Quiz #3

Case Study #14: Septic Shock

Ms. D, a 54-year-old patient, is brought to the emergency department (ED) by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although Ms. D is usually very alert and oriented, today she has been increasingly lethargic. Her medical history includes hypertension, atrial fibrillation, and diabetes mellitus type 2. The initial vital sign values are as follows: BP = 102/38 HR = 102 bpm O2 Sat = 76% RR = 30 bpm Temp = 102.4 F

The cardiac monitor shows this rhythm for Ms. D. Routine treatment orders for dysrhythmias are in the ED protocols. Which action should the nurse take next? 1. Continue to monitor cardiac rhythm. 2. Administer metoprolol 5 mg IV push. 3. Prepare to perform cardioversion at 50 J. 4. Administer amiodarone 150 mg IV push.

Ans: 1 Although atrial fibrillation at rapid rates can cause a significant drop in cardiac output, the current rate of 100 to 110 beats/min is not a likely cause of the patient's hypotension. Ongoing cardiac rhythm monitoring is necessary, but no treatment of the patient's chronic atrial fibrillation is needed at this time. Cardioversion or administration of antidysrhythmic medications such as amiodarone or metoprolol may be considered if the heart rate increases.

After infusion of the normal saline bolus, Ms. D's blood pressure is 92/42 mm Hg. Lactate level is elevated at 36.04 mg/dL (4 mmol/L). Norepinephrine infusion is prescribed at 8 mcg/min, and infusion is started through a peripheral IV line. When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? 1. Shut off the infusion pump. 2. Assess for pain at the site. 3. Notify the HCP about the possible norepinephrine extravasation. 4. Inject the pale area with phentolamine solution per hospital protocol.

Ans: 1 The first action should be to stop the infusion because pallor and coolness at the site indicate possible extravasation. Assessment for pain, notification of the HCP, and injection of phentolamine at the site to cause vasodilation are also appropriate but should be done after stopping the infusion.

At the end of the shift, the supervisor consults with the nurse about which of these oncoming staff mem- bers should be assigned to care for Ms. D. Which RN will be best to assign to care for this patient? 1. Travel RN with 20 years of ICU experience who has been working in this ICU for 4 months 2. Newly graduated RN who worked in the ICU as a nursing assistant and has finished the precepted orientation 3. Experienced ICU RN who has been called in on a day off to work for the first 4 hours of the shift 4. RN who has been floated from the post-anesthesia care unit (PACU) to the ICU for the shift

Ans: 1 The travel RN has the required experience to provide care in this complex case and has been working at the hospital long enough to be familiar with how to obtain supplies, communicate with other departments, and so on. The other nurses either lack experience in caring for critically ill patients (the new graduate and the PACU nurse) or will not be able to offer the continuity of care that is desirable for the patient.

*Ms. D's ABG* pH = 7.23 PaCO2 = 62 mmHg PaO2 = 50 mmHg HCO3 = 22 mEq/L O2 Sat = 82% Based on an analysis of the ABG values, which collaborative intervention will the nurse anticipate next? 1. Sodium bicarbonate bolus IV 2. Endotracheal intubation and mechanical ventilation 3. Continuous monitoring of Ms. D's respiratory status 4. Nebulized albuterol therapy

Ans: 2 The ABG values indicate that the patient is hypoxemic (low Pao2 and oxygen saturation) and has a severe uncompensated respiratory acidosis (low pHand elevated Paco2). Because she is unable to maintain adequate oxygenation and ventilation independently, intubation and mechanical ventilation are indicated. Sodium bicarbonate is administered only if metabolic acidosis is present. Although the patient will need ongoing respiratory monitoring and may also benefit from albuterol therapy, these therapies are not adequate in a patient with these severe ABG abnormalities.

Based on the assessment data and vital signs, which collaborative actions should the nurse anticipate at this time Select all that apply. 1. Send specimens for blood and urine culture. 2. Start norepinephrine infusion at 8 mcg/min. 3. Give normal saline bolus of 30 mL/kg. 4. Draw blood for serum lactate level. 5. Administer vancomycin 1 g IV. 6. Administer sodium bicarbonate 1 meq/kg IV.

Ans: 1, 3, 4, 5 The initial resuscitation bundle in the Surviving Sepsis guidelines recommends that the measurement of the lactate level, the obtaining of cultures, the administration of broad-spectrum antibiotics, and the infusion of crystalloid solutions such as normal saline be initiated rapidly when sepsis is suspected. Norepinephrine will be indicated if blood pressure remains low after rapid fluid infusion has been accomplished. Even though the pH becomes higher, it is best to treat the cause of the acidosis so sodium bicarbonate is not used to treat acidosis.

After the successful intubation, the nurse performs a rapid assessment of Ms. D and documents the findings: "Apical pulse irregularly irregular. Face flushed and warm. Extremities cool and mottled. Breath sounds audible bilaterally with crackles present in lung bases. Reports pain with suprapubic palpation. Urine is amber and cloudy, with red streaks. 100 mL urine output when Foley catheter inserted." The patient's current vital sign values and capillary blood glucose are as follows: BP = 86/40 HR = 102 bpm O2 Sat = 93% RR = 32 bpm Temp = 103 F Capillary Blood Glucose = 167 mg/dL Which data collected about this patient are most important in alerting the nurse to a diagnosis of sepsis? Select all that apply. 1. Hematuria 2. Atrial fibrillation 3. Temperature 4. Apical pulse rate 5. Blood glucose level 6. Respiratory rate

Ans: 1, 3, 4, 6 The criteria for sepsis is evident in this patient. She has an altered mental status, tachycardia (over 100 beats/min), hypotension (systolic less than 100), temperature over 38.3°C, and a respiratory rate over 22 breaths/min. Ms. D's hematuria (especially with associated suprapubic and back pain) suggests urinary tract infection, pyelonephritis, or both. Atrial fibrillation is chronic for this patient and not an indicator of sepsis. Blood glucose higher than 140 mg/dL (7.77 mmol/L) would suggest sepsis in a nondiabetic patient but is not unusually elevated in this patient who has diabetes.

Ms. D is transferred to the ICU, and a two-port central IV line is started at the subclavian site to infuse fluids and norepinephrine. The ICU nurse is working with an experienced LPN/ LVN in caring for Ms. D. Which nursing activities included in the care plan should be assigned to the LPN/LVN? Select all that apply. 1. Documenting the hourly urinary output 2. Monitoring the central line site for signs of infection 3. Checking capillary blood glucose levels every 2 hours 4. Completing a head-to-toe assessment every 4 hours 5. Administering sliding-scale insulin lispro per protocol 6. Infusing normal saline at 400 mL/hr

Ans: 1, 3, 5 LPN/LVNs are educated and licensed to perform tasks such as monitoring and documenting intake and output, monitoring blood glucose at the bedside, and administering insulin under the supervision of an RN. Although LPN/ LVNs can collect data about stable patients, head- to-toe and central line assessments of critically ill patients should be done by RNs. LPN/LVNs may be able to administer IV fluids to stable patients (depending on state nurse practice acts and on hospital policy), but infusion of large volumes to unstable patients requires more education and scope of practice and should be done by RN staff members with experience in caring for critically ill patients.

Which method of oxygen administration will be best to increase Ms. D's oxygen saturation? 1. Nasal cannula 2. Non-rebreather mask 3. Venturi mask 4. Simple face mask

Ans: 2 A nonrebreather mask can provide a fraction of inspired oxygen (Fio2) of close to 100%, which will be needed for this severely hypoxemic patient. Nasal cannulas deliver a maximum Fio2 of 44%, simple face masks deliver an Fio2 of up to 60%, and Venturi masks provide a maximum Fio2 of 55%.

The nurse quickly reviews Ms. D's latest laboratory test results, which have just arrived on the unit: Hematocrit = 32% Hemoglobin = 10.9 Platelet = 96,000 WBC = 26,000 BUN = 56 mg/dL Creatinine = 2.9 mg/dL Glucose = 330 mg/dL Potassium = 5.2 mEq/L Sodium = 140 mEq/L Which laboratory value requires the most immediate action by the nurse? 1. Creatinine level 2. Glucose level 3. Potassium level 4. Hemoglobin level

Ans: 2 The elevated glucose level will require administration of the ordered insulin lispro using the hospital standard sliding-scale insulin orders. Potassium will move into cells along with glucose as insulin is administered, so the patient's potassium level does not require additional treatment. The other abnormalities indicate the need for continued monitoring but will not require any immediate action at this time.

Based on the initial history and assessment, what is the first action of the nurse? 1. Administer an acetaminophen suppository to lower the temperature. 2. Start oxygen and maintain oxygen saturation at 90% or higher. 3. Place the patient on a cardiac monitor. 4. Initiate intravenous access with normal saline at a keep open rate.

Ans: 2 The oxygen saturation indicates that the patient is severely hypoxemic (despite an increased respiratory rate). Because this hypoxia will affect all other body systems, it should be treated immediately. The other orders should also be rapidly implemented, but they do not require action as urgently as the low oxygen saturation.

Ms. T is receiving an oral dose of sulfasalazine 500 mg every 6 hours for treatment of ulcerative colitis. Which assessment finding is cause for greatest concern? 1. Decreased appetite 2. Nausea and vomiting 3. Decreased urine output 4. Headache

Ans: 3 Sulfasalazine is potentially nephrotoxic. The other adverse effects are also possible but are less serious.

After 2 hours, the values for vital signs are as follows: BP = 104/56 HR = 104 bpm O2 Sat = 92% CVP = 3 mmHg RR = 26 bpm Temp = 101.6 F Which information about Ms. D is most important for the nurse to communicate rapidly to the HCP? 1. Decreased blood pressure 2. Ongoing atrial fibrillation 3. Low central venous pressure 4. Continued temperature elevation

Ans: 3 The low central venous pressure indicates that the patient is still hypovolemic and will need an increase in IV fluids. The arterial blood pressure and temperature have improved. The patient has chronic atrial fibrillation, and the rate has remained stable.

When the nurse is infusing the normal saline, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? 1. Palpating for any peripheral edema 2. Monitoring urine output 3. Listening to lung sounds 4. Checking for jugular venous distention

Ans: 3 The most common complication of too-rapid IV infusion of fluids is volume overload, leading to fluid overload and heart failure. Although peripheral edema, decreased urine output, and jugular venous distention may be indicators that heart failure is developing, they do not occur as rapidly as the backup of fluids into the pulmonary capillaries and then into the alveoli.

Which of these actions prescribed by the HCP will be most important for the nurse to question? 1. Increase oxygen flow rate (Fio2). 2. Raise normal saline rate to 450 mL/hr. 3. Administer acetaminophen 650 mg rectally. 4. Increase norepinephrine infusion rate to12 mcg/kg.

Ans: 4 In a hypovolemic patient, increasing the norepinephrine rate will not improve perfusion and may increase the risk for adverse norepinephrine effects such as arrhythmias. The nurse may question the other prescribed actions, but these are not as likely to result in poor patient outcomes. A higher-than-prescribed normal saline infusion rate may be needed to improve volume status, the patient's temperature is already decreasing in response to antibiotic therapy, and oxygen saturation is already at an adequate (though not optimal) level.

The nurse is preparing to transfer Ms. D to the intensive care unit (ICU). Using the SBAR (situation, background, assessment, recommendations) format, in what order will the nurse communicate pertinent information about Ms. D to the ICU nurse? 1. "Current blood pressure is 92/42, pulse rate is 112, and respirations are 32. Capillary blood glucose is 167 mg/dL (9.27 mmol/L), and lactate level is 36.04 mg/dL (4 mmol/L). Blood and urine cultures are pending." 2. "The patient has diabetes and chronic atrial fibrillation. She has been experiencing nausea, abdominal pain, and back pain. Today she was noted to be increasingly lethargic." 3 "Ms. D will need a central line insertion for fluid and vasopressor management, along with titration of norepinephrine and normal saline to maintain mean arterial pressure at 65 mm Hg." 4. "Ms. D is ready to transfer to intensive care. She has septic shock and is receiving mechanical ventilation, norepinephrine drip, and normal saline infusion through a peripheral line."

Ans: 4, 2, 1, 3 When using the SBAR format, the nurse initially describes the current situation, then gives appropriate background information, and then the most current assessment data. Finally, the nurse provides recommendations for any anticipated patient needs so that the receiving staff can prepare for patient care.

When the nurse is preparing to assist with the endotracheal intubation of Ms. D, in which order will these actions be accomplished? 1. Use capnography to check for exhaled carbon dioxide. 2. Secure the endotracheal tube in place. 3. Preoxygenate with the bag-valve mask device at 100% oxygen. 4. Inflate the endotracheal tube cuff. 5. Obtain all the needed equipment and supplies. 6. Insert the endotracheal tube orally through the vocal cords.

Ans: 5, 3, 6, 4, 1, 2 All needed equipment and supplies should be obtained before the intubation attempt.To minimize hypoxemia during the procedure, the patient should be preoxygenated for 3 to 5 minutes before the intubation attempt. After the endotracheal tube is inserted by the HCP, inflation of the endotracheal tube cuff is needed for effective ventilation. Checking for exhaled carbon dioxide through continuous waveform capnography is the most accurate way to assess endotracheal placement. After the initial assessment of endotracheal placement is completed, the tube should be secured.

Case Study #9: Multiple Patients with GI Problems An RN is the leader of a team caring for patients with gastrointestinal disorders on a medical-surgical unit. The team includes a newly graduated RN who has recently completed hospital orientation, an experienced assistive personnel (AP), and a nursing student. The following information about the six assigned patients is included in the hand-off report.

1. Ms. H, a 42-year-old woman, has right upper quadrant pain that radiates to the right shoulder. She has a history of gallstones. She was admitted through the emergency department last night with acute cholecystitis. The night shift nurse reports, "She had a good night." 2. Ms. D, a 60-year-old woman, was admitted with vomiting and pain in the mid abdomen related to a bowel obstruction. She reports abdominal pain that has gradually improved since the insertion of a nasogastric (NG) tube. She is receiving IV fluids and is currently NPO. 3. Ms. T, a 29-year-old woman, was admitted for an acute exacerbation of ulcerative colitis. She appears wasted and malnourished. She has severe diarrhea and reports pre-defecation abdominal pain and generalized tenderness to palpation. The plan is to start administering total parenteral nutrition (TPN) through a central line this morning. 4. Mr. A, a 26-year-old man, will be discharged in the afternoon. He is homeless and frequently sleeps in a nearby shelter. He had discharge teaching from the enterostomal therapist yesterday regarding his infected wound secondary to a ruptured appendix; he wants a review of the wound care instructions before he leaves. 5. Mr. K, an 85-year-old man, is frail but alert and oriented to person and place. He was transferred from an extended- care facility to receive a percutaneous endoscopic gastrostomy (PEG) tube that was placed 5 days ago. He has a large family. They ask a lot of questions and argue continuously among themselves and with the staff. His vital signs are stable. 6. Mr. R, a 57-year-old man, has periumbilical pain. The pain is very severe, despite medication, and radiates to the back. Mr. R was admitted with acute pancreatitis. He is NPO and has an NG tube and IV line. He is belligerent and confused. His white blood cell (WBC) count and blood glucose level are increased.

Ms. H decided to have the ERCP. The procedure was successfully performed without incident and she returns to the medical-surgical unit. What is the priority assessment in the immediate postprocedural care? 1. Signs/symptoms of perforation 2. Signs/symptoms of pancreatitis 3. Signs/symptoms of an allergic reaction 4. Signs/symptoms of biliary colic

Ans 1: Perforation is the major complication that can occur during any type of endoscopic procedure. The nurse would assess for signs/symptoms, such as abdominal pain, distention, nausea, vomiting, fever, and shock. Pancreatitis is the most common complication; however, the pathogenesis of pancreatitis will develop more slowly. Assessment for pancreatitis will become the priority after the immediate dangers of airway obstruction (return of gag reflex and independent control of airway) and perforation (hemorrhage and peritonitis) are passed. Severe anaphylactic reactions to contrast media would be expected to occur immediately after administration. Delayed reactions may occur but are much less severe. Biliary colic (se- vere pain, tachycardia, diaphoresis, and prostration) could occur when gallstones are dislodged and move through the ducts; however, biliary colic is not expected after the procedure.

Ms. H's (acute cholecystitis) ERCP shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are the key signs and symptoms that the nurse will watch for? 1. Rebound tenderness and a sausage-shaped mass in the right upper quadrant (RUQ) 2. Flatulence, dyspepsia, and eructation after eating or drinking 3. RUQ abdominal pain that radiates to the right shoulder or scapula 4. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration

Ans. 4 Severe pain with tachycardia, pallor, diaphoresis, and prostration (exhaustion) are signs and symptoms of severe biliary colic. Keep the patient flat and notify the rapid response team because of the potential for shock. Rebound tenderness and a sausage-shaped mass in the RUQ suggest peritoneal inflammation. Flatulence (gas), dyspepsia (indigestion), and eructation (belching) after eating are commonly reported by patients when they first seek help for gallbladder problems. RUQ pain that radiates to the right shoulder or scapula is reported by some patients in their descriptions of pain patterns.

The night shift nurse has just finished giving the RN team leader a report on the six patients. Which patient has the highest acuity level and the greatest risk for shock? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG tube) 6. Mr. R (acute pancreatitis)

Ans. 6 Mr. R has acute pancreatitis and several prognostic factors that increase the risk for death: age older than 50 years, increased WBC count, and an el- evated blood glucose level. Shock can occur secondary to bleeding; release of kinins, which cause vasodila- tion; or release of enzymes into the circulation. He is also at risk for infection and sepsis. Respiratory com- plications of pancreatitis include pneumonia, atelec- tasis, pleural effusions, and acute respiratory distress syndrome.

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider (HCP) will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Begin IV normal saline at a high rate up to 250 mL per hour. 3. Administer furosemide (Lasix) 100 mg IV push immediately. 4. Call a code for respiratory arrest.

Ans: 1 A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless HCPs intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Research has shown that patients with ARDS who are treated with conservative amounts of IV fluids while ventilated have improved lung function and shorter intensive care unit stays. Furosemide is a loop diuretic, which will not help with oxygenation.

A patient has chronic obstructive pulmonary disease. Which intervention for airway management should the nurse delegate to the assistive personnel (AP)? 1. Assisting the patient to sit up on the side of the bed 2. Instructing the patient to cough effectively 3. Teaching the patient to use incentive spirometry 4. Auscultating breath sounds every 4 hours

Ans: 1 Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of APs. Teaching, instructing, and assessing patients all require addition- al education and skills and are more appropriate to the scope of practice of licensed nurses

Psychosocial assessment reveals that Mr. A (appendectomy) faces several financial and personal problems. Which finding has the greatest impact on discharge teaching for wound care and other follow-up issues? 1. He is homeless and has no family in the city. 2. He has no money for the prescribed medications. 3. He has no transportation to the follow-up appointment. 4. He cannot read or write very well.

Ans: 1 Because Mr. A is homeless, he will need instructions for adapting the dressing change procedures because of inconsistent access to hot water, soap, and adequate bathroom facilities. The social worker can be contacted for assistance with financial issues related to medication or transportation. Simplify written material and verbally reinforce it or instruct Mr. A to have a friend read the information to him.

A patient with chronic obstructive pulmonary disease has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

Ans: 1 Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to APs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

The nurse is reviewing the medication administration record for Ms. T (ulcerative colitis). Which situation needs the most immediate investigation? 1. Two tablets of senna were given yesterday morning. 2. An oral dose of folic acid was given yesterday morning. 3. An IV infusion of infliximab 5 mg/kg was given yesterday evening. 4. An IV hydrocortisone 100 mg was given yesterday evening.

Ans: 1 Generally, laxatives should not be given to patients with ulcerative colitis. In Ms. T's situation, controlling her diarrhea is one of the main treatment goals. Senna is a stimulant laxative and will increase peristalsis and cramping. Folic acid is administered when sulfasalazine is prescribed. Infliximab and hydrocortisone (and sulfasalazine) can be used for patients with ulcerative colitis to reduce the inflammation.

Which parameter indicates a need for an immediate change in the ventilator settings? 1. Paco2 2. O2 saturation 3. HCO3- 4. Pao2

Ans: 1 Lower-than-normal Paco2 levels cause cerebral vasoconstriction and result in further cerebral hypoxia. The RN should notify the HCP and anticipate a decrease in the ventilator rate. The oxygen percentage being delivered by the ventilator should be evaluated because a lower fraction of inspired oxygen (Fio2) may be adequate. Nevertheless, the current Pao2 will not have any adverse effect on cerebral perfusion. The decrease in HCO3- reflects a compensatory mechanism for the patient's respiratory alkalosis and will resolve spontaneously when the Pao2 level rises.

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? 1. A 68-year-old patient with a history of smoking and emphysema 2. A 57-year-old patient who experienced a cardiac arrest 3. A 49-year-old postoperative patient who had a colectomy 4. A 29-year-old patient who is recovering from flail chest

Ans: 1 Older patients, especially those who have smoked or who have chronic lung problems such as chronic obstructive pulmonary disease (COPD)., are at risk for ventilator dependence and failure to wean. Age- related changes, such as chest wall stiffness, reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. Younger patients without respiratory illnesses are likely to wean from the ventilator without difficulty.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus (PE) must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of PE? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

Ans: 1 Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT)and PE. None of the other options are risk factorsfor PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short.

The assistive personnel (AP) is helping with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the AP? 1. Encourage the patient to eat foods that are high in calories and protein. 2. Feed the patient as quickly as possible to prevent early satiety. 3. Offer lots of fluids between bites of food. 4. Try to get the patient to eat everything on the tray.

Ans: 1 Patients with COPD often have food intolerance, nausea, early satiety (feeling too "full" to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high-protein foods can be done by the AP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.

The RN is teaching the nursing student about enteral feedings for patients such as Mr. K, who has a PEG tube. Which assessments must be performed? Select all that apply. 1. Check for residual volume. 2. Assess for bowel sounds. 3. Check placement before each feeding. 4. Monitor for allergic reactions. 5. Assess for abdominal distention. 6. Check blood glucose levels.

Ans: 1, 2, 3, 5, 6 Assessment for tube feedings generally includes checking for residual (except for jejunostomy tubes), assessing for bowel sounds, and checking for placement, abdominal distention, and hyperglycemia. Allergic reactions are not expected, although a history of food or fluid allergies would be assessed for and reported before the selection and preparation of the formula.

When the nurse assesses Ms. A at 2:00 PM, her left leg is pale, swollen, and very firm to palpation. The left leg pulses are only faintly audible using a Doppler pulse monitor. Which action is most appropriate at this time? 1. Call the orthopedic surgeon to communicate the assessment 2. Elevate the left leg on two pillows to decrease the swelling 3. Continue to monitor the left leg's appearance and pedal pulses 4. Assess the patient for indications of pain, such as restlessness

Ans: 1 The assessment data suggest the development of compartment syndrome, an emergency that can lead to permanent neuromuscular damage within 4 to 6 hours without rapid treatment. Elevation of the leg will further reduce blood flow to the leg. Continuing to monitor the leg without correcting the compartment syndrome will allow the ischemia to persist. Although restlessness may indicate pain in patients with intact neurologic function, Ms. A's neurologic status is severely compromised, and monitoring for restlessness will not be helpful in assessing for ischemic leg pain.

Ms. T, who is hospitalized with ulcerative colitis, reports 10-20 small diarrhea stools per day, with abdominal pain before defecation. She appears depressed and uninterested in self-care or suggested therapies. What is the priority nursing concepts to consider when planning interventions? 1. Elimination 2. Nutrition 3. Pain 4. Adherence

Ans: 1 The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and adherence with the treatment plan are important long-term goals that can be addressed when the patient is feeling better physically.

Ms. A suddenly begins to vomit. Which action should the nurse take first? 1. Use the backboard to log-roll Ms. A to her side. 2. Suction Ms. A's airway with an oral suction device. 3. Hyperoxygenate Ms. A with a bag-valve mask system. 4. Insert a nasogastric (NG) tube and connect to low suction.

Ans: 1 The most important goal for an unconscious patient who is vomiting is to prevent aspiration. Turning Ms. A to her side (while maintaining cervical spine stability through the use of the backboard and cervical collar) is the best method to ensure that she does not aspirate. Suctioning would also be used but does not clear the airway as well as having the patient positioned on her side. Hyperoxygenation may also be required for this patient but will not protect the airway while she is vomiting. An NG tube is usually not inserted in patients with possible facial fractures. Insertion of an orogastric tube may be indicated but would not protect from aspiration at the present time.

After being intubated and placed on mechanical ventilation, Ms. A is transported to the radiology department. The CT scans indicate that she has a large epidural hematoma. In addition, chest and left leg radiographs show that she has a left femur fracture and evidence of aspiration pneumonia. When the nurse reassesses Ms. A, she is flaccid and has no response to verbal or painful stimulation. Her pupils are dilated and nonreactive to light. Vital sign values are BP 190/40, HR 40, O2 Sat 92%, RR 14, Temp 96 F Which complication is the nurse most concerned about at present? 1. Brainstem herniation 2. Respiratory acidosis 3. Hemorrhage 4. Hypothermia

Ans: 1 The patient's fixed and dilated pupils, widened pulse pressure, and bradycardia are caused by increasing pressure on the brainstem and indicate that she is at risk for brainstem herniation, which would result in brain death. Immediate surgical intervention is needed to prevent this complication. She is at risk for the other complications, but they are not as life threatening.

The assistive personnel (AP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the AP to improve the patient's comfort? 1. Apply water-soluble jelly to the nares. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside.

Ans: 1 When the oxygen flow rate is higher than 4 L/min, the mucous membranes can become dried out. The best treatment is to add humidification to the oxygen delivery system by having the AP apply water- soluble jelly to the nares. Applying the jelly can also help decrease mucosal irritation. None of the other options will treat the problem.

Which information regarding Mr. R (acute pancreatitis) is appropriate to report to the HCP? Select all that apply. 1. Hematocrit has decreased by more than 10%. . 2. Calcium level is 7.5 mg/dl (1.875 mmol/L). 3. Partial oxygen pressure (Po2) is less than 60 mm Hg. 4. Pain is unrelieved by medication. 5. Blood type is O positive. 6. NG tube and IV line are intact.

Ans: 1, 2, 3, 4 The low calcium level and the falling hematocrit and Po2, in combination with the elevated WBC count and his age, are indicators of a high mortality risk. A high level of pain is not a prognostic factor, but severe unrelieved pain should always be reported. Blood type will not affect the HCP's decisions about therapy. Reporting on the NG tube and IV line would be appropriate for a hand-off report, but information about equipment is not reported to the HCP unless there is a specific problem that requires an order or a change of therapy.

Which tasks can be delegated to the AP? Select all that apply. 1. Assisting Ms. T with perineal care after diarrheal episodes 2. Measuring vital signs every 2 hours for Mr. R 3. Transporting Ms. H off the unit for a procedure 4. Gently cleansing the nares around Ms. D's NG tube 5. Removing Mr. A's dressing 6. Helping Mr. K brush his teeth

Ans: 1, 2, 3, 4, 6 Measuring vital signs, performing hygienic care, and transporting (stable) patients are within the scope of the AP's duties. The AP should not remove the dressing. If the dressing needs to be removed, the nurse should remove it, conduct the wound assessment, clean the area, and redress as needed.

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the assistive personnel (AP) who will help the patient with activities of daily living? Select all that apply. 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. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

Ans: 1, 2, 3, 5 When a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is within the scope of practicefor professional nurses. All of the other instructionsare appropriate for the AP scope of practice when caring for a patient receiving anticoagulants.

In the care of Mr. K (PEG tube), which health care team members are demonstrating the roles and responsibilities that support interprofessional collaboration? Select all that apply. 1. The AP tells Mr. K's family that she will be in at 10:00 AM to assist Mr. K with hygiene. 2. The RN gives the AP specific instructions about how to clean around Mr. K's PEG tube. 3. The RN acknowledges that the AP has the best working relationship with Mr. K's daughter. 4. The enterostomal therapist performs care for Mr. K, but staff and family are unsure about follow-up. 5. The nursing student recognizes that dealing with Mr. K's family dynamics exceeds her abilities. 6. The surgeon does mini-grand rounds with the nursing student to explain the purpose of Mr. K's PEG tube.

Ans: 1, 2, 3, 5, 6 The AP informs the family. The RN gives specific instructions. The RN acknowledges the strengths of a team member. The nursing student recognizes her own limitations. The surgeon enhances the student's learning.These team members have filled their roles and responsibilities toward interprofessional collaboration. The enterostomal therapist performs a task but fails to communicate to other team members what is needed for follow-up care.

The RN is observing the nursing student perform an abdominal assessment on Ms. D, who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? Select all that apply. 1. Palpating for abdominal distention with the index fingertip 2. Auscultating for bowel sounds with the NG tube attached to low wall suction 3. Performing the physical assessment before asking about pain 4. Checking the NG collection canister for quantity and quality of drainage 5. Inspecting for visible signs of peristaltic waves or abdominal distention 6. Checking for skin turgor over the lower abdominal area

Ans: 1, 2, 3, 6 The flat palmar surface of the hand is better than the fingertips when palpating for distention. If the wall suction is activated, it will interfere with auscultating for bowel sounds. Asking about pain will guide the physical assessment steps. The skin on the anterior chest under the clavicle is a better place to check for turgor than the lower abdomen, especially if abdominal distention is present. Checking the drainage and inspecting for peristaltic waves or distention are correct actions.

Which patients would be best to assign to the new RN? Select all that apply. 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. A (appendectomy) 5. Mr. K (PEG tube) 6. Mr. R (acute pancreatitis)

Ans: 1, 2, 4 Ms. H, Ms. D, and Mr. A are in the most stable condition and represent the least complex cases according to the shift report. Mr. R's confusion and belligerence will make pain management especially difficult. Laboratory results and potential complications must be closely monitored. Ms. T is at risk for electrolyte imbalances, especially hypokalemia. She needs repetitive perineal hygiene and skin assessment. TPN and central line management require additional skills. Mr. K is in stable condition, but because of the family dynamics, his care should be handled by an experienced nurse.

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing an in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

Ans: 1, 2, 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/ LVN. Independently completing the admission assess- ment, developing the nursing care plan, or evaluating a patient's abilities requires additional education and skills within the scope of practice of the professional RN.

Which tasks related to the TPN can be delegated to the AP? Select all that apply. 1. Take vital signs every 4 hours. 2. Notify nurse if the pump alarm goes off. 3. Check the volume infused every 4 hours. 4. Weigh Ms. T every day. 5. Measure and record the intake and output. 6. Clean the catheter insertion site.

Ans: 1, 2, 4, 5 Taking vital signs, reporting alarms, weighing the patient, and measuring and recording intake and output are within the scope of practice for the AP. The nurse should take responsibility for periodically checking the volume infused. The rate can be affected by a pump malfunction or catheter problems. Cleaning the catheter insertion site is a sterile procedure; the nurse would be responsible for assessing, cleaning, and redressing the site as needed.

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply. 1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 3. Wash all bedding in cold water to reduce and destroy dust mites. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate. 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

Ans: 1, 2, 4, 5, 6 Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply. 1. Do not rush through your morning activities of daily living. 2. Avoid working with your arms raised. 3. Eat three large meals every day focusing on calories and protein. 4. Organize your work area so that what you use most is easy to reach. 5. Get all of your activities accomplished then take a nap. 6. Don't hold your breath while performing any activities.

Ans: 1, 2, 4, 6 Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to alternate activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller, more frequent meals may be less tiring. Teach the patient to avoid holding their breath when performing any activity because this interferes with gas exchange.

To provide good continuity of care for Mr. A (appendectomy), who is homeless, which members of the interdisciplinary team should routinely have access to Mr. A's medical records? Select all that apply. 1. The hospital social worker who is helping Mr. A to locate resources 2. The surgeon who performed Mr. A's appendectomy 3. An epidemiologist who is collecting data on the homeless 4. All of the APs who work in the medical-surgical area 5. The administrator of the shelter where Mr. A frequently stays 6. The nurse who works at the shelter where Mr. A frequently stays

Ans: 1, 2, 6 Health care staff who provide direct care for the patient have routine access to the patient's medical records. An epidemiologist could access records to gather data at the aggregate level, but this would require special permission. Only the APs who assist in the care of the patient would have access to records, and AP access may be restricted to flow sheets, for recording vital signs, intake and output, and so on. The administrator of the shelter might be advised about a patient's condition, but the information is likely to come from the nurse or HCP who oversees patient care at the shelter.

The nurse is acting as preceptor for a newly graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

Ans: 1, 2, 6 The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

The nurse is the team leader RN working with a student nurse. The student nurse is teaching a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in the correct order the steps that the student nurse should teach the patient. 1. Remove the inhaler cap and shake the inhaler. 2. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away. 3. Breathe out completely. 4. Hold your breath for at least 10 seconds. 5. Press down firmly on the canister and breathe deeply through your mouth. 6. Wait at least 1 minute between puffs.

Ans: 1, 3, 2, 5, 4, 6 Before each use, the cap is removed, and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler.

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1. The student nurse uses a sterile catheter and glove 2. The student nurse applies suction while inserting the catheter 3. The student nurse applies suction during catheter removal 4. The student nurse uses a twirling motion when withdrawing the catheter 5. The nurse uses a no. 12 French catheter 6. The student applies suction for at least 20 seconds.

Ans: 1, 3, 4, 5 The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use the sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.

Because of Mr. K's (PEG tube) advanced age, which complications of enteral feedings may occur? Select all that apply. 1. Hyperglycemia 2. Hypotension 3. Aspiration 4. Diarrhea 5. Fluid overload 6. Weight loss

Ans: 1, 3, 4, 5 Older adult patients are especially at risk for hyperglycemia, aspiration, diarrhea, and fluid overload. Hypotension and weight loss should not occur because of enteral feedings.

The postcraniotomy care plan for the first postoperative day includes these nursing actions. Which actions can the nurse assign to an experienced LPN/LVN working in the ICU? Select all that apply. 1. Checking the gastric pH every 4 hours 2. Performing a neurologic status examination every 2 hours 3. Assessing breath sounds every 4 hours 4. Turning the patient side to side every 2 hours 5. Monitoring intake and output hourly 6. Sending a urine specimen to check specific gravity daily 7. Taking and recording vital signs

Ans: 1, 5, 6, 7 Checking gastric pH, monitoring intake and output, obtaining urine specimens, and taking vital signs are included in LPN/LVN education and scope of practice. An experienced LPN/LVN would be expected to report any changes in patient status to the supervising RN. Usually repositioning a patient would also be included in the LPN/LVN role; however, this patient is at risk for increased ICP during positioning and should be monitored by the RN during and after repositioning. Assessments of breath sounds and neurologic status in critically ill patients should be accomplished by an experienced RN.

Mr. R (acute pancreatitis) demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse suspect? 1. Hypovolemic shock 2. Pleural effusion 3. Paralytic ileus 4. Acute respiratory distress syndrome

Ans: 2 A dry cough, left-sided chest pain when breathing deeply, shortness of breath, and low-grade fever are signs and symptoms of pleural effusion. Patients with acute pancreatitis can develop many complications: pancreatic infection that can lead to septic shock, hemorrhage secondary to necrotizing hemorrhagic pancreatitis, acute kidney failure, paralytic ileus, hypovolemic shock, pleural effusion, acute respiratory distress syndrome, atelectasis, pneumonia, multiorgan system failure, disseminated intravascular coagulation, and type 2 diabetes mellitus.

The nurse reports Ms. D's laboratory results to the HCP, who then prescribes adding potassium to the IV fluid. Based on this prescription, which additional information should the nurse give to the HCP? 1. Latest blood pressure result 2. Urinary output per hour 3. Total drainage from the NG tube 4. Report on abdominal assessment

Ans: 2 All of this information could be given to the HCP, but validating renal function is a standard action before administering IV potassium. If the blood pressure is very low, the HCP could prescribe a fluid bolus, but potassium would not usually be added to that solution. Drainage from the NG tube would be replaced with IV fluids and electrolytes; therefore the HCP could use this information to adjust the IV rate. Abdominal assessment is part of the evaluation of therapy.

About 20 minutes after Ms. A is positioned on her right side, her ICP has increased to 30 mm Hg. Which action should the nurse take next? 1. Administer the as-needed (PRN) mannitol 100mg IV. 2. Assess the alignment of Ms. A's head and neck. 3. Elevate the head of the bed to 45 degrees. 4. Check Ms. A's pupil size and response to light.

Ans: 2 Because the patient has just been repositioned, it is likely that the elevated ICP is caused by poor positioning. The head and neck should be maintained in good alignment because neck flexion can cause venous obstruction and an increase in ICP. Administration of mannitol and further elevation of the head of the bed may be needed if repositioning Ms. A's head and neck is ineffective. These measures should only be used, however, if her MAP is high enough to maintain a CPP of 60 mm Hg. Checking Ms. A's pupils would not offer any additional information, and the stimulation may increase the ICP.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

Ans: 2 Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but not as urgent as investigating a chest tube leak.

The AP asks, "Why can't Ms. T (ulcerative colitis) get out of bed and do things for herself? She's only 29 years old." What is the team leader's best response? 1. "The HCP prescribed bed rest for a few days." 2. "Decreasing activity helps to decrease the diarrhea." 3. "I see you're frustrated; just do your best to help." 4. "She is too depressed to get out of bed."

Ans: 2 Explaining the physiologic reason helps the AP to understand that rest is part of the therapy. Following the HCP's orders is important, but it is an inadequate explanation. Acknowledging frustration is appropriate, but a generalized platitude, such as "do your best," does not help the AP understand the goals of therapy. Depression is not an indication for bed rest.

Mr. K (PEG tube) needs 1200 kcal/day. The enteral feeding formula provides 1 kcal/mL. After reviewing the feedings that were given yesterday, which action would the nurse take first? *Time of Yesterday's Feedings and Amount* 7:00AM = 100mL 11:00AM = 50mL 3:00PM = 200mL 7:00PM = 100mL 1. Give additional feedings to catch up on nutritional needs. 2. Look at the original prescription to determine frequency and amount. 3. Look at weight trends to see if patient is losing or maintaining weight. 4. Call the nurse who cared for Mr. K yesterday and ask what happened.

Ans: 2 First the nurse would look at the original prescription. If the prescribed amount seems insufficient, the nurse could contact the HCP and the nutritionist to have the feeding changed. If the prescribed orders were not followed, the charge nurse should be notified to follow up with all of the nurses who are caring for Mr. K to prevent reoccurrence. Looking at weight trends is part of the routine assessment for pa- tients with feeding tubes and those at risk for nutritional problems. Mr. K only received 450 kcal yesterday, but trying to catch up by overfeeding may cause distention, vomiting, fluid overload, or electrolyte imbalances.

The nurse is 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 nasal cannula. Which finding concerns the nurse immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. Patient sitting up and leaning over the nightstand 4. A large barrel chest

Ans: 2 For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respi- ratory rate. If the nurse does not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chron- ic emphysema.

What instructions will the nurse give to the AP about how to reposition Mr. R to relieve discomfort related to acute pancreatitis? 1. Place him in High Fowlers position 2. Help him to lie in a side-lying "fetal" position 3. Lay the bed flat and put the patient's legs on a pillow 4. Help him to sit on the edge of the bed and dangle his legs

Ans: 2 For patients with pancreatitis, the fetal position or sitting up and holding the knees to the chest will open the retroperitoneal space, which helps to decrease discomfort. For Mr. R, having him lie down is preferable to having him sit because of his mental status and condition.

Ms. A's mother, who has been staying at the bedside, asks the nurse why her daughter is receiving omeprazole, stating that her daughter has no history of peptic ulcers. Which answer is best? 1. "Omeprazole will lower the chance that she will aspirate" 2. "Omeprazole decreases the incidence of gastric stress ulcers" 3. "Omeprazole will reduce the risk for gastroesophageal reflux" 4. "Omeprazole prevents gastric irritation caused by the orogastric tube"

Ans: 2 Gastric stress ulcers are a common complication of head injury unless histamine2 blockers (e.g., fa- motidine) or proton pump inhibitors (e.g., omeprazole) are administered prophylactically. Administration of omeprazole may decrease the risk of pneumonitis if aspiration occurs, minimize the effects of gastroesophageal reflux, and decrease stomach irritation, but none of the other responses addresses the use of proton pump inhibitors in patients with head injury.

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

Ans: 2 Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips. Elevating the head of the bed may help with oxygenation but will not help with hoarseness. Responses 3 and 4 are important but do not speak directly to the patient's concern.

The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

Ans: 2 Manual ventilation of the patient will al- low the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high- pressure alarm and resolving the hypoxemia.

The health care provider (HCP) prescribes these actions. Which action will the nurse take first? 1. Notify family members of Ms. A's admission. 2. Obtain computed tomography (CT) scan of head. 3. Clean the occipital laceration and apply a dressing. 4. Infuse famotidine 20 mg IV every 12 hours.

Ans: 2 National advanced trauma life support guidelines indicate that a CT scan should be done as soon as possible after a closed head injury to determine the extent and types of injury and guide interventions, such as surgery. The other actions are also appropriate for the patient but do not need implementation as rapidly.

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching? 1. "Everyone in my family needs to go and see the doctor for TB testing." 2. "I will continue to take my isoniazid until I am feeling completely well." 3. "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag." 4. "I will change my diet to include more foods rich in iron, protein, and vitamin C."

Ans: 2 Patients taking isoniazid must continue taking the drug for 6 months. The other three statementsare accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing and placing tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.

The RN is teaching an assistive personnel (AP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the AP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation com- pared with light-skinned patients." 2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

Ans: 2 Teach the AP that compared with light- skinned adults, adults with darker skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen sta- tus. None of the other responses are correct.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced assistive personnel (AP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

Ans: 2 The AP's educational preparation includes measuring vital signs, and an experienced AP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the assistive personnel (AP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

Ans: 2 The AP's training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the AP can remind and encourage the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN's scope of practice. Monitoring the patient's cardiovascular response to activity is a complex process requiring additional education, training, and skill and falls within the RN's scope of practice.

The laboratory informs the nurse that the phlebotomist may have mislabeled or drawn the sample for AM blood test from another patient, not Mr. R (acute pancreatitis). What should the nurse do first? 1. Call the phlebotomist to come back 2. Draw a new blood sample and label it 3. Report the phlebotomist to his or her supervisor 4. Ask the phlebotomist to explain what happened

Ans: 2 To expedite the blood work, the nurse would draw the specimen. The other options will only delay getting the results. When the nurse has time, tracking down the cause of the error will help to prevent future recurrences.

As the shift ends, the nurse is preparing Ms. A for transfer to surgery for an emergency fasciotomy. What is the best option for obtaining informed consent for the fasciotomy? 1. Informed consent is not needed for emergency surgery. 2. Permission for surgery can be given by Ms. A's mother. 3. Consent for surgery is not required for unconscious clients. 4. Authorization can be given by the nursing supervisor.

Ans: 2 When a patient is unable to provide informed consent for a procedure, a close family member (who is likely to be most knowledgeable about the patient's wishes) is able to give permission. Emergency procedures can take place without written consent for an unconscious or incompetent patient when no family or legal representative is available to give permission. The nursing supervisor does not have the authority to consent to surgery for an unconscious patient.

The night nurse gives a brief and incomplete report. Which question should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H, who was admitted for acute cholecystitis? 1. "What are her vital signs?" 2. "Is she going to surgery or radiology this morning?" 3. "Is she still having pain?" 4. "Does she need any morning medications?"

Ans: 2 When the shift report is incomplete, the nurse can ask for any type of additional information; however, morning surgery or procedures impact the immediate plan of care for the individual patient and the organization of care for other assigned patients. HCPs frequently communicate verbally to the nursing staff, but the written notes may be pending, especially if it is an emergency admission or if the HCP is trying to complete rounds or do procedures. Vital sign values and the need for medications can be obtained from the records if the off-going nurse neglects to give that information. A current pain report can and should be obtained directly from the patient.

Based on Ms. A's history, vital signs, and assessment data, the patient is most at risk for which types of shock? Select all that apply. 1. Cardiogenic 2. Hypovolemic 3. Neurogenic 4. Septic 5. Anaphylactic

Ans: 2, 3 Ms. A's bradycardia and hypotension suggest that she is experiencing neurogenic shock in response to her head injury. It is also important to remember that with any traumatic injury, hypovolemic shock caused by hemorrhage should be considered. In this case, Ms. A should be assessed for blood loss associated with her leg injury and for internal bleeding caused by blunt trauma to her chest and abdomen. There are no indications in the patient's history that she is at risk for cardiac, septic, or anaphylactic shock.

The nurse is supervising an RN who floated from the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admit- ted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply. 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours. 6. Teach the patient to avoid vigorous nose blowing.

Ans: 2, 3, 4, 5, 6 The correct position for a patient with an anterior nosebleed is upright and leaning for- ward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed

Using the SBAR (situation, background, assessment, recommendations) format, in which order will the nurse communicate this information about the patient to the HCP? 1. "I am concerned that Ms. A may develop worsening cerebral hypoxia caused by cerebral vasoconstriction and I would like to decrease the respiratory rate setting on the ventilator." 2. "This is the nurse caring for Ms. A. The patient's most recent ABGs indicate that her Paco2 is too low, possibly worsening her cerebral perfusion." 3. "Her current ventilator respiratory rate is set at 20, and ABGs show the Paco2 is 25 mm Hg (3.33 kPa), with a pH of 7.54. O2 saturation is 96% (0.96) with a Pao2 of 90 mm Hg (11.97 kPa)." 4. "Ms. A is a 20-year-old woman who had evacuation of an epidural hematoma and has been non responsive and ventilator dependent since surgery."

Ans: 2, 4, 3, 1 Using the SBAR format, the nurse first describes the primary concern (situation) and then provides background information about the patient. Next, the nurse discusses pertinent assessment data. Finally, recommendations for needed changes in the treatment plan are communicated.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated by the nurse to the assistive personnel (AP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient the symptoms of pneumothorax.

Ans: 2, 4, 5 Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for an AP. Assessing or teaching patients requires additional knowledge and training that is within the scope of practice for professional nurses.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

Ans: 3 The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the assistive personnel (AP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

Ans: 3 APs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic AP ,but an experienced AP could assist the patient with positioning after the AP and the patient had been taught the proper technique. In that case, the AP would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

Mr. A (appendectomy) will be discharged with prescriptions for pain medication and an antibiotic. What is the most important point that the nurse will emphasize about the medications? 1. "Take the pain medication before the pain becomes severe." 2. "The pain medication may make you feel drowsy or sleepy." 3. "All of the antibiotics should be taken, even if you feel good." 4. "The antibiotics should not be shared with any other person."

Ans: 3 All of the teaching points are important; however, Mr. A had a ruptured appendix, and it is essential that he complete the antibiotic prescription so that the infection will completely resolve. Recurrent infections can be more difficult to treat because the organisms will develop a resistance.

It is confirmed that Ms. H needs to have an endoscopic retrograde cholangiopancreatography (ERCP) this morning. While preparing the patient to go to the procedure, the nurse discovers the following information. Which finding is the most urgent to report to the health care provider (HCP)? 1. Ms. H reveals that she is supposed to be taking medication for high blood pressure. 2. Ms. H has several sudden episodes of vomiting large amounts of green bile emesis. 3 Ms. H has been hesitant to sign the consent form and the form is still unsigned. 4. Ms. H reports that she had "some type of reaction" to contrast media in the past.

Ans: 3 An absolute contraindication would be an unsigned consent form. If a patient makes new dis- closures about medical history (e.g., untreated conditions or history of untoward affects), these require further investigation before the procedure begins. Nausea and vomiting are not uncommon during acute cholecystitis, and the HCP may order NG tube insertion to decompress the stomach to reduce the risk for aspiration.

The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism).The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider (HCP)? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.

Ans: 3 Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the HCP needs to be called.

The nurse notes that Mr. R (acute pancreatitis) has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? 1. Remove the IV line and restart it at a different site. 2. Remind the AP to handle Mr. R very gently. 3. Assess for other signs of obvious or occult bleeding. 4. Obtain an order for coagulation studies.

Ans: 3 First, the nurse would assess for additional evidence of bleeding. Findings would be immediately reported to the HCP because patients with acute pancreatitis have an increased risk for coagulation disorders, such as disseminated intravascular coagulation. Restarting the IV line at a different site will not alleviate the problem. If there is a coagulation disorder, the new insertion site will also bleed. It would be appropriate to initiate interventions for bleeding precautions, such as gentle handling. The nurse anticipates that the HCP will want coagulation studies after assessment findings are reported.

The HCP told Ms. H (acute cholecystitis) that she would probably need a laparoscopic cholecystectomy; however, the ERCP and laboratory results are still pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? 1. Describe the surgical procedure. 2. Call the HCP to come and speak with her. 3. Provide some written material about gallbladder disease and options. 4. Explain general postoperative care, such as coughing and deep breathing exercises.

Ans: 3 Giving written information about gallbladder disease and options will help Ms. H to prepare any questions she might have for the HCP. If diagnostic results are pending, calling the HCP is premature. Describing the surgical procedure is inappropriate because there is more than one type of procedure, and the one to be used is still undetermined. Explaining postoperative care would be appropriate after the need for cholecystectomy has been verified by the HCP.

The new RN asks the team leader if it is okay to give Ms. D (bowel obstruction) a dose of psyllium using the HCP's standing orders. Ms. D says she feels constipated and takes psyllium on a regular basis at home. What is the team leader's best response? 1. "Call the HCP to see if the standing orders apply to Ms. D." 2. "Give the psyllium according to the standing orders." 3. "Laxatives can cause perforation if there is a bowel obstruction." 4. "The patient can't be constipated because she is NPO."

Ans: 3 Laxatives should not be used for patients with bowel obstructions or fecal impactions because increased peristaltic action can cause rupture and perforation. Assessment for return of bowel function (e.g., passing flatus, hearing bowel sounds) should be performed, and evidence of function should be pointed out to the patient. The patient should be told that being NPO will decrease fecal mass and that an eventual return of function and normalization of bowel pattern are the therapeutic goals.

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? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease who is ventilator dependent

Ans: 3 Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status (refer to questions 37 and 41), the team leader would advocate for which intervention(s)? 1. Perform additional laboratory tests and continue monitoring. 2. Prepare Mr. R for emergency surgery. 3. Prepare Mr. R for transfer to the intensive care unit (ICU). 4. Reestablish NG suction and apply restraints or use one-on-one observation.

Ans: 3 Mr. R has severe life-threatening problems that warrant transfer to the ICU. The HCP is responsible for the decision to transfer Mr. R; however, the nurse must recognize and advocate for patients who are decompensating. Ordering laboratory and other diagnostic testing may be needed, and restraints or one-on-one observation could be suggested to prevent dislodging equipment, but ultimately, the patient should be transferred to the ICU. Surgery is unlikely until aggressive medical management measures are exhausted.

The LPN/LVN reports that Ms. A's output for the past hour was 1200 mL and that her urine is very pale yellow. Which action is best for the nurse to take at this time? 1. Instruct the LPN/LVN to continue to monitor the urine output hourly. 2. Send a urine specimen to the laboratory to check specific gravity. 3. Notify the neurosurgeon and anticipate an increase in the IV rate 4. Assess the patient's neurologic status for signs of increased irritability

Ans: 3 Ms. A's high urine output suggests that she has developed diabetes insipidus, a common complication of intracranial surgery. Because diabetes insipidus can rapidly lead to dehydration in a patient who is unable to take in oral fluids, the priority action needed is to increase the IV rate. Continuing to monitor the output and checking the specific gravity would also be needed but would not correct the risk for hypovolemia and hypotension. Because Ms. A's neurologic status is so poor, it is unlikely that changes in her neurologic status would be helpful in determining the effects of fluid and electrolyte imbalance.

The nurse has just finished assisting the health care provider (HCP) with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the HCP? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

Ans: 3 Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure.

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important in the plan of care? 1. Administer ordered antibiotics as scheduled 2. Hyperoxygenate the patient before suctioning 3. Maintain the head of bed at a 30 to 45 degree angle 4. Suction the airway when course crackles are audible

Ans: 3 Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the assistive personnel (AP)? 1. Discussing weight-loss strategies such as diet and exercise with the patient 2. Teaching the patient how to set up the bilevel positive airway pressure machine before sleeping 3. Reminding the patient to sleep on his side instead of his back 4. Administering modafinil to promote daytime wakefulness

Ans: 3 The AP can remind patients about actions that have already been taught by the nurse and are part of the patient's plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can administer or assign medication administration to an LPN/LVN.

What is the best approach by the nurse when communicating concerns about the medical resident's decision making? 1. Call the medical resident's supervisor about the concerns. 2. Ask the nursing supervisor to discuss appropriate care with the medical resident. 3. Advise the medical resident that lumbar puncture could cause brainstem herniation. 4. Explain that lumbar puncture is not within the medical resident's scope of practice.

Ans: 3 The Core Competencies for Interprofessional Collaborative Practice indicate that professionals should clearly express knowledge and opinions about patient care to ensure common understanding of information, treatment, and care decisions. In this situation, the nurse needs to rapidly and clearly communicate with the resident to prevent injury to the patient. Calling the resident's supervisor or asking the nursing supervisor to intervene may also be appropriate, but a more direct approach is best in the current situation. The resident will be familiar with medical scope of practice.

What is the best way to clearly document Ms. A's level of consciousness? 1. Patient is comatose. 2. Patient is unresponsive. 3. Patient's Glasgow Coma Scale score is 4. 4. Patient has a decreased level of consciousness.

Ans: 3 The Glasgow Coma Scale offers a standardized and objective way to assess and document neurologic status. Although the other responses also accurately describe the patient's level of conscious- ness, they do not provide objective data that can be readily used to determine changes in the patient's neurologic status.

Which staff member will be best to assign to take primary responsibility for Ms. A's ongoing care? 1. The RN from a temporary agency with extensive previous emergency experience who has been working in this ED for 3 days 2. The LPN/LVN with 10 years of experience in the ED who is in the last semester of an RN program 3. The RN who has worked in the ED for the past 5 years after transferring from the mother and baby unit 4. The RN who has 12 years of intensive care unit (ICU) experience and has floated to the ED today

Ans: 3 The initial care of patients with traumatic injuries requires the expertise of an RN with extensive ED experience. Neither the agency RN nor the float RN will be familiar with the location of equipment and with the organization of care in the ED. Although the LPN has experience, the LPN/LVN scope of practice does not include the complex assessments and interventions that will be needed in caring for this patient. (The LPN could be assigned to assist the RN in caring for Ms. A, however.)

While the nurse is teaching Mr. A about dressing changes for his appendectomy wound, he says, "When you live on the street, you can't do everything the way you nurses do in the hospital." What is the most important thing to emphasize in helping him to accomplish self-care? 1. "Change the dressing in the AM and the PM." 2. "Use the gauze package to make a sterile field." 3. "Wash your hands before a dressing change." 4. "Discard any opened packages of unused gauze."

Ans: 3 Washing the hands is the first basic step for a dressing change. Helping Mr. A identify other ways to maintain asepsis would be more useful than stressing strict sterile technique. Changing the dressing in the morning and the evening may be ideal, but this type of dressing change can be done at any time.

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

Ans: 3 When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when perform- ing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organ- isms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.

Ms. D (bowel obstruction) reports feeling weak. She seems more confused compared with her baseline.The NG drain-age container has a large amount of watery bile-colored fluid. Which laboratory values should be checked first? 1. Blood urea nitrogen and creatinine levels 2. Platelet count and WBC count 3. Sodium level, potassium level, and pH of blood 4. Bilirubin level, hematocrit, and hemoglobin level

Ans: 3 With continuous NG suction, there is a loss of sodium and potassium. Also, the loss of acid via suctioning will result in an increase in blood pH or metabolic alkalosis. Full assessment of laboratory data is always important when a change in status is noted, but the other values are less relevant to this patient's NG therapy.

Which reporting tasks are appropriate to delegate to the AP? Select all that apply. 1. Reporting on the condition of Ms.T's perineal area after application of ointment 2. Reporting the quality and color of NG drainage for Ms. D 3. Reporting whether Mr. R's blood pressure is below 100/60 mm Hg 4. Reporting if any of the patients are complaining of pain 5. Reporting if Mr. A is seen leaving the unit to smoke a cigarette 6. Reporting that Mr. K's family has questions

Ans: 3, 4, 5, 6 The AP can report on changes in vital sign values; giving parameters for notification is better than asking for general reports on any changes. The AP can report that a patient is having pain but is not expected to assess that pain. The AP can report that the family has questions but should not be expected to answer questions about the patient's care. All staff should be aware of when registered patients come and go on the unit and should keep each other advised. (Note: Patients should also be encouraged to tell someone if they are going off the unit.) Judging the response to treatment and evaluating drainage are responsibilities of the RN.

A labor and delivery nurse calls and says, "I heard that Mr. R was hospitalized. He's my ex-husband, so I looked up his medical record. How's he doing?" What should the RN team leader do first? 1. Invite the L&D nurse to come and see Mr. R in person 2. Ask Mr. R if he wants information released to his ex-wife 3. Report the L&D nurse for violation of patient privacy 4. Explain to the L&D nurse that no information can be given out

Ans: 4 Even if a person is employed by the hospital, only staff members who provide direct care should have access to medical records and patient information. It is inappropriate to invite the L&D nurse to visit the patient. There should be some investigation as to how the L&D nurse found out that the patient was admitted. Health Insurance Portability and Accountability Act violations are very serious. If staff members are giving out information about patients, those employees and the L&D nurse need to be reminded of the consequences (e.g., loss of license or job). Possibly, more safeguards are needed for computer access to records

A patient with chronic obstructive pulmonary disease tells the assistive personnel (AP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign reported by the AP is most important for the nurse to report to the health care provider? 1. Blood pressure of 152/84 mm Hg 2. Respiratory rate of 27 breaths/min 3. Heart rate of 92 beats/min 4. Oral temperature of 101.2°F (38.4°C)

Ans: 4 A patient who did not have the pneumonia vaccination or flu shot is at an increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern.

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

Ans: 4 An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

For Mr. R (acute pancreatitis), the calcium level is 7.5 2. mg/dl (1.875 mmol/L). Which assessment will the nurse perform? 1. Assess for Cullen sign.his legs. 2. Assess for Grey-Turner sign. 3. Assess for McBurney sign. 4. Assess for Chvostek sign.

Ans: 4 For a low calcium level (normal range 9.0- 10.5 mg/dl [9.0-10.5 mmol/L]), the nurse will assess for Chvostek sign. This is accomplished by gently tapping the facial nerve in front of the ear and observing for contraction of the facial muscles. Hypocalcemia, a complication of acute pancreatitis, can cause tetany, laryngospasm, and seizures. Grey-Turner sign is a bluish discoloration of the flank that occurs with retroperitoneal bleeding of the pancreas. Cullen sign, a bluish discoloration of the periumbilical area, is associated with acute hemorrhagic pancreatitis. Tenderness over McBurney point is a sign for acute appendicitis.

Toward the end of the shift, the team leader finds the new RN in the bathroom crying. The new nurse says, "I'm a terrible nurse. I'm so disorganized, and I'm so far behind. I'm going to quit. I hate this job." What is the best thing to do? 1. Have her take a short break off the unit. 2. Offer to take one of her patients. 3. Ask the AP to help her. 4. Calm her down and help her prioritize.

Ans: 4 Helping her to prioritize will build skill and confidence. She feels upset, but she has not made any errors that have compromised patient care (the team leader would point this out to her). Sending her off the unit further delays care, leaves her without support, and hinders opportunities to problem solve. Asking the AP to help her or helping her with select tasks is the second-best choice because it demonstrates team support. Taking over one of her patients is not necessary unless care and safety are compromised.

Ms. T is discouraged and dispirited about her ulcerative colitis. She is resistant to TPN because "i'm being kept alive with tubes." Which explanation will encourage Ms. T to continue with the TPN therapy? 1. "It will help you regain your weight." 2. "It will create a positive nitrogen balance." 3. "Your health care provider has ordered this important therapy for you." 4. "Your bowel can rest, and the diarrhea will decrease."

Ans: 4 If the bowel is allowed to rest, the cramping will stop. Stopping the diarrhea is a priority for Ms. T. Chronic, frequent diarrhea is demoralizing, and fluid and electrolyte losses cause weakness. The other options also provide accurate information, but the potential resolution of the most disturbing symptom will encourage her to take the TPN.

All of these patients must receive their routine morning medications. Which patient should receive his or her medication last? 1. Ms. H (acute cholecystitis) 2. Ms. D (bowel obstruction) 3. Ms. T (ulcerative colitis) 4. Mr. K (PEG tube)

Ans: 4 In the provision of routine care and when all patients are stable, patients who need extra time should be left until last so that care for others is not delayed. Mr. K will require more time and assistance because of age and weakness. Also, his medications must be crushed and administered via PEG tube, which is more time consuming. Dealing with Mr. K's family is also more time consuming. Older adult patients and their families typically benefit from and appreciate caregivers who do not act rushed or hurried.

For Mr. K (PEG tube), several new medications and a change in the enteral feeding solution are included in the discharge plan. Which team member is the nurse most likely to consult before teaching the patient and family about these new medications and enteral solution? 1. Nutritionist to verify that the calories and other nutrients are sufficient 2. Home health nurse to verify that follow-up teach- ing will be performed 3. Social worker to verify that the medications and formula are covered by insurance 4. Pharmacist to verify that the medications are compatible with the feeding solution

Ans: 4 In this circumstance, the nurse is most likely to consult the pharmacist to see if there are any incompatibilities. The nurse is less likely to consult the other team members at this time unless there are specific issues related to insufficient nutrition, a problem with home health care, or inadequate insurance coverage

After the respiratory therapist performs suctioning on a patient who is intubated, the assistive personnel (AP) measures vital signs for the patient. Which vital sign value should the AP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)

Ans: 4 Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not as urgent.

A new medical resident is working in the ED today. Which action by the resident indicates a need for im- mediate intervention by the nurse? 1. Assessing for the Babinski sign 2. Increasing the IV infusion rate to 200 mL/hr 3. Ordering an electrocardiogram (ECG) 4. Preparing to perform a lumbar puncture

Ans: 4 Lumbar puncture is contraindicated in a patient who may have increased ICP because it increases the risk for herniation of the brainstem through the foramen magnum at the base of the skull. Checking for a positive Babinski sign and obtaining an ECG are not priorities for this patient but would not place the patient at any increased risk. Increasing the IV rate is appropriate based on the patient's blood pressure.

The RN is supervising the nursing student in administering Ms. D's (bowel obstruction) medications through the NG tube. When would the nurse intervene? 1. The student compares the medication administration record with the original prescription. 2. The student draws up 30 mL of sterile water for flush in a large-bore syringe. 3. The student performs three checks of the medication names and dosages. 4. The student crushes tablets and puts all medications in the same cup.

Ans: 4 Medications should be given separately because of an increased risk for physical and chemical incompatibilities, increased chance of clogging the tube, and altered therapeutic response. In addition, if the medications are given one-by-one, the nurse knows exactly which medications the patient has received, but if the medications are mixed together and a problem occurs (e.g., vomiting, clogging, allergic reaction), then the amount received for each medication is unknown. The other actions are correct.

*Ms. A's Labs* Hematocrit = 42% (0.42)12.6 g/dL Hemoglobin level = 12.6 g/dL (126 g/L) Platelet count = 200,000/mm3 (200 × 109/L) White blood cell count = 7500/mm3 (7.5 × 109/L) BUN = 13 mg/dL Chloride = 102 mE/L Creatinine = 0.7 mg/dL Glucose = 144 mg/dL Magnesium = 1.7 mEq/L Potassium = 4.1 mEq/L Sodium = 133 mEq/L pH = 7.3 PaCO2 = 56 mmHg PaO2 = 65 mmHg HCO3 = 22 mEq/L O2 Sat = 88% Based on the laboratory values, which collaborative intervention will the nurse anticipate next? 1. Type and cross-match for three units of packed red blood cells. 2. Administer magnesium sulfate 1 g IV over the next 3 hours. 3. Give insulin aspart dose based on the standard sliding scale. 4. Obtain an endotracheal intubation tray and assist with intubation

Ans: 4 Ms. A's ABG results indicate uncompensated respiratory acidosis and hypoxemia. Because her respiratory drive is suppressed, she will need rapid intubation and ventilation using a mechanical positive- pressure ventilator. She may need surgery, in which case it would be appropriate to have blood available in the blood bank. Although ongoing monitoring of the magnesium level is indicated, the magnesium level is in the low-normal range, so administration of mag- nesium is not a priority at this time. Insulin would not typically be administered for a small glucose elevation such as this in a nonfasting patient.

Which action by the nurse should be completed first? 1. Administer 100% oxygen by nonrebreather mask. 2. Administer 500 ml normal saline IV bolus. 3. Insert a nasopharyngeal airway (NPA). 4. Direct the paramedic to perform a jaw thrust maneuver.

Ans: 4 National guidelines for the emergency management of traumatic brain injury indicate that the assessment of airway and breathing is the prior- ity action for this patient. Ms. A's slow and irregular respiratory rate is a risk factor for hypoxemia, which would decrease oxygen delivery to the brain as well as other vital organs and tissues. Performance of a jaw thrust maneuver will open the airway and should be used for a patient with C-spine precautions. Once the airway is clear and open, an oral pharyngeal airway can be inserted, oxygen can be applied, and the patient can be prepared for intubation. An NPA should not be inserted at this time because the patient has a head injury and the NPA could penetrate a fractured cribriform plate. IV fluids can be administered after airway and oxygenation issues have been addressed.

Ms. A is transported to the operating room, where the epidural hematoma is evacuated, and an open reduction and internal fixation of her left leg fracture is completed. After surgery, Ms. A is transferred to the ICU. She is attached to a cardiac monitor and has an arterial line in place. She is making no spontaneous respiratory effort but is being mechanically ventilated. Ms. A's indwelling urinary catheter is draining large amounts of clear, pale yellow urine. An intracranial monitor is in place. Her vital sign values and intracranial pressure (ICP) are as follows: BP = 112/64 (MAP 80 mmHg) HR = 50-56 bpm ICP = 22 mmHg (Normal ICP = 5-15) O2 Sat = 93% RR = 20 bpm Temp = 97.4 F Which of the assessment data listed above requires the most immediate nursing action? 1. Cardiac rhythm 2. Blood pressure 3. O2 saturation 4. ICP

Ans: 4 Normal ICP is 0 to 15 mm Hg, and CPP should be at least 60 mm Hg or higher. CPP is calculated using the formula MAP − ICP = CPP. Ms. A's CPP is 58 mm Hg (80 − 22 = 58); interventions should be implemented immediately to decrease her ICP and improve CPP. The other data indicate a need for ongoing monitoring but do not require immediate intervention.

After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking 3. Oxygen saturation of 93% 4. Crowing noise during inspiration

Ans: 4 Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a sign that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the rapid response team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger, and an oxygen saturation of 93% is low normal

Because of Ms. T's (ulcerative colitis) severe diarrhea, the nurse is reviewing the laboratory results. Which laboratory results are cause for greatest concern? 1. WBC count is 11,000/mm3 (11x109/L). 2. Hemoglobin is 11 g/dl (6.83 mmol/L); hematocrit is 36% (0.36 volume fraction). 3. Erythrocyte sedimentation (ESR) rate is 22mm/hr. 4. Sodium is 132 mEq/L (132 mmol/L); potassium is 3.0 mEq/L 3.1mmol/L).

Ans: 4 The low potassium (K+) level is the greatest concern because of the potential for cardiac dysthymias. Sodium (Na+) is also lost during diarrhea episodes. The WBC count, C-reactive protein, and ESR rate are likely to be increased because of the inflammatory process of the disease. Low hemoglobin (Hgb) and hematocrit (Hct) can occur because of ulceration and irritation of the intestinal mucosa

After the change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? 1. A 68-year-old patient on a ventilator whose sterile sputum specimen must be sent to the laboratory 2. A 57-year-old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics 4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

Ans: 4 The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent.The other patients need to be assessed as soon as possible, but none of their situations are urgent. In patients with COPD, pulse oximetry oxygen saturations of more than 90% are acceptable.

When assisting a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95%to 100% fraction of inspired oxygen (Fio2) andcall the health care provider (HCP) to discuss the patient's status.

Ans: 4 The patient's history and symptoms suggest the development of acute respiratory distress syndrome, which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95% to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing the respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia

Case Study #13: Head and Leg Trauma and Shock

Ms. A, a 20-year-old college student who had been drinking at a fraternity party before she fell from a second-floor balcony, has just arrived in the emergency department (ED). A fellow college student who accompanies Ms. A tells the triage nurse, "She was completely knocked out right after the fall. But then she woke up a little, so we thought she was okay—until she stopped moving again." When the nurse assesses Ms. A, there is no response to commands or to having her name called. Her eyes are shut, and she does not open them even when the nurse applies nail bed pressure. Her pupils are unequal, with the right pupil larger than the left. Ms. A's blood pressure is 70/30 mm Hg, she is in a sinus bradycardia with a rate of 40 beats/min, and her respiratory rate is 6 breaths/min. Her respirations are irregular, and she has 20-second periods of apnea. She has a large occipital laceration, and her left leg is misaligned. The paramedics have a cervical collar and backboard in place. A 16-gauge catheter has been inserted at the left antecubital area, and lactated Ringer solution is infusing at 150 mL/hr.