ALL LaCharity Chapters

1. You are working in the emergency department (ED) when a client arrives reporting substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether you should anticipate implementing the acute coronary syndrome (ACS) standard protocol? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

1. Ans: 2. Troponin I level Cardiac troponin levels are elevated 3 hours after the onset of ACS (unstable angina or myocardial infarction [MI]) and are very specific to cardiac muscle injury or infarction. Although levels of creatine kinase MB and myoglobin also increase with MI, the increases occur later and/or are not as specific to myocardial damage as troponin levels. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization

10. You are working in the ED caring for a client who was just admitted with left anterior chest pain, possible ACS. Which action will you take first? 1. Insert an IV catheter. 2. Auscultate heart sounds. 3. Administer sublingual nitroglycerin. 4. Draw blood for troponin I measurement.

10. Ans: 3. Administer sublingual nitroglycerin. The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority. Focus: Prioritization

11. An 80-year-old client on the coronary step-down unit tells you that he does not want to take the ordered docusate (Colace) because he does not have any problems with constipation. Which action is most appropriate? 1. Document the medication on the client's chart as "refused." 2. Mix the medication with food and administer it to the client. 3. Explain that his decreased activity level may cause constipation. 4. Reinforce that the docusate has been prescribed for a good reason.

11. Ans: 3. Explain that his decreased activity level may cause constipation. The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as "refused" or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it, unless someone else has health care power of attorney and has authorized use of the medication. Focus: Prioritization

12. You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

12. Ans: 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute MI is to completely eliminate the pain. Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time. Focus: Prioritization

13. You are preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had an MI and her husband. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is most appropriate? 1. "Do you think your family may want you to make some lifestyle changes?" 2. "Can you tell me why you don't feel that you need to make any changes?" 3. "You are still in the stage of denial, but you will want this information later on." 4. "Even though you don't want to change, it's important that you have this teaching."

13. Ans: 2. "Can you tell me why you don't feel that you need to make any changes?" For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give you more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle. Focus: Prioritization

14. You are caring for a hospitalized client with heart failure who is receiving captopril (Capoten) and spironolactone (Aldactone). Which laboratory value will be most important to monitor? 1. Sodium level 2. Blood urea nitrogen level 3. Potassium level 4. Alkaline phosphatase level

14. Ans: 3. Potassium level Hyperkalemia is a common adverse effect of both ACE inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening. Focus: Prioritization

15. The health care provider telephones you with new prescriptions for a client with unstable angina who is already taking clopidogrel (Plavix). Which medication is most important to clarify further with the health care provider? 1. Aspirin (Ecotrin) 162 mg daily 2. Omeprazole (Prilosec) 20 mg daily 3. Metoprolol (Lopressor) 50 mg daily 4. Nitroglycerin patch (Nitrodur) 0.4 mg/hr

15. Ans: 2. Omeprazole (Prilosec) 20 mg daily Since proton pump inhibitors such as omeprazole affect the metabolism of clopidogrel and decrease its effectiveness, the health care provider may want to discontinue the omeprazole in this client with unstable angina. The other medications should also be verified, but current national guidelines for clients with unstable angina indicate that providers should consider avoiding proton pump inhibitors in those who require clopidogrel. Focus: Prioritization

16. At 10:00 AM, a hospitalized client receives a new order for transesophageal echocardiography (TEE) as soon as possible. Which action will you take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

16. Ans: 1. Put the client on "nothing by mouth" (NPO) status. Because TEE is performed after the throat is numbed using a topical anesthetic and possibly after IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the TEE but do not need to be implemented immediately. Focus: Prioritization

17. You assess a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern? 1. Blood pressure is 144/78 mm Hg 2. Pedal pulses are palpable at +1 3. Left groin has a 3-cm bruised area 4. Apical pulse is 122 beats/min and regular

17. Ans: 4. Apical pulse is 122 beats/min and regular The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern. Focus: Prioritization

18. You are working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to an experienced UAP? 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

18. Ans: 1. Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated Measurement of ankle and brachial blood pressures for ankle-brachial index calculation is within the UAP's scope of practice. Calculating the ankle-brachial index and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN. Focus: Delegation

19. While working on the cardiac step-down unit, you are serving as preceptor to a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate? 1. 19-year-old with rheumatic fever who needs discharge teaching before going home with a roommate today 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV 3. 50-year-old with newly diagnosed stable angina who has many questions about medications and nursing care 4. 75-year-old who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

19. Ans: 2. 33-year-old admitted a week ago with endocarditis who will be receiving ceftriaxone (Rocephin) 2 g IV The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses. Focus: Assignment

2. You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client finding will require the most immediate action? 1. Blood pressure of 152/88 mm Hg 2. Heart rate of 134 beats/min 3. Oxygen saturation of 91% 4. Chest pain level of 3 (on a scale of 10)

2. Ans: 4. Chest pain level of 3 (on a scale of 10) Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization

20. You are monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol (Tenormin) and has a first-degree heart block, with a rate of 58 beats/min

20. Ans: 3. Client who has just arrived on the unit with an acute MI and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of MI. Focus: Prioritization

21. Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate.

21. Ans: 1. Defibrillate at 200 J. Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available. Focus: Prioritization

22. Two weeks ago, a 63-year-old client with heart failure received a new prescription for carvedilol (Coreg) 3.125 mg orally. When evaluating the client in the cardiology clinic, you obtain the following data. Which finding is of most concern? 1. Reports of increased fatigue and activity intolerance 2. Weight increase of 0.5 kg over a 1-week period 3. Sinus bradycardia at a rate of 48 beats/min 4. Traces of edema noted over both ankles

22. Ans: 3. Sinus bradycardia at a rate of 48 beats/min Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, the slow heart rate does require further follow-up, because bradycardia may progress to more serious dysrhythmias such as heart block. Focus: Prioritization

23. You have just received a change-of-shift report about these clients on the coronary step-down unit. Which one will you assess first? 1. 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change 3. 56-year-old who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure 4. 77-year-old who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6° F (38.1° C)

23. Ans: 2. 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change The client's symptoms indicate acute hypoxia, so immediate further assessments (such as assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon, because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client. Focus: Prioritization

24. As the charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and UAPs, you have developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to delegate to an LPN/LVN team member? 1. Weighing all residents with heart failure each morning 2. Listening to lung sounds and checking for edema each week 3. Reviewing all heart failure medications with residents every month 4. Updating activity plans for residents with heart failure every quarter

24. Ans: 2. Listening to lung sounds and checking for edema each week LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice. Focus: Delegation

25. During a home visit to an 88-year-old client who is taking digoxin (Lanoxin) 0.25 mg daily to treat heart failure and atrial fibrillation, you obtain this assessment information. Which finding is most important to communicate to the health care provider? 1. Apical pulse of 68 beats/min and irregularly irregular 2. Digoxin taken with meals 3. Vision that is becoming "fuzzy" 4. Lung crackles that clear after coughing

25. Ans: 3. Vision that is becoming "fuzzy" The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregularly irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure. Focus: Prioritization

26. You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

26. Ans: 2, 4, 3, 1 2. Have the client sit down. 4. Administer PRN oxygen by nasal cannula. 3. Check the client's blood pressure. 1. Call the client's physician. The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization

27. A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the client's physician about the change in status. 4. Reassure the client that embolization is common in endocarditis.

27. Ans: 3. Notify the client's physician about the change in status. The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the physician should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain. Focus: Prioritization

28. A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for you to delegate to the UAP? 1. Teaching family members the signs of infection 2. Monitoring capillary perfusion once every 8 hours 3. Evaluating foot sensation and movement each shift 4. Assisting the client in cleaning around the Unna boot

28. Ans: 4. Assisting the client in cleaning around the Unna boot Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members. Focus: Delegation

29. During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, you obtain these data. Which finding has the most immediate implications for the client's care? 1. Arterial line indicates a blood pressure of 190/112 mm Hg. 2. Cardiac monitor shows frequent premature atrial contractions. 3. There is no response to verbal stimulation. 4. Urine output is 40 mL of amber urine.

29. Ans: 1. Arterial line indicates a blood pressure of 190/112 mm Hg. Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and/or hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability. Focus: Prioritization

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

3. Ans: 1, 4, 6 1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation

30. You are developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. Which nursing activity included in the care plan will need to be performed by RN staff members? 1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs 2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes 4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

30. Ans: 3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously-taught information are activities that can be delegated to other nursing personnel under the supervision of the RN. Focus: Delegation

31. You are preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse? 1. Famotidine (Pepcid) 20 mg IV 2. Furosemide (Lasix) 40 mg IV 3. Digoxin (Lanoxin) 0.25 mg PO 4. Warfarin (Coumadin) 2.5 mg PO

31. Ans: 4. Warfarin (Coumadin) 2.5 mg PO Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed. Focus: Prioritization

32. A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. Blood urea nitrogen 4. Hematocrit

32. Ans: 2. B-type natriuretic peptide Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored, but do not indicate whether the client has heart failure. Focus: Prioritization

4. Based on this information in a client's medical record, which topic will you plan on including in the initial teaching plan for a client who has a new diagnosis of stage 1 hypertension? Health History- Denies any chronic health problems, currently takes no medications. Physical Exam- 5'6" , 115lbs, BMI 18.6. Social and Diet HX- Accountant, 1 glass of wine 1-2 times week, Eats fast food frequently. 1. Benefits and adverse effects of beta-blockers 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out

4. Ans: 4. Low-sodium food choices when eating out Research indicates that reducing sodium intake will lower blood pressure. Lifestyle management is appropriate initial therapy for this client with stage 1 hypertension and no cardiovascular disease or risk factors. Antihypertensive medications would not be prescribed unless lifestyle changes were attempted for several months without a decrease in blood pressure. This client's assessment data indicate that she is not overweight and does not drink alcohol excessively, so discussing changes in these risk factors would not be appropriate. Focus: Prioritization

5. You make a home visit to evaluate a hypertensive client who has been taking enalapril (Vasotec). Which finding indicates that you need to contact the health care provider about a change in the drug therapy? 1. Client reports frequent urination. 2. Client's blood pressure is 138/86 mm Hg. 3. Client coughs often during the visit. 4. Client says, "I get dizzy sometimes."

5. Ans: 3. Client coughs often during the visit. A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme (ACE) inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization

6. While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

6. Ans: 1, 2 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization

7. You are the charge nurse for the coronary care step-down unit. Which client is best to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

7. Ans: 2. Client receiving IV furosemide (Lasix) to treat acute left ventricular failure An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have ACS and with collaborative treatments such as coronary angioplasty and coronary artery stenting. Focus: Assignment

8. At 9:00 pm, you admit a 63-year-old with a diagnosis of acute MI. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase [Activase]) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine (Pepcid) for esophageal reflux. 3. The client has ST-segment elevations on the 12-lead ECG. 4. The client has had continuous chest pain since 8:00 AM.

8. Ans: 4. The client has had continuous chest pain since 8:00 AM. Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. Focus: Prioritization

9. You are working with an experienced UAP and an LPN/LVN on the telemetry unit. A client who had an acute MI 3 days ago has a nursing diagnosis of Activity Intolerance related to fatigue and chest pain. Which nursing activity included in the care plan is best delegated to the LPN/LVN? 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities 2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation 3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand 4. Explaining the rationale for alternating rest periods with exercise to the client and family

9. Ans: 1. Administering nitroglycerin (Nitrostat) if chest discomfort occurs during client activities Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice. Focus: Delegation

A nursing student reports to you that he has observed several types of behavior among the patients. Which patient needs priority assessment? A. A patient who is having command hallucinations B. A patient who is demonstrating clang associations C. A patient who is verbalizing ideas of reference D. A patient who is using neologisms

A. A patient who is having command hallucinations

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months In caring for this patient with anorexia nervosa, which task can be delegated to the UAP? A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals B. Observing for the reporting ritualistic behaviors related to food C. Obtaining special food for the patient when she requests it D. Weighting the patient daily and reinforcing that she is underweight

A. Sitting with the patient drug meals and 1 to 1 1/2 hours after meals

A patient on the acute psychiatric unit develops neuroleptic malignant syndrome. Which task should be delegated to the mental health assistant? A. Wiping the patient's body with cool moist towels B. Monitoring VS every 15 minutes C. Attaching ECG monitor D. Assigns the RN to transfer the patient to the ICU

A. Wiping the patient's body with cool moist towels

You are caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse

Ans: 1 A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not corrected. All of the other symptoms need to be addressed, but are of lower priority. Focus: Prioritization

You are assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. Which is the priority nursing diagnosis? 1. Risk for Infection related to organisms specific to cat bites 2. Impaired Skin Integrity related to puncture wounds 3. Ineffective Health Maintenance related to immunization status 4. Risk for Impaired Physical Mobility related to potential tendon damage

Ans: 1 Cats' mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Appropriate first aid would include rigorous washing of the wound site with soap and water to combat infection. There is also a risk for tendon damage due to deep puncture wounds, but this is usually evaluated by an orthopedic surgeon after initial emergency care is started. A tetanus shot can be given before discharge. Focus: Prioritization

You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this client? 1. Arrange transportation to a safe house. 2. Make a referral to a counselor. 3. Advise the client about contacting the police. 4. Make an appointment to follow up on the injuries.

Ans: 1 Safety is a priority for this client, and she should not return to a place where violence could recur. The other options are important for the long-term management of this case. Focus: Prioritization

A man, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? 1. Risk for Injury related to seizures 2. Risk for Other-Directed Violence related to hallucinations 3. Risk for Situational Low Self-Esteem related to police custody 4. Risk for Imbalanced Nutrition: Less than Body Requirements related to chronic alcohol abuse

Ans: 1 The client demonstrates neurologic hyperreactivity and is on the verge of a seizure. Client safety is the priority. The client needs medications such as chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to address the other problems. The other diagnoses are pertinent but less urgent. Focus: Prioritization

The emergency medical service team has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the UAP? 1. Performing chest compressions 2. Initiating bag-valve mask ventilation 3. Assisting with oral intubation 4. Placing the defibrillator pads

Ans: 1 UAPs are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice, and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide assistance as needed during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Focus: Delegation

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. Which actions would require immediate intervention by the supervising RN? (Select all that apply.) 1. Gently cleansing the amputated digits and the hand with a povidone-iodine (Betadine)/normal saline solution 2. Cleansing the amputated digits and placing them directly into an ice slurry 3. Wrapping the cleansed digits in saline-moistened gauze, sealing them in a plastic bag, and placing them in an ice slurry 4. Cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline 5. Placing the amputated digits in the correct anatomic position and then wrapping the hand and digits with sterile gauze.

Ans: 1, 2, 4, 5 The only correct intervention is to gently cleanse the digits with normal saline, wrap them in sterile gauze moistened with saline, and place them in a plastic bag or container. The container is then placed on ice. Focus: Supervision, knowledge

A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform? 1. Assessing immediate emotional state and physical injuries 2. Collecting hair samples, saliva specimens, and scrapings beneath fingernails 3. Providing emotional support and supportive communication 4. Ensuring that the chain of custody of evidence is maintained

Ans: 3 An LPN/LVN is able to listen and provide emotional support for clients. The other tasks are the responsibility of an RN or, if available, a sexual assault nurse examiner who has received training in assessing, collecting, and safeguarding evidence, and caring for assault victims. Focus: Delegation

A group of people arrive at the ED by private car reporting extreme periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the priority action? 1. Measure vital signs and listen to lung sounds. 2. Direct the clients to the decontamination area. 3. Instruct clients to don personal protective equipment. 4. Direct the clients to the cold or clean zone for immediate treatment.

Ans: 2 Decontamination in a specified area is the priority. Performing assessments delays decontamination and does not protect the total environment. These clients do not need to don personal protective equipment (PPE); however, personnel should don PPE before assisting with decontamination or assessing the clients. The clients must undergo decontamination before entering cold or clean areas. Focus: Prioritization

You notify the ED physician about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later you see an order for discharge and a follow-up appointment in the morning. You reexamine the client and the symptoms seem worse. What should you do first? 1. Contact the nursing supervisor and express your concerns. 2. Express your findings and concerns to the physician. 3. Discharge the client, but stress the importance of follow-up. 4. Follow the physician's orders and write an incident report.

Ans: 2 First try to express your concerns to the physician. The ED can be very hectic, and the ED staff should work as a team and watch out for each other as well as the clients. If the physician refuses to consider your concerns, then you may have to contact the nursing supervisor or write an incident report. This client has the signs of peritonitis. If the client dies or suffers a poor outcome, you are as liable as the physician if you fail to intervene. Focus: Prioritization

Which pediatric pain patient should be assigned to a newly-graduated RN? 1. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose 2. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures 3. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness 4. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

Ans: 2 The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management. Focus: Delegation

You are assigned to telephone triage. A client who was just stung by a common honeybee calls for advice. The client reports pain and localized swelling but has no respiratory distress or other systemic signs of anaphylaxis. What is the first action that you should direct the caller to perform? 1. Call 911. 2. Remove the stinger by scraping. 3. Apply a cool compress. 4. Take an oral antihistamine.

Ans: 2 The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance. Focus: Prioritization

You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization

Identify the five most critical elements in performing disaster triage for multiple victims. 1. Obtain past medical and surgical histories. 2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note color, presence of moisture, and temperature of the skin. 6. Obtain a history of allergies to food or medicine. 7. Check vital signs, including pulse and respirations. 8. Obtain a list of current medications. 9. Inquire about the last tetanus shot. _____, _____, _____, _____, _____

Ans: 2, 3, 4, 5, 7 These would be appropriate for disaster triage. The other items are important and would be addressed when the staff has time and resources to collect the additional information. (Note: During nondisaster situations, it would be appropriate to include all items.) Focus: Prioritization

You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a UAP to get the crash cart. _____, _____, _____, _____, _____

Ans: 2, 4, 1, 3, 5 Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. (Use a pocket mask or bag-valve mask.) CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team is present. Focus: Prioritization

When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization

As the pediatric unit charge nurse, you are making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN/LVN? 1. 1-year-old with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant 2. 2-year-old with Wiskott-Aldrich syndrome who has orders for a platelet transfusion 3. 3-year-old who has chronic graft-versus-host disease and is incontinent of loose stools 4. 6-year-old who received chemotherapy a week ago and is admitted with increasing lethargy and a temperature of 101° F (38.3° C)

Ans: 3 LPN/LVN scope of practice includes care of patients with chronic and stable health problems, such as the patient with chronic graft-versus-host disease. Chemotherapy medications are considered high-alert medications and should be given by RNs who have received additional education in chemotherapy administration. Platelets and other blood products should be given by RNs. The 6-year-old patient has a history and clinical manifestations consistent with neutropenia and sepsis and should be assessed by an RN as quickly as possible. Focus: Assignment

You are caring for several children with cancer and are reviewing morning laboratory results for all of your patients. Which of these patient conditions combined with the indicated laboratory result causes you the greatest immediate concern? 1. Nausea and vomiting with a potassium level of 3.3 mEq/L 2. A nosebleed with a platelet count of 100,000/mm3 3. Fever with an absolute neutrophil count of 450/mm3 4. Fatigue with a hemoglobin level of 8 g/dL

Ans: 3 National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3. Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. Focus: Prioritization

In caring for a 3-year-old with pain, which assessment question would be the most useful? 1. "Can you point to the pain with one finger and tell me what that pain feels like inside of you?" 2. "If number 1 were a little pain and number 10 were a big pain, what number would your pain be?" 3. "The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" 4. "One chip is 'a little bit of hurt' and four chips are 'the most hurt.' How many chips would you take for your hurt?"

Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning, crying, etc.) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and the use of advanced vocabulary. Focus: Prioritization

When an unexpected death occurs in the ED, which task is most appropriate to delegate to the UAP? 1. Escorting the family to a place of privacy 2. Going with the organ donor specialist to talk to the family 3. Assisting with postmortem care 4. Helping the family to collect belongings

Ans: 3 Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Focus: Delegation

An anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? 1. Notify the physician immediately. 2. Administer supplemental oxygen. 3. Have the student breathe into a paper bag. 4. Obtain an order for an anxiolytic medication.

Ans: 3 The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified. Focus: Prioritization

An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse? 1. Trauma team 2. Triage 3. Ambulatory or fast-track clinic 4. Pediatric medicine team

Ans: 3 The fast-track clinic deals with clients in relatively stable condition. The triage, trauma, and pediatric medicine areas should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. Focus: Assignment

A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access.

Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization

You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/LVN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment

You are caring for a client with frostbite to the feet. Place the following interventions in the correct order. 1. Apply a loose, sterile, bulky dressing. 2. Give pain medication. 3. Remove the client from the cold environment. 4. Immerse the feet in warm water of 105° F to 115° F (40.6° C to 46.1° C). 5. Monitor for compartment syndrome. _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5 The client should be removed from the cold environment first, then the rewarming process can be initiated. It will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment. Focus: Prioritization

A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing. 7. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5, 6, 7 For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 5, 1 The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available. Focus: Prioritization

You are talking to a group of people about an industrial explosion in which many people were killed or injured. Which individual has the greatest risk for psychiatric difficulties, such as post-traumatic stress disorder, related to the incident? 1. Individual who repeatedly watched television coverage of the event 2. Person who recently learned that her son was killed in the incident 3. Individual who witnessed the death of a co-worker during the explosion 4. Person who was injured and trapped for several hours before rescue

Ans: 4 Any of these people may need or benefit from psychiatric counseling. Obviously, there will be variations in previous coping skills and support systems; however, a person who experienced a threat to his or her own life is at the greatest risk for psychiatric problems following a disaster incident. Focus: Prioritization

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? 1. ED physicians and charge nurses 2. Experienced RNs and experienced paramedics 3. RNs, LPNs/LVNs, and UAPs 4. At least one representative from each group of ED personnel

Ans: 4 At least one representative from each group should be included, because all employees are potential targets for violence in the ED. Focus: Assignment

. A 6-year-old who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is your best response to this behavior? 1. Remind the child that foods tasted good today and will help the body to get strong. 2. Allow the mother and child time alone to review and control the behavior. 3. Ask the mother to leave until the child can finish eating and then invite her back. 4. Explain to the mother that the behavior could be a normal expression of anger.

Ans: 4 Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress. Focus: Prioritization

An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP? 1. Reporting evidence of severe mucosal ulceration 2. Assisting the child in swishing and spitting an anesthetic mouthwash 3. Assessing the child's ability and willingness to drink through a straw 4. Helping the patient to eat a bland, moist, soft diet

Ans: 4 Helping the patient to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. Plain water or saline rinses are preferable if the child cannot gargle or spit out fluids. The RN should assess and administer oral preparations as needed. Focus: Delegation

An intoxicated client comes in with slurred speech, mild confusion, and uncooperative behavior. The client cannot provide a good history but admits to "drinking a few on the weekend." What is the priority nursing action for this client? 1. Obtain an order for determining blood alcohol level. 2. Contact the family to obtain additional history and baseline information. 3. Administer naloxone (Narcan) 2 to 4 mg as ordered. 4. Administer IV fluid with supplemental thiamine as ordered.

Ans: 4 The client has symptoms of alcohol abuse and there is a risk for Wernicke-Korsakoff syndrome, which is caused by a thiamine deficiency. Multiple drug abuse is not uncommon; however, the primary concern with an opiate overdose is respiratory depression, and the client does not show any respiratory distress or alterations in respiratory pattern. Additional information or the results of the blood alcohol testing are part of the total treatment plan but should not delay the immediate treatment. Focus: Prioritization

It is the summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs attention first? 1. Elderly person with reports of dizziness and syncope after standing in the sun for several hours to view a parade 2. Marathon runner who reports severe leg cramps and nausea, and shows tachycardia, diaphoresis, pallor, and weakness 3. Relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests tachypnea, hypotension, fatigue, and profuse diaphoresis 4. Homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

Ans: 4 The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The elderly client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures. Focus: Prioritization

The following clients come to the ED reporting acute abdominal pain. Prioritize them for care in order of the severity of their conditions. 1. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. 40-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week 4. 65-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour 5. 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 6. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night _____, _____, _____, _____, _____, _____

Ans: 4, 5, 2, 3, 1, 6 The client with a pulsating mass has an abdominal aneurysm that may rupture, and he may decompensate suddenly. The woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider. Focus: Prioritization

After emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function. 1. Obtain an order for a chest radiograph to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral. 5. Check exhaled carbon dioxide levels. _____, _____, _____, _____, _____

Ans: 5, 3, 4, 2, 1 Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the midepigastric area, tube placement must be corrected immediately. Securing the tube can be performed after these assessments are performed. Finally, radiographic study will verify and document correct placement. Focus: Prioritization

You are working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 minutes 2. Firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to the hands and forearms 4. Teenager with a crushed leg that is very swollen who is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. 12-year-old with wheezing and very labored respirations unrelieved by an asthma inhaler _____, _____, _____, _____, _____, _____

Ans: 6, 2, 4, 3, 5, 1 Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, because CPR efforts have been prolonged. Focus: Prioritization

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months Ms. C's self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to appropriately verbalize an appropriate diet and exercise plan. What is the priority nursing diagnosis? A. Imbalanced Nutrition: Less that Body Requirements B. Disturbed Body Image C. Risk for Situational Low Self-Esteem D. Ineffective Health Maintenance

B. Disturbed Body Image

A well-known celebrity is admitted to your unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response? A. Please be discreet and do not interrupt the work flow B. How did you find out that the patient was admitted to this unit? C. Please wait. I need to call the nursing supervisor about this request D I'm sorry; the patient has asked that only family be allowed to visit

B. How did you find out that the patient was admitted to this unit?

The team has to apply restraints to a combative patient in order to prevent harm to others or to self. Which action requires your intervention? A. Mental health assistant uses a quick-release knot B. MD secures the restraint to the side rail C. RN check the pulses distal to restraint D. LPN explains to the patient why he being restrained

B. MD secures the restraint to the side rail

You are interviewing a patient with suicidal ideations and a history of major depression. Which comment concerns you the most? A. I have had problems with depression most of my adult life B. My father and my brother both committed suicide C. My wife is having health problems and she relies on me D. I am afraid to kill myself, and I wished I had more courage

B. My father and my brother both committed suicide

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months For Ms. C, which route for delivery of nutrition and fluids will the health care team try first? A. NG B. PO C. IV D. Hypodermoclysis

B. PO

A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how ti prevent medication errors. A. Advise the pharmacy of any corrections as appropriate B. Recognize the "look-alike, sound-alike" drugs increase the chances of error C. Consult a medication book to verify the purpose of the drugs and generic and brand names D. Check the original medication order to verify what was prescribed E. Write an incident report, as appropriate, if you believe that a system error is occurring F. Call the MD for clarification of the order as appropriate

B. Recognize the "look-alike, sound-alike" drugs increase the chances of error D. Check the original medication order to verify what was prescribed C. Consult a medication book to verify the purpose of the drugs and generic and brand names F. Call the MD for clarification of the order as appropriate A. Advise the pharmacy of any corrections as appropriate E. Write an incident report, as appropriate, if you believe that a system error is occurring

An LPN complains to you that she is always assigned to the same patient with chronic depression. What should you do? A. Look at the assignment sheet and see if there is any way to switch assignments with another LPN B. Tell her to care for the patient today, but that you will remember the request for future assignments C. Remind her that continuity of care and patient-centered care are the primary goals D. Explain that patients with chronic conditions are more likely to fall under the LPN scope of practice

B. Tell her to care for the patient today, but that you will remember the request for future assignments

As the charge nurse, you are reviewing the assignment sheet for an acute psychiatric unit. Which experienced team member should be reassigned? A. Male LVN assigned to a male patient with chronic depression and excessive rumination B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa C. Female RN assigned to a newly admitted female patient who has command hallucination sand delusions of persecution D. Older female RN with medical-surgical experience assigned to a male patient with Alzheimer disease

B. Young male mental health assistant assigned to a female adolescent with anorexia nervosa

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions. A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000 B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

Which task can be assigned to a medical-surgical UAP who has been floated to the acute psychiatric unit? A. Performing one-to-one observation of a patient who is suicidal B. Assisting the OT to conduct a craft class C. Accompanying an elderly patient who wanders on a walk outside D. Assisting the medication nurse who is having problems with a patient

C. Accompanying an elderly patient who wanders on a walk outside

An elderly man was admitted for palliative care of terminal pancreatic cancer. The wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis if this sentinel event? (Select all that apply) A. The wife and all immediate family members B. Only the MD who discharged the patient C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient E. Only the RN who discharged the patient F. Any MD who has involved int eh care of this patient

C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient F. Any MD who has involved int eh care of this patient

There is a patient on the medical-surgical unit who has been there for several months. He is hostile, rude, and belligerent, and no one likes to interact with him. How should you handle the assignment? A. Rotate the assignment schedule so that no one has to care for him more than once or twice a week B. Pair a float nurse and a nursing student and assign the patient to that team because they will have a fresh perspective toward the patient C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions D. Assign yourself as primary caregiver sot hat you can role-model how patients should be treated

C. Identify two or three experienced nurses as primary caregivers and develop a plan that includes psychosocial interventions

Mr. J has a panic disorder and it appears that he is having some problems controlling his anxiety. Which symptoms concern you the most? A. His HR is increased and reports chest tightness B. He demonstrates tachypnea and carpopedal spasms C. He is pacing and pounding his fists together D. He is muttering to himself and is easily startled

C. He is pacing and pounding his fists together

You arrive home and find that the house of your neighbor (Jane) is on fire. A fireman is physically restraining her from running back into the house. What is the best response? A. Jane, come and sit in my house until this is over with B. Jane, calm down and let the fireman do his job C. Jane, look at me and hold my hand D. Jane, tell me why you are struggling so hard

C. Jane, look at me and hold my hand

Which behavior would be the most problematic and require vigilance to prevent danger to self or others? A. Avolition B. Echolalia C. Motor agitation D. Stupor

C. Motor agitation

A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He is being prescribed haloperidol. What is the priority action? A. Encourage him to look at you and stay with him until the spasms pass B. Place the patient on aspiration precautions until the spasms subside C. Obtain an order for IM or IV diphenhydramine D. Obtain an order for and administer an anti seizure medication

C. Obtain an order for IM or IV diphenhydramine

A patient comes in to the clinic with nausea, constipation, and "excruciating stomach pain." Over a period of several years, this patient has come in two or three times a month with the same report, but multiple diagnostic tests have consistently yielded negative results for physical disorders. What is the priority nursing intervention for this patient? A. Advocate for the patient to have a psychiatric consultation B. Ensure that the patient sees the same health care provider for continuity C. Perform a physical assessment to identify any physical abnormalities D. Assess for concurrent symptoms of depression or anxiety

C. Perform a physical assessment to identify any physical abnormalities

A patient with a diagnosis of hypochondriasis has made multiple clinic visits and undergone diagnostic tests for "cancer," with no evidence of organic disease. Today he declares, "I have a brain tumor. I can feel it growing. My appointment is tomorrow, but I can't wait!" What is the most therapeutic response? A. Present reality: "Sir, you have been seen many times in this clinic and had many diagnostic tests. The results have always been negative." B. Encourage expression of feelings: "Let me spend some time with you. Tell me about what you are feeling and why you think you have a brain tumor." C. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment." D. Respect the patients wishes: "Sir, sit down and I will make sure that you see the physician right away. Don't worry; we will take care of you."

C. Set boundaries: "Sir, I will take your VS, but then I am going to call your case manager so that you can discuss the scheduled appointment."

You are reviewing the principle of "least restrictive" intervention with the staff. Place the following intervention in the correct ascending order from the least restrictive to the most restrictive. A. Escort the patient to a quite room for a time out B. Restrain the patient's arms and legs with soft cloth restraints C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard E. Restrain the patient's upper extremities with wrist restraints F. Place the patient in an isolation room with a mental health assistant observing

C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard A. Escort the patient to a quite room for a time out F. Place the patient in an isolation room with a mental health assistant observing E. Restrain the patient's upper extremities with wrist restraints B. Restrain the patient's arms and legs with soft clothrestraints

A patient comes into the walk-in clinic and tells you that he wants to be admitted to alcohol rehabilitation program. Which question is the most important to ask? A. What made you decide to enter a program at this time? B. How much alcohol do you usually consume in a day? C. When was the last time your had a drink? D. Have you been in a rehabilitation program before?

C. When was the last time your had a drink?

Which patient should be assigned to a newly-graduated nurse who has just started on the unit? A. Patient who is frequently admitted for borderline personality disorder and suicidal gesture B. Patient admitted yesterday for disorganized schizophrenia and psychosis C. Patient newly admitted to determine differential diagnosis of depression, dementia, or delirium D. Patient newly diagnosed with major depression and rumination about loss and suicide

D. Patient newly diagnosed with major depression and rumination about loss and suicide

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months At this time, what is the primary collaborative goal for the treatment of Ms. C? A. Assist her to increase feelings of control B. Decrease power struggles over eating C. Resolve dysfunctional family roles D. Restore normal nutrition and weight

D. Restore normal nutrition and weight

You are caring for a patient in whom a conversation disorder was recently diagnosed. She is experiencing a sudden loss of vision after witnessing a violent fight between her husband and adult-age son. What is the priority therapeutic approach to use with this patient? A. Reassure her that her blindness is temporary and will resolve with time B. Gently point out that she seems to be able to see well enough to function independently C. Encourage expression of feelings and link emotional trauma to the blindness D. Teach ways to cope with blindness, such as methodically arranging personal items

D. Teach ways to cope with blindness, such as methodically arranging personal items

An adolescent girl is admitted to your medical-surgical unit for diagnostic evaluation and nutritional support related to anorexia nervosa. She is mildly dehydrated, her potassium is 3.5 and she has experienced weight loss of more than 25% within the past 3 months You find Ms. C in her room jogging in place and doing jumping jacks "for about the last 20 minutes." What is the best response to give at this time? A. You can of for a few more minutes, but then you will tell me why your are exercising B. If you continue to exercise like this, you are just going to have to eat more at mealtimes C. Stop jogging right now. This is unacceptable behavior and you will lose all privileges D. We have talked about exercise, any you agreed to reach your target weight goal first

D. We have talked about exercise, any you agreed to reach your target weight goal first

The ED is calling to report on a patient who will be admitted to your acute psychiatric unit. HE has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions and minor lacerations. What is the priority question that you should ask? A. When will the patient be transferred? B. Will a police officer be with him while he is on the unit? C. Why isn't the patient being admitted to the trauma unit? D. What is the patient's current mood and behavior?

D. What is the patient's current mood and behavior?

A patient diagnosed with paranoid schizophrenia tells you that "Dr. Smith has killed several other patients and now he is trying to kill me." What is the best response? A. I have worked here a long time. No one has died. You are safe here B. What has Dr. Smith done to make you think he would like to kill you? C. All of the staff, including Dr. Smith, are here to ensure your safety. D. Whenever you are concerned or nervous, talk to me or any of the nurses

D. Whenever you are concerned or nervous, talk to me or any of the nurses

You are the pediatric unit charge nurse working with a new RN. Which action by the new RN requires the most immediate action on your part? 1. Placing a child who has chemotherapy-induced neutropenia into a negative-pressure room 2. Wearing goggles to change the linens of a patient who has diarrhea caused by Clostridium difficile 3. Instructing UAPs to use an N95 respirator mask when caring for a child who has pertussis 4. Admitting a new patient with respiratory syncytial virus (RSV) infection to a room with another child who has RSV

child in a negative-airflow room will increase the likelihood of infection for this patient. Although private rooms are preferred for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients who are infected with the same microorganism. The use of an N95 respirator is not necessary for pertussis, and goggles are not needed for changing the linens of patients infected with C. difficile; however, these precautions do not increase risk to the patients. Focus: Prioritization

In the work setting, what is your primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? 1. Knowing the agency's emergency response plan 2. Being aware of the signs and symptoms of potential agents of bioterrorism 3. Knowing how and what to report to the Centers for Disease Control and Prevention (CDC) 4. Making ethical decisions about exposing self to potentially lethal substances

gives guidance that includes the roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of exposure to many agents will mimic common complaints, such as flulike symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self. Focus: Prioritization