Adult I: TopHat Questions Week 1

Which fluid can the nurse anticipate when the physician orders a hypotonic solution? A. 0.45% NS B. 0.9% NS C. 3% NaCl D. D10 1/2 NS

0.45% NS

The IV order reads: D5 1/4 NS infused at 100 ml/hr. Using tubing with a drip factor of 15gtts/ml, what is the drip rate (gtts/min)?

25

A 58 year old patient presents in the ER a BP of 210/140, vomiting and confusion. Which category should the nurse assign to this patient? A. Urgent B. Non-urgent C. Emergent D. Semi-urgent

A

Four patients develop changes in skin appearance. Which patient should the nurse see first? A. Patient A with bluish color around the lips B. Patient B with yellow color of the skin and sclera C. Patient C with erythema of the face and neck D. Patient D with dark brown spots on the chest

A

The RN is working with an UAP and LPN. Which assignment is most appropriate to assign to the LPN? A. Emptying a urine catheter bag on a immobile patient B. Assessing the lungs on a patient with leg cellulitis C. Taking vital signs on the post-op patient D. Teaching a newly diagnosed patient about diabetes

A

The charge nurse is reviewing IV therapy orders. What information is included in each order? (Select all that apply) A. Specific type of solution B.Rate of administration C. Specific drug to be added to the solution D.Method for diluting the drugs for the solution E. Specific type of administration equipment

A, B, C

When a nurse administers the hypertonic solution such as 3% NaCl to patient, what actions are essential? Select all that apply. A. Auscultate lung sounds B. Monitor blood pressure C. Monitor urine output D. Check sodium level E. Check for tetany

A,B,C,D

Which tasks should the registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A. Empty the foley bag B. Refill water pitcher C. Assess vital signs D. Ask the patient if the pain med helped E. Ambulate the patient to the bathroom

A,B,E

An adult patient is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized and is bleeding profusely from a large gash on his head. What action should the nurse take first? A. Stop the Bleeding B. Check his airway C. Take his vital signs D. Verify his neurological status

B

The RN is working with an UAP and LPN. Which assignment is most appropriate to assign to the LPN? A. Emptying a urine catheter bag on a immobile patient B. Assessing the lungs on a patient with leg cellulitis C. Taking vital signs on the post-op patient D. Teaching a newly diagnosed patient about diabetes

B

The nurse is caring for the patient recovering from surgery. A physician orders 1L Lactated Ringer's solution to be delivered over 8 hours. Which hourly rate should the nurse set the IV pump? A. 10 ml/hr B. 125 ml/hr C. 150 ml/hr D. 200 ml/hr

B

The nurse is reviewing the skin of several patients in a long-term care facility. Which of the following requires immediate action? A. toes nails are thickened and yellow in color B. an irregular border is noted on a black mole on the scalp C. silver color scales are noted on the elbows D. striae are noted on abdomen and buttocks

B

The registered nurse (RN) requests the unlicensed assistive personnel (UAP) ambulate a patient with orthostatic hypotension and weakness, up and down the hall after breakfast and lunch for 10 minutes and to report back when task completed. Which right of delegation did the RN violate? A. Right task B. Right circumstance C. Right direction D. Right supervision

B

Which patient task can the registered nurse assign to the unlicensed assistive personnel (UAP)? A. Assist a client with a new colostomy with his colostomy irrigation B. Obtain a stool sample from a patient reporting diarrhea C. Obtain a urine sample from an indwelling catheter D. Obtain a diet history from a patient complaining of heartburn

B

Which task is most appropriate for the RN to delegate to the UAP? A. Monitor the post-op patient for shortness of breath after ambulating the patient in the hallway B. Obtain the pulse ox on a patient who became short of breath while ambulating in the hallway C. Determine when it is appropriate for the patient to rest during ambulation D. Reinforce with the patient the need to balance rest with activity

B

A charge nurse recognizes that the new RN's is in need of further education regarding delegation of patient care when charge nurse overhears the RN makes which statement to the nursing assistant? A. "Make sure you wear gloves when you emptying the foley bag." B. "Prepare a sitz bath for Mrs. Jones who has a perineal laceration." C. "When changing Mr. Jones, socks, let me know if there is any further drainage on the toes." D. "The supplies to perform post mortem care are in the closet down the hall."

C

Immediately following a storm has passed, the nurse along with the rescue team is searching for injured people. A victim lying next to a broken natural gas main is not breathing and bleeding heavily from his leg wound. Which action should the nurse take first? A. Start rescue breathing and CPR B. Apply pressure to the wound C. Remove the victim from the immediate area D. Leave this patient and check another patient less injured

C

One more time now that we explored IV therapy... If the Franks's condition was more critical (seizures etc. ) what type of IV solution should the nurse anticipate being ordered? A. Isotonic B. Hypotonic C. Hypertonic

C

The charge nurse is working with a licensed practice nurse (LPN), unlicensed assistive personnel (UAP) and another registered nurse (RN). Which patient assignment is appropriate to delegate to the other RN? A. Patient A with an arm fracture needs assisting with feeding and bathing B. Patient B with diabetes and a wound infection needs the daily insulin injection C. Patient C needs his chest pain re-assessed before giving a second dose of medication D. Patient D with chronic bronchitis needs transportation to radiology for a chest X-Ray

C

Which patient should the emergency room nurse list as urgent? A. Patient A admitted to ER with chest discomfort and shortness of breath B. Patient B admitted with slurred speech and left side weakness C. Patient C admitted with abdominal pain and right-sided rebound tenderness D. Patient D admitted with ear pain and sinus congestion with fever

C

List in order of priority which patient the the nurse should assess 1st, 2nd, 3rd and last. A. Patient post op day #2 practice hip repair who reports not having a bowel movement since before surgery. B. Patient admitted with chronic bronchitis and reports cough with green sputum C. Patient reporting anxiety and feeling stressed with clenched fists D. Patient admitted with chronic renal failure who has been without dialysis for 3 days

C, D, B, A

A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? A. Delegate the LPN to assess the bowel sounds on a post-op patient B. Assign the LPN to administer the daily antihypertensive meds to a patient scheduled for a chest X-Ray. C. Assign the float RN to a patient with diabetes and urinary frequency D. Request that the UAP ask the patient about his arthritis pain

D

A triage nurse, working in the Emergency Room received four admissions. Which patient should the nurse see first? A. A 40 year old client who is diaphoretic and complains of chest pain B. An 18 year old client who thinks he might have a broken tooth from playing football C. A 35 year old client who cut her finger with a knife while preparing food D. A 60 year old client who is dyspneic and has swollen lips after being stung by a bee.

D

After assessing the patency of the patient's IV catheter, the nurse attempts to flush the catheter and meets resistance. What actions should the nurse take next? A. Get a larger size syringe and repeat the flush attempt B. Use a heparinized solution and repeat the flush attempt C. Gently force-flush the catheter and check for blood return D. Stop the flush attempt and discontinue the IV

D

The chronic pain patient reports to the charge nurse that the nurses have not been responding to requests for pain medication. Which action should the charge nurse take first? A. Check the MARs and nurses notes for the past several days B. Request the nurse educator provide an in-service about pain management C. Perform a complete pain assessment and history on the patient D. Have a conference with the nurses responsible for the patient's care

D

The nurse assesses the patient's IV fluids (via gravity) and notices that it is running slowly. Which action should the nurse take first? A. Discontinue the IV site and notify IV team for a restart B. Lower the bag below the heart to check for a blood return C. Apply a warm soak because venous spasms may be present D. Check the tubing for kinks and straighten the line as needed

D

The nurse is providing care to the patient with cystitis. Which task can be delegated to the UAP? A. Teach the patient the manifestations of cystitis B. Check the patient's urine for color and odor C. Review the plan of care to correct the cystitis D. Provide the patient with a clean-catch urine container.

D

List one of the rights of delegation and give an example of how it is met by the RN during delegation

Multiple Answers

List one task that can be delegated to UAP & LPN and one task that cannot be delegated

Multiple Answers