2060 Exam 1

What metabolic changes occur as a result of tissue ischemia during the compensatory stage of hypovolemic shock? Select all that apply. 1 Acidosis 2 Alkalosis 3 Hypokalemia 4Hyperkalemia 5 Vasodilation

ANS: 1, 4 In the compensatory (nonprogressive) stage of shock, tissue hypoxia leads to acidosis because of changes in anaerobic metabolism. Hyperkalemia occurs as well from the changes in metabolism. The patient is acidotic, not alkalotic. Hypovolemic shock is associated with vasoconstriction, not vasodilation.

The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? 1The pacemaker spike falls on the T wave. 2Pacemaker spikes are noted, but no P wave or QRS complex follows. 3The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. 4The patient demonstrates hiccups.

ANS: 2 Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode. Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly; demand pacing should cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.

The nurse is caring for a patient with septic shock. Which blood glucose levels indicate a positive outcome? 1 90 mg/dL 2 140 mg/dL 3 180 mg/dL 4 200 mg/dL

ANS: 2 A patient with septic shock may have hyperglycemia, which may be detrimental. If the blood glucose levels are maintained between 110-150 mg/dL, it indicates a positive outcome. Therefore, the patient has a positive outcome that is indicated by the blood glucose level of 140 mg/dL. Blood glucose levels of 90 mg/dL, 180 mg/dL, and 200 mg/dL indicate negative outcomes.

The laboratory report of a patient with sepsis shows a serum lactate level of 40 mg/dL. Which intervention would be most appropriate in this patient? 1 Obtaining blood cultures 2Providing mechanical ventilation 3 Administering crystalloids intravenously 4 Administering broad-spectrum antibiotics

ANS: 3 Administering crystalloids intravenously would be most appropriate if the patient has a serum lactate level of 40 mg/dL. Obtaining the blood cultures would be useful in identifying the type of infection. Providing mechanical ventilation would be beneficial in patients with poor oxygenation. Broad-spectrum antibiotics are prescribed as empirical therapy during the initial stages of infection by an unknown organism.

The new director of case management assessed the need to improve the organization's patient satisfaction with the discharge process. Which statement below illustrates the vision that would lead the team to this goal? a. "The department will deliver reliable, collaborative, and compassionate discharge planning services to all patients." b. "The department will hold weekly meetings every Tuesday at 11:00 AM." c. "There will be implementation of a new uniform policy so staff can be readily identified." d. "Staff are encouraged to complain about difficult patients, families, and physicians."

ANS: A A vision is a statement about the long-term desired state for the department. The other choices describe specific actions, not a long-term vision statement.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Ask the nursing assistive personnel to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tell the nursing assistive personnel that catheter care is sloppy. d. Remove the catheter.

ANS: A If the staff member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and offer demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. Telling that catheter care is sloppy does not correct the problem. The catheter does not need to be removed.

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

When a patient's adverse reaction to a blood transfusion is differentiated, which of the following signs/symptoms indicates the presence of an anaphylactic response? a. Wheezing and chest pain b. Headache and muscle pain c. Hypotension and tingling of the extremities d. Crackles in the lungs and increased central venous pressure

ANS: A Observe the patient for wheezing, chest pain, and possible cardiac arrest. All of these are indications of an anaphylactic reaction. Be alert to patient complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction. Observe patients receiving massive transfusions for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with the patient's calcium. Crackles in the bases of lungs and rising central venous pressure (CVP) are indications of circulatory overload.

The nurse is performing CPR on an adult patient who has an endotracheal tube in place. At what rate does the nurse, who is alone, administer breaths? a. 8 per minute b. 12 per minute c. 20 per minute d. 24 per minute

ANS: A Rescue breaths for CPR with an advanced airway (endotracheal tube/tracheotomy) are given at 8 to 10 breaths/min.

According to situational and contingency theory, which of the following is true? a. The theory challenges the concept that one leadership style is always best. b. The theory supports employee feelings, morale, and feedback during the change process. c. Motivation through inspiration and recognition is the focus for transforming employee behavior. d. A leader is someone who possesses great intelligence and decision-making authority.

ANS: A Situational and contingency theory challenges the assumption that there is "one best way" to lead. "The theory supports employee feelings, morale, and feedback during the change process" describes behavioral leadership. "Motivation through inspiration and recognition is the focus for transforming employee behavior" describes transformational leadership. "A leader is someone who possesses great intelligence and decision-making authority" describes Great Man or Trait theory.

While measuring an oral airway for proper fit, the nurse places the airway so that the flange is held parallel to the front teeth with the airway against the patient's cheek. Where is the end of the curve? a. At the angle of the jaw b. Above the ear c. To the level of the nose d. Upside down

ANS: A Size is correct if, when the flange is held parallel to the front teeth with the airway against the patient's cheek, the end of the curve reaches the angle of the jaw.

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

ANS: A The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

When using an automated external defibrillator, it is important for the nurse to ensure that no one is touching the patient: a. after connecting the cable to the machine. b. when the machine is plugged in. c. while the pads are applied. d. while the machine analyzes the rhythm.

ANS: A The nurse needs to ensure that no one is touching the patient while the machine is analyzing because this may interfere with correct interpretation of the patient's rhythm and could put anyone touching the patient at risk of being shocked. CPR may be continued up until the machine is ready to analyze, although CPR may need to be momentarily stopped for placement of the chest pad, and when the AED instructs the user to resume CPR. There is no risk in touching the patient while the machine is plugged in, and it is not possible to apply the pads without touching the patient. CPR should be performed until an AED is brought to the patient and the cable is ready to be inserted into the machine with the pads already in place.

The nurse enters the patient's room and finds that the patient is not breathing and has no pulse. The patient does not have a do-not-resuscitate order. What would the nurse's most immediate action be? a. Call the cardiac/respiratory arrest team. b. Begin CPR. c. Call a co-worker for help. d. Get the crash cart.

ANS: A The nurse's first action should be to summon the cardiac/respiratory arrest team because it will take them a few minutes to arrive, and the patient's best outcome depends on their rapid arrival. As soon as the team has been called, the nurse should begin CPR. If the arrest is not called over the public address system, the nurse should call a co-worker for help while performing CPR or after initiating CPR. If the code is called over the public address system, co-workers will hear the call and will come to the room without being summoned. Once co-workers have been alerted, they can obtain the crash cart and summon additional support.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

ANS: A This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client's oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

The nurse is caring for a patient on mechanical ventilation. The nurse determines that the endotracheal tube is properly placed by which assessment? a. Auscultating both lungs and watching the rise and fall of both sides of the chest b. Monitoring and comparing the blood pressure in both arms c. Observing and measuring inspiratory and expiratory rates d. Checking the settings on the ventilator and the low-pressure and high-pressure alarm settings

ANS: A Verify placement of the endotracheal tube by auscultating the lungs and assessing chest wall symmetry. This ensures that the tube has not migrated into the right main stem bronchus. Many factors can cause blood pressure fluctuations and fluctuations in respiratory rate. Always assess the patient first. Once the patient is determined to be safe, the settings for the ventilator alarm can be checked as well.

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the client's vital signs. d. Obtain consent for a central line.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

ANS: A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

ANS: A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the client's nose. d. Turn the client every 2 hours or as needed.

ANS: A Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard

ANS: A The nurse should assess this client's coping styles and support systems in order to provide holistic care. The other options do not address the client's distress.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

ANS: A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. "Increase the fiber and water in your diet." b. "Reduce fat to less than 30% each day." c. "Report dry mouth and decreased sweating." d. "Lorcaserin may cause loose stools for a few days."

ANS: A This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat.

The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Changing the patient's position every 2 hours b. Keeping the head of the bed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping the head flat during and for 30 minutes after enteral feedings

ANS: A, B Best practice guidelines indicate that the following interventions are advantageous in preventing VAP: elevating the head of the bed at 30 to 45 degrees to prevent aspiration, changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infection, providing oral care with a toothbrush every 8 hours to remove dental plaque organisms (toothettes are not adequate to clean dental plaque, but they may be used between brushings for comfort), maintaining the endotracheal cuff pressures at 20 cm H2O to decrease movement of secretions to the lower airways, and carefully monitoring the patient for aspiration when enteral feedings are infusing.

The patient is placed on mechanical ventilation. After the initial settings have been applied, the nurse should watch for which of the following complications? (Select all that apply.) a. Signs of decreased cardiac output b. Tension pneumothorax c. Pneumonia d. Failure to wean

ANS: A, B, C Multiple complications are associated with positive-pressure ventilation: decreased cardiac output, aspiration, tension pneumothorax, bronchospasm, laryngeal trauma, sinusitis, and ventilator-associated pneumonia. Failure to wean is not a major factor in starting the use of a ventilator; however, as the length of time needed for mechanical ventilation increases, the risk for failure to wean from the ventilator is increased.

What is the purpose of administering a transfusion? (Select all that apply.) a. Restore intravascular volume. b. Restore the oxygen-carrying capacity of blood. c. Provide clotting factors. d. Improve blood pressure.

ANS: A, B, C Transfusions are used to restore intravascular volume with whole blood or albumin, to restore the oxygen-carrying capacity of blood with RBCs, and to provide clotting factors and/or platelets. Although increasing blood volume may increase blood pressure, increasing blood pressure is not a primary objective of transfusion.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension

ANS: A, B, C Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

The nurse in the ICU is caring for a newly admitted patient with chest pain. She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.) a. Electrolyte disturbances b. Heart damage c. Medications d. Respiratory arrest

ANS: A, B, C, D Causes of dysrhythmia may include electrolyte disturbances (potassium, magnesium, calcium), heart damage, and certain prescribed or recreational medications. Early intervention for a respiratory arrest usually prevents a cardiac arrest.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

The nurse walks into her patient's room to find him unresponsive. She begins CPR, knowing that during a "code" situation, chest compressions should be interrupted for which of the following situations? (Select all that apply.) a. Ventilation b. Pulse checks c. Intubation d. Defibrillation

ANS: A, B, C, D The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute with few and very brief interruptions for ventilation, pulse checks, intubation, and defibrillation.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

ANS: A, B, C, D Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

ANS: A, B, C, E Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

The nurse is caring for several patients who require oxygen therapy. The nurse anticipates an order for noninvasive positive-pressure ventilation (NIPPV) for the patients with which diagnoses? (Select all that apply.) a. Pulmonary edema b. Obstructive sleep apnea c. Stroke with dysphagia d. Congestive heart failure

ANS: A, B, D In the cardiac patient, NIPPV reduces pulmonary edema because the increased alveolar pressure forces interstitial fluid out of the lungs and back into the pulmonary circulation. In patients who retain carbon dioxide, such as with obstructive sleep apnea, NIPPV keeps the airway open and prevents upper airway collapse. In selected patients, such as those with postpolio syndrome and other neuromuscular diseases, congestive heart failure, sleep disorders, and pulmonary diseases, NIPPV is often the treatment of choice in supporting ventilation without the hazards associated with endotracheal intubation. NIPPV is contraindicated in patients at high risk for aspiration, as after a stroke with dysphagia.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures.

ANS: A, B, E Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

ANS: A, C The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube. The nurse carefully inflates the cuff of the endotracheal tube using the minimal leak method, knowing that a properly inflated cuff provides which benefits to the patient? (Select all that apply.) a. Prevents aspiration of gastric contents b. Promotes accumulation of secretions below the epiglottis c. Prevents air from escaping between the tube and the tracheal wall d. Promotes lung inflation for mechanical ventilation

ANS: A, C, D A cuff on an endotracheal tube prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when a patient is receiving mechanical ventilation. The goals of correctly inflating the cuff on an artificial airway are to promote lung inflation for mechanical ventilation, prevent aspiration of gastric contents, and at the same time allow drainage of secretions that accumulate between the epiglottis and the cuff.

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

ANS: A, D The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

ANS: A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

ANS: A, D, E The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

When applying an automated external defibrillator, the nurse would: a. connect the cable to the machine, apply the pads, and turn on the power. b. turn on the power, apply the pads, and connect the cable. c. turn on the power, connect the cable, and apply the pads. d. connect the cable, turn on the power, and apply the pads.

ANS: B As soon as the cable is connected, the machine begins to attempt to analyze the rhythm, so the power should be turned on and the pads should be applied to the chest wall before the cable is connected to the machine. Connecting the cable, applying the pads, and then turning on the power would cause the machine to malfunction or would delay analysis while it cycles on. Connecting the cable before applying the pads could result in the rescuer being shocked.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

A staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. This nurse highly values which element of shared decision making? a. Authority b. Autonomy c. Responsibility d. Accountability

ANS: B Autonomy is freedom of choice and responsibility for the choices. Authority refers to legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions.

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formati

The patient is brought to the emergency department after a motor vehicle accident. The patient has head and neck trauma and has stopped breathing. What should the nurse do? a. Open the airway using the head tilt-chin lift method. b. Open the airway using the jaw-thrust method. c. Give two breaths using mouth-to-mouth and a barrier device. d. Give two breaths using a bag-mask device.

ANS: B First determine whether the patient has spontaneous respirations by opening the airway. Consider spinal cord injury in patients with trauma. In these situations, a rescuer must use the jaw-thrust maneuver. Prevention of head extension and neck movement is very important to prevent paralysis or spinal cord injury. Apply a rigid cervical collar as soon as possible to reduce cervical spine motion.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when standing by the patient. Which intervention should the nurse perform first to address this problem? a. Deflating the cuff of the endotracheal tube b. Repositioning the patient or tube c. Inserting a new endotracheal tube d. Notifying the health care provider

ANS: B If an air leak is audible with the ear, it is too large. Repositioning the patient or the tube may correct the problem. Reinflation of the cuff may be necessary. Prepare for insertion of a new tube by the health care provider or trained personnel if the cuff ruptures. Repositioning and reinflating the cuff are performed before the health care provider is notified.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

ANS: B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment: Blood pressure: 90/62 mm Hg Pulse: 120 beats/min Respiratory rate: 28 breaths/min Urine output: 20 mL/hr via catheter Laboratory Results: Serum potassium: 2.6 mEq/L Medications: Potassium chloride 40 mEq IV bolus STAT Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

To be an effective nursing leader today requires effective collaboration, which is modeled by which answer below? a. The nursing manager of the observation unit was certain the psychology department would assist the unit with a motivational plan, so she did not request their assistance. b. The nursing manager of the observation unit worked with the psychology department and physical therapy to develop a motivational plan for patients on the unit. c. The nursing director of behavioral health services followed the administrative directive to reduce services and refused to provide services for patients on other units. d. Frustrated by the trend of patients unwilling to work with therapy, the unit manager recommended that these patients be placed on another unit.

ANS: B The nursing manager works collaboratively with other departments to solve the patient care issue. In the other choices, the unit manager does not involve collaboration to resolve the patient concern.

A nurse is working in an intensive care unit (critical care). Which type of nursing care delivery model will this nurse most likely use? a. Team nursing b. Total patient care c. Primary nursing d. Case-management

ANS: B Total patient care is found primarily in critical care areas. Total patient care involves an RN being responsible for all aspects of care for one or more patients. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs.

A patient is admitted with a diagnosis of COPD and the health care provider orders BiPAP. Which action by the nurse is appropriate? a. Set the initial BiPAP settings at 4 to 8 cm H2O for inspiration and expiration. b. Draw arterial blood gas (ABG) levels after the first hour. c. Make sure the mask does not have quick-release straps. d. Set the initial BiPAP settings at 4 to 10 cm H2O for inspiration and at 10 to 15 cm H2O for expiration.

ANS: B When BiPAP is initiated, especially in patients with underlying COPD, it is important to obtain ABG levels after the first hour and then per agency policy (usually every 2 to 6 hours) during the first day because these patients may retain carbon dioxide. BiPAP initial settings are 10 to 15 cm H2O for inspiratory pressure and 4 to 10 cm H2O for expiratory pressure. It is imperative that the mask have quick-release straps. In the case of an emergency (e.g., vomiting, respiratory arrest), quick-release straps allow the mask to be removed quickly. This system also allows the patient to remove the mask quickly as needed.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."

ANS: B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

ANS: B A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters.

ANS: B Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating "quiet time" so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

ANS: B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the client's tissues. The other options are appropriate for any client, and are not specific to obese clients.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge? a. "All my friends and neighbors are planning a party for me." b. "I hope I can get my water turned back on when I get home." c. "I am going to have my daughter scoop the cat litter box." d. "My grandkids are so excited to have me coming home!"

ANS: B All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

ANS: B Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "I'll be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "I must use an electric razor instead of a straight razor to shave."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on anticoagulant therapy should be instructed on bleeding precautions, including using an electric razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K. Clients recovering from open heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

ANS: B Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because "I just have to know how much she weighs!" What action by the client's nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State "That is a violation of client confidentiality." c. Tell the nurse "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurse's behavior.

ANS: B Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

ANS: B Lower blood volume will decrease MAP. The other answers are not accurate.

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

ANS: B Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the client's willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this client's situation, but safety takes priority.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

ANS: B Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn't give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

ANS: B Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection. The medication does not place the client at risk for bleeding, orthostatic hypotension, or a change in heart rate.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the unaffected side. d. Stay with the client and reassure him or her.

ANS: B Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

What is the nurse's responsibility for the patient after he has been intubated during a code event? (Select all that apply.) a. Ventilate using a bag-mask device at a rate of 22 breaths per minute. b. Auscultate the epigastric area. c. Auscultate both lungs. d. Call for a chest radiograph.

ANS: B, C Assist in confirmation of endotracheal tube placement by auscultating the epigastric area for lack of breath sounds and then the lungs for bilateral breath sounds. Intubation personnel usually perform secondary confirmation by using a carbon dioxide detector. Ventilate using a bag-mask device upon intubation at a rate of 8 to 10 breaths per minute. Avoid hyperventilation. Increased intrathoracic pressure due to incomplete exhalation results in reduced cardiac output. A chest radiograph usually is obtained after the patient has been stabilized to confirm placement of the endotracheal tube and central venous catheters.

The nurse is caring for an unconscious patient who has an oral airway in place, and who has copious amounts of oral secretions. What may the nurse have to do while caring for this patient? (Select all that apply.) a. Cleanse the mouth frequently using lemon glycerin swabs. b. Replace or clean the oral airway. c. Suction the oral cavity frequently. d. Keep the airway in place for extended periods

ANS: B, C Do not use lemon glycerin swabs for oral care because they are drying to mucosal tissues and promote bacterial growth. The oral airway will have to be removed, cleaned or discarded, and replaced in patients with excessive oral secretions. Frequent suctioning of the oral cavity may be required. Oral airways are not a long-term solution. They can cause significant lip and tongue erosion.

The nurse is reviewing lab results for a patient with hypoxemia. The nurse is aware that which of the following results may worsen the patient's hypoxemia? (Select all that apply.) a. Low sodium levels b. Low hemoglobin levels c. Increased blood pH d. Decreased blood pH

ANS: B, C Hypoxemia is a deficiency of arterial blood oxygen. Decreased hemoglobin levels reduce the amount of oxygen transported to the cells. Acidemia (decreased blood pH) increases the ability of hemoglobin to release oxygen to the tissues. Alkalemia (increased blood pH) decreases the ability of hemoglobin to release oxygen to the tissues.

The patient is on mechanical ventilation. Which actions by the nurse are appropriate? (Select all that apply.) a. Keep the patient in a supine position. b. Note and mark the level of the endotracheal (ET) tube at the lips or nares. c. Have suction equipment available for immediate use. d. Perform mouth care at least twice daily.

ANS: B, C The patient should be positioned with the head of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing the risk for aspiration and ventilator-associated pneumonia. Note and mark the level of the ET tube at the lips or nares. This provides a baseline for depth of tube placement and ensures that the tube is not too close to the carina or in the right main stem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of the ET or tracheostomy tube, to prevent plugging of the airway, and to reduce the risk for infection. Perform mouth care at least 4 times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and the risk for ventilator-associated pneumonia.

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

ANS: B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

A patient on mechanical ventilation has an FiO2 setting of 38%. The nurse is reviewing arterial blood gas results and pulse oximetry readings. The nurse is aware that the desired level of oxygen is which of the following? a. PaO2 greater than 90 mm Hg b. SpO2 greater than 60% c. PaO2 greater than 60 mmHg d. SpO2 greater than 95%

ANS: C A patient on mechanical ventilation ideally has an FiO2 setting less than 40% to maintain PaO2 levels greater than 60 mm Hg and SpO2 levels greater than 90%.

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

The nurse finds a patient lying on the bathroom floor. The patient is unresponsive and has a pulse but is not breathing. What is the nurse's first action? a. Give two breaths using mouth-to-mouth without a barrier device. b. Give two breaths using mouth-to-mouth without a barrier device and watch for chest movement. c. Give two breaths using a bag-mask device. d. Start chest compressions until an AED is available.

ANS: C Give two breaths using mouth-to-mouth with a barrier device or a mouth-to-mask device or a bag-mask device. Watch for chest rise and fall. In a hospital setting where protected methods of artificial ventilation are available, mouth-to-mouth without a barrier device is not recommended because of the risk for microbial contamination. Watch for chest rise and fall. Motion, by itself, could be caused by fasciculation and is not indicative of air moving into and out of the chest.

The nursing unit director exhibits the definition of leadership in which of the following responses? a. The nurse manager refers the concern to the director of the department. b. The nurse manager corrects the concern with the patient directly and does not communicate her actions to the staff. c. The nurse manager meets with the staff to discuss the concern and identify solutions. d. The nurse manager tells the staff that they need to correct the situation by tomorrow and leaves the meeting.

ANS: C Leadership is defined as an interactive process that provides needed guidance and direction which is present in the correct answer. The other choices do not involve an interactive process with staff to resolve the concern.

The nurse is preparing to insert an oral airway in a patient who is exhibiting signs of potential respiratory distress. The nurse knows that candidates for oral airway placement are those: a. with oral trauma. b. with loose teeth. c. who are unconscious. d. who have had recent oral surgery.

ANS: C Never insert an oral airway in a conscious patient or a patient with recent oral trauma, oral surgery, or loose teeth. Use oral airways only in unconscious patients. Oral airways may stimulate vomiting or laryngospasm if inserted in the semiconscious or conscious patient.

A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing the ventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O

ANS: C Subglottal secretions should be removed every 4 to 6 hours or before position changes. Oral care should be provided with a chlorhexidine swab or toothbrush (if chlorhexidine is contraindicated) every 8 hours. The ventilator circuits should be changed every 48 hours because of potential bacteria within the tubing condensation. The endotracheal cuff pressures should be maintained at 20 cm H2O to decrease movement of secretions into the lower airways.

The patient is receiving a unit of packed RBCs. Fifteen minutes into the procedure, he complains of severe kidney pain, and his temperature increases by 3° F. The nurse stops the transfusion immediately, suspecting that which of the following reactions is occurring? a. Delayed hemolytic transfusion reaction b. Nonhemolytic febrile reaction c. Acute hemolytic transfusion reaction d. Severe allergic reaction

ANS: C Symptoms of an acute hemolytic reaction usually begin within 15 minutes of transfusion initiation and include severe pain in the kidney area and chest, increased temperature (up to 105° F), increased heart rate, and a sensation of heat and pain along the vein receiving blood, as well as chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular coagulation, and possibly death. Symptoms of a delayed hemolytic reaction usually begin 2 to 14 days after the transfusion and include unexplained fever, an unexplained decrease in hemoglobin/hematocrit (Hgb/Hct), increased bilirubin levels, and jaundice. Symptoms of a nonhemolytic febrile reaction begin between 30 minutes after initiation and 6 hours after completion of transfusion and include fever greater than 1° C above baseline, flushing, chills, headache, and muscle pain; they occur most frequently in immunosuppressed patients. Symptoms of an acute severe allergic reaction usually begin within 5 to 15 minutes of initiation of transfusion and include coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.

The nurse is providing CPR to an unresponsive patient according to the 2010 American Heart Association (AHA) resuscitation guidelines. The nurse is performing chest compressions correctly when she performs them at which rate? a. 60 to 80 per minute b. 120 per minute c. 100 per minute d. 40 to 60 per minute

ANS: C The 2010 AHA resuscitation guidelines recommend performing chest compressions at a rate of 100 per minute.

A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is appropriate? a. Apply sterile gloves to connect the oxygen to the tracheostomy tube. b. Check the oxygen tubing frequently to make sure water is present in the tubing. c. Attach the T tube to a humidified oxygen source. d. Monitor the response to oxygen with hourly arterial blood gas levels.

ANS: C The T tube connects an oxygen source to an artificial airway such as a tracheostomy tube. Humidification is necessary because the artificial airway bypasses the normal humidification process of the nose and mouth. Clean gloves, not sterile gloves, are used to connect oxygen to the artificial airway. Fluid should be drained from the tubing so that it does not provide a medium for bacterial growth. Hourly ABGs are not the standard for monitoring patients with artificial airways and oxygen.

The nurse is providing an educational seminar to a group of nursing students on the advantages of using an automated external defibrillator (AED). She knows that her teaching has been effective when the students reply: a. "Health care providers do not need to learn CPR to use the AED." b. "The health care provider is given a printout of the rhythm change." c. "The health care provider can safely use both CPR skills and AED skills." d. "The health care provider can adjust the level of shock administered."

ANS: C The advantage of the AED is that laypeople or health care providers trained in basic life support, who have less training than ACLS personnel, can defibrillate. AEDs eliminate the need for training in rhythm interpretation and make early defibrillation practical and achievable. The AED is an automated external defibrillator that incorporates a rhythm analysis system. Upon rhythm identification, some AEDs will automatically provide the electrical shock after a verbal warning (fully automated). Other AEDs will recommend a shock, if needed, and then will prompt the responder to press the shock button. The provider does not need to adjust anything.

A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by the nurse is appropriate? a. Use manual ventilation to hyperoxygenate the patient with 100% oxygen via Ambu bag. b. Push the catheter and slide the plastic sleeve back when the patient exhales. c. Push the catheter in until resistance is felt or the patient coughs. d. Apply suction for no longer than 30 seconds as you remove the catheter.

ANS: C The catheter is pushed in while the plastic sleeve is slid back between the thumb and forefinger until resistance is felt or the patient coughs. Hyperoxygenation is done by adjusting the FiO2 setting on the ventilator. Manual ventilation is not recommended. The catheter is pushed in when the patient inhales. Suction is applied for no longer than 15 seconds.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

The nurse is caring for several patients receiving oxygen by various delivery systems. Which assessment finding by the nurse indicates proper use of the oxygen device? a. No mist is noted in a face tent. b. The reservoir of the rebreathing mask collapses on inhalation. c. The flow rate is between 1 and 6 L/min for a nasal cannula. d. The flow rate for an oxygen hood is set at 3 L/min.

ANS: C The nasal cannula is used with an oxygen flow rate of 1 to 6 L/min. The face tent provides high humidity, and mist is expected. The reservoir of the rebreathing mask remains partially inflated when operating effectively to avoid rebreathing of carbon dioxide. The flow rate for an oxygen hood may be 5 L/min or more to prevent CO2 narcosis.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the client's intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.

The hospital must reduce the number of readmissions from 11% to 8% in the next year. Which of the following best represents the transformational leadership style in accomplishing this goal? a. The director communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week. b. The organization charters three work teams to identify solutions for the top three causes for readmissions. These teams are given full authority to implement their solution. c. The director of quality develops a vision statement and action plan to achieve the goal. The director works directly with the involved departments to implement the action plan. d. The CEO communicates the goal to the organizational directors and managers and states that they are entrusted to solve the problem.

ANS: C Transformational leaders communicate a vision and motivate employees to accomplish the goal. The director who communicates the goal of reducing readmissions to the hospital operations team and tells them to submit their action plan by the end of the week leaves the solution to achieve the goal to the followers to develop without motivating them. The solution that is left to the work teams to resolve is not an example of transformational leadership. The CEO entrusts the managers and directors to solve the problem without giving them a vision or engaging in the solution with them.

Percussion and vibration is ordered on a patient with retained pulmonary secretions. Which action by the student nurse should the nursing instructor question? a. Performs percussion for 3 to 5 minutes in each position as tolerated b. Uses the wrist and elbow to create movement when performing percussion c. While the patient inhales, gently pushes down and vibrates the chest wall with the flat part of the hand d. Repeats the vibration 3 times and then instructs the patient to take a deep breath and cough while exhaling

ANS: C Vibration is performed while the patient is exhaling, not inhaling. Percussion is performed for 3 to 5 minutes in each position. When clapping, most arm movement comes from the elbow and wrist joints. Vibration is repeated 3 times and then the patient cascade coughs by taking a deep breath and doing a series of small coughs until the end of the breath.

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

ANS: C A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

ANS: C Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client's previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene? a. Assessing the IV site before giving the drug b. Obtaining a programmable ("smart") IV pump c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

ANS: C Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a "smart" pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the UAP knew how to take blood pressure b. Double-checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task

ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right away. An experienced UAP should know how to take vital signs and the nurse should not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the UAP.

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

ANS: C The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale.

ANS: C This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

ANS: C To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the client's neck, not in back. The other actions are appropriate.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

ANS: C While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the client's psychosocial status as the priority.

A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking? a. Authority b. Autonomy c. Responsibility d. Accountability

ANS: D Accountability refers to individuals being answerable for their actions. The nurse in this situation is not taking ownership of the inappropriate delegation of a task. Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position.

A patient has been using continuous positive airway pressure (CPAP), and now the health care provider is recommending bi-level positive airway pressure (BiPAP). The patient is asking the nurse to explain the difference again. Which response is appropriate? a. "CPAP maintains a set positive airway pressure during inspiration only." b. "CPAP opens the airways during inspiration and allows them to close during expiration." c. "BiPAP maintains a set pressure that is the same for inspiration and expiration." d. "BiPAP delivers sufficient expiratory pressure to keep the airways open."

ANS: D BiPAP uses two modes of pressure: one for inspiration and one for expiration. During expiration, BiPAP delivers sufficient pressure to keep the airways open. CPAP maintains a set positive airway pressure during inspiration and expiration. It keeps the airways open and prevents upper airway collapse.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

Which sign or symptom of airway compromise may require insertion of an oral airway? a. Ability of the patient to speak b. Ability of the patient to cough forcefully c. Presence of wheezing between coughs d. Presence of gurgling with the respiratory cycle

ANS: D Identify the need to insert an oral airway. Signs and symptoms include upper airway gurgling with breathing, absence of a gag reflex, increased oral secretions, excessive drooling, grinding of teeth, clenched teeth, biting of the orotracheal or gastric tube, labored respirations, and increased respiratory rate. These conditions place the patient at risk for obstruction of the upper airway. Normal response shows no evidence of airway obstruction or compromise. Wheezing may be present as a symptom of allergy but not necessarily of airway obstruction.

The nurse who is certified as a Critical Care Registered Nurse (CCRN™) represents the unit on the organizational performance improvement team. This is an example of _____ leadership. a. formal b. unit c. organizational d. informal

ANS: D Informal leaders are recognized as leaders because of their capabilities and actions. Formal leaders are recognized because of the position they hold such as director or manager. Unit leadership refers to the leader of the particular unit. Organizational leadership refers to any leader within the organization.

The nurse is teaching a patient how to use an Acapella device. What instruction should the nurse give to the patient? a. Take a full deep breath in and fill your lungs. b. Hold your breath for 5 to 10 seconds after placing the mouthpiece in your mouth. c. Cough forcefully to clear your lungs while maintaining a tight seal on the mouthpiece. d. Exhale slowly for 3 to 4 seconds through the device while it vibrates.

ANS: D Instruct the patient to try not to cough and to exhale slowly for 3 to 4 seconds through the device while it vibrates. The patient should be instructed to take in a breath that is larger than normal, but not to fill the lungs completely—about 75% of inspiratory capacity. Hold the breath for 2 to 3 seconds, and try not to cough

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

A patient is admitted to the emergency department following a motor vehicle accident. The patient is unconscious and has a broken jaw, a broken nose, and facial lacerations. The patient's breath sounds are diminished, and the health care provider suspects atelectasis. Frequent suctioning is required to clear the airway. Oxygen saturation levels range from 70% to 75%. The nurse recognizes that this patient most likely will have which type of ventilatory device ordered? a. CPAP b. BiPAP c. Nasal cannula d. Mechanical ventilation

ANS: D Noninvasive ventilation, including CPAP and BiPAP, is contraindicated in cardiac or respiratory arrest, nonrespiratory organ failure, facial surgery or trauma, inability to protect the airway and/or high risk for aspiration, and inability to clear secretions. A nasal cannula cannot be used with nasal obstruction from a broken nose.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A nurse has a transactional leader as a manager. Which finding will the nurse anticipate from working with this leader? a. Increased turnover rate b. Increased patient mortality rate c. Increased rate of medication errors d. Increased level of patient satisfaction

ANS: D Research has found that on nursing units where the nurse manager uses transactional leadership there is an increased level of patient satisfaction, a lower patient mortality rate, and a lower rate of medication errors. Turnover rate is decreased since staff retention is increased with transformational leadership.

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

ANS: D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by the nurse demonstrates proper procedure when providing endotracheal tube care? a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line b. Instructing the assistant to hold the tube away from the lips while changing the tape c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours

ANS: D The endotracheal tube should be repositioned to the opposite side or at the center of the mouth every 24 to 48 hours to prevent formation of pressure sores at the sides of the mouth. The proper depth of the endotracheal tube is determined by noting the centimeter mark at the lip or gum line. This line is marked on the tube and is recorded in the patient's record at the time of intubation. The tube should not be held away from the lips because this allows too much "play" in the tube and increases the risk for tube movement and accidental extubation. The oral airway should not be removed if the patient is actively biting down until tape partially or completely secures the tube.

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take? a. Close the staff lounge. b. Enforce a stricter dress code. c. Include the findings on each staff member's annual evaluation. d. Place a hard copy of announcements and unit policies in each staff member's mailbox.

ANS: D The identified problem is lack of staff communication. Sending an e-mail was not effective; therefore, giving each staff member a hard copy along with e-mailing is another approach the manager can take. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or facility activities. Including the findings on evaluations, closing the lounge, and enforcing stricter dress codes do not address the problem.

The nurse is caring for a patient on a mechanical ventilator and the low-pressure alarm sounds. Which action by the nurse is most appropriate? a. Assess for secretions in the airway and suction the patient. b. Administer a sedative to the patient to prevent coughing. c. Assess the endotracheal tube cuff to make sure it is deflated. d. Check the ventilator tubing and reconnect if disconnected.

ANS: D The low-pressure alarm sounds when the ventilator has no resistance to inflating the lung. The patient may be disconnected from the ventilator, or a leak may have developed in the ventilator circuit. The high-pressure alarm sounds when the ventilator has met resistance to delivery of the tidal volume. This may result from coughing, increased secretions, or biting on the endotracheal tube. The cuff of the endotracheal tube is inflated to create a seal for positive-pressure ventilation. A cuff that is leaking could cause the low-pressure alarm to sound.

A patient has been found with no pulse or respirations. The cardiopulmonary arrest team has been called. What should the nurse do while awaiting the team's arrival? a. Gather the patient's medical record and medication administration record. b. Obtain the crash cart. c. Notify the patient's primary care provider. d. Perform CPR.

ANS: D The nurse's responsibility while awaiting the arrest team is to perform CPR, with or without assistance as available. Other team members can collect the patient's records, obtain the crash cart, and notify the primary care provider. The nurse assigned to the patient should stay with the patient to provide the history when the team arrives.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption, nor do these statements decrease complications of digoxin therapy.

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future. The nurse personally provides care to address the client's concerns instead of pushing the client's issues off on a chaplain or psychiatrist. The nurse should not jump to conclusions and suggest taking the client off the transplant list, which is the best treatment option.

A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. "All weight-loss drugs can cause suicidal ideation." b. "No drugs are currently available for weight loss." c. "Only over-the-counter medications are available." d. "There are three drugs currently approved for this."

ANS: D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

ANS: D This client may have a trachea-innominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.