NURS 1115B Exam 1

less hydrogen ions means

higher pH

Define osmotic pressure

holds fluids in

calcium and phosphorus have an ___________________ relationship.

inverse

Alkalosis causes high or low potassium?

low, because all the potassium goes into the cell

What electrolytes are in the intracellular fluid?

potassium and magnesium

What electrolytes are in the extracellular fluid?

sodium, chloride, bicarb

UAP's and LPNs cannot drink TEA. T.E.A stands for?

teach, evaluate, assess

What tasks can NOT be delegated by the RN? Acronym T.A.P.E.

teaching, assessment, planning, evaluation

19.An experience LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experience LPN? (Select all that apply) A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth admission assessment D. Initiate the nursing care plan E. Evaluate the patient's technique for using MDI's.

A,B

Josh is working on a pediatric unit today and has six patients. He is working with a care team that includes an unlicensed assistive personnel (UAP), a licensed practical nurse (LPN), and a respiratory therapist (RT) on call. The following patients and diagnoses are assigned to him: 1. A six-year-old returning from tonsillectomy needing PRN intramuscular (IM) or oral (PO) pain medication. 2. A four-year-old with an asthma exacerbation needing their respiratory treatment. 3. A 10-month-old who is post-surgery for pyloric stenosis needing a bath. 4. A 12-year-old who had a four-wheeler accident two days ago resulting in a fractured femur and multiple wounds who needs a dressing change to a wound on their arm. 5. A 14-year-old who is 12-hours post-appendectomy after a rupture complaining of nausea. 6. A four-month-old with respiratory syncytial virus (RSV) needing their nose cleared of drainage Consider the following: 1. Which patient(s) would be appropriate to delegate to the UAP? 2. Which patient(s) would be appropriate to delegate to the LPN? 3. Which patient(s) would be appropriate to call RT? 4. Which patient should Josh see first, and why?

(1) The UAP can manage the bath for the ten-month-old (c). Using UAPs for personal care activities is appropriate delegation of duties. (2) The LPN can manage the PRN pain medication that is either IM or PO for the six-year-old post-tonsillectomy patient (a), the 12-year-old needing a dressing change to the wound on their arm (d), and the four-month-old nose suctioning (f) (typically with a bulb syringe). If the pain medication was an intravenous medication, the LPN would not be able to administer in the majority of states. It is crucial to know the LPN scope of practice in the state that nurses are practicing in to avoid delegating tasks that are out of their scope of practice. (3) The RT could be contacted to see if they are available to administer the respiratory treatment (b). (4) Josh should see the 14-year-old complaining of nausea after surgery for a ruptured appendix (e) as the patient could be having a complication related to their surgery and should be fully assessed by the nurse quickly

Nurse Amy has an LPN and UAP on her care team to assist with patient care. Which of the following tasks would be appropriate to delegate to the LPN? Which would be appropriate to delegate to the UAP? (Answer key is at the end of the module) 1. Assist a patient with MS to ambulate to the bathroom. 2. Assess a newly admitted patient with pneumonia. 3. Take the initial vital signs while administering a unit of blood to a patient. 4. Administer a vitamin B12 injection to a patient with pernicious anemia

(a) The UAP can assist the patient in ambulating to the bathroom.(d) The LPN can administer the B12 injection to the patient with pernicious anemia.(b, c) Amy will need to complete the admission assessment on the pneumonia patient and takethe initial vital signs during blood administration. The LPN role in blood administration variesamong states as well as institutions, but typically the RN must at minimum do the initial set ofvital signs and hang the blood

Kyle is on a four-week assignment at a level 1 trauma center as a CCU nurse. He is in his second week and feels comfortable with the unit and the staff. He has two patients. Patient A is a 46- year-old male who is 12 hours status-post-CABG and patient B is a 32-year-old female who had a motor-vehicle-accident (MVA) 36 hours ago and has multiple fractures and flail chest. Please place the following tasks related to their care in the most appropriate order. (Answer key is at the end of the module) 1. Morning assessments. 2. Administer PRN pain medication to patient B. 3. Take report from the night nurse. 4. Adjust patient A's medications based on the doctor's orders and the most recent set of lab results. 5. Call the healthcare provider about patient B's morning lab results 6. Review the medication administration record (MAR) and create a medication administration schedule for both patients. 7. Empty the Jackson-Pratt (JP) drains in patient A's chest. 8. Personal care (bath, oral care, and change clothing) for both patients

(c) Take report from the night nurse. (a) Morning assessments. (b) Administer PRN pain medication to patient B. (e) Call the healthcare provider about patient B's morning lab results. (d) Adjust patient A's medications based on the doctor's orders and the most recent set of lab results. (f) Review the MAR and create a medication administration schedule for both patients. (g) Empty the JP drains in patient A's chest. (h) Personal care (bath, oral care, and change clothing) for both patients

Cindy just took a job as a home health nurse, and today is her first day off orientation. She has four patients to see. Which should she visit first, and why? (Answer key is at the end of the module) 1. A patient with a new diagnosis of MS who stated to her husband that she wants to die. 2. A patient with PD who is walking with a short, shuffling gait as reported by his wife. 3. A patient with a recent C5 spinal cord injury whose mother reports redness and drainage at the Halo vest sites. 4. A patient with a low back injury (L4) that called the office reporting a severe headache

(c) The patient with a recent C5 spinal cord injury reporting redness and drainage at the insertion sites of the Halo vest is the priority. The Halo vest is inserted into a bone and an infection around the insertion site can lead to osteomyelitis. This could become life-threatening and should be investigated immediately. (d) The next priority would be the patient with a low back (L4) injury and complaining of severe headaches. This would be a more urgent concern if the spinal injury were higher, as it could indicate autonomic dysreflexia. However, at this level, it is less urgent and more likely represents a rebound headache due to pain medication or a slow spinal fluid leak. (a) The MS patient who states she wants to die would be the next patient to see, yet not as urgent as the two back injuries. (b) Finally, the PD patient with the shuffling gait is expected; this will require education for the patient and family regarding the disease process

Chris is a new nurse on the medical-surgical unit, and today is his first shift since completing his orientation. He is caring for a patient that weighs 425 pounds with MS who is minimally responsive. The UAP asks for assistance in moving the patient in the bed. Which of the following actions would be most appropriate? (Answer key is at the end of the module) 1. Refuse to move the patient since their weight is this high. 2. Tell the family that the patient will need to assist with repositioning in bed. 3. Get another nurse or UAP to help move the patient in bed. 4. Obtain a lifting device that will accommodate a patient of this weight

(d) It is important for Chris and his team to obtain a lifting device for a patient of this size as the opportunity for injury is very high. Since the patient is minimally responsive, they would not be able to help, and another person may not be enough help to turn the patient or move them without injury

After John completes his morning assessments, he reviews the MAR and sees he has several medications to give. Which of the following medications should be given first, and why? (Answer key is at the end of the module) 1. Acyclovir (Zovirax) for a resident with a diagnosis of Bell's palsy. 2. Cephalexin (Keflex) for a resident with a diagnosis of a urinary tract infection (UTI). 3. Acetylsalicylic acid (Aspirin) for a resident with a diagnosis of cerebrovascular accident (CVA). 4. Neostigmine (Prostigmin) for a resident with a diagnosis of MG

(d) Neostigmine (Prostigmin) promotes muscle function in patients that are diagnosed with MG. This medication should always be administered on time to prevent loss of muscle tone, especially the muscles of the upper respiratory tract. This would be the priority medication to administer at this time. The three remaining medications can be administered 30 minutes before or after their scheduled time without implications, so none of these are considered priority medications

What is the difference between Crystalloids vs Colloids?

- crystalloids BETTER! (NaCl, D5W, LR, plasma late) pass freely, EXTRAvascular space/interstitial space, cheaper, less AE - colloids (albumin 5%, alkbuked, albumin, albutein, alburx, flexbumin)

Hypotonic solutions would have an osmolarity less than ____________ ?

280

What is the osmolarity of plasma?

280-300

2. As the registered nurse , which tasks below should you NOT delegate to the LPN ? Select all that apply ) A. Performing an assessment on a new admission B. Collecting a urine sample from an indwelling Foley catheter C. Developing a plan of care for a patient who is admitted with Guillain Barre Syndrome . D. Educating a patient about how to monitor for side effects associated with Warfarin . E. Auscultating lung and bowel sounds . F. Starting a blood transfusion G. Administering IV Morphine 2 mg for pain . H. Providing wound care to a stage 3 pressure injury .

A, C, D, F, G

Hypertonic solutions would have an osmolarity greater than __________ ?

300

What percent of the body is water?

60%

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium

A,D,E

1. Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first? A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter A 56-year-old male, who had an arthroscopy of his left knee 3 hours ago, who is asking to be discharged A 60-year-old female, who is in traction to manage chronic muscle spasms, who is requesting assistance to order her evening meal The order doesn't matter; all clients are of equal priority

A

2. A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for aspiration Risk for falls Risk for impaired skin integrity Decreased intracranial adaptive capacity

A

6. A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? Safety Self-care Skin care Activity

A

9. Some clients with acoustic neuromas have vertigo. What is a priority nursing action for clients with vertigo? Protect the client from injury. Provide small meals of tepid food. Mobilize the client at every opportunity. Provide ice to the affected ear

A

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety? A) "What prescription and nonprescription medications do you currently take?" B) "Have you previously been admitted to the hospital, either for surgery or for medical treatment?" C) "How long do you expect to be at home recovering after your surgery?" D) "Would you say that you tend to eat a fairly healthy diet?"

A

A nurse is speaking to a group of prospective nursing students about what it is like to be a nurse. What is one characteristic the nurse would cite as necessary to possess to be an effective nurse? A) Sensitivity to cultural differences B) Team-focused approach to problem-solving C) Strict adherence to routine D) Ability to face criticism

A

A nurse on a postsurgical unit is providing care based on a clinical pathway. When performing assessments and interventions with the aid of a pathway, the nurse should prioritize what goal? A) Helping the patient to achieve specific outcomes B) Balancing risks and benefits of interventions C) Documenting the patient's response to therapy D) Staying accountable to the interdisciplinary team

A

A patient has questioned the nurse's administration of IV normal saline, asking whether sterile water would be a more appropriate choice than "saltwater." Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patient's fluid volume deficit is due to acute or chronic renal failure

A

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

A

You are admitting a patient to your medical unit after the patient has been transferred from the emergency department. What is your priority nursing action at this time? A) Identifying the immediate needs of the patient B) Checking the admitting physician's orders C) Obtaining a baseline set of vital signs D) Allowing the family to be with the patient

A

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

A

You are the nurse evaluating a newly admitted patient's laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

A

3. On your unit there are two RNs : one is a new RN while the other is an experienced RN . In addition , there are three LPNs and two nursing assistants . Which tasks delegated to one of the nursing assistants by the new RN needs to be re - evaluated ? ( Select all that apply ) A. Apply hydrocortisone cream to eczema on skin after giving the patient a bath. B. Assist the patient with administering a Fleet Enema. C. Empty an ostomy bag. D. Collect and record patient's blood pressure, heart rate, temperature,oxygen saturation, respirations, and pain rating. E. Assist a patient with ambulating

A, B

5. A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure? A health history obtained by the primary physician A signed consent form from the client The medication reconciliation form Prescriptions for postoperative medications

B

UAP key words that are appropriate?

ADL's, Assist, Gather, Remind, Reinforce

5. An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task. A. True B. False

B

7. A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? decreasing anxiety maintaining an open airway providing pain relief measures encouraging activity

B

LPN key words that are appropriate?

Auscultate, Check, Observe, Monitor, Reinforce, Collect, Set up, Would care, Suction, Urinary Cath, Blood glucose (Don't assign an LPN to do a task a UAP can do!)

13. A RN from the women's health clinic is temporarily reassigned to a medical surgical unit. Which of these client assignments would be most appropriate for this nurse? A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care. B. A client from a motor vehicle accident with an external fixation device on the leg. C. A client admitted for a barium swallow after a transient ischemic attack. D. A newly admitted client with a diagnosis of pancreatic cancer.

B

17. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? A. Ask the client and family if they are satisfied with the care given. B. Determine if the home health aide's care is consistent with the plan of care. C. Investigate if the home health aide is prompt and stays an appropriate length of time for care. D. Check the documentation of the aide for appropriateness and comprehensiveness.

B

3. A client is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care? Monitor the client's level of consciousness. Protect the client's airway. Provide psychosocial support. Administer medications as prescribed

B

A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

B

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transpor

B

A nurse on a medical-surgical unit has asked to represent the unit on the hospital's quality committee. When describing quality improvement programs to nursing colleagues and members of other health disciplines, what characteristic should the nurse cite? A) These programs establish consequences for health care professionals' actions. B) These programs focus on the processes used to provide care. C) These programs identify specific incidents related to quality. D) These programs seek to justify health care costs and systems.

B

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

B

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? A) "I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup." B) "Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids." C) "It is normal to be a little confused following surgery, and it is safe not to urinate at night." D) "If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. "

B

The view that health and illness are not static states but that they exist on a continuum is central to professional health care systems. When planning care, this view aids the nurse in appreciating which of the following? A) Care should focus primarily on the treatment of disease. B) A person's state of health is ever-changing. C) A person can transition from health to illness rapidly. D) Care should focus on the patient's compliance with interventions.

B

When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize? Core body temperature Heart rate and rhythm Blood pressure Oxygen saturation level

B

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

B

7. Which patients below are best assigned to the LPN? (Select all that apply) A. A 30-year-old male patient with an active GI bleed that requires multiple blood transfusions. B. A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker. C. A 29-year-old male patient who is post-op day 6 from a colostomy placement that is on a clear liquid diet. D. A 55-year-old male patient who reports chest pain and has ST segment elevation on his EKG

B, C

11.The measurement and documentation of vital signs is expected for clients in a long-term facility. Which staff type would it be a priority to delegate these tasks to? A. Practical Nurse (LPN) B. Registered Nurse (RN) C. Unlicensed assistive personnel (UAP) D. Volunteer

C

16.A staff nurse complains to the nurse manager that the unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A. "I will arrange for a conference with you and the UAP within the next week." B. "I can assure you that I will look into the matter." C. "I would like for you to approach the UAP about the problem the next time it occurs." D. "I will add this concern to the agenda for the next unit meeting."

C

18.Which one of these tasks can be safely delegated to a licensed practical nurse (LPN)? A. Asses the function of a newly created ileostomy. B. Care for a client with a recent complicated double barrel colostomy. C. Provide stoma care for a client with a well-functioning ostomy. D. Teach ostomy care to a client and their family members.

C

20.The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year-old airborne precautions for tuberculosis (TB). B. A 68-year-old just returned from bronchoscopy and biopsy. C. A 72-year-old who needs teaching about the use of incentive spirometry. D. A 69-year-old with COPD who is ventilator dependent

C

4. A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Posting a "No smoking" sign over the client's bed Applying an oil-based lubricant to the client's mouth and nose Assessing the client's respiratory status, orientation, and skin color Changing the mask and tubing daily

C

8. A client the nurse is caring for experiences a seizure. What would be a priority nursing action? Restrain the client during the seizure. Insert a tongue blade between the teeth. Protect the client from injury. Suction the mouth during the convulsion

C

A hospice nurse is caring for a patient who is dying of lymphoma. According to Maslow's hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying patient? A) Spiritual B) Social C) Physiologic D) Emotional

C

A nurse is planning a medical patient's care with consideration of Maslow's hierarchy of needs. Within this framework of understanding, what would be the nurse's first priority? A) Allowing the family to see a newly admitted patient B) Ambulating the patient in the hallway C) Administering pain medication D) Teaching the patient to self-administer insulin safely

C

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, "A patient in renal failure partially loses the ability to regulate changes in pH." What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH

C

A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's care best be coordinated? A) By planning care using a surgical approach B) By identifying the professional with the most knowledge of the patient C) By implementing an interdisciplinary approach to care D) By using the nursing process to guide all aspects of care and treatment

C

Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for patients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when patients return to their homes, what action should the nurse prioritize? A) Promotion of health literacy during hospitalization B) Close communication with insurers C) Thorough and evidence-based discharge planning D) Participation in continuing education initiatives

C

10.A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to member of the care team. The nurse preceptor recognizes that this reluctance most likely is due to A. Role modeling behaviors of the preceptor. B. The philosophy of the new nurse's school of nursing. C. The orientation provided to the new nurse. D. Lack of trust in the team members.

D

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? A) A social worker should temporarily sign the informed consent. B) Consent should be obtained from the hospital's ethics committee. C) Surgery should be done without informed consent. D) Surgery should be delayed until the parents arrive.

C

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

C

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, you notice that the patient's potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

C

You are making initial shift assessments on your patients. While assessing one patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload Ans: C

C

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70.

C

8. Select all the task you could delegate to a nursing assistant as the RN. A. Wound dressing change B. IV flush C. Collecting vital signs D. Weighing a patient E. Mouth care F. Suctioning a patient G. Applying oxygen to a patient H. Connecting a patient to their IV fluids I. Assisting a patient with a bath J. Applying denture paste to dentures

C, D, E, I, J

1. You are making the patient assignment for the next shift . On your unit there are three LPNs , two RNs , and two nursing assistants . Which patients will you assign to the LPNs ? ( Select all that apply) . A. A 68 - year - old male patient who is expected to be discharged home with IV antibiotic therapy. B. A 25 - year - old female patient newly admitted with diabetic ketoacidosis . C. A 75 - year - old male patient with dementia who has an ileostomy and to scheduled tube feedings . D. A 65 - year - old female patient who has an order to remove the Foley catheter .

C,D

Candace has been assigned to the neurology floor for the first time. She is typically a pediatric nurse. She is very nervous about this assignment as she is not accustomed to this type of patient. The charge nurse assigns her five patients and gives her a shift report on all five. Which of the following should be of greatest concern to Candace? (Answer key is at the end of the module) 1. A 47-year-old female who had a brain aneurysm repair two days ago. She just arrived on the neuro unit from the ICU, and Candace was told in the shift report that she is stable with occasional reports of pain. She has an IV in the left antecubital with half-normal saline (0.45% NaCl) infusing and one in the right forearm that is heparin locked with flushes every shift. The UAP tells Candace that the patient is comfortable, but that her IV pump is "going off," and the bag of fluid looks low. 2. A 33-year-old male who had a stroke and has a platelet level of 250,000 μ/L on his most recent set of labs. He is resting comfortably in bed, watching television. His morning medications are due, and his urinary catheter needs to be removed. 3. A 26-year-old female who was admitted yesterday with an exacerbation of a seizure disorder. She had a valproic acid (Depakene) level of 75 μ/L this morning. She has not had her morning medications, including her valproic acid (Depakene), and is currently eating breakfast. 4. A 52-year-old male with a brain tumor and a history of seizures, on phenytoin (Dilantin) with a current level of 28 mg/dL. He is asleep and has asked to be left alone. 5. A 40-year-old female with multiple sclerosis (MS) receiving prednisone (Deltasone) IV. Her steroid dose was due one hour ago, but her IV needs to be restarted as it was pulled out overnight. She is currently in the shower with the assistance of a UAP. (Lacharity et al., 2019) What order should Candace see these patients in?

Candace should be most concerned about the 52-year-old male with a phenytoin (Dilantin) level of 28 mg/dL, as a therapeutic level is 10-20 mg/dL, and this is significantly higher. Phenytoin (Dilantin) toxicity can have serious implications, and the healthcare provider should be notified ASAP. This should be the priority among this group of patients as all the other lab values and information is within normal limits. She should see the patients in the following order: (a) The 47-year-old female needing her IV checked to either replace the bag of fluid or troubleshoot why the alarm is sounding. This is a noisy annoyance that could indicate a potentially dangerous situation (an empty IV bag continuing to infuse), so Candace should quickly replace the bag of IV fluid before addressing her primary priority. (d) The 52-year-old male with the elevated phenytoin (Dilantin) level to assess his condition prior to calling the healthcare provider. (e) The 40-year-old female with MS to restart her IV and initiate her medication. (b) The 33-year-old male to administer medications and discontinue his urinary catheter. (c) The 26-year-old female with the valproic acid (Depakene) level of 75 μ/L, which is within normal limits for a morning assessment

12. A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to the unlicensed assistive personnel (UAP)? A. Teach the client how to cough up secretions B. Changes the tracheostomy trach ties C. Monitor if client has shortness of breath D. Perform routine tracheostomy care

D

14. The Rn delegates the task of taking vital signs of all the clients on the medical-surgical unit to unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on the client's left arm. Which of these statements is most immediately accurate? A. The RN has no accountability for this situation. B. The RN did not delegate appropriately. C. The UAP is covered by the RNs license. D. The UAP is responsible for following instructions.

D

15.The nurse is a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate? A. "Tell the family they can bring in a pizza if the patient would prefer that." B. "Make sure the patient gets at least 2 cartons of milk." C. "Stop the IV if the patient is able to eat solid food." D. "Encourage the patient to eat slowly to prevent gas."

D

9. A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical-surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse? A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes. B. A client with balanced skeletal traction and who needs assistance with morning care. C. A client who had an above-the-knee amputation yesterday and has a temperature of 101.4 F. D. A client who had a total hip replacement 2 days ago and needs blood glucose monitoring.

D

A group of nursing students are participating in a community health clinic. When providing care in this context, what should the students teach participants about disease prevention? A) It is best achieved through attending self-help groups. B) It is best achieved by reducing psychological stress. C) It is best achieved by being an active participant in the community. D) It is best achieved by exhibiting behaviors that promote health.

D

An elderly man tells you that his wife died 14 months ago and that he cannot stop grieving over his loss. What should you encourage the patient to consider? A) Improve his nutritional intake. B) Make an appointment at a wellness clinic. C) Walk on a daily basis. D) Increase his interaction with his social network.

D

The home health nurse is assisting a patient and his family in planning the patient's return to work after surgery and the development of postsurgical complications. The nurse is preparing a plan of care that addresses the patient's multifaceted needs. To which level of Maslow's hierarchy of basic needs does the patient's need for self- fulfillment relate? A) Physiologic B) Transcendence C) Love and belonging D) Self-actualization

D

The nurse caring for a 91-year-old patient with osteoarthritis is reviewing the patient's chart. This patient is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this patient? 32. A) Depression B) Chronic illness C) Inadequate pain control D) Drug interactions

D

The public health nurse is presenting a health promotion class to a group of new mothers. How should the nurse best define health? A) Health is being disease free. B) Health is having fulfillment in all domains of life. C) Health is having psychological and physiological harmony. D) Health is being connected in body, mind, and spirit.

D

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

D

With increases in longevity, people have had to become more knowledgeable about their health and the professional health care that they receive. One outcome of this phenomenon is the development of organized self-care education programs. Which of the following do these programs prioritize? A) Adequate prenatal care B) Government advocacy and lobbying C) Judicious use of online communities D) Management of illness

D

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

D

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume statu

D

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

D

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

D

6. An RN has a critical patient that needs constant monitoring. However, the RN also has other patient in need of care. Which tasks below could the RN delegate to the LPN to help continue the process of patient care? (Select all that apply) A. Admitting and assessing the new admission B. Completing the discharge teaching to a patient going home C. Updating and evaluating the patient's plan of care. D. Administering subcutaneous Heparin E. Obtaining a routine 12-lead EKG F. Collecting a stool specimen G. Flushing a central line with normal saline.

D, E, F

4. When delegating you know that as an RN you must follow the 5 Rights of Delegation to make sure you are delegating properly. Select all the 5 Rights of Delegation. (Select all that apply) A. Right Credentials B. Right Direction/Communication C. Right Supervision/Evaluation D. Right Experience E. Right Task F. Right Person G. Right Patient H. Right Circumstance I. Right Time J. Right Order

E, F, H, B, C

Jill is a travel nurse that went through a four-hour orientation to the unit she is working on today. She is receiving report on the six patients she will have for the shift. Which of the following actions should be a priority? (Answer key is at the end of the module) a. Ensure that she has access to the computer system and medication dispensing system on the unit. b. Develop a schedule for lunch and breaks in collaboration with the other staff. c. Request a bedside report rather than the current reporting system at this facility, since this is what she is used to. d. Ensure that she knows where the policy and procedure manual is located. e. Identify a contact person on the unit that can provide information if needed

Jill's priority should be ensuring access to the computer system and medication dispensing system on the unit in order to deliver proper care of her patients (a). The second priority would be to determine a contact person that can help with needed information (e), followed by the policy and procedure manual (d). Each of these can help her provide care for her patient assignment. Developing a schedule is a great way to organize for the day (b). It would be appropriate to ask for the bedside report, and if the nurses reporting are not opposed, then this style of hand-off can be utilized (c)

If a patient has been throwing up you would expect them to have a metabolic acidosis or alkalosis?

Metabolic alkalosis, vomiting causes a loss of hydrogen ions and a gain of bicarbonate

Name leukotriene modifiers and what they are used for

Montelukast (Zafirlukast, Zileuton) Treats exercise induced asthma "Lukast will decrease the effect of Leukotrienes" Reduces airway inflammation and bronchoconstriction by decreasing leukotrienes Side effects: increased liver enzymes with Zafirlukast Take in the evening or two hours before exercise

Avoid these key word patients for New nurse, Float, traveler RN.

New onset, sudden, new admission, transfer, newly diagnosed, unstable, discharges, require education

Case Study 1 Rachel is a medical-surgical nurse that has been practicing for two years in her unit. Today, she has been asked to work in the emergency department (ED) and has the following patients. In what order should she see the following patients, and why? (Answer key is below) 1. A 10-year-old with a 2 cm laceration to her left arm. The laceration is bleeding through a 4 X 4 gauze every 5-10 minutes. 2. A 21-year-old with complaints of a "migraine headache," vomiting, pain (9 out of 10), and unable to open their eyes due to light sensitivity. 3. A 62-year-old male with COPD and increased difficulty breathing for the past two hours. His family reports a recent cold and significant worsening in the past 24 hours. 4. A 45-year-old female with chest pain that is talking on her cell phone to her son as she is being checked in

Rachel should see the patients in this order: (c) A 62-year-old male with COPD and increased difficulty breathing for the past two hours. His family reports a recent cold and that he has been worsening significantly in the past 24 hours. This patient is a priority due to airway. (d) A 45-year-old female with chest pain that is talking on her cell phone to her son as she is being checked in. This patient likely has an MI and care should be initiated before her condition declines. (a) A 10-year-old with a 2 cm laceration to her left arm. The laceration is bleeding through a 4 X 4 gauze every 5-10 minutes. This patient would take priority over pain since she is bleeding, even if a small amount of bleeding. (b) A 21-year-old with complaints of a "migraine headache," vomiting, pain (9 out of 10), and unable to open their eyes due to light sensitivity. While the patient is uncomfortable, this should not be life-threatening

Stacy has been a nurse for six months and was just released from orientation on her unit. She has seven patients today. The following reports were given about her patients. Which patient should she see first? (Answer key is below) 1. A 42-year-old cholecystectomy patient that is four hours post-op and having uncontrolled pain. 2. A 26-year-old newly diagnosed type 1 diabetic with a blood sugar of 320. 3. A 19-year-old patient who attempted suicide with acetaminophen (Tylenol) last night and is being transferred to a psych unit this afternoon. 4. An 82-year-old Alzheimer's patient with increased confusion and right-sided weakness that started approximately an hour ago. 5. A 60-year-old female who had a myocardial infarction (MI) last night and is going to surgery in one hour

Stacy should see the 82-year-old Alzheimer's patient with increased confusion and right-sided weakness that started approximately an hour ago (d). This patient may be experiencing a stroke and require immediate care. The MI patient (e) is already scheduled for surgery and is likely stable according to the report. While all of the patients need to be seen as soon as possible, this is the priority due to the limited window for interventions with potential stroke

The "Five Rights of Delegation" that must be used when assigning care to others are?

The "right" person The "right" task The "right" circumstance The "right" directions and communication The "right" supervision and evaluation

Anti-IgE medication administered via injection every 2-4 weeks

Xolair

The more hydrogen ions present in a solution, the more _____ the solution.

acidic

John is an agency nurse who is assigned to an acute care unit in a long-term care facility. He receives a report on his patients for the day. Who should he assess first after receiving report? 1. A resident with congestive heart failure (CHF) with 3+ pitting edema in their bilateral lower extremities. 2. A resident with Parkinson's disease (PD) that started hallucinating during the night and is sleeping now. 3. A resident with Alzheimer's disease (AD) that was wandering in the hallway at 2 am. 4. A resident with terminal cancer who the UAP reported has lost eight pounds since their last weight check four weeks ago.

b) The patient with PD who experienced hallucinations during the night should be seen first. This patient may be experiencing an adverse reaction to his PD medications. The other patients' symptoms are consistent with their conditions. (a) The second patient to see would be the CHF patient, as 3+ pitting edema may require a medication adjustment, but this type of edema is expected with CHF. (c) It is not abnormal for an AD patient to wander at night. (d) Significant weight loss is expected with terminal cancer patients

Define hydrostatic pressure

the pressure within a blood vessel that tends to push water out of the vessel