated because if the test taker can think of one time when some other level of licensure could safely perform the task, then the option automatically becomes wrong.

The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first? 1. Take the client's pulse, respirations, and blood pressure. 2. Call for a stat electrocardiogram and a troponin level. 3. Place sublingual nitroglycerin 1/150 g under the tongue. 4. Notify the HCP that the client has pain.

Answer: 3 1. If the client is in distress, assessment is not the first intervention if there is an action the nurse can take to relieve the distress. The nurse should administer the nitroglycerin first. 2. Calling for an electrocardiogram and troponin level should be implemented but not before administering the nitroglycerin. 3. Placing nitroglycerin under the client's tongue may relieve the client's chest pain and provide oxygen to the heart muscle. This is the nurse's first intervention. 4. Notification of the HCP can be done after the nurse has stabilized the client.

The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering? 1. The loop-diuretic furosemide (Lasix) to a client who had a 320-mL output in 4 hours. 2. The anticoagulant enoxaparin (Lovenox) to a client who had open-heart surgery. 3. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery. 4. The ACE inhibitor captopril (Capoten) to a client who has a B/P of 100/68.

Answer: 3 1. Lasix should be administered to the client who has an adequate urinary output. 2. Lovenox is prescribed to prevent deep vein thromboses (DVT) in clients who are immobile, such as a postsurgical client. 3. The nurse should not administer an antiplatelet medication to a client going to surgery because this will increase postoperative bleeding. The nurse should hold this medication and discuss this with the surgeon. 4. The client's blood pressure is within an acceptable range. The nurse should administer this medication.

The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The cardiac glycoside to the client who has an apical pulse of 58. 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. 3. The antidysrhythmic to the client in ventricular fibrillation. 4. The calcium-channel blocker who has a blood pressure of 110/68.

Answer: 3 1. The cardiac glycoside, such as digoxin, should not be administered unless the apical pulse is 60 or above. 2. Because the client's serum K+ level is already low, the nurse should question administering a loop diuretic. 3. The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodarone, should be administered first. 4. The client's blood pressure is above 90/60, so the calcium-channel blocker can be administered but it is not priority over a client who is in a life-threatening situation. MAKING NURSING DECISIONS: The test taker should know which medications are priority, such as life-threatening medications, insulin, and mucolytics (Carafate). These medications should be administered first.

The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement? 1. Encourage the client to walk 30 minutes a day. 2. Request an HH-registered dietician to talk to the client. 3. Refer the client to a cardiac rehabilitation unit. 4. Discuss the client's need to lose 1 to 2 pounds a week.

Answer: 3 1. The client should be encouraged to exercise, but it should be in a supervised setting such as a cardiac rehabilitation unit because the client has diabetes and hypertension. 2. The client should adhere to a low-fat, low-cholesterol, carbohydrate-counting diet, but this is not the priority intervention. The client needs to be in a supervised setting, and diet teaching is included in cardiac rehabilitation. 3. Cardiac rehabilitation includes progressive exercise, diet teaching, and classes on modifying risk factors. This supervised setting would be the priority intervention for this client when the client is discharged from HH. 4. The client should lose weight slowly, but the priority intervention for this client would be a referral to a supervised setting where the client can lose weight slowly and safely.

The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with mitral valve stenosis. 2. The client diagnosed with asymptomatic sinus bradycardia. 3. The client diagnosed with fulminant pulmonary edema. 4. The client diagnosed with acute atrial fibrillation.

Answer: 3 1. The client with mitral valve stenosis can live with this diagnosis and it is not a life-threatening condition. 2. The client with asymptomatic sinus bradycardia is stable and because the client is not exhibiting any signs/symptoms, this client does not need to be assigned to the most experienced nurse. 3. A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client. 4. A client with acute atrial fibrillation is not in a life-threatening situation; therefore, this client would not be assigned to the most experienced nurse.

The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization

Answer: 3 1. The client with rheumatic heart fever is expected to have carditis and should be on bed rest. The nurse needs to talk to the client about the importance of being on bed rest but this client is not in a life-threatening situation and does not need the most experienced nurse. 2. These ABG values are within normal limits; therefore, a less experienced nurse could care for this client. 3. Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client. 4. A cardiac catheterization is a routine procedure and would not require the most experienced nurse. MAKING NURSING DECISIONS: The test taker must determine which client is the most unstable and would require the most experienced nurse, thus making this type of question an "except" question. Three clients are either stable or have non-life-threatening conditions.

The cardiac clinic nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the office area. Which action should the clinic nurse implement? 1. Tell the UAP in front of the client to not comment on the weight. 2. Ask the UAP to put the client in the room and take no action. 3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA. 4. Report the UAP to the director of nurses of the clinic.

Answer: 3 1. The clinic nurse should not correct the UAP in front of the client. This is embarrassing to the UAP and makes the client uncomfortable. 2. The clinic nurse must correct the UAP's behavior. The client's weight gain should not be announced in the office area so that all staff, clients, and visitors can hear. This is a violation of confidentiality. 3. The clinic nurse should correct the UAP's behavior, but it should be done in private and with an explanation as to why the action is inappropriate. This is a violation of confidentiality because the scale is located in the office area and any client or visitor passing by, as well as other staff members, can hear the comment. 4. The clinic nurse should handle this situation. If the UAP's behavior shows a pattern of behavior, then it should be reported to the director of nurses.

The nurse and the UAP enter the client's room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first? 1. Ask the UAP to check whether the client is asleep. 2. Tell the UAP to perform cardiac compressions. 3. Instruct the UAP to get the crash cart. 4. Request the UAP to put the client in a recumbent position.

Answer: 3 1. The first step in cardiopulmonary resuscitation according to the AHA guidelines is to establish unresponsiveness by "shaking and shouting." If the client does not respond to being shaken, then the nurse can proceed to the next step, which is to "look, listen, and feel" for breaths. This is assessment and, according to AHA guidelines, the UAP could perform this function if alone. However, the nurse should assess the client before a UAP. 2. Administering chest compressions is performed after establishing unresponsiveness and lack of respiration. 3. The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is determined, the nurse should not delegate any client care. 4. The nurse should place the client in the recumbent position before attempting to perform chest compressions; the nurse should send the UAP for help and the crash cart.

The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP? 1. Monitor the client's arterial blood gases. 2. Re-infuse the client's blood using the cell saver. 3. Assist the client to take a sponge bath. 4. Change the client's saturated leg dressing.

Answer: 3 1. The nurse and respiratory therapist, not the UAP, are responsible for monitoring the ABGs. 2. Infusion of blood and blood products, even the client's own, cannot be delegated to a UAP. 3. The UAP can assist with hygiene needs; this is one of the main tasks that may be delegated to UAPs. 4. The nurse must assess the surgical site for bleeding, infection, and healing. The UAP cannot perform assessments.

The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first? 1. Check the radial pulse before administering digoxin, a cardiac glycoside. 2. Monitor the amiodarone level for the client receiving amiodarone. 3. Obtain the latest PTT results on the client with a heparin drip. 4. Check the liver function panel for the client receiving a dopamine drip.

Answer: 3 1. The nurse checks an apical pulse, not a radial pulse, prior to administering digoxin. 2. There is no serum amiodarone level; therefore, the nurse cannot implement this intervention. 3. Intravenous heparin increases the client's partial thromboplastin time and causes an anticoagulant effect. The nurse should always be aware of the client's most current PTT levels when therapeutic heparin is being administered. 4. The nurse should monitor the client's renal function, creatinine level, not the liver function. MAKING NURSING DECISIONS: The nurse must be aware of interventions that must be implemented prior to administering medications. The nurse must know what to monitor prior to administering medications because untoward reactions and possibly death can occur.

The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse? 1. The client who has an INR of 2.8. 2. The client who has a serum potassium level of 3.8 mEq/L. 3. The client who has a serum digoxin level of 2.6 mg/dL. 4. The client who has a glycosylated hemoglobin of 6%.

Answer: 3 1. The therapeutic range for INR is 2 to 3; therefore, this client would not need to be contacted first. 2. The client's serum potassium level is within the normal range—3.5 to 5.5 mEq/L. Therefore, this client would not need to be contacted first. 3. The client's digoxin level is higher than the therapeutic level for digoxin, which is 0.8 to 2 mg/dL. This client should be contacted first to assess for signs/ symptoms of digoxin toxicity. 4. The glycosylated hemoglobin, which is the average of blood glucose levels over 3 months, should not be more than 8%. This client, with a level of 6%, does not need to be contacted.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

Answer: 3 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 3. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate.

The hospice nurse is triaging phone calls from clients. Which client should the nurse call first? 1. The client whose family reports the client is not eating. 2. The client who wants to rescind the out-of-hospital DNR. 3. The client whose pain is not being controlled with the current medications. 4. The client whose urinary incontinence has caused a Stage 1 pressure ulcer.

Answer: 3 1. This client should be seen, but a client who is terminally ill and is refusing to eat is not an emergency situation. 2. The client has a right to rescind the out-of-hospital DNR but paperwork is not priority over a client who is in pain. 3. One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately. 4. A Stage 1 pressure ulcer must be assessed and treatment started but this is not priority over pain control.

The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy? 1. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early. 2. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week. 3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly. 4. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position.

Answer: 3 1. This is a win-win strategy that focuses on goals (to have adequate staff) and attempts to meet the needs of both parties. The director of nurses keeps an experienced nurse, and the UAP keeps her position. Both parties win. 2. This is a possible win-win strategy in which both parties win. The UAP keeps her job, and the director of nurses can hire a UAP who will be able to work the assigned hours. 3. This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses. 4. This is a negotiation in which the conflicting parties give and take on the issues. The UAP gets one more chance, and the director of nurse's authority is still intact.

The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first? 1. Prepare all the needed equipment for the visit. 2. Call the client to arrange a time for the visit. 3. Review the client's referral form/pertinent data. 4. Make the necessary referrals for the client.

Answer: 3 1. The nurse should prepare the needed equipment, but it is not the nurse's first intervention. 2. The nurse should call and arrange a time convenient for the visit, but the nurse should first review the client referral so the nurse is aware of the need for the visit. 3. The nurse should review the client's referral form and other pertinent data concerning the client's condition first before taking any further steps. The nurse may need to contact the referring agency if the information is unclear or if important information is missing. This is assessment. 4. The nurse will not know which referrals will be needed until after the first visit.

The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority. 1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. 2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. 3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. 4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morning.

Answer: 3, 1, 4, 2, 5 3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and the temperature to see if interventions should be initiated based on a progression of the septicemia. 1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift. 4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring. 2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the problem. 5. A dressing change can take some time to complete. This is a physiological situation but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change.

The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client's identification band. 5. Clamp the primary 1 distal to the port.

Answer: 3, 2, 4, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1-mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer's recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes.

The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic.

Answer: 4 1. All clients in the ICU are on telemetry, and the UAP could bathe the client. This would not warrant intervention by the charge nurse. 2. The UAP can perform glucometer checks at the bedside, and there is nothing that indicates the client is unstable. This would not warrant intervention by the charge nurse. 3. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. 4. This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client.

Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing? 1. If the client or family is hostile or obnoxious, call the police. 2. Carry the HH care agency identification in a purse or wallet. 3. Visits can be scheduled at night with permission from the agency. 4. Inform the agency of the times of the client's scheduled visits.

Answer: 4 1. If the client or family is intoxicated, hostile, or obnoxious, the nurse should leave and reschedule the visit. There is no need to call the police unless the nurse thinks he or she will be hurt. 2. The HH nurse should wear the agency identification on the shirt or blouse; it should be visible to anyone talking to the nurse. 3. To be eligible for HH visits, the client must be homebound, and all visits should be done in the daylight hours as a safety precaution. 4. The agency should be informed of the schedule so the nurse can be located if the nurse does not return when expected.

The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse? 1. "I have to go to the bathroom a lot during the morning." 2. "I get up very slowly when I have been sitting for a while." 3. "I do not salt my food when I am cooking it but I add it at the table." 4. "I drink grapefruit juice every morning with my breakfast."

Answer: 4 1. If the client takes the loop diuretic in the morning, then going to the bathroom frequently in the morning would not warrant intervention. 2. Rising from a sitting position slowly helps prevent orthostatic hypotension, which is a potential side effect of all the medications. This statement would not warrant intervention. 3. This statement indicates the client is adhering to a low-sodium diet, as he should be. No intervention is warranted. 4. Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants intervention by the nurse.

Which client warrants immediate intervention by the nurse? 1. The client diagnosed with pericarditis who has chest pain with inspiration. 2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. 3. The client diagnosed with Marfan syndrome who has pectus excavatum. 4. The client diagnosed with atherosclerosis who has slurred speech and drooling.

Answer: 4 1. The client with pericarditis is expected to have chest pain with inspiration; therefore, this client does not warrant immediate intervention. 2. The client with mitral valve regurgitation is expected to have thready peripheral pulses and cool, clammy extremities. Therefore, this client does not warrant immediate intervention. 3. The client with Marfan syndrome is expected to have a chest that sinks in or sticks out, known as funnel chest or pectus excavatum; therefore, this client does not warrant immediate intervention. 4. Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first. MAKING NURSING DECISIONS: The test taker should ask "is the assessment data normal for" the disease process. If it is normal for the disease process, the nurse would not need to intervene; if it is not normal for the disease process, then this warrants intervention by the nurse.

Which client should the telemetry nurse assess first after receiving the a.m. shift report? 1. The client diagnosed with deep vein thrombosis who has an edematous right calf. 2. The client diagnosed with mitral valve stenosis who has heart palpitations. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with congestive heart failure who has pink frothy sputum.

Answer: 4 1. The nurse would expect the client with a deep vein thrombosis to have an edematous right calf, so the nurse would not need to assess this client first. 2. The nurse would expect the client with mitral valve stenosis to have heart palpitations (sensations of rapid, fluttering heartbeat). 3. The nurse would expect the client with arterial occlusive disease to have intermittent claudication (leg pain), so the nurse would not need to assess this client first. 4. The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first. MAKING NURSING DECISIONS: The test taker must determine which sign/symptom is not expected for the disease process. If the sign/ symptom is not expected, then the nurse should assess the client first. This type of question is determining if the nurse is knowledgeable of signs/symptoms of a variety of disease processes.

The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first? 1. The client diagnosed with hypertension who is reporting a BP of 148/92. 2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%. 3. The client diagnosed with congestive heart failure who has edematous feet. 4. The client diagnosed with chronic atrial fibrillation who is having chest pain.

Answer: 4 1. This blood pressure—148/92—is elevated, but it would not be life threatening for someone diagnosed with hypertension; therefore, the nurse would not contact this client first. 2. A pulse oximeter reading of 93% is low but still within normal limits, and a client with cystic fibrosis, a chronic respiratory condition, would be expected to have a chronically low oxygen level. This client would not need to be contacted first. 3. The client with CHF would be expected to have edematous feet; this client would not need to be contacted first. 4. The client with chronic atrial fibrillation is at risk for pulmonary emboli, a potentially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first.

The nurse is caring for Mr. A.B., a client on a telemetry unit. At 0830 the client complains of chest pain. Which medication should the nurse administer? 1. Administer 1/2 inch of nitroglycerin transdermally now. 2. Morphine sulfate 2 mg IVP STAT. 3. Oxycodone 7.5 mg/acetaminophen 325 mg PO now. 4. Nitroglycerin 0.4 mg sublingual STAT.

Answer: 4 1. This medication could be administered but it will not have as rapid an impact as the SL dose. 2. Nitroglycerin is administered first because it will dilate the vessels and resolve the cause of the chest pain. If the chest pain still is present after three (3) NTG then the morphine should be administered. 3. Oxycodone and acetaminophen will not address the chest pain specifically. 4. The nurse should administer the medication that will have the most rapid onset and directly resolve the problem. Nitroglycerin is a potent vasodilator and will dissolve rapidly under the tongue (sublingually).

The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtts/min the first 15 minutes. 2. Check the unit of blood and the client's blood band with another nurse. 3. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter. 4. Assess the client's vital signs and lung sounds, and assess for a rash. 5. Obtain informed consent for the unit of blood from the client.

Answer: 5, 4, 3, 2, 1 5. The nurse must first obtain informed consent prior to administering the blood product. 4. The nurse needs to complete the pre-transfusion assessment including assessing for any signs of allergic reaction prior to administering the unit of blood. 3. The blood must be hung with Y-tubing and normal saline, and an 18-gauge angiocatheter is preferred. 2. The nurse must check the unit of blood from the laboratory with another nurse and with the client's blood band. 1. During the first 15 minutes, the blood transfusion must be administered slowly to determine if the client is going to have an allergic reaction.