Prioritization

NCLEX question

A,B,D are correct

A client in his early 60s is brought to the ER complaining of shortness of breath. Initial assessment findings include crackles, finger clubbing, and dry cough. The client states that he has previously worked in construction for 15 years. The ER physician suspects asbestosis. Which nursing problem should the nurse prioritize in the client? a. Impaired gas exchange b. Imbalanced nutrition: Less than body requirements c. Fatigue d. Ineffective airway clearance

ANSWER: A A is correct. In asbestosis, there is filling and inflammation of lung spaces with asbestos fibers. These fibers move into the alveolar space and cause fibrosis, leading to increased production in secretions impairing gas exchange. This should be a priority problem for the nurse. B is incorrect. There is imbalanced nutrition on the patient because of his difficulty of breathing and intolerance to activity. However, it should not be prioritized over the gas exchange. C is incorrect. Because of the client's impaired oxygenation, there is not enough oxygen that reaches the muscles to sustain activity. However, this problem must not take priority over the gas exchange. D is incorrect. Due to the increased secretions brought about by the asbestos fibers, there is an ineffective airway clearance. Although equally crucial with gas exchange, the nurse should prioritize impaired gas exchange over airway clearance because treatment for asbestosis is focused on the relief of symptoms. Oxygen delivery to the cells holds more importance.

Due to an absent staff nurse, the postpartum unit is assigned a nurse from the medical ward as a floater. Which of the following patients should the charge nurse assign to the float nurse? A. A 20-hour postpartum client who will be discharged the following morning B. A 16-hour postpartum client who had eclampsia during delivery C. A 10-hour postpartum client who has soaked 4 perineal pads in one hour. D. A 5-hour postpartum client whose fundus is still not at the miline.

Answer: B

NCLEX Question A registered nurse and a licensed practical nurse are working together in a psychiatric ward. Which of the following clients may the RN assign to the LPN? A. A client taking amitriptyline, now swinging his jaw and grimacing. B. A client with dementia that is confused and disoriented. C. A client with bipolar disorder and a Lithium level of 2.0 mEq/L. D. A client with a history of chronic alcoholism experiencing delirium tremens.

Answer: B

Your client is a patient with low potassium levels and accelerated hypertension. The physician has listed the cause as "hyperaldosteronism." Which of the following endocrine disorders cause an increased amount of aldosterone? Select all that apply. A. Cushing's disease B. Addison's disease C. Crohn's disease D. Pheochromocytoma

ANSWER: A Cushing's disease (Choice A) is caused by an increased secretion of adrenocorticotropic hormone (ACTH) from the pituitary gland. Increased ACTH causes increased stimulation and hyperplasia of the adrenal cortex. This leads to increased levels of both glucocorticoids(cortisol) and mineralocorticoids(aldosterone). The physician may order ACTH and Cortisol levels to establish the diagnosis of Cushing's disease. Clinical symptoms include abdominal obesity, moon facies, neck hump, abdominal striae, increased blood glucose, secondary diabetes, hypertension, and Hypokalemia. Other manifestations include Osteoporosis and increased risk of fractures. Clients are prone to increased risk of infections because excess steroids (cortisol) cause immunosuppression. Choice B is incorrect. Addison's disease is autoimmune destruction of the adrenal cortex. The resulting adrenal insufficiency would cause low levels of cortisol and aldosterone. There is a reflex increase in ACTH due to feedback from the Adrenal gland. Clinical manifestations of Addison's disease include fatigue, diarrhea, hyperpigmentation, and hypotension (opposite of hyperaldosteronism). Hypoaldosteronism can be associated with hyperkalemia (elevated potassium levels), hyponatremia (low sodium levels), and mild metabolic acidosis. Choice C is incorrect. Crohn's disease is a GI disorder involving inflammation of the digestive tract. It does not cause increased aldosterone. Choice D is incorrect. Pheochromocytoma is a tumor of Adrenal Medulla. Since medulla produces catecholamines, cancer involving this area is associated with high levels of Adrenaline and Nor-adrenaline. Adrenal medulla does not produce aldosterone. Therefore, secondary refractory hypertension in Pheochromocytoma is mediated by Catecholamine excess, not by aldosterone excess.

Practice SATA question: You are putting together a community health presentation about the signs and symptoms of depression to promote awareness of the disease and educate the public. Which of the following signs and symptoms would be essential to include? Select all that apply. A. Anhedonia B. Flight of ideas C. Looseness of associations D. Sleep disturbances

ANSWER: A and D A is correct. Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable things. For example, a mother who usually loves going to see her children in their dance recitals says she no longer wants to go. The things that once brought someone joy do not do that anymore due to depression. This can be difficult for families to understand and can cause a lot of frustration. You should educate your community that this is not the patient's fault, but a part of the disease process of depression. B is incorrect. Flight of ideas is not a typical symptom of depression, but rather mania. Flight of ideas is defined as a rapid shifting of ideas with only superficial associative connections between them that is expressed as a disconnected rambling from subject to subject.” It is tough to have a coherent conversation with someone who is experiencing a flight of ideas because they jump from topic to topic so quickly. It is common that this symptom of mania presents in the manic phases of bipolar disorder, but not in depression alone. C is incorrect. Looseness of associations is a common symptom of schizophrenia, but not of depression. Looseness of associations is defined as speech that is disconnected and fragmented, with the individual jumping from one idea to another unrelated or indirectly related idea.” People who have schizophrenia often have disorganized thoughts and are unable to communicate those thoughts to others in a coherent manner. This is not usually the case with a patient experiencing depression. D is correct. Sleep disturbances are an incredibly common symptom in depression and should undoubtedly be a point of education. In patients suffering from depression, their sleep disturbances usually occur when they wake up in the middle of the night and are unable to go back to sleep. In patients suffering from anxiety, there are also significant sleep disturbances, but the trouble is usually falling asleep rather than staying asleep.

Reword questions in your OWN words The nurse assists a mother in labor to the bathroom, and notes that the fetal heart rate increases from 130 to 190. She sits the mother back down in bed, and the fetal heart rate remains 190. Which of the following nursing actions would be appropriate? Select all that apply. a. Lie the mother down on her left side b. Decrease the rate of her IV fluids c. Administer oxygen d. Continue to monitor the mother

ANSWER: A&C A is correct. The nurse has noted fetal tachycardia. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. Any nonreassuring fetal heart rate will require intervention. You can remember these interventions with the mnemonic LION: lie the mother on her left side, increase IV fluids, oxygen, and notify the healthcare provider. In this case, the nonreassuring sign of fetal tachycardia necessitates intervention, and lying the mother on her left side is an appropriate intervention B is incorrect. Decreasing the rate of the mother's IV fluids is not appropriate. Instead the nurse should increase the rate of IV fluids to help better facilitate blood perfusion to the placenta and fetus. Increasing not decreasing the fluids is the appropriate nursing intervention. C is correct. Administering oxygen is an appropriate nursing intervention for the noted fetal tachycardia. This will go along with repositioning the mother on to her left side, increasing the rate of IV fluid administration, and notifying the healthcare provider. D is incorrect. It is inappropriate to simply continue to monitor the mother. The nurse has noted fetal tachycardia, a nonreassuring sign that requires intervention. The nurse should lie the mother on her left side, increase her IV fluids, administer oxygen, and notify the healthcare provider.

Which of the following is an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide? A. Privacy and a client room without stimulation or the presence of others. B. An empathetic and non-judgment exploration of the client's feelings. C. Probing the client for details of their suicide plan. D. The use of restraints and seclusion.

ANSWER: B Correct Answer is B. An empathetic and nonjudgment exploration of the client's feelings and facilitating the client's open verbalization of their beliefs is the only appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide, as based on the client information provided in this question. Choice A is incorrect. Privacy and a client room without stimulation or the presence of others are contraindicated with severe depression and thoughts of suicide because one to one monitoring is necessary. Choice C is incorrect. Probing the client for details of their suicide plan is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because probing is not therapeutic, and it is invasive. Choice D is incorrect. The use of restraints and seclusion is not an appropriate crisis intervention technique to assist a client who has severe depression and thoughts of suicide because control and privacy are not indicated until all other preventive alternative interventions have failed. The client is in immediate danger, which is not found in this question.

Choose Acute Problems over Chronic Problems The nurse in the Intensive Care Unit notes bleeding from the client's transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for Sepsis. What should be the nurses immediate next action? a. Assess the client's hemoglobin and hematocrit level b. Check the client's oxygen saturation. c. Apply pressure to the intravenous site. d. Call the physician

Answer: D Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors. Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should undoubtedly check the client's Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC. Choice B is incorrect. Assessing the client's oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.

Avoid answers that include words like: always/never A hypertensive client has prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal substance to help lower her blood pressure. Which is the most appropriate response for the nurse? A.Tell the client that herbal substances unsafe and should never be used B. Encourage the client to discuss the use of herbal substances with her attending physician C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes D. Tell the client that if she takes the herbal substance it will require the nurses to check her blood pressure closely

ANSWER: B The most appropriate response is B. Although the use of herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are on conventional medication therapy are discouraged from using herbal materials with similar pharmacological effects because the combination may lead to an excessive reaction of unknown interaction effects. The nurse would advise the client to discuss the use of the herbal substance with her attending physician. Options A, C, and D are inappropriate nursing actions.

The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % Which of the following is the priority nursing action at this time? a. Keep the child calm and call for emergency airway equipment b. Obtain IV access c. Assess the throat for a cherry red epiglottis d. Place the child on a high flow nasal cannula at 100% FiO2 Answer:

Answer: A

A client in septic shock in the intensive care unit is receiving a Dopamine infusion. Upon assessment, the nurse notices that the client's; blood pressure is 195/120 mm Hg. Which initial nursing action would the nurse implement? a. Discontinue dopamine. b. Notify the physician c. Administer Furosemide. d. Assess the clients' GCS

Answer: A A is correct. The initial action for the nurse is to discontinue Dopamine, which is a vasoconstrictor, the medication that causes the client's high blood pressure. B is incorrect. The nurse needs to notify the physician in order to arrange an adjustment of the medication dosage. However, this should not be the initial action of the nurse. C is incorrect. The nurse can give Furosemide to decrease the patient's blood pressure. But the nurse should terminate the exact cause of hypertension which is Dopamine. D is incorrect. The nurse can assess the client's GCS, but the nurse should decrease the client's blood pressure.

You are caring for a 46 year old woman who has just been diagnosed with Stage IV breast cancer. She shares with you that she was estranged from her father over a decade ago, but now that she is sick is thinking about reaching back out to him. As the nurse, you know this falls under which category in Maslow's Hierarchy of Needs? A. Love and belonging B. Physiological C. Esteem D. Self-actualization

Answer: A A is correct. Love and belonging is the level on Maslow's hierarchy of needs where this patient's relationship with her mother would fall. B is incorrect. Physiological needs include items such as oxygen, fluids, nutrition, shelter, and elimination. The patient's relationship with her mother would fall under love and belonging. C is incorrect. Esteem needs include things such as self-confidence, recognition, self-worth, status, and respect. The patient's relationship with her mother would fall under love and belonging. D is incorrect. Self-actualization needs include things such as Full potential of self, effective coping, and problem solving capabilities. The patient's relationship with her mother would fall under love and belonging.

The nurse is caring for a patient who intentionally overdosed on amitriptyline. What action should the nurse prioritize? A. Obtain a 12-lead electrocardiogram B. Request a prescription to consult psychiatry C. Determine the reasoning for the overdose D. Establish a therapeutic relationship

Answer: A A is correct. Obtaining a 12-lead electrocardiogram is the priority. Amitriptyline is a TCA and can cause cardiac arrhythmias. If the client has overdosed on amitriptyline, they are at high risk for arrhythmias. This is a physiological need and the nurse must prioritize this action first. B is incorrect. Requesting a prescription to consult psychiatry is important, but not the priority. This client has a physiological issue that must be addressed first. C is incorrect. Determining the reasoning for the overdose will also be important, but will fall under the safety category of the hierarchy of needs. The nurse should prioritize any physiological needs first, which in this case includes the risk for cardiac arrhythmias. D is incorrect. Establishing a therapeutic relationship falls under the love and belonging category of the hierarchy of needs. The nurse should prioritize any physiological needs first, which in this case includes the risk for cardiac arrhythmias.

A nurse is caring for a client receiving digoxin. The client's most recent serum digoxin level was 2.5 ng/mL. Which of the following priority nursing actions should the nurse take? Select all that apply. A. Withhold the client's scheduled dose B. Administer the dose as prescribed C. Assess the client's urinary output D. Assess the client's most recent sodium level E. Assess the client's heart rate and rhythm

Answer: A and E The client's digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than two ng/mL is considered toxic. The nurse is correct to withhold the scheduled dose (Choice A) and assess the client's heart rate and rhythm (Choice E) as the client is likely to be experiencing bradycardia. Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate the toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.

The manager at a home health nursing agency is making assignments for her RNs. Which client should be assigned to the most experienced RN? A. A client recovering from Guillain-Barre syndrome complaining of constant fatigue. B. A client with stage 3 and stage 4 pressure ulcers on the sacral area. C. A 2-week postoperative laryngectomy client due to laryngeal cancer. D. A client being discharged from home health services in the coming week.

Answer: B Choice B is correct. A client with stage 3 and 4 pressure ulcers would require extensive wound care and experienced nurses who can properly care for the pressure ulcers. Choice A is incorrect. A client with Guillain-Barre syndrome that complains of fatigue is appropriately expected to have this symptom; this would not require the most experienced nurse. Choice C is incorrect. A client recovering from a laryngectomy would not require extensive teaching nor nursing care; this client would not need the most experienced nurse. Choice D is incorrect. A client being discharged from home health has been given discharge instructions starting from the time they are admitted; once they are ready for discharge, they would have received enough teaching from the nurse and other allied health team members; they would not require the most experienced nurse.

A nurse working in a busy long-term care facility needs to delegate to the unlicensed assistive personnel she is working with. Which of the following tasks would be appropriate to delegate? Select all that apply. A. Performing an initial assessment B. Checking vital signs C. Setting up oxygen D. Listen to the patient's lung sounds

Answer: B and C A is incorrect. Performing an initial assessment is not an appropriate task to delegate. Assessment is out of the scope of practice of unlicensed assistive personnel. B is correct. Checking vital signs is an appropriate task to delegate. C is correct. Setting up oxygen is part of routine room set up and is an appropriate task to delegate. D is incorrect. Listening to the patient's lung sounds requires assessment, which is out of the scope of practice of unlicensed assistive personnel.

The nurse is taking vital signs on her patient with a diagnosis of ALL. His temperature is 38.7C. What is the nurse's first priority? a. Place cool washcloths on the patient's head. b. Continue with her assessment c. Obtain intravenous access on the patient. d. Assess the patient's perfusion.

Answer: C A is incorrect. Placing cool washcloths on the patient's head is not the priority, there is a better answer. This would only need to be done if the patient was at risk for seizures due to an incredibly high body temperature. The temperature of 38.7C does not warrant cooling measures, and the nurse has another immediate priority given the patients immunosuppression and her suspicion of an infection. B is incorrect. It is not appropriate for the nurse to simply continue with her assessment. She suspects an infection in her patient who is immunocompromised. Another answer has an immediate priority that the nurse must do. C is correct. It is the priority action to establish intravenous access on this patient. This patient has a diagnosis of ALL, so the nurse knows that he is immunocompromised. He is very susceptible to infections, and with a fever of 38.7C she has a high index of suspicion for an infection. Broad spectrum IV antibiotics will need to be started right away, therefore it is the priority for the nurse to start an IV. D is incorrect. Assessing the patient's perfusion has nothing to do with the nurses suspicion of an

Which of these patients should the LPN/LVN see first? A. A patient with a newly placed NG who is complaining of pain around the face and a plugged nose. B. A post-op prostatectomy patient who complains of bladder spasms and blood in his foley bag. C. A patient in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm. D. A patient newly diagnosed with Hepatitis A who reports stomach pain and itchy skin.

Answer: C Choice C is correct. Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away. Learning to prioritize the care of patients is an essential nursing skill. When daily patient assignments are given, the nurse should consider the report given by the previous shift, any immediate complaints/requests by the patient, and any existing orders to then determine the order in which assessments will be done. Using "problem urgency" will help determine which patient should be seen first. According to problem urgency criteria, the patient complaints/problems would be ranked based on the degree of threat they pose to the patient's life or how immediate the need for care is. High priority problems are considered life-threatening or could have destructive long-term effects on the patient (for example ineffective airway clearance or substance abuse). Medium priority problems do not pose a direct threat to life but may cause destructive physical or emotional changes (ineffective denial, unilateral neglect). Low priority problems require minimal supportive nursing intervention (mild anxiety, interrupted breastfeeding).

A medical-surgical ward nurse is taking a floater shift in the ICU. The charge nurse would assign which patient to the nurse? A. A 2-hour post lung transplant client B. A client with a CVP reading of 13 cm of water C. A client with pneumonia D. A client with Hantavirus pulmonary syndrome

Answer: C Choice C is correct. The client with pneumonia is neither in immediate danger nor in any complicated condition. The medical-surgical nurse can safely assess and administer medication to this client. This client can be assigned to the nurse. Choice A is incorrect. The client is still in critical condition and is prone to organ rejection. This client should be assigned to an experienced nurse. Choice B is incorrect. The client has an increased CVP reading, which indicates volume overload or right ventricular failure. This client needs to be assigned to a much more experienced nurse. Choice D is incorrect. Hantavirus pulmonary syndrome is a deadly disease that has a specific treatment or cure. This client should be assigned to an experienced nurse.

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric patients around him are getting angry. What is the most appropriate action of the nurse? a. Restrain the client b. Escort the other clients from the day room c. Give Haloperidol IM d. Approach the client calmly accompanied by two other staff

Answer: D A is incorrect. Restraining the client should be the last approach for the nurse. The first intervention should be to talk to the client to remove him from the day room. B is incorrect. The nurse should not try to remove the other clients from the room. The nurse should first remove the client from the place. C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The nurse needs to remove the client from the day before the situation escalates. D is correct. The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not contact the agitated client alone but should be accompanied by other personnel.

You are the charge nurse in the nursing care unit today. As you prepare the assignments for the team members in the group, which of the following legal documents must you consider when you are writing up the tasks for the day? A. The competency checklists for all of the team members on the unit B. The job descriptions of all of the team members on the unit C. The American Nurses Association's scopes of practice for RNs and LPNs D. The state's scopes of practice for RNs, LPNs, and unlicensed assistive personnel

Answer: D Choice D is correct. The state's scopes of practice for RNs, LPNs, and unlicensed assistive personnel are the legal documents that you must consider when you are writing up the assignments for the day because the state laws about the differentiated practice of members of the nursing team outline what the RNs, LPNs, and unlicensed assistive personnel are legally permitted to do. Although you would also consider the job descriptions and competency checklists, these documents are not legal documents. Lastly, the American Nurses Association does not publish legal documents about the differentiated practice of members of the nursing team. Choice A is incorrect. Although the competency checklists for all of the team members on the unit are considered when writing up assignments for the day, competency checklists are not legal documents. Choice B is incorrect. Although the job descriptions for all of the team members on the unit are considered when writing up assignments for the day, job descriptions are not legal documents.

A nurse employed in an emergency department is doing triage on the evening shift. Which of the following clients should be assigned the highest priority? a. A client complaining of muscle aches, a headache, and malaise that has been on for 5 hours b. A client who twisted her ankle when she fell while skateboarding c. A client with a minor laceration on the index finger sustained while slicing vegetables d. A client with chest pain who claims that he just ate a very spicy pizza 2 hours ago

Answer: D In the emergency department, triage involves brief client assessment to classify clients according to their need for care and includes prioritization of care. The type of illness or injury, the severity of the problem, and the resources available are considered in the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 or highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as non urgent and are the third priority. Thus, the correct answer is D, while options A, B, and C are incorrect.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply warm compress to incision sites

Answer:B Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain. Choice A is incorrect. These symptoms are expected following this type of surgery. Manual pressure would be appropriate if the patient was actively bleeding. Choice C is incorrect. Intermittent claudication is a cramp-like pain in the leg or buttock during activity due to poor blood supply. This is a sign of arterial disease, but not of postoperative complication, and would not be a priority for this patient. Choice D is incorrect. The RN should perform a focused assessment to rule out potential complications before implementing any interventions. Applying a warm compress may be helpful for reducing the patient's pain, but will also result in vasodilation which may increase swelling.

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN? Select all that apply. A. A patient receiving antibiotics for lower extremity cellulitis. B. A patient newly admitted with an exacerbation of myasthenia gravis. C. A patient with a chest tube and receiving mechanical ventilation. D. A patient requiring a referral for an outpatient support group. E. A patient needing to receive intramuscular RhoGAM. F. A patient needing scheduled tube feedings and colostomy irrigations.

Answers: A and F

Which of the following tasks would be inappropriate for an LPN/LVN to accept as an assignment? A. Obtaining an occult blood sample from a 15-year old client with UC. B. Assessing a 35-year old client newly admitted for chest pain. C. Reinforcing teaching to a 25-year old first time mother regarding care of her new infant. D. Adjustment of a 69 year old patient's cervical traction as ordered by the MD.

B