HESI Live Review Workbook for NCLEX-RN Exam

b. Administer naloxone 0.4 mg IV The client's respiratory rate is 6. The RN should administer naloxone 0.4 mg IV immediately. One of the side effects of hydromorphone is respiratory depression. The other nursing interventions need to be completed but are not the priority.

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain 8/10. The family member requests her father be checked immediately. On arrival to the room, the RN finds the client difficult to arouse, with a respiration rate of 6. Wich is the priority nursing action? a. Elevate the head f the bed b. Administer naloxone 0.4 mg IV c. Assess breath sounds. d. Check vital signs and pulse oximetry.

a. A client from the previous shift wth unstable angina. d. A cardiotomy client who is day 2 postoperative and who has chest tubes. The client with unstable angina and the client with chest tubes need advanced monitoring and assessment that are most appropriate for the RN. The client needing a bed bath can be assigned to the UAP. The client with the enteral feeding and the client needing urinary catheterization could be assigned to the PN.

A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and two UAPs. Which client is appropriate to assign to the RN? (Select all that apply). a. A client from the previous shift wth unstable angina. b. A client with a stage 3 pressure ulcer who needs a bed bath. c. A client with an enteral feeding infusing at 30mL/HR. d. A cardiotomy client who is day 2 postoperative and who has chest tubes. e. A client with quadriplegia for whom urinary catheterization is prescribed.

c. Red meat e. White meat f Black beans Encourage a well-balanced, moderate-protein (limit protein in hepatic encephalopathy), high-carbohydrate diet with adequate vitamins. This client would need to avoid red meat, white meat, and black beans. Fruits, vegetables, and grains are allowed in the clients diet.

A client diagnosed with advanced cirrhosis of the liver has an acute exacerbation of hepatic encephalopathy. Which type of food would the RN teach the client to limit? (Select all that apply). a. Fruits b. Vegetables c. Red meat d. Bread e. White meat f Black beans

0.25 1mg/4mg x 1 mL = 0.25 mL

A client has an order for hydromorphone intravenous (IV) push 1 mg every 3 hours. The drug is available as 4 mg/mL per vial. The RN administers _______mL of hydromorphone for one dose (fill in the blank)

c. Assess the client's medical record to determine his normal bowel pattern. Assessing the normal bowel pattern in a client with possible constipation provides the information to determine an appropriate response to the client's concern. Note that two interventions (A and D) are similar and can be eliminated. Nursing interventions to correct the constipation should be performed before notifying the HCP and requesting medical intervention.

A client has not had a bowel movement is 2 days and reports this information to the RN. Which intervention would the RN implement first? a. Instruct the caregiver to offer a gass of warm prune juice at mealtimes. b. Notify the HCP and request a prescription for a stool softener. c. Assess the client's medical record to determine his normal bowel pattern. d. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

d. Increase the rate of intravenous (IV) fluids Nursing interventions to correct shock are focused on correcting decreased tissue perfusion and restoring cardiac output. Increasing the IV fluid rate will help to expand blood volume, which will increase tissue perfusion and cardiac output.

A client in shock develops a MAP of 60 mmHg and a HR of 110 BPM. Which prescribed intervention would the RN implement first? a. Increase the rate of 02 flow b. Obtain arterial blood gas results c. Insert an indwelling urinary catheter. d. Increase the rate of intravenous (IV) fluids

b. Uses NSAIDs daily. A side effect of frequest use of NSAIDs is gastric irritation and potential for ulceration. Eating heavily seasoned foods does not lead to ulceration. Excessive alcohol consumption can lead to PUD, but a glass of beer/wine a day will not. An acid-ash diet encourages meats, eggs, and cheese, and discourages mild products, fruits and vegetables; it is used to acidify urine and is not a risk factor for gastric ulcer disease.

A client is admitted with PUD and GI bleeding. Which risk factor would the RN identify in the client's history? a. Eats heavily seasoned foods. b. Uses NSAIDs daily. c. Consumes alcohol every day. d. Follows an acid-ash diet.

c. Potassium 20 mEq in 100 mL saline IV over 60 minutes. Addison's crisis leads to high potassium levels; therefore, the RN would question an order for IV administration of potassium. Administration of dextrose fluids and solutions can help to maintain glucose levels during Addison's crisis. Hydrocortisone must be administered immediately during Addison's crisis.

A client is admitted with diagnosis of Addison's crisis. Which prescription provided by the health care provider (HCP) would the RN question? a. IV D5 NS at 300 ml/HR for 3 hours. b. Hydrocortisone sodium succinate 100 mg IV push. c. Potassium 20 mEq in 100 mL saline IV over 60 minutes. d. 50% dextrose IV push.

a. 390 mL urine output in 24 hours. b. Potassium of 6.2 mEq/L. e. Weight gain. 390 mL urine output in 24 hours is a low output. A high potassium level and weight gain are indicative of the oliguric phase of acute kidney injury. Serum sodium of 155 mEq/L and metabolic alkalosis are not expected in this client.

A client is in the oliguric phase of acute kidney injury. Which finding would the RN expect to assess in the client? (Select all that apply). a. 390 mL urine output in 24 hours. b. Potassium of 6.2 mEq/L. c. Sodium (serum) 155 mEq/L d. Metabolic alkolosis. e. Weight gain.

9.75 mL/HR Calculation: Ordered amount of drug x clients wt x 60 (minutes/hour) / Drug Vehicle (amount of drug available) 500 mg = 500,000 mcg/ 250 mL = 2000 mcg/1 mL (5 mcg x 65 kg x 60 min.) / (2000 mcg / 1 mL) = 9.75 mL/HR

A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse dobutamine IV at 5 mcg/kg/min in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL per hour. _______mL/HR

a. "I will need to mix the enzyme with a protein food." The powder should be mixed with fruit juice or applesauce; avoid mixing with protein foods. Enzymes should be taken with each meal which will decrease the number and frequency of stools and lessen abdominal pain.

A client is receiving pancreative enzyme replacement therapy for chronic pancreatitis. Which statement by the client indicates a need for more effective teaching? a. "I will need to mix the enzyme with a protein food." b. "I will take the enzymes with each meal." c. "My stools will decrease in number and frequency." d. My abdominal pain may lesson.

c. RR: 25 This respiratory rate is high, especially for a client on oxygen. The RN should take action on this finding. The other findings do not require immediate nursing action.

A client recovering from ARDS is awake and alert but has residual fatigue and generalized weakness. The client's current vital signs are HR: 83 bpm, BP: 104/64 mmHg, RR: 25, and SpO2 92% on 2 L/min. via nasal cannula. Which VS requires the RN to take action? a. HR: 83 bpm b. BP: 104/64 mmHg c. RR: 25 d. SpO2 92% on 2 L/min. via nasal cannula

b. Draw 2 sets of blood cultures The top priority would be to draw two sets of blood cultures for this client with suspected sepsis. The pathogen needs to be identified to initiate treatment to eradicate the endotoxins. The other nursing interventions are not the priority.

A client us adnitted with a 2-day history of a cough, fever, and fatigue. The medical history is positive for type I diabetes and recent upper repiratoru infection (URI). Vital signs are HR 109 BPM mmHg, RR 24 breaths per minute, temp 104 F (40 C), and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? a. Initiate large-bore IV access b. Draw 2 sets of blood cultures c. Administer the ordered IV ABX d. Draw serum lactate and glucose levels.

a. Continue the annual Pap smear and mammogram, biannual clinical breast examinations, and monthly breast self-examination (BSE) The client should continue annual Pap smears, mammogram, and clinical breast examinations and monthly BSE. The other recommendations are not necessary.

A client who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation about women's health screening examinations should the RN offer? a. Continue the annual Pap smear and mammogram, biannual clinical breast examinations, and monthly breast self-examination (BSE) b. A Pap smear is no longer necessary, but continue the annual mamogram and biannual clinical breast examinations, plus monthly BSE. c. If the ovaries have been removed, only an annual mammogram and clinical breast examinations are necessary. d. Annual mammograms are not needed if biannual breast examinations and weekly BSE are performed.

d. A gelatin dessert The normal potassium level for an adult is 3.5-5 mEq/L. Therefore, gelatin, which contains not potassium, could be offered. A potassium level of 6.4 mEq/L (hyperkalemia) is life threatening. Milk, oranges, and dried fruit and nuts are potassium-rich foods and should not be offered to the client.

A client who has acute renal failure is admitted to the hospital. The client's potassium level is 6.4 mEq/L. Which snack would the RN offer? a. An orange b. A milkshake c. Driend fruit and nuts d. A gelatin dessert

b. Nocturia Changes in urine frequency, amount, and nocturia are early symptoms of renal insufficiency. Dyspnea and confusion are late signs of renal dysfunction. Stomatitis is not a symptom of renal insufficiency.

A client with a 20-year history of type 1 diabetes mellitus is having renal function tests because of recent fatigue, weakness, BUN or 8.5 mmol/L (24 mg/dL), and a serum creatinine of 146 mmol/L (1.6 mg/dL). Which additional early symptom of renal insufficiency would the RN expect? a. Dyspnea b. Nocturia c. Confusion d. Stomatitis

c. Raise the head of the bed higher. Remember to address ABCs first. The objective is to assist the client in using the accessory muscles of breathing. Raising the head of the bed farther will keep the spine straight, decrease pressure on the diaphragm, relax the abdominal muscle to improve breathing and will assist the client to breathe easier. This intervention addresses breathing, which would be the priority. Although the RN might call the HCP, obtain the pulse oximeter, and assess the client's vital signs, these would not be done first.

A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action would the RN take first? a. Call the HCP b. Obtain a bedside pulse oximeter. c. Raise the head of the bed higher. d. Assess the client's vital signs.

d. Administer the dose of oral phosphate. The serum calcium level is elevated (normally 9.5-10.1 mg/dL) in hyperparathyroidism, and the prescribed phosphate is used to lower calcium levels. Therefore, the dose of oral phosphate would be administered at this time. The other nursing interventions are not necessary for this client and do not address the elevated calcium level. *Note that b. is not an intervention, but an assessment.

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The nurse notes that the client serum calcium is 12.5 mg/dL. What action would the nurse take? a. Hold the phosphate and notify the HCP. b. Review the client's serum parathyroid hormone level. c. Give a PRN dose of IV calcium per protocol. d. Administer the dose of oral phosphate.

c. Measure the client's O2 saturation. b. Assist the client into the supine position. a. Elevate the HOB. d. Administer intravenous (IV) PRN morphine. The RN should measure the client's O2 sat., then assist the client into a supine position for repositioning and full lung expansion. After turning the client supine, elevate the HOB to healp with breathing. FInally, the RN should administer IM morphine as needed.

A client who is 1 day postoperative after a left pneumonectomy is lying on his right side with the HOB elevated 10 degrees. The RN assesses his respiratory rate at 32 breaths/min. In what order would the RN perform the following actions? a. Elevate the HOB. b. Assist the client into the supine position. c. Measure the client's O2 saturation. d. Administer intravenous (IV) PRN morphine.

c. To monitor the effectiveness of treatment Viral load testing directly measures the actual amount of HIV viral RNA particles in blood and is used to monitor the effectiveness of treatment. CD4+ T cells are monitored to determine progression of the disease. The ELISA test confirms a diagnosis of HIV. There is currently no vaccine for HIV.

A client who is HIV positive asks why it is necessary to have a viral load study performed every 3 to 4 months. Which information would the RN provide? a. To determine the progression of the disease b. to evaluate the ELISA c. To monitor the effectiveness of treatment d. To track the effectiveness of the vaccine

c. Document the assessment in the chart. Clay-colored stools streaked with fat in the presence of cholelithiasis is an expected finding in blockage of the bile duct (stool contains bilirubin). The finding should be documented in the Client Chart. The other interventions are not necessary for this client.

A client who is diagnosed with an obstruction of the common bile duct caused be cholelithiasis passes clay-colored stools containing streaks of fat. Which action would the RN take? a. Auscultate for diminished bowel sounds. b. Send a stool specimen to the lab. c. Document the assessment in the chart. d. Notify the HCP.

c. Immediately start a new IV at another site and resume the transfusion at the new site. The RN would immediately start a new IV at another site and resume the transfusion at the new site. This is not a sign of a transfusion reaction but rather phlebitis. If the client remains free of SS of a transfusion reaction, the transfusion should be continued. However, the previous site should be monitored for signs of infection and reported per facility policy. The other interventions should be completed if a transfusion reaction is suspected.

A client who is receiving a transfusion of packed red blood cells has an inflamed IV site. Which action would the RN take? a. Double-check the blood type of the transfusing usit of blood with another nurse. b. Discontinue the transfusion and send the remaining blood and tubing to the lab. c. Immediately start a new IV at another site and resume the transfusion at the new site. d. Continue to monitor the site for signs of infection and notify the HCP.

c. Monitor the symptoms. d. Continue to take the metformin as prescribed. The RN would instruct the client to monitor their symptoms but continue taking the medication as prescribed. These are normal side effects of the medication and should decrease with time. All other instructions are inappropriate.

A client who was recently prescribed metformin hydrochloride calls the clinic to discuss symptoms of bloating, nausea, cramping, and diarrhea. Which instruction would the RN provide the client? (Select all that apply) a. Discontinue the medication immediately. b. Increase fiber and fluids in the diet. c. Monitor the symptoms. d. Continue to take the metformin as prescribed. e. Seek immediate emergency medical care.

c. Assess the pulse, respirations, BP, and oxygen saturation. e. Provide 2 L of oxygen via nasal cannula. b. Administer PRN nitroglycerin prescription. a. Notify the rapid response team. d. Document assessment in the electronic medical record. For emergency care of the client with chest pain, it is important to quickly gather vital signs, provide O2, administer nitroglycerin, notify the rapid response team and finally, document.

A client with a history of coronary heart disease was admitted to the acute care unit 2 days ago for management of angina. During the assessment, the client states, "I leel like I have indigestion." In which order would the RN implement care? (Arrange from first action to last). a. Notify the rapid response team. b. Administer PRN nitroglycerin prescription. c. Assess the pulse, respirations, BP, and oxygen saturation. d. Document assessment in the electronic medical record. e. Provide 2 L of oxygen via nasal cannula.

b. Notify the health care provider. The client is in shock and showing signs of DIC. The client requires immediate attention from the health care provider. THe other nursing interventions are not the priority.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shif change, the RN assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? a. Assess the client's temp. b. Notify the health care provider. c. Clean the blood from the incision site d. Draw labs for prothrombin time (PT), partial thromboplastin time (PTT), complete blood count (CBC), and fibrinogen.

a. Apply 4 L of oxygen as ordered. This is a client with a known history whose symptoms align with cardiac problems. The client has increased work of breathing with respiratory rate of 24. THe priority in this client is to maximize perfusion to the myocardium. The RN should ensure edequate oxygenation before implementing other interventions.

A client with a known cardiac history is admitted to the acute care unit with stable angina. At 0700, the client had stable vital signs and was on 2 L of oxygen via nasal cannula. At 1000, the client reports chest pain of 6 on a scale of 1 to 10, is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52 mmHg, and has respiraotory rate of 24 breaths per minute. Which action should the RN implement first? a. Apply 4 L of oxygen as ordered. b. Administer a fluid bolus of 0.9 NS c. Administer the prescribed opioid for pain control. d. Obtain a full set of vital signs, including temperature

b. A change in the level of conciousness from awake to restless. In hypovolemic shock, the body conserves fluids, leading to decreased urine output. A key word in this question is "early." All of the other signs and symptoms occur later in the decompensation stage of shock.

A client with burn injuries has lost a significant amount of body fluid. An IV of Lactated Ringer's solution is infusing at 200 mL/HR, and the client's urine output for the past 8 hours is 400mL. Which sign or symptom is the highest priority in early distributive shock? a. A change in BP from 118/60 to 102/68. b. A change in the level of conciousness from awake to restless. c. A decrease in O2 sat. from 98% to 93%. d. A decrease in urine output over 8 hours from 400mL to 240mL.

a. Suggest that the client use a vaginal cream or lubricant. Lack of estrogen results in vaginal dryness, causing discomfort. Use of a vaginal cream or lubricant will help ease the client's discomfort. The other nursing interventions are not necessary for this client situation.

A client with menopause reports that since she stopped hormone replacement therapy (HRT), she has been experiencing increased vaginal discomfort during intercourse. What action would the RN take? a. Suggest that the client use a vaginal cream or lubricant. b. Recommend that the client abstain from sexual intercourse. c. Teach the client Kegel exercises to perform daily. d. Instruct the client to resume HRT.

a. pH-7.30, PCO2-52, HCO3-26 The findings for Option A reflect respiratory acidosis, indicating respiratory failure. The PO2 is below normal; the PCO2 is high, indicating retention of acid; and the HCO3 is normal; the PCO2 is high, indicating retention of acid; and the HCO3 is normal. pH-7.35, PCO2-44, HCO3-25 indicates a normal ABG finding. pH-7.35, PCO2-62, HCO3-31 indicates compensated respiratory acidosis which would not be see in acute respiratory failure. pH-7.30, PCO2-39, HCO3- 20 indicates metabolic acidosis.

A client with pneumonia has impending respiratory failure. Which set of ABG values demonstrate acute respiratory failure? a. pH-7.30, PCO2-52, HCO3-26 b. pH-7.35, PCO2-44, HCO3-25 c. pH-7.35, PCO2-62, HCO3-31 d. pH-7.30, PCO2-39, HCO3- 20

b. Monitor the clients VS every hour. The client has experienced excessive bleeding, and the RN would monitor the client's VS more closely (every hour). The other nursing interventions are not the priority.

A cliet who had a vaginal hysterectomys the previous day is saturating perineal pads with blood that require frequent changes during the night. Which priority action would the RN take? a. Provide iron-rich foods on each dietary tray. b. Monitor the clients VS every hour. c. Administer IV fluids at the prescribed rate. d. Encourage postoperative leg exercises.

d. The client's actions place the client at high risk for self-harm. The client's behavior places the client at high risk for self-harm. Restraints may be applied to protect the client from injury after all other measures to protect the client have been attempted. The HCP can prescribe restraints only once all other less restrictive intervestions have failed. Staffing issues are not legal indications for restraining a client. Wandering at night and other client concerns are also not reasons for applying restraints.

A family member of a client who is in a Posey vest restraint (SRD) asks why the restraint was applied. Which response would the RN make? a. The Posey vest restraint was prescribed by the health care provider. b. There is not enough staff to keep the client safe all the time. c. The other clients are upset when the client wanders at night. d. The client's actions place the client at high risk for self-harm.

b. The client has had a change in orientation to person but not to time or place. c. Swelling and redness have developed in the client's lower left leg. e. The client's last set of vial signs were: Temp. 37.9 (100.2 F); HR 87; RR 12; BP 108/74; O2 sat. 93%. A change is mental status and swelling/redness to the client's lower left leg could indicate serious postoperative complications and should be reported immediately to the RN. The clients vital signs indicate a low-grade fever that needs to be reported as well. Pain is a concern but can be assessed by the PN. The amount of drainage is small and does not need to be reported to the RN.

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation would the PN immediately report to the RN? (Select all that apply) a. The client complains of incisional pain, rating it an 8/10. b. The client has had a change in orientation to person but not to time or place. c. Swelling and redness have developed in the client's lower left leg. d. The PN emptiend 15 mL of bloody drainage from the jackson-Pratt drain. e. The client's last set of vial signs were: Temp. 37.9 (100.2 F); HR 87; RR 12; BP 108/74; O2 sat. 93%.

-Clients with airway problems are priority -Actual CPR =Circulation, Airway Breathing (CAB) -Acute before chronic

ABCs

a. Elevated serum potassium. The client with end-stage renal disease going though hemodialysis should not experience hyperkalemia. The RN should verify with the laboratory the values that reflect an elevated serum potassium. It is normal for calcium levels to increase during hemodialysis. Anemia is a normal finding in hemodialysis. A drop in serum sodium is normal in hemodialysis.

After hemodialysis, the RN is evaluating the blood results for a client who has end-stage renal disease. Which value should the RN verify with the laboratory? a. Elevated serum potassium. b. Increase in the serum calcium. c. Low hemoglobin. d. Reduction in serum sodium

b. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting. The client who is 48 hours postoperative and is complaining of N/V would need to be assessed first. These symptoms could be an indication of paralytic ileus which is a medical emergency and would need to be reported to the HCP immediately. All the other clients are not experiencing symptoms that could be life-threatening and would need to be assessed following this client.

After the change of shift report, the RN reviews assignments. Which client would the RN assess first? a. The elderly client receiving palliative care for heart failure who complains of constipation and nervouseness. b. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting. c. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours. d. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 l/min, and has a respiratory rate of 12 breaths/min.

b. The client is awake and alert, which makes the living will irrelevant and nonbinding. This client is awake and alert and is capable of making decisions regarding health care procedures at this time. Therefore, the LW has not been activated, and all plans for care should be discussed with the client before intubation takes place. A living will does not remove the client's ability to make medical decisions and all lifesaving procedures should still be explained to the client. The client should be asked if he or she has a durable power of attorney to make medical decisions. After the client has been intubated, they cannot communicate health care decisions.

An awake, alert client with impending pulmonary edema is brought to the emergency department. The client provides the RN with a copy of a living will that states that "no invasive" medical procedures should be used to "keep her alive." The health care team is questioning whether the client should be intubated. Which information would guide the teams's decision? a. The living will removes the obligation to the client in any medical decision-making. b. The client is awake and alert, which makes the living will irrelevant and nonbinding. c. Lifesaving measures do not have to be explained to the client because of the signed living will. d. The family should be contracted to determine who has durable power of attorney for health for the client.

a. Respiratory rate of 25 breaths/min. b. Orthopnea. c. S3 heart sound. Pulmonary edema or ADHF is caused by an abnormal accumulation of fluid in the lung, in both the interstitial and alveolar spaces. It is a severe impairment in the ability of the left side of the heart to maintain cardiac output, thereby causing an engorgement of the pulmonary vascular bed, leading to dyspnea, tachypnea, orthopnea, tachycardia (S3, S4 gallop), and severe coughing productive of frothy and blood-tinged sputum with noisy, wet breath sounds that do not clear with coughing. A dry, nonproductive cough and heart rate of 69 beats/min. and irregular are not characteristics of ADHF.

An older client with a history of hypertension, HF, and sleep apnea is admitted to the acute care usit. Which finding would relate most directly to a diagnosis of acute decompensated HF (ADHF)? (Select all that apply). a. Respiratory rate of 25 breaths/min. b. Orthopnea. c. S3 heart sound. d. Dry, nonproductive cough. e. Heart rate of 69 and irregular

Respect living will first.

Durable power of attorney vs. Living will

c. Ventricular fibrillation d. Pulseless ventricular tachycardia Ventricular fibrillation and pulseless ventricular tachycardia are life-threatening rhythms that require defibrillation. Stable ventricular tachycardia can be treated with medication or cardioversion. The other rhythms do not require defibrillation.

For which dysrhythmia would the RN implement defibrillation? (Select all that apply) a. Asystole b. Pulseless electrical activity c. Ventricular fibrillation d. Pulseless ventricular tachycardia e. Ventricular tachycardia f. atrial fibrillation

b. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest. d. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion. a. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn. c. A 25-year-old with a superficial burn to the right anterior arm and lateral chest. Clients are assessed using the SMART method of triage.

Four clients arrive in the emergency department after an explosion. In which order should they be assessed? All options must be used. a. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn. b. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest. c. A 25-year-old with a superficial burn to the right anterior arm and lateral chest. d. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion.

Ca++ >2.75mmol/L (10.5mEq/L) -SS: Muscle weakness, constipation, N/V, dysrhythmias, behavioral changes, anorexia, fatigue, diminished reflexes, lethargy, decreased level of consciouness, confusion, personality change, cardiac arrest -Interventions: Limit vit. D intake, avoid calcium-based antacids, administer calcitonin to reduce calcium, renal dialysis may be required

Hypercalcemia

K+ > 5 mmol/L -SS: Tall tented T waves, bradycardia, muscle weakness, tiredness, numbness, tingling, nausea, vomiting, respiratory destressed, angina, palpitations, irregular heartbeat -Interventions: 10-20% glucose with regular insulin, soldium polystyrene sulfonate is used, IV loop diuretics, renal dialysis

Hyperkalemia

Mg^2+ > 1.01 mmol/L (2.1 mEq/L) -SS: Bradicardia, peripheral vasodilation; hypotension; prolonged PR interval with a widened QRS complex; decreased or absent deep tendon reflexes -Interventions: No mag. drugs for chronic kidney disease (CKD) clients; IV administration of calcium chloride or calcium gluconate.

Hypermagnesemia

Na+ >145 mmol/L -SS: Dry mucous membranes, thick mucus, low urinary output, tissue turgor, restlessness, agitation, confusion, flushed skin, pulmonary edema, seizures, thirst, fever -Interventions: Not IVs containing albumin, Restrict dietary sodium, weigh daily

Hypernatremia

Phosphate >1.45 mmol/L -SS: Includes signs of hypocalcemia (they are opposites)- Positive Trousseau sign (carpopedal spasm which occurs when a BP cuff is inflated above systolic BP [SBP] for 3 minutes); diarrhea; numbness; convulsions; numbness and tingling of fingers, toes, and circumoral (around the mouth) region; positive Chvotek's sign (contraction of facial muscles when facial nerve is tapped); hyperactive reflexes; muscle twitching and cramping; carpal and pedal spasms, tetany; seizures; larygospaspasm; dysrhythmias -Interventions: Phosphate biders, diet low in phosphorus

Hyperphosphetemia

Ca++ <2.25mmol/L (9mEq/L) -SS: Positive Trousseau sign (carpopedal spasm which occurs when a BP cuff is inflated above systolic BP [SBP] for 3 minutes); diarrhea; numbness; convulsions; numbness and tingling of fingers, toes, and circumoral (around the mouth) region; positive Chvotek's sign (contraction of facial muscles when facial nerve is tapped); hyperactive reflexes; muscle twitching and cramping; carpal and pedal spasms, tetany; seizures; larygospaspasm; dysrhythmias -Interverntions: Administer calcium supplements, administer IV calcium slowly, encourage calcium-rich foods, vitamin D, and protein, for acute hypocalcemia, keep a tracheostomy tray and resuscitation bag at bedside in case of laryngeal spasms.

Hypocalcemia

K+ <3.5 mmol/L -SS: Rapid, thready pulse, flat T-waves, anorexia, muscle cramps, weakness, fatigue, tingling, numbness, nausea, vomiting, constipation, GI bloating, palpitations -Interventions: IV potassium (not push), foods high in K+ (oranges, bananas, apricots, cantaloupe, legumes, leafy vegetables, potatoes, meat)

Hypokalemia

Mg^2+ <0.65 mmol/L (1.3 mEq/L) -SS: Skeletal muscle weakness; hyperactive deep tendon reflexes; numbness and tinlging; painful muscle contractions; decreased GI motility; nausea -Intervention: Administer oral supplements; increase dietary intake; IV mag. via infusion pump; Monitor vital signs

Hypomagnesemia

Na+ <135mEq/L -SS: Muscle cramps, confusion, weakness, seizures -Interventions: Restrict fluids, give foods high in in Na+, and check BP

Hyponatremia

Phosphate < 0.97 mmol/L (3.0 mg/dL) -SS: Decreased cardiac output; weak peripheral pulses; skeletal muscle weakness -Interventions: Oral supplementation, increased dietary intake of phosphorus

Hypophosphetemia

d. Inform the HCP that the client has questions about the surgery. Informed consent must be obtained prior to performing any invasive or surgical procedure. The RN needs to notify the HCP that the client has questions concerning the procedure that must be addressed by the HCP. The consent form cannot be witnessed until all client questions have been clarified to obtain informed consent. It is not the nurse's responsibility to answer the questions. Reassuring the client that the surgeon will answer their questions does not address the issue and therefore should not be stated.

In completing a client's perioperative routine, the RN finds that the consent form has not been signed. The client begines to ask more questions about the surgical procedure. Which action would the RN take? a. Witness the client's signature on the consent form. b. Answer the client's questions about the surgery. c. Reassure the client that the surgeorn will answer any questions before the anesthetic is administered. d. Inform the HCP that the client has questions about the surgery.

-Address physiological needs first, followed by safety and security needs, love and belonging needs, self-esteem needs, and, finally, self-actualization needs. -When a physiological need is not addressed in the question, look for the option that addresses safety.

Malsow's Hierarchy of Needs

-P: precipitating or palliative -Q: quality -R: relief measures/regio (location) -S: severity (using a scale appropriate for age and client condition: numerical, descriptive, a set of faces with expressions) -T: timing (onset, duration) -U: effect of pain on client

PQRSTU Pain Assessment

-Assessment: requires gathering and verification of data. -Analysis: requires interpreting data, communicating the diagnoses, and determining the health team's ability to meet needs. -Planning: requires knowledge of prioritization and organization. -Implementation: reflects delegation and assignment of tasks -Evaluation: compares actual outcomes with expected outcomes.

Steps of the nursing process

-Situation: State the issue or problem -Background: Provide the client's history -Assessment: Give the most recent vital signs and current findings -Recommendations: State what should be done

SBAR

a. Check for a carotid pulse First assess the client by checking for a carotid pulse before performing an intervention. If no pulse is present, then the RN would follow BCLS guidelines. The other nursing interventions are not the priority.

The RN is caring for a client in shock of unkown etiology and observes the rhythm below on the monitor. Which is the RN's priority intervention? a. Check for a carotid pulse b. Defibrillate the client with 360 joules of energy. c. Administer an intravenous saline bolus. d. Give two breaths via Ambu bag

b. Assess the client's discomfort. A client with a complaint of sudden onset of substernal discomfort must be assessed immediately by the RN. All other interventions listed are inappropriate for this client.

THe RN is administering 0900 medications to three clients on a telemetry unit when the UAP reports that another client is complaining of a sudden onset of substernal discomfort. Which action would the RN take? a. Ask the UAP to obtain the client's vital signs. b. Assess the client's discomfort. c. Advise the client to rest in bed. d. Observe the client's ECG pattern.

b. Alterations in mental status c. Petiechial hemorrhage to chest d. Slight decrease in urine output Alterations in mental status, petechial hemorrhage to chest, and slight decrease in uring output would indicate early signs of organ ischemia. Gingival bleeding and bluish discoloration of fingertips are results of the effects of DIC but are not related to organ ischemia.

The RN admits a client with suspected early DIC. Which symptom would indicate early organ ischemia? (Select all that apply.) a. Slight gingival bleeding b. Alterations in mental status c. Petiechial hemorrhage to chest d. Slight decrease in urine output e. Bluish discoloration of fingertips

a. A 49-year-old client 1 day post-vaginal hysterectomy who is saturating pads every 3 hours. The 49-year-old client 1 day post-vaginal hysterectomy who is saturating pads every 3 hours needs to be assessed first. The amount of bleeding the client is experiencing is too high and could indicate a postoperative hemorrhage. The other clients are not a priority at this time. D-postanterior and posterior repair of what???? A cystocele?

The RN assigned to the women's health unit received the morning report. Which client would the RN assess first? a. A 49-year-old client 1 day post-vaginal hysterectomy who is saturating pads every 3 hours. b. A 34-year-old client postuterine artery embolization who has not voided since her indwelling catheter was removed 4 hours ago. c. A 52-year-old client who is 2 days postabdominal hysterectomy requesting oral analgesics instead of the client-controlled analgesia (PCA) pump. d. A 67-year-old client 1-day postanterior and posterior repair who is refusing to ambulate with unlicensed assistive personnel (UAP)

b. Cold, clammy skin e. Unsteady gait, slurred speech Cold, clammy skin, unsteady gait, and slurred speech are concerning findings and need to be reported immediately to the RN. These indicate a serious change in condition that needs further assessment. The other findings can be expected for a client with this condition or do not require immediate assessment by the RN.

The RN assigns the PN a client diagnosed with diabetes. Which finding would the RN instruct the PN to report immediately? (Select all that apply). a. Fingerstick of 247 mg/dL b. Cold, clammy skin c. Crackles at the end of inspiration d. Numbness in the fingertips and toes. e. Unsteady gait, slurred speech

c. The client with a chest tube that drained 150 mL in the last hour. The HCP should be notified if chest tube drainage is >100 mL/HR. The first client does not require the RN's immediate attention. The client receiving IV aminoglycosides should be assessed, but this is not the priority client. The client receiving chemotherapy should be assessed, but this is not the priority client.

The RN begins their shift by reviewing the status of their clients. Which client would the RN assess first? a. The client receiving oxygen per nasal cannula who is dyspneic on mild exertio and has a hemoglobin of 7 g/dL. b. The client receiving Iv amnioglycoside per Central Venous Catheter (CVC) who complains of nausea and has a trough level below threapeutic levels. c. The client with a chest tube that drained 150 mL in the last hour. d. The client receiving chemotherapy whose temperature is 37.2 C (98.9 F) and who has a white blood cell (WBC) count of 2.5 x 10^9/L (2500/mm^3)

d. "Have you received any preoperative pain medications?" Asking the client or knowing if the client has received pain medication prior to signing and witnessing the surgical consent form is essential. Pain medications can alter the client's ability to think cleary and make medical decisions. Consent should be obtained if possible, before pain medications are administered. The other questions are components of the preoperative checklist and should be reviewed with the client and family prior to the procedure.

The RN enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the RN to ask the client? a. "When did the surgeon explain the procedure to you?" b. "Is any member of your family going to be here during your surgery? c. "Have you been instructed in postoperative activities and restrictions?" d. "Have you received any preoperative pain medications?"

b. Assess unresponsiveness. d. Assess for a carotid pulse. a. Activate the code team and obtain defibrillator. f. Move the client to a flat position in bed or on the floor. g. Begin compressions e. Open airway and give two rescue breaths by bag-valve mask. c. Assess the cardiac rhythm using the "quick-look" paddies. First determine the client's level of responsiveness, breathing adequacy and if there is a pulse present. Then initiate a call for help by activating code team. THen move the client to the floor so you can begin high quality chest compressions. You deliver compressions followed by 2 breaths. Once the defibrillator arrives, you will check the rhythm using the quick-looking paddles.

The RN finds a client slumped in a chair. Place the RN's actions in order of priority from first to last for this client. a. Activate the code team and obtain defibrillator. b. Assess unresponsiveness. c. Assess the cardiac rhythm using the "quick-look" paddies. d. Assess for a carotid pulse. e. Open airway and give two rescue breaths by bag-valve mask. f. Move the client to a flat position in bed or on the floor. g. Begin compressions

a. A client with pericarditis with pain relieved by leaning forward. Pain is sometimes alleviated by leaning forward, but it requires further assessment because this also is symptomatic of cardiac tamponade. Pain is to be expected with a rib fracture. A client with stable angina who is awaiting discharge does not require immediate attention. A client with HF who needs transporting for an echocardiogram does not require immediate attention.

The RN has just received report on four clients. Which client would the RN assess first? a. A client with pericarditis with pain relieved by leaning forward. b. A client with fractured ribs with pain relieved at 6/10 on a scale of 1-10. c. A client with stable angina who is awaiting discharge instructions. d. A client with HF who needs transporting for an echo cardiogram.

c. Mental status e. Urine character f. Loose stools h. Pain The client's new onset of mental confusion is of high concern and needs immediate evaluation. This, along with the urine character, loose stools, and pain, could be indicative of a UTI, which could be very concerning in a client of this age. These findings indicate need for further follow-up. The vital signs are WNL at this time, lungs are clear, and skin is clammy. These are normal findings and can be monitored routinely.

The RN is admitting a client to the medical unit. The client is a 77-year-old with a 3-day history of non-localized abdominal discomfort. Assessment findings: Most current VSs: BP-116/64, HR: 85. RR: 21, T: 99.4, P: 4/10. A&O to person only. Incontinence, new-onset mental confusion, and loose stools. The post-void catheterization yielded 150 mL of dark, cloudy urine that had a strong odor. Lungs are clear to auscultation (CTA), no cough present. No peripheral edema. Pulses palpable. Skin is pink, clammy. a. VS b. Lung sounds c. Mental status d. Skin temp and moisture e. Urine character f. Loose stools h. Pain

a. Radiology = CT of abdomen b. Laboratory = Midstream U/A c. Medication = Ketorolac The scenario indicates that this clients may be experiencing a kidney stone. Computed tomography (CT) of abdomen is the most accurate radiological procedure to diagnose renal calculi. A midstream U/A can also be effective for diagnosing urinary complications. Ketorolac can help with pain and relax ureter to facilitate stone passage. The other orders are not indicated for this client at this time.

The RN is assessing a 25-year-old female complaining of severe left flank and abdominal pain, nausea, and vomiting. Skin is warm and clammy. She is bending over at the wairst and clutching hre abdomen and appears very tired. She reports that pain started last night and has steadily increased throughout the morning. She states she works outside but has limited break times to drink water. Assessment: her abdomen is soft and non-tender, but her left flank is extremely tender to touch.. VS: BP: 178/97, HR:110, RR:24, T:99F (37.2C), Pain:8/10 a. Radiology b. Laboratory c. Medication

d. A client with an open wound to the abdomen, and a deforemed right femur, pulse 125 BPM, RR 32, who is moaning. A red tag would be assigned to the client with an open wound to the abdomen, and deformed right femur, HR 125 BPM, delayed cap. refill, RR 32, and who is moaning. The other clients are not the priority in a disaster situation.

The RN is assessing clients at the site of a community disaster. Using the color-code system for triage, which client would the RN tag with a red code? a. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations. b. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal cap. refill, and RR of 18. c. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene. d. A client with an open wound to the abdomen, and a deforemed right femur, pulse 125 BPM, RR 32, who is moaning.

a. Airborne b. Contact e. Standard Since this client has not been decontaminated yet, health care providers would observe airborne, contact, and standard precautions. There is no such thing as aplastic precaustions. Droplet precautions are not necessary because anthrax is not spread by respiratory droplets from a person talking, coughing, or sneezing.

The RN is assigned to receive a client in the emergency department with suspected anthrax exposure predecontamination. Which transmission precautions would be most appropriate for the client? (Select all that apply). a. Airborne b. Contact c. Aplastic d. Droplet e. Standard

d. The client with cervical cancer who is receiving intracavity radiation. The client receiving intracavity radiation must be placed in a private room due to the chance of radiation contamination. All other clients have little to no chance of transmitting radioactive material to other clients.

The RN is assigning rooms for four new clients. Only one private room is available in the oncology unit. Which client would be placed in the private room? a. The client with ovarian cancer who is receiving chemotherapy. b. The client with breast cancer who is receiving external beam radiation. c. The client with prostate cancer who has just had a transurethral resection. d. The client with cervical cancer who is receiving intracavity radiation.

a. Notify the HCP of the finding. A normal stoma is pink and moist. A dry, dark red stoma after surgery may indicate infection or other complication such as decreased blood flow. The RN should notify the HCP of the finding immediately. All other interventions do not address the complication noted with the stoma appearance.

The RN is caring for a client for a client who is 24 hours postprocedure for a hemicolectomy with a temporary colostomy placement. The RN assesses the client's stoma, which is dry and dark blue. Which action should the RN take based on this finding? a. Notify the HCP of the finding. b. Document the findinging the client record. c. Replace the pouch system over the stoma. d. Place petrolatum gauze dressing on the stoma.

a. Check for a carotid pulse. Per Basic Cardiopulmonary Life Support (BCLS) guidelines, when a person is found to be unconscious, the first step the RN would take is to assess for responsiveness and checking for a carotid pulse. This action is the highest priority at this time. Then the RN would proceed with the subsequent steps in the BCLS guidelines.

The RN is caring for a client when the client suddenly becomes unconscious. The RN identifies the following rhythm on the monitor. Which is the highest priority? a. Check for a carotid pulse. b. Begin chest compressions. c. Administer epinephrine 1;10,000 IV. d. Initiate bag-valve mask ventillations.

a. Collard green c. Broccoli d. Brussel sprouts f. Spinach h. Kale Collard greens, broccoli, brussel sprouts, spinach, and kale are foods that are vitamin K rich and should be avoided while taking warfarin and other anticoagulants. Iceberg lettuce, green beans, zucchini squash are lower in vitamin K and are good substitutes for these vegetables for a well-balanced diets.

The RN is caring for a client who has a nre prescription for warfarin 2 mg PO daily. The RN is providing medication education for the client and is discussing dietary instructions including foods to avoid while taking this medication. Which vegetable would the RN instruct this client to avoid while taking warfarin? (Select all that apply.) a. Collard green b. Iceberg lettuce c. Broccoli d. Brussel sprouts e. Green beans f. Spinach g. Zucchini squash h. Kale

c. A 38-year-old client who is increasingly stuporous after an aneurysm repair. The 38-year-old client who is increasingly stuporous after an aneurysm repair is of highest priority and needs to be assessed first. Changes in LOC may be the earliest sign of increasing ICP. The other clients are not as high of a priority.

The RN is caring for several clients. Which client would the RN assess first? a. A 20-year-old client whose Glascow Coma Scale is 8 and unchanged from the last assignment. b. A 45-year-old client with a left-sided cerebrovascular accident (CVA) who refuses morning care. c. A 38-year-old client who is increasingly stuporous after an aneurysm repair. d. A 29-year-old client post motor vehicle accident (MVA) whose Glascow Coma Scale was 9 on hour ago and is now 10.

a. Administers a proton pump inhibitor as prescribed b. Rinses the clients oral cavitu with chlorihexiding every 2-4 hours. d. Implements spontaneous breathing trial. e. Performs hand hygiene before and after care. VAP prevention guidelines recommend use of reoutine peptic ulcer prophylaxis such as proton pump inhibitors, oral care per facility protocols which may include chlorihexidine rinses, use of weaning protocols which may include spontaneous breathing trials, and meticulous hand hygiene before and after care. The HOB should be elevated 30-45 degrees, not 60 degrees.

The RN is orienting a graduate nurse (GN) caring for a client dependent on a ventilator. Which action by the GN demonstrates understanding of VAP care? (Select all that apply). a. Administers a proton pump inhibitor as prescribed b. Rinses the clients oral cavitu with chlorihexiding every 2-4 hours. c. Elevates the HOB 60 degrees. d. Implements spontaneous breathing trial. e. Performs hand hygiene before and after care.

b. Tracheal deviation toward the right side. d. Oxygen saturation of 90% on 2 L/min. e. Vigorous bubbling in the suction chamber. The most common cause of tracheal deviation is a pneumothorax. Oxygen saturation should be at least 95%. Bubbling in the suction chamber should be gentle; vigorous bubbling could indicate an air leak. The other answer options do not reflect situations that require the RN to notify the HCP.

The RN is precepting an RN orientee who is caring for a client with a chest tube. The client is 12 hours postoperative from a left partial pneumonectomy. Which assessment finding will the RN advise the orientee to immediately report to the HCP? (Select all that apply). a. Pain level of 6 out of 10 on the left side. b. Tracheal deviation toward the right side. c. Drainage from the chest tube of 50mL in the last hour. d. Oxygen saturation of 90% on 2 L/min. e. Vigorous bubbling in the suction chamber.

c. During rounds, the RN talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. The RN should not discuss or gossip about a problem with a fellow coworker during shift handoff. This incident should be addressed with the UAP to ensure the incident in the shift report does not happen apain. It is inappropriate to discuss the incident in the shift report and undermine the competency of the UAP. The oncoming RN should be made aware of client concerns and what client teaching has been performed. Using the EMR ensures accurate reporting during handoff communication and is recommended to provide accurate medication administration history information. Reducing the likelihood of interruptions during handoff is an effective communication technique.

The RN is preparing for change of shift. Which action by the RN is characteristic of ineffective handoff communication? a. The RN states to the RN coming on duty, "The client is anxious about complications after surgery. Review the information I provided about how to use an incentive spirometer." b. The RN refers to the electric medical record (EMR) to review the client's medication administration record. c. During rounds, the RN talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. d. Before giving a report, the RN performs rounds on assigned clients so that there is less likelihood of interruption during handoff.

d. Inquire about bacillus Calmette-Guerin (BCG) vaccine history. The highest priority is assessing for a history of BCG vaccined because administering a PPD to a client who has received the vaccine will be positive and result in a large reaction at the site. Those clients will need to have a chest x-ray (CXR) and avoid PPD screening for at least 10 years after administration. THe other options are appropriate but not the highest priority.

The RN is preparing to administer a PPD test to a client who is entering nursin school. Which action is the RN's highest priority? a. Prepare 0.1mL solution for tuberculin syringe. b. Assess the skin condition on the forearm. c. Teach the client about positive readings. d. Inquire about bacillus Calmette-Guerin (BCG) vaccine history.

a. Prednisone b. Atenolol **f. Pantoprazole (I disagree. This is wrong per studies from the last decade that say it improves glycemic index in type 2 DM) Prednisone and pantoprazole sodium can increase blood sugar levels leading to hyperglycemia. Atenolol can mask signs of hypoglycemia (beta blockers do that!). The other medications listed do not have an effect on blood sugar levels.

The RN is reviewing the current medication list of a client, newly diagnosed with type 1 diabetes, who will be prescribed insulin. Which medication would the RN discuss with the health care provider? (Select all that apply). a. Prednisone b. Atenolol c. Clarithromycin d. Acetaminophen e. Ibuprofen f. Pantoprazole

d. Continue to monitor the insertion site. Small amounts of subcutaneous emphysema (cracking sensation) after thoracic surgery are common and will be absorbed, causing no problem. The RN should continue to monitor the insertion site for worsening that includes swelling of the neck and chest. Other actions are not indictated at this time.

The RN palpates a crackling sensation around with the insertion site of a chest tube in a client who has had thoracic surgery. Which action would the RN take? a. Return the client to surgery. b. Prepare for insertion of a larger chest tube. c. Increase the water-seal suction pressure. d. Continue to monitor the insertion site.

a. "I can take aspirin if I need it for pain." Clients prescribed prednisone need to be aware that using aspirin with steroids can cause bleeding. Clients are expected to gain 1-2lbs, but if a client were to gain 5lbs in a week, the HCP should be notified. The other client statments do not require further teaching.

The RN provides teaching to a client who is prescribed prednisone 10 mg orally daily. Which statement by the client indicates that further teaching is necessary? a. "I can take aspirin if I need it for pain." b. "I need to take medication at the same time daily." c. "I need to check for bruising on my skin." d. If I gain more than 5lbs a week, I will call the HCP."

b. Harsh, vibratory sounds on inspiration. c. Tingling of lips, hands, and toes. d. Positive Chvostek's sign. Removal of the parathyroid during a thyroidectomy can lead to a decrease in serum calcium. Laryngeal stridor may be related to tetany when parathyroid glands are damaged or removed, leading to hypocalcemia. Tingling of toes, fingers, and lips, along with muscular twitching, is a sign of tetany. A positive Chvostek's sign is noted with hypocalcemia. Hematoma formation and sensation of fullness at the incision site are not signs of dysfunctional parathyroid.

The Rn suspects a postoperative thyroidectomy client may have had an inadvertent removal of the parathyroid when the client begins to experience which symptoms? (Select all that apply). a. Hematoma formation b. Harsh, vibratory sounds on inspiration. c. Tingling of lips, hands, and toes. d. Positive Chvostek's sign. e. Sensation of fullness at the incision site.

c. Perform sterile wound irrigation. Performing a sterile wound irrigation is within the scope of practice for the pN and is an appropriate assignment for the charge nurse to make. Maintaining a 24-hour urine collection and obtaining scheduled vital signs can be performed by a UAP. An RN should be responsible for weaning a client from a mechanical ventilator.

The charge nurse is making assignments for each of four staff members, including a RN, a licensed practical nurse (PN), and two UAPs. Which is best to assign the PN? a. Maintain a 24-hour urine collection. b. Wean a client from a mechanical ventilator. c. Perform sterile wound irrigation. d. Obtain scheduled vital signs.

d. A middle-age client who receives hemodialysis and has been prescribed epoetin alfa subcutaneous daily The middle-aged client who receives hemodialysis and has been prescribed epoetin alfa SQ daily can be assigned to the PN. This injection can be administered by the PN. All other clients listed require more advanced assessment by the RN.

The charge nurse is making assignments on the renal unit. Which client would the registered nurse (RN) assign to a practical nurse (PN) who is new to the unit? a. An older client who has thick, dark red drainage in a urinary catheter 1 day after a transurethral prostatic resection. b. A middle-aged client admitted with a diagnosis of acute renal failure secondary to reaction to IV pyelogram dye. c. An older client who has end-stage renal disease and complains of nausea after receiving digoxin. d. A middle-age client who receives hemodialysis and has been prescribed epoetin alfa subcutaneous daily

d. A client with a pressure ulcer who was prescribed negative pressure (wound Vacuum-assisted closure [VAC]) care. A client receiving IV vancomycin is only for the RN due to the risk of air embolism. Central lines are for RNs only. A client with a wound VAC would be appropriate assignments to give to the PN. The client needing an x-ray can be assigned to the UAP. A client on a PCA of hydromorphone could need more advanced monitoring, which would be more appropriate for the RN. Also, blood transfusions must be initiated and supervised by an RN.

The charge nurse is planning client assignments for the shift. The care team includes an RN, a PN, and a UAP. Which client is appropriate to be assigned to the PN? (Select all that apply). a. A client scheduled for a STAT x-ray after a fall from a stretcher. b. A client receiving IV vancomycin though a peripherally inserted catheter (PICC) line. c. A client with sickle cell crisis who was transferred from the intensive care unit (ICU) to the acute care area and who is receiving hydromorphone via a client-controlled analgesia (PCA) pump. d. A client with a pressure ulcer who was prescribed negative pressure (wound Vacuum-assisted closure [VAC]) care. e. A postoperative client who has been prescribed 2 units of packed red blood cells

a. A client awaiting a blood transfusion for GI bleeding with a Hgb 7.0 g/dL (70g/L). The only client in this list that must be assigned to the RN is the client awaiting a blood transfusion for GI bleeding with a Hgb 7.0 g/dL. An RN must initiate a blood transfusion and observe the client for SS of transfusion reaction. A PN can assist with ongoing assessment of the client after the transfusion has been initiated by the RN. A PN can be assignment to administer B12 injection, converting the IV fluids to a saline lock, and manage the client with the wound VAC. The UAP can provide morning care to the client who had previously received blood transfusions.

The charge nurse is planning client assignments for the unit. The collaborative care team consists of a registered nurse (RN), a practical nurse (PN), and an unlicensed assive personnel (UAP). Which client would be assigned to the RN? (Select all that apply). a. A client awaiting a blood transfusion for GI bleeding with a Hgb 7.0 g/dL. b. A client with pernicious anemia who is awaiting vitamin B12 injection. c. A client with resolving sickle cell crisis awaiting IV fluid conversion to saline lock. d. A client with a pressure ulcer who has been prescribed negative pressure wound (vacuum-assisted closure [VAC]) care. e. A client who received two blood transfusions yesterday and is awaiting morning care.

d. Encourage the nurse to be accountable for their own behavior. The charge nurse should encourage the staff nurse to be accountable for their own behavior. Displacing blame on other members of the staff is not an appropriate response and should be addressed immediately by the charge nurse. The charge nurse should not confront the other staff members about the policy change. COnfrontation should be avoided and a discussion should take place instead. This could be handled in a unit meeting that discusses the reason these changes were made. However, this meeting is not the priority action at this moment. For future occurrences, a written policy for expression of complaints should be developed for the unit or facility.

The charge nuse confronts a staff surse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Don't blame me; nobody likes this idea." Which is the charge nurse's priority action? a. Confront the other staff members involved in the change of unit policy. b. Call a unit meeting to review the reasons the change was made. c. Develop a written unit policy for the expression of complaints. d. Encourage the nurse to be accountable for their own behavior.

b. Boiled steak, whole wheat rolls, spinach salad, coffee. This client has low hemoglobin and low hematocrit, which indicate anemia due to chemotherapy. The client should eat a diet rich in iron. Steak, spinach, and grains are good sources of iron. The other foods are not the highest sources of iron.

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin 85 mmol (8.5 g/dL); hematocrit, 32%; WBC count, 6.5 x 10^9/L (6500 cells/mm^3). Which meal choice is best for this client? a. Grilled chicken, rice, fresh fruit salad, milk. b. Boiled steak, whole wheat rolls, spinach salad, coffee. c. Smoked ham, mashed potatoes, applesauce, iced tea d. Tuna noodle casserole, garden salad, lemonade

a. Airborne b. Contact e. Standard A combination of airborne, contact, and standard precautions is recommended in cases of smallpox exposure. There is no such thing as aplastic precautions. Droplet precautions are not necessary because smallpox is not spread by respiratory droplets from a person talking, coughing, or sneezing.

The emergency department RN is assessing a client with vesicular rash as a result of suspected smallpox exposure. Which transmission precautions would be most appropriate for this client? (Select all that apply) a. Airborne b. Contact c. Aplastic d. Droplet e. Standard

b. Advise them to cease their communication. Nurses should not discuss client information in public settings, as it is a violation of Health Insurance Portability and Accountability Act of 1996 (HIPAA). This is a violation of client privacy and confidentiality and should be stopped immediately. All other options should be completed, but advising them to cease their communication should occur first.

The newly licensed RN overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed RN would be implemented first? a. Monitor the nurses closely for further occurrences. b. Advise them to cease their communication. c. Inform the nurse manager of the conversation. d. Submit an occurrence

a. The parameters of the state's or province's nurse practice act. To delegate tasks to UAP, the RN must be knowledgeable regarding the parameters of the stat's nurse practice acts. Delegation of an assessment that requires nursing judgment to UAP is inappropriate. The other answer options do not apply to this scenario.

The unlicensed assistive personnel (UAP) reports to the staff RN that a client who had surgery 4 hours ago has had a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The RN advises the UAP to check the client's dressing for excess drainage and report the finding to the RN. Which factor is most important to consider when assessing the legal ramifications of this situation? a. The parameters of the state's or province's nurse practice act. b. The need to complete the hospital's adverse occurrence report. c. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively. d. The health care provider's prescription for changing the postoperative dressing.

-Perform the least invasive intervention first. -Assess before taking action. -Treat the client, not the machine! -Gather information and perform all relevant actions before calling the health care provider (HCP). -Determine which client to assess first (most at risk, most physiologically unstable). -Follow guidelines for delegating assignments (https://www.ncsbn.org/NGND-PosPaper_06.pdf) -Remember the differences in the Scope of Practice for the Licenced Nurse (RN), the Licensed Practical Nurse (LPN/PN), and Unlicensed Assistive Personnel (UAP).

Think SAFETY!!

c. Maintain a warm room temperature. The RN would maintain a warm room temperature for a client with myxedema because clients may experience cold intolerance, which can lead to myxedema crisis. The other environmental adaptations are not necessary for this client.

Which adaptation of the environment is most important for the RN to include in the plan of care for a client diagnosed with myxedema? a. Reduce environmental stimuli. b. Prevent direct sunlight from endtering the room. c. Maintain a warm room temperature. d. Minimize exposure to visitors.

b. Irregular breathing with periods of apnea. d. Heart rate 50, blood pressure 192/60. Irregular breathing with periods of apnea is a late sign of increased ICP. A heart rate of 50 BPM and a BP of 192/60 mmHg are late signs of increased ICP. The other findings are not late signs of increased ICP.

Which assessment finding would the RN recognize as a late sign of increased ICP in a client diagnosed with a CVA or stroke? (Select all that apply) a. Alteration in the ability to respond to questions. b. Irregular breathing with periods of apnea. c. Consensual response of pupils. d. Heart rate 50, blood pressure 192/60. e. Drooping of the mouth on one side.

c. Taking vital signs for an older client with left humeral and left tibial fractures. Measuring vital signs on the uninjured arm of an elder client does not require the expertise of the RN to be performed. The other actions are beyond the scope of practice for a UAP and should be completed by the RN.

Which assignment should the RN delegate to a UAP in an acute care setting? a. Checking blood glucose hourly for a client with a continuous insulin drip. b. Giving PO medications left at bedside for the client to take after eating. c. Taking vital signs for an older client with left humeral and left tibial fractures. d. Replacing a client's pressure ulcer dressing that has been soiled by incontinence.

d. Pulse decreases from 88 to 68 beats per min. A client's pulse that drops from 88 to 68 BPM is a sign of Cushing's triad, which indicates increased ICP.

Which change in the status of a client being treated for increased ICP warrants immediate action by the Rn? a. Urinary output changes from 20 to 50 mL/HR. b. Arterial PCO2 changes from 40 to 30 mmHg. c. Glasgow Coma Scale score changes from 5 to 7. d. Pulse decreases from 88 to 68 beats per min.

d. The client with Addison disease showing tremors and diaphoresis. The client with Addison disease showing tremors and diaphoresis needs to be assessed first. These can be signs of Addisonian (adrenal) crisis, which can be a potentially fatal condition. All other findings are expected and are not life-threatening.

Which client would the RN assess first? a. The client diagnosed with hyperthyroidism who is exhibiting exopthalmos. b. The client diagnosed with type 1 diabetes who has an inflamed foot ulcer. c. The client with Cushing syndrome exhibiting moon face. d. The client with Addison disease showing tremors and diaphoresis.

c. Serum potassium level: 2.8 mEq/L (mmol/L) The serum potassium level is severely low. Normal potassium level is between 3.6 and 5.2 mEq/L. This electrolyte imbalance can lead to deadly dysrhythmias and must be resolved prior to starting an operative procedure. This requires immediate contact of the healthcare provider (HCP). The other labs are within normal limits and do not require contacting the HCP

Which laboratory result for a preoperative client would prompt the RN to contact the healthcare provider? a. Platelet count : 151 x 10^9/L (151,000/mm^3) b. White blood cell (WBC) count: 85 x 10^9/L (8500/mm^3) c. Serum potassium level: 2.8 mEq/L (mmol/L) d. Urine specific gravity: 1.031

c. Determine the behaviors that resulted in the need for admission. Think safety. An involuntary admission is based on the risk for harm to self or others; therefore, assessment of harmful behaviors is the highest priority. The other options are of lesser priority, but will be conducted during the admission process and assessment.

Which nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? a. Reassure the client that this admission is only for a limited amount of time. b. Offer the client and family the opportunity to share their feelings about the admission. c. Determine the behaviors that resulted in the need for admission. d. Advise the client about the legal rights of all hospitalized clients.

d. A client received medication prescribed for another client. Variance or incident reports are used for unusual circumstances that require investigation by the facility to prevent further occurrence. A client who receives medication that was prescribed to another client is an example of a medication variance and requires reporting using the facility's incident reporting procedure. This incident should be recorded and investigated to ensure that the occurrence does not reoccur to another client. An incident where a client refuses to take their medications or has status improvement does not require documentation via an incident report but should be documented in the chart. Although an allergic reaction is a concerning incident, this type of reporting is not appropriate. The HCP should be notified of the allergic reaction and allergy should be noted on the client's chart.

Which situation warrants a variance (incident) report by the RN? a. A client refuses to take prescribed medication. b. A client's status improves before completion of the course of medication. c. A client has an allergic reaction to a prescribed medication. d. A client received medication prescribed for another client.

a. Excess of gastric acid or a decrease in the natural ability of the GI mucosa to protect itself from acid and pepsin. b. Invasion of the stomach and/or duodenum by H. pylori. d. Taking certain drugs, including corticosteroids and anti-inflammatory medications Excess gastric acid production, decreased ability of the GI mucosa to protect itself from acid and pepsin, and invasion of the GI tract with H. pylori are all risk factors for developing PUD. Medications such as corticosteroids and NSAIDS (e.g., aspirin, ibuprofen [Advil], and naproxen [Aleve]) also lead to PUD. Viral infection, food allergies, immunologic factors, and psychosomatic factors do not lead to PUD.

While the RN is obtaining the health history of a client and reviewing the medical records, which data would alert the RN that the client has an increased risk of developing peptic ulcer disease (PUD)? (Select all that apply). a. Excess of gastric acid or a decrease in the natural ability of the GI mucosa to protect itself from acid and pepsin. b. Invasion of the stomach and/or duodenum by H. pylori. c. Viral infection, allergies to certain foods, immunological factors, and psychosomatic factors. d. Taking certain drugs, including corticosteroids and anti-inflammatory medications. e. Having allergies to foods containing gluten in their ingredients.