P/D Exam #2 Ch. 5 & 6

A client with VRE infection is admitted to the medical unit. Which action be can be delegated to the UAP who is assisting with the client's care?

Implementing contact precautions when providing care for the client.

In your role as the hosp. infection control nurse, which policy will you implement to most effectively reduce the incidence of CAUTIs?

Limit the use of indwelling urinary catheters in all hospitalized clients

You are the preceptor for an RN who is undergoing orientation to the ICU. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?

Marking the tube 1 cm where it touches the incisor tooth or nares

A client has been dx. w/ disseminated herpes zoster. Which PPE will you need to put on when preparing to assess the client? (Select all that apply)

N95 Respirator Gown Gloves

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experience UAP?

Taking vital signs and pulse ox readings every 4 hours

You are caring for four clients who are receiving IV infusions of NS. Which client is at highest risk for bloodstream infections?

Client who has a non-tunneled central line in the left jugular vein

You are admitting four clients with infections to the medical unit, but only one private room is available. Which client is it most appropriate to assign to the private room?

Client with a cough who may have TB

When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching?

"I will continue to take my isoniazid until I am feeling completely well."

you are preparing to insert a PICC line in a client's left forearm. Which solution will be best for cleaning the skin prior to the PICC insertion?

0.5% chlorhexidine in alcohol (Hibistat)

You are acting as a preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? Select all

1. 38-year old with moderate persistent asthma awaiting discharge 2. 63-year old with a trach needing trach care every shift

The LPN whom you are supervising comes to you and says "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions?

1. Assess the client's heart rate 2. Notify the physician of the incorrect medication dose 3. ask the LPN to explain how the error occurred 4. complete a med error report

an experience LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a resp. problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all

1. Auscultate breath sounds 2. administering medications via MDI 3. Checking Oxygen saturations with a pulse ox.

you are the team leader RN working with a student nurse. The student nurse is to teach a patient how to use a MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.

1. Remove the inhaler cap and shake the inhaler 2. Breathe out completely 3. open your mouth and place the mouthpiece 1-2 inches away 4. Press down firmly on the canister and breathe deeply through your mouth 5. Hold your breath for at least 10 seconds 6. wait at least 1 minutes between puffs

You are caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will you implement first?

1. Start oxygen using a non-rebreather mask.

A client who has recently traveled to china comes to the ED w/ increasing SOB and is strongly suspected of having severe acute resp. syndrome (SARS). Which of these prescribed actions will you take first?

3. Place the client on airborne and contact precautions

A patient with a Pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs? Select All

1. Use a lift sheet when moving and positioning the patient in bed 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. be sure the patient's footwear has a firm sole when the patient ambulates

You are supervising an RN who floated from the med-surg unit to the ED. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? Select all

1. apply direct lateral pressure to the nose for 5 minutes 2. maintain standard body substance precautions 3. apply ice or cool compresses for the nose 4. instruct the pt. not to blow the nose for several hours

you are providing care for a patient with recently dx. asthma. Which key points would you be sure to include in your teaching plan for this patient? select all

1. avoid potential environmental asthma triggers such as smoke 2. use the inhaler 30 minutes before exercising to prevent bronchospasm 3. be sure to get at least 8 hours of rest and sleep every night 4. avoid foods prepared with monosodium glutmate (MSG)

You are caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the clients risk for ventilator-associated pneumonia? Select All

1. keep the head of the client's bed elevated to at least 30 degrees 2. Assess the client's readiness for extubation at least daily 3. Provide oral care with chlorhexidine solution at least daily

After change of shift, you are assigned to care for the following patients. which patient should you assess first?

51-year old with asthma who reports SOB after using a bronchodilator inhaler

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit?

72-year old who needs teaching about the use of incentive spirometry

A 23- year old client comes to the outpatient clinic reporting SOB, diarrhea, abd pain, and epistaxis. which action should you take first?

Ask the client about any recent travel to Asia or the middle east

You are checking med orders that were received by telephone for a client with rheumatoid arthritis who was admitted with methotrexate toxicity. Which order is most important to clarify with the physician?

Administer Chlorambucil (Leukeran) 4 mg PO daily

A client who has frequent watery stools and a possible C. diff infection in hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN?

Administering the ordered metronidazole (Flagyl) 500mg PO to the client

Which info. about a client who has meningo-coccal meningitis is the best indicator that you can discontinue droplet precautions?

Appropriate antibiotics have been given for 24 hours.

A patient has COPD. Which interventions for airway management should you delegate to the UAP?

Assisting the patient to sit up on the side of the bed

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

Auscultating the lungs for crackles

You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?

Continuous bubbling in the water-seal chamber.

You are the charge nurse on the medical unit. Which infection control activity should you delegate to an experience UAP?

Disinfecting BP cuffs after clients are discharged

You are responsible for the care of a post-op patient with a thoracotomy. The patient has been given the nursing dx. of Activity intolerance. Which action should you delegate to the UAP?

Encouraging, monitoring, and recording nutritional intake.

As the infection control nurse in an acute care hosp., which action will you take to most effectively reduce the incidence of health care-associated infections?

Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital

A client who states that he may have been contaminated by anthrax arrives at the ED. Which action included in the ED protocol for possible anthrax exposure will you take first?

Escort the client to a decontamination room

You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? Select all

Gloves Gown

A client with A-fib is ambulation in the hallway on the coronary step-down unit and suddenly tells you "I feel really dizzy." Which action should you take first?

Help the client to sit down

The UAP tells you that a patient who is receiving oxygen at a flow rate of 6L/min by NC is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem?

Humidify the patient's oxygen

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen sat monitor reads 87% and the pt. is struggling to sit up. Which action should you take next?

Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

the patient with COPD has a nursing dx. of Ineffective breathing pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Observing how well the patient performs pursed-lip breathing

You are caring for a client who has been admitted to the hosp. with a leg ulcer that is infected with VRSA. Which nursing action can you delegate to the LPN?

Obtaining wound cultures during dressing changes

the patient with COPD tells the UAP that he did not get annual flu shot this year and has not has a pneumonia vaccine. You would be sure to instruct the UAP to report which vital sign value?

Oral temperature of 101.2 degrees F

a patient with acute resp. distress syndrome (ARDS) is receiving oxygen by non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?

Perform endotracheal intubation and initiate mechanical ventilation

A hospitalized 88-year old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first?

Place the client on contact precautions

You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP?

Reminding the patient to use an incentive spirometer every 1-2 hours while awake

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you preform the following actions?

Remove gloves - 3 take off goggles - 2 take off gown - 4 remove N95 respirator -1 Perform hand hygiene - 5

You are supervising a student nurse who is performing tracheostomy care for a pt. Which action by the student would cause you to intervene?

Removing the inner cannula and cleaning using standard precautions

you are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by NC. Which finding concerns you immediately?

Resp. Rate of 8 breaths/min

When assessing a 22-year old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen sat is 90% with the oxygen delivery at 6L/min via NC. Which action is most appropriate?

Switch patient to a non-rebreather mask at 95%-100% Fio2 and call the physician to discuss the patient's status

A healthy 65-year old woman who cares for a newborn grandchild has a clinic appt. in May. The client needs several immunizations, but tells you, "I hate shots! I will only take one today." Which immunization is the most important to give?

Tetanus, Diphtheria, Pertussis

You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800mL of fluid. Which patient assessment info is important to report to the physician?

The BP is 100/48 mm Hg and the heart rate is 102 beats/min

You have received a needlestick injury after giving a client an IM injection, but you have no info about the client's HIV status. What is the most appropriate method of obtaining this info about the client?

The occupational health nurse should discuss HIV status with the client

You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg DVT and a PE. The patient's only med is enoxaparin SubQ. Which assessment info will you need to communicate to the physician?

The patient is unable to remember her husband's first name

You are admitting a patient for whom a dx. of Pulmonary embolus must be ruled out. The patient's hx and assessment reveal all of these findings. Which finding supports the dx. of pulmonary embolus?

The patient was recently in a motor vehicle crash

After the resp. therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately?

Tympanic temp of 101.4 degrees F

you are caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can you delegate to an LPN?

Undoing and retying the restraints in order to improve client comfort

which medication order for a client with a pulmonary embolism is the most important to clarify with the prescribing physician before administration?

Warfarin (Coumadin) 1.0 mg PO

You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection?

a 5-year old who has a new pruritic rash and a possible chickenpox infection

the patient with COPD tells the UAP that he did not get annual flu shot this year and has not has a pneumonia vaccine. You would be sure to instruct the UAP to report which vital sign value?

oral temp of 101.2 degrees F

a patient with sleep apnea has a nursing diagnosis of Sleep Deprivation r/t disrupted sleep cycle. Which action should you delegate to the UAP?

reminding the patient to sleep on his side instead of his back

You are administering Vanc. 500 mg IV to a client with a MRSA wound infection when you notice that the client's neck and face are becoming flushed. Which action should you take next?

slow the rate of the vanc infusion