Quiz one management
the nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the clients drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25000 units in 500mL of fluid. the current rate of infusion is 26mL/hr. At what rate should the nurse set the pump?
24mL/hr
The nurse is initiating discharge teaching to a 68 year old male client who had quadruple coronary bypass surgery. Which PRIORITY question should the nurse ask the client? A. "Are you sexually active?" B. "Can you still drive your car?" C. "Do you have pain meds at home?" D. "Do you know when to call your HCP?"
A. "Are you sexually active?"
The nurse on the cardiac unit is discussing case management with a client who asks, "Why do I need a case manager for my heart disease?" Which statements are MOST appropriate for the nurse to respond? SELECT ALL THAT APPLY A. "Case management helps contain the costs of your health care" B. "It will help enhance your quality of life with a chronic illness" C. "It decreases the fragmentation of care across many health care settings" D. "Case management is a form of health insurance for clients diagnosed with chronic illnesses" E. "We try to provide quality care along the health care continuum"
A. "Case management helps contain the costs of your health care" B. "It will help enhance your quality of life with a chronic illness" C. "It decreases the fragmentation of care across many health care settings" E. "We try to provide quality care along the health care continuum"
The RN staff nurse delegates postmortem care to the unlicensed assistive personnel. The UAP tells the nurse she has never performed postmortem care. Which statement is the BEST response by the RN staff nurse to the UAP? A. "It can be uncomfortable. I will go with you and show you what to do" B. "The client is already dead. You cannot hurt him now" C. "There is nothing to it; it is just a bed bath and change of clothes" D. "Dont worry. You can skip it this time, but you need to learn what to do"
A. "It can be uncomfortable. I will go with you and show you what to do"
The nurse is preparing to administer two units of PRBCs to a client diagnosed with CHF. Which HCP order should the nurse Question? A. Admin each unit over 2 hours B. Admin furosemide IVP once C. Restrict the clients fluids to 1000mL per 24 hrs D. have a complete blood count done the following morning
A. Admin each unit over 2 hours
The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement FIRST? A. Assist the client to a sitting position B. Assess the clients vital signs C. Call 911 for the paramedics D. Auscultate the client's lung sounds
A. Assist the client to a sitting position
The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which interventions should the nurse implement? SELECT ALL THAT APPLY A. Continue to care for the client's needs as usual B. Place a DNR identification armband on the client C. Refer the client to a hospice organization D. Limit visitors to two at a time, so as not to tire the client E. Remove telemetry monitors from the client
A. Continue to care for the client's needs as usual B. Place a DNR identification armband on the client
The client in the cardiac intensive care unit on dopamine and BP increases to 210/130. Which intervention should the intensive care nurse implement FIRST? A. Discontinue the clients dopamine B. Notify the clients health care provider C. admin hydralazine intravenously D. assess the clients neurological status
A. Discontinue the clients dopamine
The RN and LPN are caring for a group of clients on a cardiac unit. Which nursing tasks can be assigned to the LPN? SELECT ALL THAT APPLY A. Feed the client who has an IV in both forearms B. Assess the client diagnosed with stage IV heart failure C. Perform discharge teaching with the client who had a cardiac catheterization D. Administer the intravenous piggyback ceftriaxone E. Contact the health care provider for a PRN acetaminophen order for a client
A. Feed the client who has an IV in both forearms D. Administer the intravenous piggyback ceftriaxone E. Contact the health care provider for a PRN acetaminophen order for a client
The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? SELECT ALL THAT APPLY A. Notify the health-care provider (HCP) if the client gains more than 2Ib in 1 day B. Keep the head of the bed elevated when sleeping C. Take the loop diuretic once a day before going to sleep D. Teach the client which foods are high in sodium and should be avoided E. Perform isotonic exercises at least once a day
A. Notify the health-care provider (HCP) if the client gains more than 2Ib in 1 day B. Keep the head of the bed elevated when sleeping D. Teach the client which foods are high in sodium and should be avoided E. Perform isotonic exercises at least once a day
The family member of the client experiencing a cardiac arrest refuses to leave the clients room. Which intervention should the administrative supervisor implement? A. Stay with the fam member and explain what the team is doing B. Call hospital security to escort the fam member out of the room C. Ask the health care provider whether the family member can stay D. Ignore the fam member unless he or she becomes hysterical
A. Stay with the fam member and explain what the team is doing
The LPN informs the clinic RN that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the clinic RN implement? A. Tell the LPN to notify the clinic health care provider (HCP) B. Instruct the LPN to assess the client for abnormal bleeding C. Obtain a STAT electrocardiogram on the client D. Take no action because this INR is within normal Range
A. Tell the LPN to notify the clinic health care provider (HCP)
Which med should the nurse administer FIRST after receiving the morning shift report? A. The IVPB antibiotic to the client diagnosed with endocarditis admitted at 0530 B. The antiplatelet med to the client who had a myocardial infarction C. The coronary vasodilator patch to the client diagnosed with coronary artery disease D. The statin med to the client diagnosed with atherosclerosis
A. The IVPB antibiotic to the client diagnosed with endocarditis admitted at 0530
the nurse is caring for clients on a cardiac unit. Which client should the nurse assess FIRST? A. The client diagnosed with angina who is reporting chest pain B. The client diagnosed with CHF who has bilateral 4+ peripheral edema C. The client diagnosed with endocarditis who has a temp of 100 D. The client diagnosed with aortic valve stenosis who has syncope
A. The client diagnosed with angina who is reporting chest pain
The RN charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see FIRST? A. The client diagnosed with coronary artery disease who is reporting that the nurses are being rude and wont answer the call light B. the client diagnosed with acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle level C. the client diagnosed with atrial fibrillation on an oral anticoagulant who has an international normalized ration of 2.8 D. the client 2 dats postoperative coronary artery bypass who is being transferred to the cardiac unit
A. The client diagnosed with coronary artery disease who is reporting that the nurses are being rude and wont answer the call light
The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? A. The client who has just been brought to the unit from the emergency department without any reported symptoms B. The client who received pain meds 30 min ago for chest pain that was a level 3 on a 1-10 scale C. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally D. The client who has been turning on the call light frequently and stating her care has been neglected
A. The client who has just been brought to the unit from the emergency department without any reported symptoms
while ambulating in the hallway with the nurse, the client diagnosed with myocardial infarction reports chest pain. Which interventions should the nurse implement? SELECT ALL THAT APPLY A. admin nitroglycerin 0.4mg sublingual STAT B. have client walk back to the room C. take VS D. place on supplemental O2 E. ask the unit secretary to call the HCP for orders
A. admin nitroglycerin 0.4mg sublingual STAT C. take VS D. place on supplemental O2
The client presents to the emergency department with a report of chest pain but does not have the ability to pay for the services. Which action should the ED nurse implement FIRST? A. place the client on a telemetry monitor and assess the client B. Call an ambulance to transfer the client to a charity hospital C. Have the client sign a form agreeing to pay the bill D. Ask the client why he chose to come to this hospital
A. place the client on a telemetry monitor and assess the client
The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer? SELECT ALL THAT APPLY A. sit with the client while he or she reminisces about life experiences B. Give the client a sponge bath and rub lotion on the bony prominences C. provide spiritual support for the client and family members D. Check the home to see that all necessary medical equipment is available E. Assist with light housekeeping chores and meal preparation
A. sit with the client while he or she reminisces about life experiences E. Assist with light housekeeping chores and meal preparation
The nurse is administering meds to clients with cardiac critical care area. Which client should the nurse question administering the med? A. the client receiving a calcium channel blocker who is drinking a glass of grapefruit juice B. the client receiving a beta adrenergic blocker who has an apical heart rate of 62bpm C. the client receiving nonsteroidal anti-inflammatory drugs who has just finished eating breakfast D. the client receiving an oral anticoagulant who has an international normalized ratio of 2.8
A. the client receiving a calcium channel blocker who is drinking a glass of grapefruit juice
The evening nurse in a long term care facility is preparing to administer meds to a client diagnosed with atrial fibrillation. Which med should the nurse question administering? Warfarin 5mg PO daily Metoclopramide 5mg PO tid docusate PO Bid atorvastatin PO daily A. warfarin B. metoclopramide C. Docusate D. Atorvastatin
A. warfarin
The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? A. Discuss personal information the client shared with the nurse in confidence. B. Provide the case manager with any information that is required for continuity of care. C. Explain that client confidentiality prevents the nurse from disclosing information D. Ask the case manager to get the client's permission before sharing information
B. Provide the case manager with any information that is required for continuity of care.
The home health aide tells the home health nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the home health nurse's BEST response? A. "I am so excited for you; he seems like a very nice young man" B. "You should not go out with him as long as she is a client of our agency" C. "I think you should tell the director of the home health care agency about this date" D. "You should never date someone you meet while taking care of a client"
B. "You should not go out with him as long as she is a client of our agency"
The RN HH nurse is caring for an elderly client. Which nursing task should the RN delegate to the HH aide? A. Cook and freeze meals for the client B. Assist the client to sit on the front porch C. Take the client for outings to the store D. Monitor the clients mental status
B. Assist the client to sit on the front porch
The RN staff nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nrus eon the intercom system. Which task should the nurse instruct the UAP to implement? A. Call a code blue immediately B. Check the clients telemetry leads C. Find the nurse to check the client D. Remove the telemetry monitor
B. Check the clients telemetry leads
the nurse is administering medications on a cardiac unit. Which med should the nurse question administering? A. Warfarin to a client with a PT of 14 and an INR of 1.6 B. Digoxin to a client with a potassium level of 3.3 C. Atenolol for the client with an aspirate aminotransferase of 18 D. Lisinopril for the client with a serum creatinine level of 0.8
B. Digoxin to a client with a potassium level of 3.3
The elderly client on the cardiac unit was found on the floor by the bed. Which info should the nurse document in the client's EHR? A. Fell. No injuries noted. Incident report completed. HCP notified B. Found on floor. No reports of pain. Able to move all extremities C. States no one answered call light, so attempted to get up without help D. Got out of bed without assistance and fell by the bedside
B. Found on floor. No reports of pain. Able to move all extremities
The charge nurse on a cardiac unit has received laboratory reports to assess. Which laboratory report is priority for the charge nurse to assess? A. Ms. C.T., who is on a heparin drip (aPT 15, norm 10-13; INR 1.4, norm 2.0-3.0; aPTT 56, norm 25-35 sec) B. Mr. R.S., who is scheduled for a coronary artery bypass graft this morning (aPT 11, norm 10-13; INR 1.0, norm 2.0-3.0; aPTT 34, norm 25-35 sec; WBC 5.9, norm 4.5-11.1; RBC 4.9, norm 4.21-5.81; hgb 13.5, norm 14-17.3; hct 44.2, norm 42-52%; platelets 292, norm 140-400) C. Ms. T.R., who had a cardiac cauterization 18hours ago (aPT 12; INR 1.0; aPTT 29) D. Mr. J.E., who is being evaluated for a heart murmur (aPT 9.8; INR 1.3; aPTT 26; platelet 392)
B. Mr. R.S., who is scheduled for a coronary artery bypass graft this morning (aPT 11, norm 10-13; INR 1.0, norm 2.0-3.0; aPTT 34, norm 25-35 sec; WBC 5.9, norm 4.5-11.1; RBC 4.9, norm 4.21-5.81; hgb 13.5, norm 14-17.3; hct 44.2, norm 42-52%; platelets 292, norm 140-400)
The home health nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse of blood pressure. The client's family is at the bedside. Which intervention should the HH nurse implement FIRST? A. Contact the agency's chaplain B. Pronounce the client's death C. Ask the family to leave the bedside D. Call the clients funeral home
B. Pronounce the client's death
The client on telemetry is showing ventricular tachycardia. Which action should the telemetry RN staff nurse delegate to the UAP? A. Have the UAP call the operator and announce the code B. Tell the UAP to answer the other call lights on the unit C. Send the UAP to the room to start rescue breaths D. Ask the family to step out of the room during the code
B. Tell the UAP to answer the other call lights on the unit
The wife of a client calls the clinic and tells the nurse her husband is having chest pain but wont go to the hospital. Which action should the nurse implement FIRST? A. Instruct the wife to call 911 immediately B. Tell the wife to have the client chew an aspirin C. Ask the wife what the client had to eat recently D. Request that the husband talk to the clinic physician
B. Tell the wife to have the client chew an aspirin
The UAP working on a long term care facility notifies the RN staff nurse that the client diagnosed with congestive heart failure who is on a low sodium diet is reporting that the food is inedible. Which intervention should the RN staff nurse implement first? A. have the family bring food from home for the client B. check to see what the client has eaten in the past 24 hrs C. tell the client that a low sodium diet is important for this diagnosis D. ask the dietitian to discuss food preferences with the client
B. check to see what the client has eaten in the past 24 hrs
The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurses FIRST intervention during the code? A. begin to take notes to document the code B. make sure all the jobs are being done C. arrange for an intensive care unit bed D. administer the emergency meds
B. make sure all the jobs are being done
The charge nurse on the cardiac unit is counseling a staff nurse because the nurse has clocked in late multiple times for the 7am to 7pm shift. Which conflict resolution uses the win-win strategy? A. the charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit B. the charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9am to 9pm shift. C. the charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work it will result in termination D. the staff nurse asks another employer to talk to the charge nurse to explain that he or she is a valuable part of the team
B. the charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9am to 9pm shift.
Which should the cardiac nurse assess FIRST after receiving the pm shift report? A. the client who is completing the second unit of PRBCs B. the client who is crying after being informed of a terminal diagnosis C. the client who refused to eat the dietary tray but got food from home D. the client who became short of breath ambulating in the hallway
B. the client who is crying after being informed of a terminal diagnosis
The surgical nurse is admitting a client having heart surgery to the operating room. Which info would require the nurse to call a time-out? SELECT ALL THAT APPLY A. the client is drowsy from the preoperative med and drifts off to sleep B. the consent form states mitral valve replacement and the client states aortic valve replacement C. the EHR and clients armband state the client is allergic to the narcotic analgesic morphine D. The client states his or her name and date of birth as it appears on EHR E. the surgical procedure is beginning to start and the team is present
B. the consent form states mitral valve replacement and the client states aortic valve replacement E. the surgical procedure is beginning to start and the team is present
The RN charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department? A. the nurse who has 4 years of experience in the operating room B. the nurse who just transferred from critical care to the cardiac unit C. the nurse with 1 year of experience on the cardiac unit who has been on a weeks sick leave D. The nurse who has worked in the gastrointestinal lab for 2 years and in the cardiac unit for 3 years
B. the nurse who just transferred from critical care to the cardiac unit
The RN hospice nurse is discussing the clients care with the UAP. Which statement contains the BEST info about caring for a client diagnosed with end stage heart failure who is dying? A. "perform as much care for the client as possible to conserve his or her strength" B. "Do not get too attached to the client because it will hurt when he or she dies" C. "Be careful not to promise to withhold health care info from the team" D. "The client may want to talk about his or her life, but you should discourage that"
C. "Be careful not to promise to withhold health care information from the team"
The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the hospice nurse implement? A. Assess the clients spiritual needs B. Assess the clients financial situation C. Assess the clients support system D. Assess the clients medical diagnosis
C. Assess the clients support system
The RN charge nurse is making assignments for a 30-bed cardiac unit stagged with three registered nurses, three licensed practical nurses, and three unlicensed assistive persona. Which assignment is MOST appropriate by the charge nurse? A. Assign an RN to perform all sterile procedures B. Assign an LPN to give all IV meds C. Assign a UAP to complete the a.m. care D. assign an LPN to write the care plan
C. Assign a UAP to complete the a.m. care
The RN ICU nurse and a UAP are caring for a client who has had a coronary artery bypass graft. Which nursing task should the RN staff nurse assign to the UAP? SELECT ALL THAT APPLY A. Monitor the clients arterial blood gases B. Re infuse the clients blood using the cell saver C. Assist the client to take a sponge bath D. Change the clients saturated leg dressing E. Empty the urinary catheter drainage bag
C. Assist the client to take a sponge bath E. Empty the urinary catheter drainage bag
The UAP tells the RN staff nurse the client is reporting chest pain. Which task should the RN staff nurse delegate to the UAP? A. Call the health-care provider and report the clients chest pain B. Give the client some acetaminophen while the nurse checks the client C. Bring the electronic health record to the clients room D. Notify the clients family of the onset of chest pain
C. Bring the electronic health record to the clients room
The RN cardiac clinic nurse has told the unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement FIRST? A. Tell the UAP to change it immediately B. Ask the UAP why the sharps container has not been changed C. Change the sharps container as per clinic policy D. Document the situation and place a copy of the documentation in the employee file
C. Change the sharps container as per clinic policy
the nurse is administering meds at 1800 to a client and uses the following med administration record. Which intervention should the nurse implement FIRST? Digoxin 0.125 mg PO daily (0900) Furosemide 40mg IVP daily (0900) Cephalosporin 1800 500mg PO q6h (1200, 1800) Warfarin 5mg PO daily (1800) A. Assess the client's potassium and digoxin levels B. Monitor the clients partial thromboplastin level C. Check the clients international normalized ratio (INR) D. Verify the clients name and ID number with the MAR
C. Check the clients international normalized ratio (INR)
The cardiac clinic RN staff nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the open office area. Which action should the clinic RN staff nurse implement? A. Tell the UAP in front of the client to not comment on the weight B. Ask the UAP to put the client in the room and take no action C. Explain to the UAP, in private, that this is an inappropriate comment and violates the HIPAA D. Report the UAP to the director of nurses of the clinic
C. Explain to the UAP, in private, that this is an inappropriate comment and violates the HIPAA
The RN staff nurse and the UAP enter the client's room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the RN staff nurse assign to the UAP FIRST? A. Ask the UAP to check whether the client is asleep B. Tell the UAP to perform cardiac compressions C. Instruct the UAP to get the crash cart D. Request the UAP to put the client in a recumbent position
C. Instruct the UAP to get the crash cart
The nurse in a critical care cardiac unit is administering meds to a client. Which intervention should the nurse implement FIRST? A. check the radial pulse before administering digoxin B. Monitor the amiodarone level for the client receiving amiodarone C. Obtain the latest PTT results on the client with a heparin drip D. Check the liver function panel for the client receiving a dopamine drip
C. Obtain the latest PTT results on the client with a heparin drip
The home health nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which PRIORITY intervention should the nurse implement? A. Encourage the client to walk 30 minutes a day B. Request a home health registered dietitian to talk to the client C. Refer the client to a cardiac rehabilitation unit D. Discuss the clients need to lose 1-2 pounds a week
C. Refer the client to a cardiac rehabilitation unit
The home health nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the home health nurse implement FIRST? A. Prepare all the needed equipment for the visit B. Call the client to arrange a time for the visit C. Review the client's referral form and pertinent data D. Make the necessary referrals for the client
C. Review the client's referral form and pertinent data
The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate order tells the nurse, "My wife is not breathing." Which intervention should the RN staff nurse implement FIRST? A. Contact the clients health-care provider B. Notify the rapid response team C. Stay with the client and her husband D. Instruct the UAP to perform postmortem care
C. Stay with the client and her husband
The RN staff nurse at a disaster site is triaging victims when a woman states, "I am a certified nurse aide. Can I do anything to help?" Which action should the RN staff nurse implement? A. Request the woman to please leave the area B. Ask the woman to check the injured clients C. Tell the woman to try and keep the victims calm D. Instruct the woman to help the paramedics
C. Tell the woman to try and keep the victims calm
The RN charge nurse is making assignments for clients on a cardiac unit. Which client should the RN charge nurse assign to a new graduate nurse? A. the 44 year old client diagnosed with a myocardial infarction B. The 65 year old client diagnosed with unstable angina C. The 75 year old client scheduled for a cardiac catheterization D. the 50 year old client reporting chest pain
C. The 75 year old client scheduled for a cardiac catheterization
The nurse on the cardiac unit is preparing to administer meds after receiving the morning change of shift report. Which medication should the nurse administer first? A. The cardiac glycoside to the client who has an apical pulse of 58 B. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L C. The antidysrhythmic to the client in ventricular fibrillation D. The calcium channel blocker to the client who has a blood pressure of 110/68
C. The antidysrhythmic to the client in ventricular fibrillation
The cardiac nurse received laboratory results on the following clients. Which client warrants IMMEDIATE intervention from the nurse? A. The client who has an INR of 2.8 B. The client who has a serum potassium level of 3.8 mEq/L C. The client who has a serum digoxin level of 2.6 mg/dL D. The client who has a glycosylated hemoglobin of 6%
C. The client who has a serum digoxin level of 2.6 mg/dL (0.5-2 is normal)
the hospice nurse is triaging phone calls from clients. Which client should the nurse contact first? A. The client whose family reports the client is not eating B. The client who wants to rescind the out-of-hospital DNR C. The client whose pain is not being controlled with the current meds D. The client whose urinary incontinence has caused a stage 1 pressure ulcer
C. The client whose pain is not being controlled with the current meds
The RN director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the WIN-LOSE strategy? A. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early B. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week C. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly D. The UAP is placed on 1 month probation, and any further occurrences will result in termination from this position
C. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly
The nurse is administering meds to clients on a cardiac unit. Which med should the nurse QUESTION administering? A. furosemide to a client who had a 320 mL output in 4 hours B. Enoxaparin to a client who had open heart surgery C. Ticlopidine to a client being prepared for surgery D. Captopril to a client who had a BP of 100/68
C. Ticlopidine to a client being prepared for surgery
The nruse is preparing to administer digoxin 0.25mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. RANK IN ORDER OF PERFORMANCE A. admin the med over 5 min B. dilute the med with NS C. draw up med in a tuberculin syringe D. check the client's identification band E. clamp the primary tubing distal to the port
C. draw up med in a tuberculin syringe B. dilute the med with NS D. check the client's identification band E. clamp the primary tubing distal to the port A. admin the med over 5 min
The client is admitted to determine if the client is experiencing a myocardial infarction. The client is reporting substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement FIRST? A. Take the clients pulse, respiration, and BP B. Call for a STAT electrocardiogram and a troponin level C. place sublingual nitroglycerin 0.3mg under the tongue D. Notify the HCP that the client has pain
C. place sublingual nitroglycerin 0.3mg under the tongue
The nurse on a medical unit is making rounds after receiving shift report. Which client should the nurse see FIRST? RANK IN ORDER OF PRIORItY. A. the 45 year old client who reported having chest pain at midnight last night and received nitroglycerin sublingually B. the 62 year old client who is reporting that no one answered the call light for 2 hours yesterday C. the 29 year old client diagnosed with septicemia who called to request more blankets because of being cold D. The 78 year old client diagnosed with dementia whose daughter is concerned because the client is more confused today E. the 37 year old client who has a stage 4 pressure sore and the dressing needs to be changed this morning
C. the 29 year old client diagnosed with septicemia who called to request more blankets because of being cold A. the 45 year old client who reported having chest pain at midnight last night and received nitroglycerin sublingually D. The 78 year old client diagnosed with dementia whose daughter is concerned because the client is more confused today B. the 62 year old client who is reporting that no one answered the call light for 2 hours yesterday E. the 37 year old client who has a stage 4 pressure sore and the dressing needs to be changed this morning
The RN charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? A. The client diagnosed with mitral valve stenosis B. the client diagnosed with asymptomatic sinus bradycardia C. the client diagnosed with fulminant pulmonary edema D. the client diagnosed with acute atrial fibrillation
C. the client diagnosed with fulminant pulmonary edema
The RN charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? A. the client diagnosed with acute rhematic fever carditis who refuses to stay on bedrest B. the client who has the following ABG values: pH, 7.35; paO2, 88; PaCO2, 44; Hco3, 22 C. the client who is showing multifocal premature ventricular contractions D. the client diagnosed with angina who is scheduled for a cardiac catheterization
C. the client who is showing multifocal premature ventricular contractions
The client diagnosed with arterial hypertension has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would WARRANT intervention by the nurse? A. "I have to go to the bathroom a lot during the morning" B. "I get up very slowly when I have been sitting for a while" C. "I do not salt my food when I am cooking it but I add it at the table" D. "I drink grapefruit juice every morning with my breakfast"
D. "I drink grapefruit juice every morning with my breakfast"
Which info should the experienced home health nurse discuss when orienting a new nurse to home health nursing? SELECT ALL THAT APPLY A. If the client or family is hostile or obnoxious, call the police B. Carry the home health care agency identification in a purse or wallet C. Visits can be scheduled at night with permission from the agency D. Inform the agency of the times of the clients scheduled visits E. Report unsafe environments to the home health agency
D. Inform the agency of the times of the clients scheduled visits E. Report unsafe environments to the home health agency
The nurse is caring for Mr. A.B., a client on a telemetry unit. At 0830 the client reports chest pain. Which med should the nurse administer? Morphine Sulfate 2mg IVP q1h PRN chest pain Oxycodone 7.5/acetaminophen 325mg PO q4h PRN pain Aluminum hydroxide; magnesium hydroxide; simethicone 30mL PO PRN indigestion Nitroglycerin 0.4mg SL q5min up to 3 tabs PRN chest pain Nitroglycerin Transdermal cream 1/2 inch A. 1/2 inch of nitroglycerin trans dermally now B. morphine sulfate 2mg IVP STAT C. Oxycodone 7.5mg/acetaminophen 325mg PO now D. Nitroglycerin 0.4mg sublingual STAT
D. Nitroglycerin 0.4mg sublingual STAT
The home health nurse received phone messages from the agency secretary. Which client should the nurse contact FIRST? A. The client diagnosed with HTN who is reporting a BP of 148/92 B. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93% C. The client diagnosed with congestive heart failure who has edematous feet D. The client diagnosed with chronic atrial fibrillation who is having chest pain
D. The client diagnosed with chronic atrial fibrillation who is having chest pain
Which client should the telemetry nurse assess first after receiving the am shift report? A. The client diagnosed with deep vein thrombosis who has an edematous right calf B. the client diagnosed with mitral valve stenosis who has heart palpitations C. The client diagnosed with arterial occlusive disease who has intermittent claudication D. The client diagnosed with congestive heart failure who has pink frothy sputum
D. The client diagnosed with congestive heart failure who has pink frothy sputum
The primary cardiac RN staff nurse is delegating tasks to the UAP. Which delegation task warrants intervention by the RN charge nurse of the cardiac unit? A. the UAP is instructed to bathe the client who is on telemetry B. the UAP is requested to obtain a bedside glucometer reading C. the UAP is asked to assist with a portable chest x-ray D. the UAP is told to feed a client diagnosed with dysphagia
D. the UAP is told to feed a client diagnosed with dysphagia
Which client warrants immediate intervention by the nurse? A. the client diagnosed with pericarditis who has chest pain with inspiration B. the client diagnosed with mitral valve regurgitation who has a thready peripheral pulse C. the client diagnosed with Marfan syndrome who has pectus excavatum D. the client diagnosed with atherosclerosis who has slurred speech and drooling
D. the client diagnosed with atherosclerosis who has slurred speech and drooling
The cardiac nurse is preparing to administer 1 unit of blood to a client. Which interventions should the nurse implement? RANK IN ORDER OF PRIORITY A. infuse the unit of blood at 20gtts/min the first 15min B. check the unit of blood and the clients blood band with another nurse C. initiate y-tubing with normal saline via an 18 gauge Angio catheter D. Assess the clients vital signs and lung sounds and assess for a rash E. Obtain informed consent for the blood administration from the client
E. Obtain informed consent for the blood administration from the client D. Assess the clients vital signs and lung sounds and assess for a rash C. initiate y-tubing with normal saline via an 18 gauge Angio catheter B. check the unit of blood and the clients blood band with another nurse A. infuse the unit of blood at 20gtts/min the first 15min
