Delegation questions for management final

At 8:30 am, the UAP reports that Ms. Q, with chronic hypertension, has a BP of 198/94 mm Hg. Which is the priority action, and who is the most appropriate person to accomplish this action at this time? 1. Assign the LPN/LVN to give Ms. Q's 9:00 am furosemide and enalapril now. 2. Instruct the UAP to get Ms. Q back into bed immediately. 3. Tell the UAP to recheck Ms. Q's BP every 15 minutes. 4. Send the LPN/LVN to recheck Ms. Q's BP to ensure that the reading is correct.

Ans: 1 Administering the patient's BP medications is aimed at correcting the problem and lowering the patient's BP. Getting the patient back into bed and reassessing the patient's BP are appropriate actions but do not focus on the problem of lowering the patient's BP. Focus: Supervision, Delegation, Assignment, Prioritization; Test Taking Tip: To answer a question like this, first the nurse must determine the problem; then the nurse must decide what is the best way to solve the problem. In this case, the problem is that the patient's BP is still fairly high. The best way to solve the problem is to administer medications that will lower the BP.

The nurse overhears the UAP talking to someone on the phone. The UAP says, "Yes, Mr. D is doing much better than when he first got here. I will tell him that you called, and I will give him your message." What will the nurse do first? 1. Ask the UAP about the phone conversation that was just overheard. 2. Remind the UAP that release of information is outside her scope of practice. 3. Report the UAP to the nurse manager for client privacy violation. 4. Give positive feedback for trying to help the client and the caller.

Ans: 1 First, the situation should be assessed to determine if a privacy violation has occurred. Client information should be released only to facilitate continuity of care (e.g., in a shift report) and only to those who are directly involved in the care. If Health Insurance Portability and Accountability Act (HIPAA) rules were violated, the incident would be reported to the nurse manager for potential complaints related to the UAP's actions and so that the UAP could receive the proper remediation. Giving positive feedback for sincere efforts to assist clients and families is appropriate, but guidelines must be recognized and followed. Focus: Supervision.

Which medications does the nurse anticipate including in the discharge teaching for Mr. S's self-management of gastritis? 1. H2-receptor antagonists, proton pump inhibitors, and antacids 2. Diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors 3. Mucolytics, expectorants, and nonopioid antitussives 4. HMG-CoA reductase inhibitors (statins) and bile-acid sequestrants

Ans: 1 H2-receptor antagonists, proton pump inhibitors, and antacids are typical medications used to manage gastritis and other gastrointestinal disorders that are aggravated by excessive gastric acid. Diuretics, beta- blockers, and ACE inhibitors would be used for hypertension. Mucolytics, expectorants, and nonopioid antitussives are used for symptom relief of allergic rhinitis, cough, or colds. HMG-CoA reductase inhibitors (commonly referred to as statins) and bile-acid sequestrants are used for cholesterol management. Focus: Prioritization.

The HCP orders a STAT blood transfusion. In the event of an emergency, a type-specific non-cross-matched blood product could be used. Which blood product could be used in this case? 1. O negative 2. AB negative 3. AB positive 4. A negative

Ans: 1 In a medical emergency, the patient can receive O-negative blood. An antibody reaction could result if type A or B blood is administered without typing and cross matching. Focus: Prioritization.

Mr. R tells the student nurse that when he walks for only a block or two, he experiences discomfort that is burning and cramping and that is so painful that it makes him stop. What is best way for the student to document this finding? 1. Intermittent claudication 2. Rest pain 3. Dependent rubor 4. Arterial ulcer

Ans: 1 Most patients with PAD seek medical attention for a classic leg pain known as intermittent claudication (a term derived from a word meaning "to limp"). Usually they can walk only a certain distance before discomfort (e.g., cramping or burning muscular pain) forces them to stop. The pain stops with rest. When patients resume walking, they can walk the same distance before it returns. Thus, the pain is considered reproducible. As the disease progresses, they can walk only shorter and shorter distances before pain recurs. Focus: Prioritization.

What does the nurse anticipate the HCP will order for the initial fluid replacement? 1. Normal saline (0.9% sodium chloride) 2. Half-strength saline (0.45% sodium chloride) 3. 5% dextrose in water and half-strength saline 4. Normal saline with potassium chloride

Ans: 1 Normal saline (0.9% sodium chloride) is the first fluid used to correct dehydration in most adults with diabetic ketoacidosis. Half-strength saline (0.45% sodium chloride) can be used for children and adults at risk for volume overload. Potassium supplements are added within 1 to 2 hours after starting insulin. Solutions of 5% dextrose are added to the therapy when the blood glucose level approaches 250 mg/dL (13.9 mmol/L). Focus:Prioritization.

Which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Repeating measurement of vital signs 2. Gathering equipment for nasogastric (NG) tube insertion 3. Obtaining the blood glucose level every 2 hours 4. Offering ice chips or small sips of water

Ans: 1 Repeating vital sign measurements falls within the scope of the UAP's abilities. The UAP (with training) can obtain blood glucose levels and report them; however, there is no indication that blood glucose level should be checked every 2 hours. Gathering certain types of equipment can be delegated; however, for NG tube insertion, the UAP would need an itemized list. The UAP should not be instructed to give ice chips or sips of water. It is likely that the HCP will order oral food/fluid restrictions because of vomiting and to facilitate decompression of the stomach and for possible diagnostic testing. Focus: Delegation.

Ms. A has a nursing concern of increased risk for injury. Which action will the RN delegate to the UAP? 1. Assisting the patient with morning care and repositioning in bed 2. Monitoring the patient's daily international normalized ratio 3. Checking the patient every 4 hours for signs of bleeding 4. Teaching the patient to call for assistance when getting out of bed

Ans: 1 The UAP's scope of practice and education include actions related to assisting patients with activities of daily living, such as morning care and repositioning in bed. Monitoring, assessing, and providing instructions for the patient require additional education and skills and are part of the RN's scope of practice. Focus: Delegation, Supervision.

the arterial blood gas results for Mr. D are: pH: 7.25 PaO2 97 PaCO2 25 HCO3 19 What physical assessment finding is most likely to accompany these laboratory results? 1. Kussmaul respirations 2. Dilated pupils 3. Increased urination 4. Elevated blood pressure

Ans: 1 The arterial blood gas results indicate metabolic acidosis. The pH is low (reference range, 7.35-7.45). Bicarbonate level is low (reference range, 21- 28 mEq/L [21-28 mmol/L]). PaO2 is normal because gas exchange is not impaired in metabolic acidosis. Paco2 is decreased because the deep and rapid Kussmaul respirations are the body's attempt to lower the pH by blowing off carbon dioxide. Focus: Prioritization.

Ms. B develops diaphoresis, an increased heart rate (124 beats/min), and tremors. She also reports an increasing headache. Which action should the nurse take first? 1. Check the fingerstick glucose level. 2. Check the serum potassium level. 3. Place the patient on a cardiac monitor. 4. Decrease IV fluids to 100 mL/hr.

Ans: 1 The manifestations the patient has developed are classic signs of hypoglycemia, a complication of adrenal gland hypofunction. The nurse should check the patient's glucose level first. If it is low, the patient should receive some form of glucose, most likely dextrose 50% IV. Focus: Prioritization.

All of these interventions for Mr. S are prescribed by the HCP. Which action should the RN assign to the LPN/LVN? 1. Insert a urinary catheter. 2. Administer morphine sulfate 2 mg IV push. 3. Place a second IV saline lock line. 4. Measure vital signs every 15 minutes.

Ans: 1 The patient having surgery for an AAA repair may need a urinary catheter inserted to keep the bladder empty and deflated. LPN/LVN educational preparation includes inserting urinary catheters. In some states, LPN/LVNs can insert IV catheters and administer IV drugs, but this is not true of all states and facilities. To perform these actions, the LPN/LVN would need additional education and training. Check local, state, and facility policies. IV morphine is a high-alert drug, and giving these drugs to unstable patients is best done by an experienced RN. The UAP could be delegated to measure the patient's vital signs, with instructions from the nurse about which findings to report (e.g., increased BP or heart rate). Focus: Delegation, Supervision.

The UAP informs the nurse that Ms. B's blood pressure is now 84/50 mm Hg. Which prescribed action by the HCP would the nurse implement first? 1. Infuse normal saline at 250 mL/hr. 2. Type and cross-match for 2 units of packed red blood cells. 3. Insert a second large-bore IV catheter. 4. Administer prednisone 10 mg PO.

Ans: 1 The patient is hypotensive and most likely hypovolemic. Because the patient already has an IV line, the IV fluids should be started first to address the primary problem. The second IV line and typing and cross matching need to be accomplished rapidly, and the blood sample may be drawn at the same time that the second IV line is inserted. The patient needs cortisol replacement, but with nausea and vomiting present, the oral route is not the best option and an IV form of the drug should be considered. Focus: Prioritization, Delegation; Test Taking Tip: A question like this asks the nurse to prioritize what action must be taken first. To best answer, consider what is most life threatening to the patient. In this case, the threat is severe hypovolemia and severe hypotension, which can be life threatening.

The nurse suspects that Mr. S may be at risk for alcohol withdrawal effects. What is an early manifestation? 1. Startles easily 2. Paranoid delusions 3. Slurred speech 4. Grand mal seizure

Ans: 1 Watch for signs of neurologic irritability (e.g., psychological [anxiety, jumpiness, or nervousness] and physical [fine tremors, tachycardia, diaphoresis]). Delusions and seizure are later signs. Slurred speech is more frequently associated with alcohol intoxication. Focus: Prioritization; Test Taking Tip: In studying for the NCLEX Examination, make note of the early signs and symptoms of disease processes. Detecting early symptoms is an important part of ensuring safe care.

Ms. L is a 59-year-old woman who is admitted after experiencing intermittent episodes of high blood pressure accompanied by headaches, diaphoresis, and chest pain. She tells the admitting nurse that she gets frightened and feels a "sense of doom" when these episodes occur. The endocrinologist has ordered hospitalization to rule out pheochromocytoma. Which assessment action should the nurse avoid when admitting Ms. L? 1. Palpating the patient's abdomen 2. Checking the patient's extremity reflexes 3. Testing the pupillary reaction to light 4. Measuring baseline weight with the patient standing

Ans: 1 When a patient with possible pheochromocytoma is assessed, the abdomen should not be palpated because this action could cause a sudden release of catecholamines and severe hypertension. None of the other assessments should have an adverse effect on this patient. Focus: Prioritization.

Which factor reported by Ms. H to the nurse supports the diagnosis of Cushing disease? 1. Cessation of menses at age 33 years 2. Increased craving for salty foods 3. Weight loss of 25 lb 4. Nausea, diarrhea, and loss of appetite

Ans: 1 Women with hypercortisolism (Cushing disease) may report a history of early cessation of menses. Increased androgen production can interrupt the normal hormone feedback mechanism for the ovary, which decreases the production of estrogens and progesterone and results in oligomenorrhea (scant or infrequent menses). Focus: Prioritization.

The nurse is selecting personal protective equipment (PPE) to don before inserting the NG tube. Which factors will the nurse consider before making the selection? Select all that apply. 1. Facility policies for procedures 2. Likelihood of exposure to blood and body fluids 3. Patient's ability and willingness to cooperate 4. Own skill level and proficiency at procedure 5. Patient's health history and medical conditions 6. Availability of PPE at the bedside or on the unit

Ans: 1, 2, 3, 4, 5 The facility should have policies for procedures. For example, gloves, a gown, and an eye shield might be part of the protocol. (Note to student: You may see nurses only wearing gloves for NG tube insertion; this may or may not be a violation of their facility policy.) The likelihood of exposure to blood or body fluids is increased by patient behaviors, such as pulling the tube out or thrashing movements and by nurse's skill level (e.g., unskilled attempts increase gagging, vomiting, coughing, and sneezing; repeated attempts increase saliva, tears, and mucus production). The patient's health history (e.g., tuberculosis or other respiratory disorders) may prompt the nurse to don a filter mask. For Mr. S, the nurse may opt to wear shoe covers because he reports vomiting blood. The availability of PPE should not be a deciding factor. In the case of NG tube insertion, the urgency does not outweigh the time it would take to obtain the proper equipment to maintain personal safety. Focus: Prioritization.

The nurse is preparing a teaching plan for Ms. C, who has Raynaud disease. Which key points should be included? Select all that apply. 1. "Avoid exposure to cold by wearing warm clothes." 2. "Nifedipine will help decrease and relieve your symptoms." 3. "Keep your home at a comfortably warm temperature." 4. "The problems you experience are caused by vasospasms." 5. "Stress reduction techniques can help prevent symptoms." 6. "Warm beverages such as hot coffee and tea will help decrease symptoms."

Ans: 1, 2, 3, 4, 5 The underlying pathophysiology of Raynaud disease is vasospasm of the arterioles and arteries of the upper and lower extremities, usually unilaterally. Patients with this disorder should avoid caffeinated beverages. All of the other teaching points are appropriate to share with a patient with Raynaud disease. Focus: Prioritization.

Ms. A returns from her diagnostic test with a diagnosis of DVT, which is to be treated medically. Which interventions and actions does the nurse expect the HCP to prescribe? Select all that apply. 1. Bed rest 2. Elevation of the left leg 3. Compression stockings 4. Daily massage of the left calf 5. Continue subcutaneous LMWH 6. Check daily international normalized ratio (INR) levels

Ans: 1, 2, 3, 5 Bed rest, elevation of the affected extremity, use of compression stockings, and administration of LMWH are strategies to prevent complications of DVT such as pulmonary embolus (PE). However, the nurse should be aware that some research indicates that ambulation for a patient with DVT does not worsen the risk for PE. Massage of the affected extremity increases the risk for PE. Checking INR or prothrombin time levels is not required when a patient is prescribed a LMWH drug such as enoxaparin or dalteparin. Focus: Prioritization.

Mr. S and his wife ask for privacy so that they can talk. Later, when the nurse returns to check on him, the NG tube is on the floor, there is a strong odor of alcohol on Mr. S's breath, and he appears very drowsy. What should the nurse do first? 1. Politely ask the wife to leave and call security to check the room for illicit substances. 2. Assess the patient's mental status and ask what happened to the NG tube. 3. Explain that his behavior is unacceptable and counterproductive to his therapy. 4. Reinsert an NG tube and call the HCP for an order for a STAT blood alcohol test.

Ans: 2 First assess the patient and try to determine exactly what occurred. Based on the assessment findings, the other options may be used. Focus: Prioritization.

Which tasks are appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Measuring and reporting Mr. D's vital signs every 15 minutes 2. Checking and reporting Mr. D's blood glucose level 3. Bagging and labeling Mr. D's belongings 4. Updating the roommate regarding Mr. D's status 5. Measuring emesis and cleaning the basin as needed 6. Obtaining an infusion pump from the supply room

Ans: 1, 2, 3, 5, 6 Checking vital signs, bagging up belongings, obtaining equipment, measuring output, and assisting with hygienic needs (e.g., cleaning emesis basin) are within the scope of duties for the UAP. Checking blood glucose level is accomplished with a fingerstick. UAPs, particularly in specialty areas such as the ED, will usually receive training to do this task, but this may vary from state to state and facility to facility. Information should not be released by the UAP because of confidentiality issues. Release of information to friends and family varies by facility policies, but typically the RN would escort the family in to see the client as soon as possible. Focus: Delegation.

Which serious complications may result from alcohol withdrawal delirium? Select all that apply. 1. Myocardial infarction 2. Electrolyte imbalance 3. Aspiration pneumonia 4. Anaphylaxis 5. Sepsis 6. Suicide

Ans: 1, 2, 3, 5, 6 Death can occur from myocardial infarction, fat embolism, peripheral vascular disease, aspiration pneumonia, electrolyte imbalance, sepsis, or suicide. Anaphylaxis would not ordinarily occur unless the patient was allergic to one of the treatments (e.g., drug allergy). Focus: Prioritization.

The nurse is caring for a male patient with hyperaldosteronism who is not a candidate for adrenalectomy surgery. Which interventions would the nurse expect the HCP to prescribe? Select all that apply. 1. Administer oral spironolactone. 2. Monitor for and report dry mouth, thirst, and lethargy. 3. Avoid or limit potassium-rich foods. 4. Glucocorticoid replacement therapy. 5. Instruct patient to report gynecomastia or erectile dysfunction. 6. Acetaminophen for headaches.

Ans: 1, 2, 3, 5, 6 When surgery for hyperaldosteronism (adrenalectomy) cannot be performed, spironolactone (a potassium-sparing diuretic) therapy is continued to control hypokalemia and hypertension. Patients are advised to avoid potassium supplements and foods rich in potassium. Hyponatremia can occur with spironolactone therapy, and the nurse should monitor for and report manifestations such as dry mouth, thirst, lethargy, and drowsiness. Headaches are a common manifestation of hyperaldosteronism, so acetaminophen may be prescribed as a treatment. Side effects of spironolactone should also be taught to the patient. Examples include gynecomastia and erectile dysfunction, as well as diarrhea, hives, hirsutism, and amenorrhea. Focus: Prioritization.

Which person(s) should be allowed to have access to Mr. D's medical records? Select all that apply. 1. ED provider who is managing Mr. D in the ED 2. ED nurse who is caring for Mr. D in the ED 3. ICU who will receive Mr. D upon transfer to ICU 4. Nursing student who wants to write a paper about diabetic ketoacidosis 5. Roommate of Mr. D who is a medical student and a family friend 6. Discharge nurse who will provide instructions and referrals at discharge

Ans: 1, 2, 3, 6 For protection of medical information, access is restricted to staff who are involved in the direct care of the client. Friends and family do not have access to medical records without specific consent of the client. Students are allowed some access to medical records but only if they are involved in the direct care of clients. Focus: Supervision.

A computed tomography (CT) scan reveals that Mr. S has an aneurysm that is 7.5 cm in diameter. Which preoperative care tasks should the RN delegate to the nursing student under supervision? Select all that apply. 1. Teaching Mr. S about coughing and deep breathing 2. Assessing all peripheral pulses for postoperative comparison 3. Administering bowel preparation magnesium sulfate orally 4. Drawing blood for the laboratory for typing and screening 5. Discussing the reasons for the surgery 6. Pack Mr. S's belongings in preparation for postop transfer to the surgical intensive care unit (SICU)

Ans: 1, 2, 3, 6 The nursing student should be able to provide teaching about simple concepts such as coughing and taking deep breaths, perform simple assessments such as measuring peripheral pulses, and administer oral medications, all under the supervision of the nurse. The student could also be assigned to pack Mr. S's personal belongings for postoperative transfer to the SICU. The nurse or someone with special training in performing venipuncture should draw blood for the laboratory tests. The patient may have questions about the surgery, so discussion about the reasons for surgery should carried out by an experienced nurse. The nurse could mentor the student by allowing the student to be present during the discussion. Focus: Delegation, Supervision.

The HCP prescribes NG tube insertion. The nurse places the patient in a high Fowler position, provides an emesis basin, and inspects the nostrils for patency. List the correct order of actions for this procedure. 1. Measure tube from the tip of nose, to the earlobe, to the xiphoid process. 2. Insert the lubricated tube into the most patent nostril. 3. Ask the patient to sip water as the tube is passed. 4. When tube is just above the oropharynx, instruct the patient to bend the chin forward. 5. Check pH to verify tube placement; obtain an order for a radiograph.

Ans: 1, 2, 4, 3, 5 The patient is placed in high Fowler position to prevent aspiration. The length is measured for tip placement into the stomach. Gently insert the tube into the most patent nostril. When the tube is just above the oropharynx, have the patient tip the chin down and then gently advance the tube. When the tip reaches the posterior pharynx, have the patient sip water. Swallowing closes the epiglottis and helps to prevent tracheal intubation. Checking placement is essential before instilling any fluids or medications. Focus: Prioritization.

An insulin infusion is ordered for Mr. D to begin at 0.1 units/kg/hr. Mr. D weighs 155 lb. The pharmacy delivers a premixed bag of 100 units of regular insulin in 100 mL of normal saline. Nurse A has calculated the infusion pump setting as 10 mL/hr. What will the charge nurse do next? 1. Tell Nurse A to obtain a pump and start the infusion as calculated. 2. Advise Nurse A to recalculate the infusion rate. 3. Call the HCP and ask for the exact pump setting to be clarified. 4. Allow Nurse A to administer the infusion using her own judgment.

Ans: 2 Her calculations are incorrect. The pump should be set at 7 mL/hr. 155/2.2 = 70.4 kg; round to 70 kg70 kg/x units : 1 kg/0.1 units = 7 units100 units/100 mL = 1 unit/1 mL : 7 units/x mL = 7 mL Calling the HCP is inappropriate; the nurse is responsible for calculating the pump settings. Insulin is a high-alert drug, and calculations must always be double-checked. When discrepancies are discovered, the source of the error must be determined and corrected. Focus: Prioritization, Supervision; Test Taking Tip: When weight is given in pounds and medications or fluids are prescribed per kilogram, pounds must first be converted to kilograms.

Mr. D, a 19-year-old premed student, has been brought to the emergency department (ED) by his roommate, who is a medical student and a family friend. Mr. D reports abdominal pain, polyuria, vomiting, and thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He has deep, rapid respirations, and there is a fruity odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for finals." He is alert and conversant but is having trouble focusing on the nurse's questions. Mr. D's vital signs and blood glucose are as follows: glucose: 685 BP: 100/60 HR: 120 RR: 32 Temp: 100.8 To clarify pertinent data, what questions are appropriate to ask Mr. D? Select all that apply. 1. "When did your symptoms start?" 2. "How many times have you vomited?"3. "When were you diagnosed with diabetes?" 4. "Where does your abdomen hurt?" 5. "Did you take any insulin today?" 6. "Do you have any allergies?"

Ans: 1, 2, 4, 5, 6 The onset of symptoms and the amount of fluid loss help to determine acuity. Pain assessment of the abdomen should be performed to obtain a baseline; his pain is probably associated with diabetic ketoacidosis, but infection or trauma could also be factors. If Mr. D had insulin today, this could affect treatment. Information about allergies should be obtained for all clients regardless of the presenting problem. Knowing when the client was diagnosed with diabetes does not alter the priority actions at this point. Focus: Prioritization.

The UAP reports to the RN that Mr. Z, with Buerger disease, awoke from a nap reporting pain in the arch of his left foot. Which actions should the RN take? Select all that apply. 1. Assess the patient's pain. 2. Administer prescribed nifedipine. 3. Place the patient in a supine position and elevate the foot. 4. Lower the room temperature. 5. Instruct the patient to avoid cold temperatures. 6. Check the patient's toes for any signs of gangrene or ulcers.

Ans: 1, 2, 5, 6 Placing the patient in a supine position and elevating his foot places the extremity above heart level, which slows arterial blood flow to the foot and may lead to increased pain. A patient with Buerger disease should avoid cold and should wear warm clothes. All of the other actions are appropriate for a patient with Buerger disease. Checking the digits for ulcers or gangrene is essential for a patient with this condition. Focus: Prioritization.

The RN is preparing a health teaching plan for Ms. Q. Which key aspects would be included? Select all that apply. 1. Weight reduction strategies 2. Avoidance of tobacco and caffeine 3. Drink no more than three alcohol-containing drinks per day 4. Exercise 6 to 7 days a week for at least 1 hour 5. Use of relaxation techniques to decrease stress 6. Restrict dietary sodium as recommended by the American Heart Association (AHA)

Ans: 1, 2, 5, 6 The patient is overweight, so weight loss is appropriate as are sodium restriction, avoidance of tobacco and caffeine, and relaxation techniques to reduce stress. A female patient should not consume more than one alcoholic drink per day. Exercise is a good strategy but should be started slowly and is recommended for 3 to 4 days per week for about 40 minutes per day according to AHA guidelines. Focus: Prioritization.

Ms. H had a complete adrenalectomy, and the nurse is preparing to teach her about cortisol replacement therapy. Which key points should be included in the teaching plan? Select all that apply. 1. "Take your medication in divided doses, with the first dose in the morning and the second dose between 4:00 and 6:00 pm." 2. "Take your medications on an empty stomach to facilitate absorption." 3. "Weigh yourself daily using the same scale and wearing the same amount of clothes." 4. "Never skip a dose of medication." 5. "Call your doctor if you experience persistent nausea, severe diarrhea, or fever." 6. "Report any rapid weight gain, round face, fluid retention, or swelling to your doctor."

Ans: 1, 3, 4, 5, 6 Cortisol replacement drugs should be taken with meals or snacks because the patient can develop gastrointestinal irritation when the drugs (e.g., cortisone, hydrocortisone, prednisone, fludrocortisone) are taken on an empty stomach. All of the other teaching points are appropriate. Focus: Prioritization.

In caring for Mr. D, the nurse is vigilant for signs and symptoms of hypokalemia. What signs and symptoms should the nurse watch for? Select all that apply. 1. Fatigue 2. Cold, clammy skin 3. Muscle weakness 4. Hypotension 5. Weak pulse 6. Shallow respirations

Ans: 1, 3, 4, 5, 6 Other signs and symptoms of hypokalemia include paralytic ileus, nausea and vomiting, abdominal distention, confusion, and irritability. Cold, clammy skin is more associated with hypoglycemia or decreased perfusion. Focus: Prioritization.

The RN is supervising a nursing student who will assess Ms. H. Which findings will the RN teach the student nurse to expect in a patient with Cushing disease? Select all that apply. 1. Truncal obesity 2. Weight loss 3. Bruising 4. Hypertension 5. Thickened skin 6. Dependent edema

Ans: 1, 3, 4, 6 A patient with Cushing disease typically has paperlike thin skin and weight gain as a result of an increase in total body fat caused by slow turnover of plasma fatty acids. Weight loss is to be expected in a patient with hypocortisolism (e.g., Addison disease). The other findings are typical of a patient with Cushing disease. Focus: Supervision, Prioritization.

The RN has assigned the student nurse to teach Mr. R about foot care related to his PAD. Which teaching points would the RN instruct the student nurse to include? Select all that apply. 1. "Keep your feet clean by washing with a mild soap in room temperature water." 2. "Wear comfortable, well-fitting shoes except when at home." 3. "Cut the toenails straight across and keep them clean and filed." 4. "Apply lubricating lotion to feet to prevent dried and cracked skin." 5. "Use a heating pad to keep your feet warm, especially at night." 6. "Avoid extended pressure on your feet and ankles."

Ans: 1, 3, 4, 6 Comfortable, well-fitting shoes should be worn at all times, even in the home, and heating pads should not be applied to the feet. The other four teaching points are appropriate when teaching a patient with PAD how to care for his or her feet. Focus: Prioritization.

The nurse is reviewing the potassium values that were obtained when Mr. D first arrived in the ED. Which serum potassium level is most concerning? 1. 3.5 mEq/L (3.5 mmol/L) 2. 2 mEq/L (2 mmol/L) 3. 5.8 mEq/L (5.8 mmol/L) 4. 6 mEq/L (6 mmol/L)

Ans: 2 Initially in clients with diabetic ketoacidosis, the serum potassium level is expected to be within normal limits or elevated; regardless of the laboratory value, there is an overall potassium deficit. After insulin therapy, hypokalemia is expected as the potassium shifts back into the cells; therefore, if the potassium level is initially low, it will be even lower after therapy. Focus: Prioritization; Test Taking Tip: Potassium imbalances can cause lethal cardiac dysthymias. It is likely that the NCLEX® Examination will include questions about potassium levels. It is worthwhile to memorize the reference range

Mr. S has recovered so the RN and student nurse are preparing for discharge teaching. Which key points would be included in the teaching plan? Select all that apply. 1. Stair climbing is initially strictly limited. 2. A bedside commode is required even if there is a first-floor bathroom. 3. Heavy lifting (usually more than 15 to 20 lb [6.8 to 9.1 kg]) is avoided. 4. Use caution for activities that involve pulling, pushing, or straining. 5. Expect to experience abdominal fullness, chest pain, and shortness of breath. 6. Driving a car will be restricted for several weeks.

Ans: 1, 3, 4, 6 When a patient is discharged to home, stair climbing may be restricted initially, and he or she may need a bedside commode if the bathroom is inaccessible. Teach the patient who has undergone surgical repair about activity restrictions, wound care, and pain management. Patients may not perform activities that involve lifting heavy objects (usually more than 15 to 20 lb [6.8 to 9.1 kg]) for 6 to 12 weeks postoperatively. Advise them to use caution for activities that involve pulling, pushing, or straining. Most patients are restricted from driving a car for several weeks after discharge. Teach patients receiving treatment for hypertension about the importance of continuing to take prescribed drugs. Instruct them about the signs and symptoms that must promptly be reported to the HCP, which include abdominal fullness or pain, chest or back pain, shortness of breath, or difficulty swallowing or hoarseness. Focus: Prioritization.

Which laboratory values would the nurse expect to find for Ms. H? Select all that apply. 1. Elevated serum cortisol level 2. Decreased serum sodium level 3. Elevated serum glucose level 4. Decreased lymphocyte count 5. Increased serum calcium level 6. Decreased urine androgen level

Ans: 1, 3, 4, A patient with Cushing disease (hypercortisolism) would have lab values that include increased serum, salivary, and urinary cortisol levels. Other lab value expectations include increased blood glucose level, decreased lymphocyte count, increased serum sodium, and decreased serum calcium. In a 24-hour urine collection, there would also be increased levels of cortisol and androgens. Focus: Prioritization.

A nursing concern of risk for infection related to immunosuppression and inadequate primary defenses has been identified for Ms. H. Which nursing care actions should the RN delegate to the UAP? Select all that apply. 1. Providing the patient with a soft toothbrush 2. Instructing the patient to avoid activities that can result in skin trauma 3. Reminding the patient to change positions in bed every 2 hours 4. Assessing the patient's skin for reddened areas, excoriation, and edema 5. Ensuring that the patient has tissues and a bag for disposal of used tissues 6. Teaching the patient to avoid crowded areas and people with cold symptoms

Ans: 1, 3, 5 The UAP can provide articles for self-care (e.g., toothbrushes, tissues, small trash bags) and reinforce what the RN has already taught the patient. The UAP can also remind the patient about changing positions once the nurse has instructed the patient to do this. Instructing and assessing are within the scope of practice of the professional nurse. Focus: Delegation, Supervision.

What precautions should the RN instruct the student nurse to be sure to teach the patient while taking nifedipine? Select all that apply. 1. "Side effects of this drug can include facial flushing and headaches." 2. "Be sure to check your respiratory rate before taking this drug." 3. "When you get out of bed, do so slowly because of the potential for hypotension." 4. "You should be sure to consume foods rich in potassium such as bananas." 5. "Avoid grapefruit and grapefruit juice while taking this drug." 6. "Take over-the-counter calcium tablets every day while on this drug."

Ans: 1, 3, 5 While they are taking vasodilating drugs, such as nifedipine, teach patients about side effects such as facial flushing, hypotension, and headaches. Also teach patient taking nifedipine to avoid grapefruit and grapefruit juice to prevent severe adverse effects, including possible death. Nifedipine is a calcium channel blocker, and these drugs do not affect respirations or serum potassium and calcium levels. Focus: Prioritization.

What are three key components of emergency management of a patient with adrenocortical insufficiency? Select all that apply. 1. Hormone replacement with hydrocortisone 2. Administration of potassium-sparing diuretics 3. Hypoglycemia management with IV glucose 4. Subcutaneous insulin before meals and at bedtime 5. Hyperkalemia management with a potassium-binding and potassium- excreting resin 6. Fluid restrictions to maintain body weight and prevent edema

Ans: 1, 3, 5 With acute adrenal insufficiency, the nurse must be aware of three major areas of concern for treatment, which are hormone replacement, hyperkalemia management, and hypoglycemia management. Focus:Prioritization.

Which tasks can the nurse direct an experienced UAP to perform to facilitate Mr. D's transfer to the ICU? Select all that apply. 1. Giving Mr. D's roommate directions to the ICU waiting room 2. Independently transporting Mr. D to the ICU 3. Collecting and organizing the chart and laboratory reports 4. Obtaining a portable oxygen tank and cardiac monitor 5. Connecting Mr. D's ECG leads to the portable cardiac monitor 6. Obtaining the last set of vital sign values

Ans: 1, 4, 5, 6 The UAP can direct family and visitors to appropriate waiting areas, obtain equipment, and measure vital signs. An RN or HCP should accompany Mr. D to the ICU; the UAP can help but should not independently transport clients to the ICU. The unit secretary usually prepares the papers, but the RN is responsible for ensuring that everything is in order. In specialty areas such as the ED, UAPs may receive additional training to connect clients' cardiac leads to the cardiac monitor; however, the RN is responsible for assessing the cardiac rhythm. Focus: Delegation.

Which patient care action would the nurse assign to an experienced LPN/LVN? 1. Interpret Ms. B's lab values. 2. Change Ms. B's dressing to her right side. 3. Prepare a nursing care plan for Ms. B. 4. Administer IV promethazine for nausea.

Ans: 2 Interpreting lab values, preparing care plans, and administering IV drugs are within the scope of practice for the professional RN. In some states, an LPN/LVN may administer some IV drugs with additional training (although administration of IV drugs to unstable patients is best done by RN staff who have education and scope of practice to evaluate patient response). Be sure to check the scope of practice in your state and at your facility. Changing a simple dressing is within the scope of practice for an LPN/LVN, although the RN would want to be sure to assess the wound site. Focus: Assignment, Supervision.

As the charge nurse, which patients would be appropriate to assign to a newly graduated RN who has just completed orientation to the unit? Select all that apply. 1. Ms. L with pheochromocytoma, who is scheduled for adrenalectomy and needs preoperative teaching 2. Ms. B with adrenal gland hypofunction, whose blood pressure is dropping and who is experiencing Addisonian crisis 3. Ms. H with Cushing disease, who is very anxious and fearful about her scheduled adrenal surgery 4. Mr. J with hyperaldosteronism, whose current serum potassium level is 3.2 mEq/L (3.2 mmol/L) 5. Mr. M with rule-out Addison disease, who is newly admitted with muscle weakness, weight loss, and hypotension 6. Ms. A, who was admitted 2 days ago to rule out hyperaldosteronism

Ans: 1, 4, 6 The new graduate RN who has just completed orientation should be assigned patients whose conditions are relatively stable and not complex. The new graduate should be familiar with the adrenal surgery after completing her orientation and should be able to provide any teaching the patient needs. The patient with a low potassium level will need some form of potassium supplementation, which the new nurse should be able to administer. The patient who was admitted 2 days ago to rule out hyperaldosteronism would be stable and not in need of complex nursing care. Patients with significant changes would benefit from care by experienced RNs. The patient in Addisonian crisis and the fearful, anxious patient would also benefit from being cared for by an experienced nurse. The newly admitted patient may have many questions and would also benefit from care with and experienced RN. Focus: Assignment.

The nurse is talking to Mr. S about self-care measures that he should take to prevent recurrence of acute gastritis. For Mr. S, what is the most important point to emphasize? 1. Eat a well-balanced diet that includes protein and carbohydrates. 2. Avoid drinking excessive amounts of alcoholic beverages. 3. Use caution in taking aspirin, other nonsteroidal anti-inflammatory drugs, and corticosteroids. 4. Drink at least eight glasses of noncaffeinated fluid each day.

Ans: 2 All the teaching points are relevant for self-management of gastritis, but based on the patient's history and the possible use of alcohol even in the hospital, it would appear that Mr. S may have the greatest difficulty in avoiding alcohol consumption. Focus: Prioritization.

The ED nurse is trying to call a report to the ICU but is told, "We were not notified about the admission." What should the nurse do first? 1. Call the admissions office supervisor to resolve the delay. 2. Ask the unit secretary to call the admissions office now. 3. Write an incident report; a delay violates Joint Commission guidelines. 4. Ask the ICU nurse to take the report regardless of the clerical omission.

Ans: 2 Ask the secretary to correct the omission by calling the admissions office right away. If the ED nurse has a good relationship with the ICU nurse, she or he will probably take the report; however, the ED nurse retains responsibility for the client's care until the admission procedure and transfer are completed. After the client's needs are met, the nurse could investigate the situation to determine if the admitting process can be improved. Writing an incident report would be appropriate, because The Joint Commission has a CORE measure that addresses waiting times in the ED. Focus: Prioritization, Supervision.

The ED nurse is reviewing the intensive care unit (ICU) admission orders. There is a prescription for an IV potassium infusion. Related specifically to the potassium infusion, which information would the ICU nurse be most interested in knowing? 1. Mental status and cognition have improved with therapy. 2. Urinary output is 60 mL/hr, and urine is a clear yellow color. 3. Admitting blood pressure (BP) was 100/60 mm Hg; last BP is 125/76 mm Hg. 4. There are two existing peripheral IV lines, and both flush easily.

Ans: 2 Before potassium is administered, it is important to know that the kidneys are functioning. The other information is important but has less relevance to the potassium infusion. Focus: Prioritization.

The nurse is talking to Mr. S about his alcohol consumption. Which statement represents the most common defense mechanism that is used by people who have problems with alcoholism? 1. "You would drink, too, if you were married to my wife." 2. "My wife and I have a couple of beers after work. It's no big deal." 3. "If you think I drink a lot, you should see my wife put it away." 4. "I would rather talk to my wife about this situation when I get home."

Ans: 2 Denial is the most common defense mechanism seen among substance abusers. Option 1 represents rationalization, or giving reasons for behavior. Option 3 represents projection, which is a transfer of unacceptable behavior onto others. Option 4 represents suppression, which is a conscious awareness of and avoidance of dealing with the problem. Focus: Prioritization.

After receiving her morning dose of enalapril, Ms. Q states that she experienced dizziness when getting out of bed to use the bathroom. What is the RN's priority action? 1. Ask the patient about presence of a nagging cough. 2. Check orthostatic BPs lying, sitting, and standing. 3. Assess the patient for signs of allergy such are rashes. 4. Check the patient's bladder for urinary retention.

Ans: 2 Enalapril is an angiotensin-converting enzyme (ACE) inhibitor drug. These drugs commonly cause dizziness and can increase the patient's risk for falls. The priority action at this time is to check orthostatic BPs. The nurse would also teach the patient to move slowly from lying to sitting and standing positions and to call for help when getting out of bed. A nagging cough is a side effect of these drugs, and the nurse would want to know about this, but it is not urgent at this time. ACE inhibitors do not cause fluid retention, and dizziness is not a sign of allergy to the drug. Focus: Prioritization.

The nurse sees that Mr. S's international normalized ratio (INR) value is 2.5. Which action should the nurse take next? 1. No action should be taken because this is an expected finding related to gastrointestinal bleeding. 2. HCP should be notified for possible prescription of fresh-frozen plasma (FFP). 3. Laboratory findings should be reevaluated at completion of treatments. 4. The blood bank should be contacted for additional units of packed red blood cells.

Ans: 2 FFP can be used to replace the coagulation factors. This patient has a history of alcohol abuse and may have liver disease, and the liver produces prothrombin and other blood clotting factors. The INR should be 1.1 or below. A higher than normal INR indicates that blood clotting will be slower than expected. For anticoagulation therapy, the therapeutic range is 2.0 to 3.5 (depending on the purpose of therapy, such as deep vein thrombosis prophylaxis or prosthetic valve prophylaxis). Focus: Prioritization.

Ms. A, whose calf is swollen from peripheral venous disease, asks why she must have an injection of low-molecular-weight heparin (LMWH). What is the RN's best response? 1. "LMWH will dissolve the clots in your legs." 2. "LMWH will prevent new clots from forming." 3. "LMWH will thin your blood and slow down clotting." 4. "LMWH will prevent the clots from migrating to your lungs."

Ans: 2 LMWH can be used to treat or prevent DVT. When used for treatment, LMWH prevents new blood clots from forming and prevents existing clots from getting larger. This allows the normal body systems to dissolve the clots that are already formed. This also reduces the risk of pulmonary embolism. The drug does not "thin" a patient's blood or dissolve an existing clot. Focus: Prioritization.

Ms. C asks the student nurse how the drug nifedipine will help with her Raynaud disease. What is the student nurse's best response? 1. "It will slow down your heart rate and decrease your pain." 2. "It will cause vasodilation and decrease the vasospasms that cause your pain." 3. "It will lower your blood pressure and decrease the workload of your heart." 4. "It will help keep your fluid and electrolytes in balance to decrease your pain."

Ans: 2 Nifedipine is calcium channel blocker and a vasodilating drug that will decrease the painful vasospasms that occur and cause the symptoms of Raynaud disease. Nifedipine will decrease heart rate and BP and may impact fluid and electrolytes, but vasodilation is the therapeutic effect when nifedipine is used to treat Raynaud disease. Focus: Prioritization.

The nurse is preparing to transfer Mr. D to the ICU and notices the cardiac monitor display. Which ECG pattern is cause for greatest concern? 1. sinus brady 2. Vtach 3. afib 4. artifact

Ans: 2 Option 2 shows ventricular tachycardia, which can be associated with an electrolyte imbalance, such as hypokalemia. This is a significant cause of death in clients with diabetic ketoacidosis. Option 1 shows normal sinus rhythm; note that one P wave normally precedes every QRS complex. Option 3 shows atrial fibrillation (AF). Clients with AF should be assessed for decreased cardiac output. Clients may tolerate AF, but this finding should be reported to the HCP because there is an increased risk for emboli. Option 4 shows artifact, which is usually caused by loose leads or client movement. Focus: Prioritization; Test Taking Tip: Rhythm interpretation takes a lot of practice, but ventricular dysrhythmias are among the most dangerous. Develop ability to differentiate normal from abnormal ECG findings and then focus study on the most serious cardiac dysrhythmias.

When Mr. S is assessed, which assessment technique would the RN instruct the student nurse to avoid? 1. Auscultating the abdomen for a bruit 2. Palpating the abdomen to detect a mass 3. Observing the abdomen for a pulsation 4. Performing a pain assessment

Ans: 2 Palpation of the abdomen must be avoided because the mass may be tender, and there is risk of causing a rupture. Auscultating for a bruit and observing for pulsation are appropriate assessment techniques. Pain assessment is appropriate because such patients typically experience steady, gnawing abdominal, flank, or back pain that is unaffected by movement and may last for hours or days. Focus: Supervision, Prioritization; Test Taking Tip: To answer a question like this, the nurse must be aware of assessment techniques that can be dangerous and cause injury to the patient. In this case, palpating the abdomen could cause rupture of the AAA with severe bleeding and risk for death.

In providing nursing care for Ms. L, which action should the nurse delegate to the UAP? 1. Working with the patient to identify stressful situations that may lead to a hypertensive crisis 2. Reminding the patient not to smoke, drink caffeinated beverages, or change positions suddenly 3. Assessing the patient's hydration status and reporting manifestations of dehydration or fluid overload 4. Telling the patient to limit activity and remain in a calm, restful environment during headaches

Ans: 2 The UAP should remind the patient about elements of the care regimen that the nurse has already taught the patient. Assessing, instructing, and identifying stressful situations that may trigger a hypertensive crisis require additional education and skill appropriate to the scope of practice of the professional RN. Focus: Delegation, Supervision.

After the SBAR report is completed, Mr. S is prepared for transport to his room on the medical-surgical unit. He is greeted by the medical-surgical nurse who will assume responsibility for this care. He is tired but also anxious to see the HCP and to be informed about the plan of care so that he can "get out of here as soon as possible." The HCP recommends that Mr. S have an EGD to stop the bleeding. The nurse sees that the HCP has written on the order sheet: "Have patient sign consent form for EGD." What should the nurse do first? 1. Assess the patient's understanding of the procedure, explain the risks, and obtain the patient's signature if he appears to understand. 2. Call the HCP and politely state that obtaining the patient's consent for a procedure is outside the scope of nursing practice. 3. Ask the charge nurse to clarify if HCPs would typically write this type of order and, if so, how it should be handled. 4. Decline to follow the order, write an incident report, and call the unit manager to report the HCP for writing an inappropriate order.

Ans: 2 The best response is to politely and firmly state that the action is outside the scope of nursing practice. Support from the charge nurse would be nice, but if the HCPs typically expect the nurses to have the consent form signed, then the nurse still has to decide whether to go along with the unit norms or to act according to own ethical beliefs and personal understanding of scope of practice. Assessing the patient's understanding is always useful, and if the patient does not understand, then the HCP would have to return to speak with the patient. Declining to follow the order, writing an incident report, and calling the unit manager are viable options, but trying to directly resolve the issue with the HCP would expedite the patient's care. Focus: Prioritization.

The health care provider (HCP) has ordered several immediate (STAT) interventions for Mr. S. Which task would the nurse perform first? 1. Draw blood for complete blood count, and type and crossmatch. 2. Establish two peripheral IV lines with 16-gauge catheters. 3. Insert an NG tube and observe gastric contents. 4. Repeat the vital signs and apply pulse oximeter.

Ans: 2 The priority for this patient is fluid loss and potential for hypovolemic shock, so the nurse would insert two large-bore peripheral IVs. (Note to student: In clinical, you may see experienced nurses drawing blood from newly inserted peripheral IVs catheters before IV fluid is started; however, drawing blood is not the priority concern.) NG tube is an important part of the therapy for this patient, but it is not considered a life-preserving measure. Repeat vital signs and application of the pulse oximeter are needed. This can be delegated, but the UAP must be instructed to report all values so that the nurse can monitor trends. Focus: Prioritization.

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

Ans: 2 To expedite the STAT order, the nurse would draw the specimen. The other options will only delay the STAT order. After Mr. S's condition is stabilized, tracking down the cause of the error will help prevent recurrences. Focus: Prioritization, Supervision.

Mr. S needs to be admitted to the medical-surgical unit for observation and continued management of acute gastritis with bleeding. The ED nurse is calling the receiving nurse on the medical-surgical unit. Prioritize the following information according to the SBAR (situation, background, assessment, recommendation) format. 1. "Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours." 2. "This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding." 3. "Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an esophagogastroduodenoscopy (EGD)." 4. "Mr. S is currently alert and oriented but is anxious. The last vital signs are blood pressure, 140/80 mm Hg; pulse, 90 beats/min; respirations, 24 breaths/min; and pulse oximetry reading, 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 mL/hr in each IV line. He received one unit of packed red blood cells and one unit of fresh-frozen plasma. He has a NG tube in the right nares. Initially, there was small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction."

Ans: 2, 1, 4, 3 Situation: Identify self, location, and purpose of communication. Background: Include relevant information that provides context for the problems or concerns. Assessment: Include current data that are directly related to care. Recommendations: Suggest actions that are needed for follow up and highlight issues that might evolve over time. Focus: Prioritization.

At noon, the LPN/LVN goes to cardiopulmonary resuscitation (CPR) training and is replaced by an RN floated from the postanesthesia care unit (PACU). Which patients should the team leader assign to the PACU RN? Select all that apply. 1. Ms. C, who needs teaching about how to avoid exacerbation of symptoms for her condition 2. Mr. Z, who still needs information about available smoking cessation programs 3. Ms. Q, whose BP is still elevated and needs frequent BP monitoring 4. Ms. A, who is worried because the HCP just told her she has a deep vein thrombosis (DVT) 5. Mr. S, who reports that his back pain is getting much worse 6. Mr. R, whose left great toe arterial ulcer continues to be painful even after the student nurse administered his pain medication

Ans: 2, 3 Mr. Z is in stable condition, and the PACU nurse could begin educating him about smoking cessation. The PACU nurse is skilled at BP monitoring and would have no difficulty meeting Ms. Q's needs for care. Ms. A and Ms. C need the care of a nurse who is experienced in caring for and educating patients with peripheral vascular disease to teach and answer questions. Mr. S's worsening back pain may indicate expansion of his AAA, and he should be assigned to an experienced nurse. Mr. R's care should continue to be assigned to the nurse who has been caring for him since the beginning of the shift and is familiar with his case. He will need frequent pain assessments and may need additional pain interventions. Focus: Assignment.

Which actions will the nurse delegate to the UAP in providing care for Ms. B? Select all that apply. 1. Encouraging the patient to take in adequate oral fluids 2. Measuring vital signs every 15 minutes 3. Recording intake and output accurately every hour 4. Getting a baseline weight to guide therapy 5. Administering oral antinausea medication 6. Assisting the patient up to the bathroom

Ans: 2, 3, 4, 6 The patient is experiencing nausea and vomiting, so oral fluids are not appropriate at this time. The UAP can take frequent vital sign measurements, record intake and output, weigh the patient, and assist the patient to the bathroom. The nurse should instruct the UAP about which variations in vital signs must be reported. Administration of medications is appropriate to the scope of practice of licensed nurses. This could be assigned to an LPN/LVN. Focus: Delegation, Assignment, Supervision.

The RN is the team leader working with a licensed practical nurse/licensed vocational nurse (LPN/LVN), an experienced unlicensed assistive personnel (UAP), and a senior nursing student to provide nursing care for six patients in a vascular surgery unit. The patients are as follows: • Ms. C, a 38-year-old woman with systemic lupus erythematosus who has developed symptoms of Raynaud phenomenon. She reports numbness, tingling, and cold in her wrists and hands bilaterally • Mr. R, a 57-year-old man with chronic peripheral arterial disease who reports severe pain due to an arterial ulcer on his left great toe • Mr. Z, a 44-year-old man with Buerger disease who wants to discuss enrolling in a smoking cessation program • Ms. Q, a 69-year-old overweight woman with chronic hypertension whose blood pressure (BP) at the end of the night shift was 208/96 mm Hg • Mr. S, a 72-year-old man for whom an abdominal aortic aneurysm (AAA) must be ruled out, and who is reporting severe, worsening back pain • Ms. A, a 65-year-old woman with peripheral venous disease and left calf swelling who is scheduled for venous duplex ultrasonography this morning The nurse understands that which conditions are at increased risk for development when a patient has hypertension? Select all that apply. 1. Gastric ulcers 2. Kidney disease 3. Stroke (brain attack) 4. Emphysema 5. Myocardial infarction 6. Parkinson disease

Ans: 2, 3, 5 Hypertension, or high BP, is the most common health problem seen in primary care settings and can cause stroke, myocardial infarction (heart attack), kidney failure, and death if not treated early and effectively.Focus: Prioritization.

The RN is teaching the student nurse who is caring for Mr. R how to differentiate peripheral arterial from peripheral venous ulcers. Which characteristics would the RN stress are indications of arterial ulcers? Select all that apply. 1. Claudication is absent. 2. Rest pain is present. 3. Ulcers occur at ends of and between toes. 4. Brown pigmentation is often present. 5. Pallor is seen when raising the extremity, and dependent rubor is seen when lowering it. 6. Treatment involves damp-to-dry dressing changes.

Ans: 2, 3, 5 With PAD ulcers, claudication, and rest pain are present. Ulcers are deep and occur at the ends of or between the toes. Brown pigmentation occurs with venous ulcers, not arterial. Arterial ulcers are pale when elevated but show dependent rubor when lowered. Treatment of arterial ulcers involves surgical revascularization; for venous ulcers treatment includes long-term wound care, including unna boot application and damp-to-dry dressings. Focus: Prioritization.

In the initial emergency care for Mr. D, which HCP prescriptions would the nurse question? Select all that apply. 1. Start a peripheral IV line with a large-bore catheter. 2. Obtain a urine specimen with a small-bore straight catheter. 3. Administer regular insulin subcutaneously. 4. Maintain the client in a semi-Fowler position. 5. Initiate continuous electrocardiographic (ECG) monitoring. 6. Encourage intake of oral fluids as tolerated.

Ans: 2, 3, 6 The nurse should question the insertion of a straight catheter to obtain a urine specimen for a client who is alert and able to use a urinal or commode because there is currently an emphasis to reduce catheter- associated urinary tract infections. (Note to student: The HCP may order an indwelling catheter for critically ill clients because hourly urinary output reflects cardiac output and kidney perfusion.) Subcutaneous insulin is not absorbed fast enough and is inappropriate for emergency situations. (IV insulin would be appropriate.) The client is likely to be on food and fluid restrictions until the vomiting resolves. In addition, intra-abdominal conditions (e.g., appendicitis) should be ruled out before allowing oral fluids. At least one peripheral IV is needed for fluid replacement during the acute period. Semi-Fowler position is preferred to reduce the risk for aspiration. ECG monitoring is appropriate for all critical care clients. In this case, electrolyte imbalances increase the risk for dysrhythmias. Focus: Prioritization; Test Taking Tip: If the nurse is questioning the HCP, the plan of care, or the interventions, the question is asking you to identify the incorrect options.

The nurse is performing additional assessment and history taking for Mr. S. Which finding should be immediately reported to the HCP? 1. Melena stools 2. History of nonsteroidal anti-inflammatory drug use 3. Tense and rigid abdomen 4. Risk factors for human immunodeficiency virus

Ans: 3 A tense, rigid abdomen could signal perforation, peritonitis, or a worsening hemorrhage. The other findings are relevant but are less immediately urgent. Focus: Prioritization.

Mr. D says to the nurse, "Please don't call my mother. If she knows I'm in the hospital, she'll make me quit school and move back home. I know I messed up, but I really don't want to move back in with my parents." What is the best therapeutic communication response? 1. "None of the staff will say anything, but you should tell her yourself." 2. "Your mom loves you, and she is just concerned about your well-being." 3. "It sounds like you want to be independent and responsible for yourself." 4. "You are an adult, and you have a right to make your own decisions."

Ans: 3 Acknowledging and reflecting underlying feelings is therapeutic. Options 1 and 4 give unsolicited advice, and option 2 is a platitude that is not supported by firsthand knowledge of the mother-son relationship. Focus:Prioritization; Test Taking Tip: To provide a therapeutic answer, first determine what the client is trying to express; then determine the need. In this case, the nurse selects reflection to help Mr. D to expand on his emotional concerns.

The RN is reviewing the lipid profile for Ms. Q, who has been diagnosed with atherosclerosis. Which finding is of most concern? 1. Total serum cholesterol level of 220 mg/dL 2. Triglyceride level of 165 mg/dL 3. Low-density lipoprotein (LDL) cholesterol level of 155 mg/dL 4. High-density lipoprotein (HDL) cholesterol level of 38 mg/dL

Ans: 3 Although all of these lipid profile findings are abnormal, the LDL cholesterol ("bad cholesterol") level is much too high. A desirable LDL cholesterol level is less than 130 mg/dL for a healthy person or less than 70 mg/dL for a patient with cardiovascular disease (CVD) or diabetes. The national guidelines for cholesterol management focus on lowering LDL as the primary goal. The other results are of concern and should be attended to, but they are not as excessively abnormal as is the LDL level. Focus: Prioritization.

Which nursing assessment finding supports the possible diagnosis of DVT for Ms. A? 1. Spasm of her left calf 2. Shortness of breath 3. Unilateral swelling of her left calf 4. Sharp chest pain

Ans: 3 Classic signs and symptoms of DVT include calf or groin tenderness or pain and sudden onset of unilateral swelling of the leg. Shortness of breath and sharp chest pain are signs of the complication of pulmonary embolus in which a clot dislodges and travels to the pulmonary circulation. Focus: Prioritization.

After the NG tube is inserted, which assessment finding is cause for greatest concern? 1. The patient reports that the tube is irritating nose and throat feels sore. 2. Gastric contents have a coffee-ground appearance. 3. The patient demonstrates coughing and cannot speak clearly. 4. Gastric fluid is bright red and has small clots.

Ans: 3 Coughing and an inability to speak or difficulty in speaking clearly suggests that the tube has been inserted into the trachea. The tube should be removed immediately. Bright red blood with clots indicates active bleeding; this finding verifies the patient's initial history and should be immediately reported to the HCP so that therapy can begin. Coffee-ground appearance of gastric contents indicates old blood; this finding should also be reported but is less urgent. Irritation of the throat and around the nares is commonly reported. Perform hygiene around the nares as needed; irritation of the throat usually subsides, but an anesthetic throat spray may offer some temporary relief. Focus: Prioritization.

The HCP orders a 24-hour urine collection for vanillylmandelic acid (VMA), metanephrine, and catecholamine testing. Which instruction given to Ms. L by a nursing student would cause the nurse to intervene? 1. "You will be on a special diet for 2 to 3 days before the urine collection for this test." 2. "You should not drink caffeinated beverages or eat citrus fruits, bananas, or chocolate." 3. "You will take your usual medications, including the aspirin and the beta- blocker for your high blood pressure." 4. "In 2 to 3 days, you will begin the 24-hour urine collection after discarding the first void in the morning."

Ans: 3 During the 3- to 4-day VMA testing period, medications usually withheld include aspirin and antihypertensive agents. Beta-blockers are avoided because these drugs may cause a rebound rise in blood pressure. All of the other instructions are appropriate for this diagnostic test. Focus: Delegation, Supervision.

For the initial emergency care of Mr. D, what is the priority collaborative treatment goal? 1. Correction of hyperglycemia with IV insulin 2. Correction of acid-base imbalance using IV bicarbonate 3. Correction of fluid imbalance with IV fluids 4. Correction of potassium imbalance with IV potassium

Ans: 3 Fluid replacement is the first priority. Furthermore, the fluid dilutes the glucose levels, which helps to correct osmotic diuresis. The serum potassium level may not reflect the total body potassium. Hypokalemia is anticipated because of loss of potassium in the urine; however, potassium levels are closely monitored, and supplements are given accordingly. Insulin is given to slowly lower the blood glucose level, but this occurs after rehydration and evaluation of potassium levels. Bicarbonate is rarely given unless acidosis becomes life threatening; acidosis usually resolves with fluids, electrolytes, and insulin. Focus: Prioritization.

The RN is teaching a UAP about fluid retention when a patient such as Ms. H is diagnosed with Cushing disease. Which method does the RN instruct the UAP is best for indicating fluid retention? 1. Strict intake and output measures 2. Measuring urine specific gravity 3. Checking daily weights with the same scale 4. Comparing ankle swelling on a day by day basis

Ans: 3 Fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention. The best and most accurate way to detect fluid retention is to weigh the patient on a daily basis. Weigh the patient at the same time daily (before breakfast) using the same scale. Have the patient wear the same type of clothing for each weight check. Focus: Prioritization, Supervision, Delegation.

As the nurse is getting ready to transfer Mr. D to the ICU, the unit secretary hands the nurse the last blood glucose result, which is 150 mg/dL(8.33 mmol/L). What should the nurse do first? 1. Proceed with the transfer because blood glucose is trending toward the normal value. 2. Stop the insulin infusion, proceed with the transfer, and inform the ICU nurse on arrival. 3. Immediately notify the HCP and anticipate an order for IV fluid of 10% glucose. 4. Slow the insulin infusion and obtain an order to have the blood glucose redrawn.

Ans: 3 Hyperglycemia should be reduced gradually, and in the critical phase if the blood glucose falls below 250 mg/dL (13.9 mmol/L), 10% IV glucose solution is added, and the insulin is continued. Focus: Prioritization.

During the EGD procedure, Mr. S is given midazolam hydrochloride. What is the priority assessment related to this medication? 1. Monitor for cardiac dysrhythmias. 2. Assess for adequate relief of pain. 3. Monitor depth and rate of respirations. 4. Assess for relief of nausea and vomiting.

Ans: 3 Midazolam hydrochloride is commonly used for procedures requiring moderate sedation. Depression of depth and rate of respirations is a possible side effect. Focus: Prioritization.

What is the priority nursing concept to consider in planning the initial emergency interventions for Mr. D? 1. Gas exchange 2. Acid-base imbalance 3. Fluid and electrolyte imbalance 4. Adherence

Ans: 3 Mr. D is severely dehydrated and is at risk for hypovolemic shock and electrolyte imbalance. Although he is demonstrating Kussmaul respirations, this breathing pattern is the body's attempt to compensate for the acidosis. Acid-base imbalance is usually corrected by administering fluids, electrolytes, and insulin. Adherence is relevant but can be addressed after Mr. D's condition is stabilized. Focus: Prioritization.

The nurse is most likely to seek out which laboratory results to determine if there are untoward effects associated with vomiting, NG suction, or lavage? 1. White blood cell (WBC) counts 2. Hematocrit and hemoglobin 3. Serum electrolytes 4. Blood urea nitrogen (BUN) and serum creatinine

Ans: 3 The nurse always monitors all laboratory results, but vomiting, NG suction, and lavage (if it is ordered) are most likely to cause fluid and electrolyte imbalances. Fluid loss can cause hemoconcentration and cause artificially elevated levels for hematocrit, hemoglobin, and BUN. BUN is generally more affected by fluid loss than serum creatinine. The WBC count could be elevated because of stress, inflammation, or infection. Focus: Prioritization; Test Taking Tip: Use concept-based learning to recognize that vomiting, suctioning, and lavage share a common effect: altering fluid and electrolyte balance.

The ED nurse is preparing the SBAR (situation, background, assessment, recommendation) report before the ICU transfer. Which detail would be most important to include as background to ensure that Mr. D's right to privacy is maintained? 1. Client is a premed student who was studying for finals, and this interfered with his normal routine. 2. Roommate is a medical student and a family friend, and he brought Mr. D to the ED. 3. Client has not informed family that he is in the hospital, and he is reluctant to allow notification. 4. Client arrived alert and conversant, but he initially he had trouble focusing on questions.

Ans: 3 The nursing staff is likely to encourage the client to inform his family, but the ICU staff should be aware that he is resistant to notifying his family. (Note to student: Policies vary greatly, but some facilities do not allow staff to confirm or deny the admission or discharge of clients. In such cases, the client may be asked to provide a list of people that can visit or phone in.) Focus: Prioritization.

Ms. B is a 68-year-old woman admitted to the medical unit through the emergency department (ED) after being hit in the abdomen by an automobile while walking home. An 18-gauge IV catheter was inserted in the left forearm, and normal saline was started at 100 mL/hr. ED vital signs were blood pressure, 118/80 mm Hg; heart rate, 82 beats/min; respiratory rate, 26 breaths/min; and oral temperature, 98.4°F (36.9°C). Ms. B has a small dressing to a wound on her right side with a small amount of serosanguinous drainage present. The unlicensed assistive personnel (UAP) checks her vital signs while she is lying down with the head of her bed elevated and reports that the patient's blood pressure is now 92/58 mm Hg, and she describes feelings of weakness, fatigue, and abdominal pain. When the nurse assesses Ms. B, it is also discovered that she is nauseated and has just vomited 560 mL of greenish fluid and undigested food from breakfast. Laboratory values from the ED were as follows: aldosterone 3ng/dL Cortisol 2mcg/dL Potassium 5.2 Sodium 136 Based on the assessment of Ms. B, what is the nurse's first action? 1. Administer an antiemetic. 2. Measure abdominal girth. 3. Notify the health care provider (HCP). 4. Start another IV and hang another bag of normal saline.

Ans: 3 The patient's signs and symptoms indicate possible adrenal crisis (Addisonian crisis), or acute adrenocortical insufficiency, a life-threatening event in which the need for cortisol and aldosterone is greater than the available supply. It often occurs in response to a stressful event (e.g., surgery, trauma, severe infection), especially when the adrenal hormone output is already reduced. The other actions are important and will likely be implemented rapidly because a common cause of acute adrenal gland hypofunction is hemorrhage, but the first priority is that the HCP must be notified immediately. Focus: Prioritization.

Mr. S continues to report severe back pain. On assessment, the RN detects a bruit and notices pulsation in the left lower quadrant. What is the nurse's best first action? 1. Measure abdominal girth. 2. Place the patient in a high sitting position. 3. Notify the patient's health care provider (HCP). 4. Administer pain medication.

Ans: 3 The patient's symptoms and the nurse's assessment findings indicate an AAA that may be expanding, and this places the patient at risk for rupture. This is an urgent situation, and the HCP should be notified immediately. The nurse should not place the patient in a high sitting position because this may place added pressure on the patient's AAA, leading to rupture. Focus: Prioritization.

Mr. S, a 50-year-old man, has driven himself to the emergency department (ED) after vomiting bright red blood twice within the past 6 hours. He arrives alert andoriented × 3 but appears anxious. He is able to provide only a vague history but admits to drinking "a few" last weekend. He knows that he is "supposed to stop drinking" and takes "something for his stomach," but he cannot recall the name of the medication. He reports intermittent dizziness and fatigue that has been worsening over the past 2 days. His skin is dry and pale. His abdomen is slightly distended. He reports pain (4 on a scale of 1 to 10) in the midepigastric area. Capillary refill is prolonged, blood pressure is 140/90 mm Hg, pulse rate is 110 beats/min, respiratory rate is 24 breaths/min, and temperature is 99°F (37.2°C). What is the priority nursing concept to consider in planning emergency interventions for Mr. S? 1. Pain 2. Anxiety 3. Fluid and electrolyte balance 4. Adherence

Ans: 3 Vomiting of bright red blood is a sign of active bleeding. The patient's physical assessment findings and vital sign values are indicative of physiologic compensation for blood loss. Pain, anxiety, and adherence can be addressed after the patient is stabilized. Focus: Prioritization.

A nursing concern of poor peripheral perfusion has been identified for Ms. C. Which actions should the RN delegate to the experienced UAP? Select all that apply. 1. Assessing for peripheral pulses, edema, capillary refill, and skin temperature 2. Inspecting the skin for the presence of tissue breakdown and arterial ulcers 3. Reminding the patient to perform active range-of-motion exercises as tolerated 4. Reinforcing with the patient the need to take in adequate fluids during the day 5. Assisting the patient to sit at the bedside and then transfer to a chair 6. Administering daily oral doses of nifedipine

Ans: 3, 4, 5 The UAP can remind about and reinforce nursing care measures that have already been taught by the RN. Assisting patients to get out of bed is also within the scope of practice for UAPs. Assessing and inspecting the patient require additional education and skills appropriate to the RN's scope of practice. Administering oral medications should be done by licensed nurses. Focus: Delegation, Supervision.

Cushing disease is diagnosed in Ms. H because of hypercortisolism (increased secretion of cortisol), and she is scheduled for an adrenalectomy. Which preoperative actions should the nurse assign to the LPN/LVN? Select all that apply. 1. Assessing the patient's cardiac rhythm 2. Reviewing the patient's laboratory results 3. Checking the patient's fingerstick glucose results 4. Administering insulin on a sliding scale as needed 5. Discussing goals and outcomes of care with the patient 6. Giving the patient oral preoperative medications

Ans: 3, 4, 6 The educational preparation of the LPN/LVN includes fingerstick glucose monitoring and administering oral and subcutaneous medications. Assessing cardiac rhythms and reviewing laboratory results require additional education and skill and are appropriate to the RN's scope of practice. Focus: Assignment, Supervision.

Ms. H is admitted to the acute medical-surgical unit for a workup for Cushing disease. Which vital sign value reported to the RN by the UAP is of most concern for a patient with Cushing disease (hypercortisolism)? 1. Heart rate of 102 beats/min 2. Respiratory rate of 26 breaths/min 3. Blood pressure of 156/88 mm Hg 4. Oral temperature of 101.8°F (38.8°C)

Ans: 4 A patient with hypercortisolism (Cushing disease) is immunosuppressed because excess cortisol reduces the number of circulating lymphocytes and inhibits production of cytokines and inflammatory chemicals such as histamine. These patients are at greater risk for infection. Therefore, it is essential that the nurse be told about any temperature elevation with this patient. Focus: Prioritization, Supervision, Delegation; Test Taking Tip: To answer a question such as this one, the nurse needs to understand basic pathophysiology and then apply that knowledge to the patient situation. In this case, the patient is immunosuppressed and is at risk for infection, so the nurse would be extra alert for any signs of infection.

Which member of the health care team is demonstrating a behavior that is an example of a barrier to interprofessional collaboration? 1. ICU nurse asks the ED nurse to hold the client for 30 minutes until shift change is over. 2. Admitting endocrinology specialist directs the ED nurse to change the rate of all IV fluids. 3. ED provider reviews the triage nurse's admission notes before completing the provider summary. 4. ED nurse tells the charge nurse that the UAP failed to record vital signs in a timely fashion.

Ans: 4 Before going straight to the charge nurse, the nurse should speak directly to the UAP about the vital signs to problem solve and find a solution. This action builds trust and team building. The ICU nurse and the ED nurse are negotiating, which is fundamental to collaboration. For clients with diabetic ketoacidosis, fluids, rates of fluids, and medications are continuously adjusted according to the client's condition. By reading the nurse's notes, the ED provider demonstrates respect and trust that the nurse has gathered valuable information that should be included in the overall summary of care. Focus: Supervision.

After the EGD procedure, Mr. S returns to the medical-surgical unit. He is drowsy but readily arouses to light stimuli. His vital signs are blood pressure, 110/74 beats/min; pulse, 82 beats/min; respirations, 20 breaths/min; and temperature, 99°F (37.2°C). What is the priority intervention? 1. Offer cool oral fluids for sore throat. 2. Raise the side rails of the bed. 3. Apply a small ice pack to the periorbital area. 4. Assess the presence of the gag reflex.

Ans: 4 During the EGD procedure, a local anesthetic is sprayed into the throat. This makes the passage of the tube less uncomfortable for the patient; however, it also depresses the gag reflex. Food and fluids should be held until the gag reflex returns to reduce the risk of aspiration. A sore throat is expected for a few days and is treated with throat lozenges and cool fluids. The side rails are up during the recovery period but are generally considered as a form of restraints. HCP must prescribe restraints for use on the medical- surgical unit. Periorbital bruising may occur in a few patients but should resolve spontaneously after several days. Focus: Prioritization; Test Taking Tip: Generally, the priorities for postprocedure care for invasive procedures are based on the ABCs (airway, breathing, and circulation). In this case, assessing for the gag reflex is part of airway management.

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

Ans: 4 Even if the L&D nurse is employed by the hospital, only staff members who provide direct care should have access to medical records and patient information. It is inappropriate to invite the L&D nurse to visit the patient. There should be some investigation as to how the L&D nurse found out that the patient was in the ED. If an ED staff member is giving out information about patients, that employee needs to be reminded of the consequences. There should also be some report on the behavior of the L&D nurse. Possibly, more safeguards are needed for computer access to records. The L&D nurse also needs to be reminded of the consequences of obtaining these medical records. Possibly, her or his license could be revoked or suspended or have sanctions placed on it. Focus: Prioritization.

The HCP instructs the nurse to give 1 L of IV fluid over the next hour. The available IV pump delivers fluid in mL/hr and allows three digits for programming the flow rate. What should the nurse do first? 1. Try to find a pump that will accurately deliver the fluid. 2. Program the IV pump for 1 L/hr and start the infusion. 3. Ask the HCP to revise the rate to accommodate the available equipment. 4. Program the IV pump for 999 mL/hr and start the infusion.

Ans: 4 Many pumps only allow 3 digits for programming flow, so the nurse knows to use the available IV pump and program the rate to 999 mL/hr. It would not be possible to change the pump to deliver in L/hr. Focus:Prioritization.

The nurse has completed the triage assessment and history taking. Now what is the priority action? 1. Page the ED health care provider (HCP) to come to triage. 2. Call the client's parents for permission to treat. 3. Notify the client's primary HCP. 4. Take the client immediately to a treatment room.

Ans: 4 Mr. D should be taken to a treatment room, where evaluation and treatment can begin immediately. Paging the ED provider to come to the triage area is not necessary unless the client becomes unresponsive in the triage area. Calling the parents is not necessary because Mr. D is old enough to provide consent for himself. (If Mr. D were under age, the treatment would not be delayed if the parents were unavailable in an emergency situation.) Calling the primary HCP is usually done by the ED provider after the preliminary workup is completed. (Policies for calling primary HCPs vary among institutions.) Focus: Prioritization.

Despite the nurse's best efforts at therapeutic communication, Mr. S refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose." What should the nurse do first? 1. Physically restrain him and insert the tube. 2. Explain the "against medical advice" (AMA) form. 3. Notify the nursing supervisor and patient advocate. 4. Page the HCP and document the attempt.

Ans: 4 Page the HCP and document actions. The HCP may opt to order restraints if the patient cannot make safe decisions. The HCP may try to convince the patient to agree to the therapy or have the patient sign an AMA form if he continues to refuse treatment. The nursing supervisor and the patient advocate can be notified if the situation escalates. Focus: Prioritization.

Three days later, the nursing student returns to complete her clinical rotation on the peripheral vascular unit. To facilitate continuity of care and enhance the student's learning experience about AAA, the student is assigned to assist in the postoperative care and discharge planning for Mr. S. Mr. S underwent surgery 3 days ago and was transferred back to the vascular surgery unit. The student nurse reports that the patient has no bowel sounds present. What does the RN tell the student is the best action? 1. Check the nasogastric tube for kinks. 2. Notify the surgeon immediately. 3. Obtain an abdominal radiograph immediately (STAT). 4. Document the finding in the chart.

Ans: 4 Postoperatively after AAA repair, bowel sounds are usually absent for 2 or 3 days, and patients have a nasogastric tube in place on low suction until bowel sounds return. The nurse should document the finding only and teach the student that this is to be expected and why. Focus: Delegation, Supervision, Prioritization.

A nursing concern of chronic pain has been identified for Mr. R, who has chronic peripheral arterial disease (PAD). Which action by the nursing student causes the RN to intervene? 1. Administering a narcotic analgesic 45 minutes before an ulcer dressing change 2. Asking the patient if he has ever tried progressive muscle relaxation 3. Assessing the patient's response to pain medication administration 4. Agreeing to hold the patient's docusate at the patient's request

Ans: 4 The nurse should intervene when the patient asks to have the docusate held because opioids often cause the side effect of constipation. The patient must be taught about the importance of this medication in preventing unwanted side effects. If the patient has a good reason for refusing the docusate (e.g., he has been having episodes of diarrhea), then the nurse may hold the drug (documenting the reason), but the nurse should teach the student about the importance of asking why the patient is requesting that the drug be held. The other actions are appropriate. Giving the pain medication before the dressing change will make the procedure less painful. Focus: Assignment, Supervision.

The nurse is preparing to administer a blood transfusion to Mr. S. First, the nurse inspects the bag for leaks, clots, or unusual color and compares the bag label with the chart and the blood bag forms. Place the steps of transfusion in the correct order. 1. Prime the correct tubing and filter with normal saline. 2. Take vital signs before starting the transfusion. 3. Transfuse the first 10 mL slowly; monitor the patient closely. 4. Have two nurses (or HCPs) compare the blood band identification with the tag on the blood bag. 5. Document the outcomes, names of personnel, and starting and ending times. 6. Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete.

Ans: 4, 1, 2, 3, 6, 5 Inspect the bag. If the product appears unusable or if the bag is damaged, contact the blood bank for another unit. Checking labels against the original prescription and blood bank forms is essential. At the bedside, two licensed professionals should compare the bag and identification band. (Note: Priming of the tubing and filter could be done any time before starting the transfusion. In an emergency situation, equipment preparation can be done while waiting for the unit to come from the blood bank.) Measuring vital signs immediately before starting the transfusion provides a baseline in case of transfusion reaction. An acute reaction is most likely to result with transfusion of a small amount blood (or within 15 minutes). A delayed reaction may occur several days after the transfusion. Frequent measurement of vital signs (according to hospital policy) and complete documentation are standard requirements. Focus: Prioritization.

What are priority interventions to perform for this patient? Select all that apply. 1. Prepare for endotracheal intubation. 2. Assist with central line placement. 3. Check stool for occult blood. 4. Administer supplemental oxygen. 5. Monitor vital signs and oxygen saturation. 6. Monitor hemoglobin and hematocrit.

Ans: 4, 5, 6 Use the ABCs (airway, breathing, and circulation) to prioritize. The patient shows no overt signs of respiratory distress; however, there is a high risk for hypovolemic shock, and supplemental oxygen should be given based on the assumption that the patient has already sustained blood loss and therefore has decreased oxygen-carrying capacity. Vital signs and oxygen saturation should be monitored every 15 minutes for all unstable patients. Hemoglobin and hematocrit are obtained on arrival to establish a baseline for comparison. The patient does not need endotracheal intubation at this point. In an emergency situation, peripheral IVs are usually established first because central line placement is a sterile procedure that takes more time. Eventually the stool should be checked for occult blood, but the presence or absence will not affect the emergency treatment decisions. Focus: Prioritization.

After the change-of-shift report, the RN makes rounds on the patients. List the priority order for assessing these patients. 1. Ms. C 2. Mr. R 3. Mr. Z 4. Ms. Q 5. Mr. S 6. Ms. A

Ans: 5, 4, 2, 6, 1, 3 The worsening back pain of Mr. S may signal an AAA that is enlarging, and he is at risk for rupture, which is urgent and immediately life threatening. Ms. Q's hypertension should be assessed next because she is at risk for complications such as stroke. Next, Mr. R, the patient with the severe pain, should be assessed and given pain medication. Ms. A is scheduled for Doppler studies and may have questions and need teaching before the procedure. Ms. C, the patient with Raynaud disease, should be assessed next, although the symptoms she is reporting are typical of this problem. Finally, the nurse should see Mr. Z to discuss arranging for someone to talk with him about smoking cessation. Focus: Prioritization.