Management-Hurley-Case Study 1-4-Delegation Quiz 4 COMPLETE

•"I will be able to eat and drink what I want after I start dialysis." •Even after beginning HD, patients are still required to restrict fluid intake. In addition, patients on HD have nutritional restrictions (e.g., protein, potassium, phosphorus, sodium restrictions). All of the other patient statements indicate an appropriate understanding of HD.

After discussing renal replacement therapies with the HCP and nurse, Ms. J is considering hemodialysis (HD). Which statement indicates that Ms. J needs additional teaching about HD? •"I will need surgery to create an access route for HD." •"I will be able to eat and drink what I want after I start dialysis." •"I will have a temporary dialysis catheter for a few months." •"I will be having dialysis three times every week."

•Changing the patient's incontinence pad as needed •Performing pulse oximetry every shift •Reminding the patient to use incentive spirometry every hour while awake •Encouraging the patient to drink adequate oral fluids •Assisting patients with activities of daily living such as toileting are within the scope of practice of UAPs. After licensed nurses or respiratory therapists have taught the patient to use incentive spirometry, the UAP can play a role in reminding the patient to perform it. UAPs can participate in encouraging patients to drink adequate fluids. Assessing and teaching are not within the scope of practice of UAPs. Performing pulse oximetry is appropriate for experienced UAPs after they have been taught how to use the pulse oximetry device to gather additional data.

After the rapid response, the respiratory therapist provides the patient with a hand-held nebulizer treatment, and Mr. W is stable enough to be admitted to the acute care unit. Which interventions would the acute care RN delegate to an experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Changing the patient's incontinence pad as needed •Performing pulse oximetry every shift •Teaching the patient to cough and deep breathe •Reminding the patient to use incentive spirometry every hour while awake •Assessing the patient's breath sounds every shift •Encouraging the patient to drink adequate oral fluids

•Administer furosemide 20 mg orally each morning •Discharge planning and IV administration of antibiotics are more appropriate to the scope of practice of the RN. However, in some states, LPN/LVNs with special training may administer IV antibiotics. (Be aware of state regulations and nursing practice laws in your state.) Administering oral medications is appropriate to assign to LPN/LVNs, and in this case, furosemide may help clear up the crackles. Although the LPN/LVN could weigh the patient, this intervention is also appropriate to the scope of practice of the UAP.

An LPN/LVN tells the RN that the patient is now receiving oxygen at 2 L/min via nasal cannula and his pulse oximetry reading is now 91%, but he still has crackles in the bases of his lungs. What intervention should the RN assign to the LPN/LVN? •Begin creating a plan for discharging the patient •Administer furosemide 20 mg orally each morning •Get a baseline weight for the patient now •Administer cefotaxime IV piggyback every 6 hours

•Decreased level of consciousness •Changes in level of consciousness during or after HD can signal dialysis disequilibrium syndrome, a life-threatening situation that requires early recognition and treatment with anticonvulsants. This should be immediately reported to the HCP so that appropriate treatment can be prescribed. Decreases in weight and blood pressure are to be expected as a result of dialysis therapy. A small amount of drainage is common after HD.

Assessment of Ms. J after dialysis reveals all of these findings. Which assessment finding necessitates *immediate* notification of the HCP? •Weight decrease of 4.5 lb (2 kg) •Systolic blood pressure decrease of 14 mm Hg •Decreased level of consciousness •Small blood spot near the center of the dressing

•Measuring vital signs every 2 hours •Accurately recording intake and output •Assisting the client to the bedside commode •Measuring vital signs, recording intake and output, and assisting clients with activities of daily living are all within the scope of practice of the UAP. Administration of IV drugs, venipuncture for laboratory tests, and assessments are beyond the scope of practice of UAPs and are applicable to the practice scope of the professional nurse. In some facilities, UAPs may receive additional training to perform venipuncture, but the RN would need to assess the UAP's ability to safely perform this skill before delegation.

Because Ms. S continues to experience chest pain and has elevated levels of cardiac markers, the following interventions have been prescribed. Which interventions should the nurse delegate to an experienced UAP? *Select all that apply.* •Measuring vital signs every 2 hours •Accurately recording intake and output •Administering tenecteplase IV push •Drawing blood for coagulation studies •Assessing the cardiac monitor every 4 hours •Assisting the client to the bedside commode

•Document this finding as the only action •Normal sinus rhythm with a rate of 88 beats/min is a normal finding. There is no need to delay the client's discharge, give early medications, or draw additional cardiac markers.

Before discharging Ms. S, the HCP orders an electrocardiogram. This test reveals normal sinus rhythm with a heart rate of 88 beats/min. What is the nurse's *best* action at this time? •Delay the client's discharge until she is seen by the HCP •Administer the client's next dose of atenolol 3 hours early before she goes home •Contact the HCP and ask about drawing an additional set of cardiac markers •Document this finding as the only action

•Troponin T level of more than 0.20 ng/mL (0.2 μg/L) •A troponin T level of more than 0.20 ng/mL (0.2 μg/L) is an elevated level and indicates myocardial injury or infarction (heart attack). Although the other laboratory values are all abnormal except the potassium, which is low normal, none of them is life threatening. The low normal potassium level would be the second highest concern and might require supplementation to keep it within normal limits. Remember that hypokalemia can also be a risk for dysrhythmias.

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea. She started feeling ill about 10 hours before she called her daughter, who brought her to the ED for admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate that was in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She states, "It just gets worse and worse." Ms. S has been under a health care provider's (HCP's) care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker for 43 years but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed, and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU *vital sign values* on admission are as follows: -Blood pressure: 174/92 mm Hg -Heart rate: 120 to 130 beats/min, irregular -O2 saturation: 94% on room air -Respiratory rate: 30 to 34 breaths/min -Temperature: 99.8° F (37.7° C) (oral) All of these laboratory values were obtained for Ms. S in the emergency department. Which value would be of *most* concern to the nurse and have *immediate* implications for the care of the client? •Potassium level of 3.5 mEq/L (3.5 mmol/L) •Troponin T level of more than 0.20 ng/mL (0.2 μg/L) •Glucose level of 123 mg/dL (6.83 mmol/L) •Slight elevation of white blood cell count

•Crackles bilaterally •Barrel chest and clubbed fingers are signs of COPD. The patient had a productive cough on admission to the hospital. Bilateral crackles are a new finding and indicate fluid-filled alveoli and pulmonary edema. Fluid in the alveoli affects gas exchange and can result in worsening ABG concentrations.

During morning rounds, the nurse notes all of these assessment findings for Mr. W. Which finding indicates a *worsening* of the patient's condition? •Barrel-shaped chest •Clubbed fingers on both hands •Crackles bilaterally •Frequent productive cough

•Ask the UAP if he needs assistance completing the intake and output records •The UAP is new to the unit and may need assistance or instruction regarding the completion of this assignment.

Near the end of the shift, the LPN/LVN reports that the UAP has not totaled clients' intake and output for the past 8 hours. What is the nurse's *best* action? •Confront the UAP and instruct him to complete this assignment at once •Assign this task to the LPN/LVN •Ask the UAP if he needs assistance completing the intake and output records •Notify the nurse manager to include this on the UAP's evaluation

•Assisting the client with ambulation to the bathroom to urinate •Assisting clients with activities of daily living (including ambulation to the bathroom) is appropriate to the educational preparation and scope of practice of the UAP. An LPN/LVN could administer the oral drug. Teaching, assessing, and administering medications fall within the scope of practice for licensed nurses.

Mr. B, the client newly admitted from a long-term care facility with decreased urine output and altered level of consciousness The RN is working on a care plan for Mr. B. Which care intervention is *most* appropriate to delegate to the UAP? •Checking the client's level of consciousness every shift •Assisting the client with ambulation to the bathroom to urinate •Teaching the client the side effects of antibiotic therapy •Administering sulfamethoxazole-trimethoprim orally every 12 hours

•Check bilateral pedal pulses every 15 minutes during the first hour •Check right groin area for bleeding every 15 minutes during first hour •Continue IV fluids normal saline at 50 mL/hr •Give client's daily multivitamin and stool softener on return to medical unit •The LPN/LVN is experienced and post cardiac catheterization care would be familiar to her. Basic assessments such as checking peripheral pulses, watching for bleeding, and monitoring IV fluid flow, as well as administering oral drugs are within his or her scope of practice. Most IV drugs are administered by RNs; however, some LPN/LVNs may administer these drugs with additional training. The client would most likely be on bed rest, keeping the affected extremity straight for 4 to 6 hours after the procedure.

Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which postprocedure tasks would be *best* assigned to the LPN/LVN? *Select all that apply.* •Check bilateral pedal pulses every 15 minutes during the first hour •Check right groin area for bleeding every 15 minutes during first hour •Continue IV fluids normal saline at 50 mL/hr •Assist client to bathroom as needed during first 6 hours after procedure •Administer morphine sulfate 2 mg IV push as needed for pain •Give client's daily multivitamin and stool softener on return to medical unit

•Initiate a dietary consult •Monitor serum prealbumin levels •Suggest four to six small meals per day •Instruct the patient to use his bronchodilator 30 minutes before meals •A dietitian can help with the selection of foods that are easy to chew, do not form gas, and are high in calories and protein. Serum prealbumin levels are a good indicator of nutritional status and should be monitored. Small meals can help prevent meal-related dyspnea. Using a bronchodilator before meals will reduce bronchospasm. The second response does not demonstrate respect for the patient's role in his care. Dry foods stimulate coughing.

Mr. W has lost 15 lb (6.8 kg) over the past year. On assessment, he tells the nurse that his appetite is not what it used to be, and he becomes short of breath while eating. Which interventions should be included in his nursing care plan? *Select all that apply.* •Initiate a dietary consult •Stress that he must eat all of his meals or he'll become malnourished •Monitor serum prealbumin levels •Suggest four to six small meals per day •Instruct the patient to use his bronchodilator 30 minutes before meals •Encourage dry foods to avoid coughing

•Administer oxygen at 2 L/min via nasal cannula •Initiate a rapid response •Teach the patient how to cough and deep breathe •Remind the patient to practice incentive spirometry every hour while awake •The patient's major problem at this time is impaired gas exchange with hypoxemia. Strategies to compensate include administration of low-flow oxygen as well as interventions to improve gas exchange, such as having the patient cough and deep breathe and perform incentive spirometry. These strategies may improve the patient's condition and prevent the need to initiate a code, transfer to the ICU, or both. A saline lock is a good idea, but giving the patient too much fluid may worsen his condition by producing a fluid overload. The patient's symptoms call for initiation of a rapid response to treat him now and prevent the need for a code.

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department, Mr. W undergoes chest radiography, and admission laboratory tests are performed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W's *ABG results* include the following: -pH: 7.37 -Arterial partial pressure of carbon dioxide (Paco2): 55.4 mm Hg -Arterial partial pressure of oxygen (Pao2): 51.2 mm Hg -Bicarbonate (HCO3−) level: 38 mEq/L (38 mmol/L). Based on the patient's ABG results, what are the nurse's priority actions at this time? *Select all that apply.* •Administer oxygen at 2 L/min via nasal cannula •Initiate a rapid response •Teach the patient how to cough and deep breathe •Begin IV normal saline at 100 mL/hr •Arrange a transfer to the intensive care unit (ICU) •Remind the patient to practice incentive spirometry every hour while awake

•Compensated respiratory acidosis with hypoxemia •The pH is on the low side of normal, and the Paco2 is elevated, which indicates an underlying respiratory acidosis. The HCO3− level is elevated, which indicates compensation. Both the Pao2 and the oxygen saturation levels are low, which points to hypoxemia. These blood gas results are typically expected when a patient has a chronic respiratory problem such as COPD.

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department, Mr. W undergoes chest radiography, and admission laboratory tests are performed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W's *ABG results* include the following: -pH: 7.37 -Arterial partial pressure of carbon dioxide (Paco2): 55.4 mm Hg -Arterial partial pressure of oxygen (Pao2): 51.2 mm Hg -Bicarbonate (HCO3−) level: 38 mEq/L (38 mmol/L). What is the nurse's interpretation of these results? •Compensated metabolic acidosis with hypoxemia •Compensated metabolic alkalosis with hypoxemia •Compensated respiratory acidosis with hypoxemia •Compensated respiratory alkalosis with hypoxemia

•Send an arterial blood gas (ABG) sample to the laboratory •Baseline ABG results are important in planning the care of this patient. The unit clerk can schedule the pulmonary function tests and chest radiography. The albuterol therapy is a routine order.

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department, Mr. W undergoes chest radiography, and admission laboratory tests are performed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W's *vital sign values* are as follows: -Blood pressure: 154/92 mm Hg -Heart rate: 118 beats/min -O2 saturation: 88% on 1 L/min oxygen by nasal cannula -Respiratory rate: 38 breaths/min -Temperature: 100.9° F (38.3° C) (oral) The health care provider's (HCP's) prescribed actions for this patient include all of the following. Which intervention should the nurse complete *first*? •Send an arterial blood gas (ABG) sample to the laboratory •Schedule pulmonary function tests •Repeat chest radiography each morning •Administer albuterol via MDI 2 puffs every 4 hours

•Place the patient on a cardiac monitor •Get a baseline set of vital signs •Draw admission labs and place a saline lock •Send the patient for a chest x-ray •Baseline data that are essential to decisions for the care of this patient take priority at this time including vital signs, cardiac rhythm, lab values, and chest x-ray findings. Placement of a saline lock is essential for administration of fluids and emergency drugs. Changing the patient's incontinence pad is important to protect his skin but is not urgent. Ordering a lunch tray may be premature because the interventions for this patient's care are undecided when he is first admitted to the ED.

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department, Mr. W undergoes chest radiography, and admission laboratory tests are performed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W's *vital sign values* are as follows: -Blood pressure: 154/92 mm Hg -Heart rate: 118 beats/min -O2 saturation: 88% on 1 L/min oxygen by nasal cannula -Respiratory rate: 38 breaths/min -Temperature: 100.9° F (38.3° C) (oral) Which *priority* actions will the nurse take when the patient is initially admitted to the emergency department (ED)? *Select all that apply.* •Place the patient on a cardiac monitor •Get a baseline set of vital signs •Draw admission labs and place a saline lock •Change the patient's adult pad •Send the patient for a chest x-ray •Order the patient a lunch tray

•Clearance of thick secretions •The patient's major problems at this time relate to airway and breathing including thick sputum, difficulty breathing, and respiratory distress. The patient's skin care, blood pressure, and elevated temperature will need to be followed up on soon but are not as urgent at this time as his respiratory status.

Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by emergency medical services after reporting severe dyspnea and shortness of breath. He has been experiencing coldlike symptoms for the past 2 days. He has a productive cough with thick yellowish sputum. When Mr. W awoke in the nursing home, it was found that he was having difficulty breathing even after using his albuterol metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress. His history includes chronic obstructive pulmonary disease (COPD) related to smoking 2 packs of cigarettes per day since he was 15 years old; he quit smoking 2 years ago when he was admitted to the long-term facility. Mr. W has been incontinent of urine and stool for the past 2 years. In the emergency department, Mr. W undergoes chest radiography, and admission laboratory tests are performed, including serum electrolyte levels and a complete blood count. A sputum sample is sent to the laboratory for culture and sensitivity testing and Gram staining. Mr. W's *vital sign values* are as follows: -Blood pressure: 154/92 mm Hg -Heart rate: 118 beats/min -O2 saturation: 88% on 1 L/min oxygen by nasal cannula -Respiratory rate: 38 breaths/min -Temperature: 100.9° F (38.3° C) (oral) What is the *priority* nursing concern for this patient? •Skin care due to incontinence •Clearance of thick secretions •Rapid heart rate •Elevated temperature

•"IV potassium is very irritating to the veins and can cause phlebitis." •"Tissue damaged by potassium can become necrotic." •"The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr (5 to 10 mmol/hr)." •"The goal is to prevent infiltration into the tissue." •A dilution no greater than 1 mEq (1 mmol) of potassium to 10 mL of solution is recommended for IV administration. The maximum recommended infusion rate is 5 to 10 mEq/hr (5 to 10 mmol/hr); this rate is never to exceed 20 mEq/hr (20 mmol/hr) under any circumstances. In accordance with National Patient Safety Goals, potassium is not given by IV push to avoid causing cardiac arrest. Oral potassium can cause nausea, and vomiting (give it with food to prevent this), but this does not answer the UAP's question.

Mr. W is receiving an IV dose of potassium 10 mEq/100 mL (10 mmol/100 mL) normal saline to run over 1 hour. The UAP asks the nurse why it takes so long to infuse such a small amount of fluid. What should the nurse explain to the UAP? *Select all that apply.* •"IV potassium is very irritating to the veins and can cause phlebitis." •"Tissue damaged by potassium can become necrotic." •"Oral potassium can cause nausea, so IV potassium is preferred." •"The maximum recommended infusion rate for IV potassium is 5 to 10 mEq/hr (5 to 10 mmol/hr)." •"That's a good question, and I will ask the HCP if I can give the drug IV push." •"The goal is to prevent infiltration into the tissue."

•Administer the patient's 12:00 pm oral medications •The scope of practice for an experienced LPN/LVN includes administering oral medications. Although the LPN could certainly check the patient's vital signs, pack his personal belongings, and change his incontinence pad, these interventions are also within the scope of practice for a UAP.

Mr. W is to be transferred back to the long-term care facility after lunch. Which nursing care intervention would be *best* for the RN to assign to the experienced LPN/LVN? •Administer the patient's 12:00 pm oral medications •Check and record a set of vital signs at 12:00 pm •Pack the patient's personal items to be taken with him •Change Mr. W's incontinence pad before he is transferred

•Contact and notify the HCP immediately •A low serum potassium places the patient at risk for cardiac dysrhythmias, which can be life threatening. The HCP should be notified immediately and will likely order IV or oral potassium supplements to move the patient's level back into the normal range. Later, before discharge, the nurse would certainly want to teach the patient about potassium-rich foods, but this is not urgent. Oxygen is essential for the patient's respiratory problem but will not correct the low potassium, nor will IV normal saline.

Mr. W's emergency department lab values include a serum potassium of 2.8 mg/dL (2.8 mmol/L). What is the *priority* nursing action at this time? •Teach the patient about potassium-rich foods •Provide the patient with oxygen at 2 L per nasal cannula •Contact and notify the HCP immediately •Initiate 0.9% saline at 20 mL/hr

•Crackles in both lower and middle lobes •All of these findings are important, but only the presence of crackles in both lungs is urgent because it signifies fluid-filled alveoli and interruption of adequate gas exchange and oxygenation, worsening of the patient's condition, and possibly pulmonary edema. The patient's peripheral edema is not new. The faint pulses are most likely caused by the presence of peripheral edema. The dry and peeling skin is a result of chronic diabetes and merits careful monitoring to prevent infection, but it is not immediately urgent.

Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting her health care provider (HCP) because of shortness of breath and increased swelling in her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease. Ms. J states that her symptoms have become worse over the past 2 to 3 months and that she uses the bathroom less often and urinates in small amounts. Her medical history includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes (14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and right eye 1 year ago, and four pregnancies with healthy births. She also has gastroesophageal reflux disease (GERD), which is controlled with over-the-counter ranitidine 75 mg as needed. During admission assessment, Ms. J has all of these findings. For which finding should the nurse notify the HCP *immediately*? •Bilateral pitting ankle and calf edema rated + 2 •Crackles in both lower and middle lobes •Dry and peeling skin on both feet •Faint but palpable pedal and post-tibial pulses

•Check vital signs every 4 hours •Record accurate intake and output •Check oxygen saturation by pulse oximetry •Check and record the fingerstick blood glucose before lunch •Checking vital signs and recording intake and output fall within the scope of practice for any UAP. An experienced UAP will have been taught to use pulse oximetry to check oxygen saturation and to use a glucometer to check a patient's fingerstick blood glucose. However, in Canada, glucose monitoring is considered an advanced skill and would not be performed by UAP. Placing an IV line and teaching require additional education and training that are more within the scope of practice for a licensed nurse.

Ms. J is a 63-year-old woman who is admitted directly to the medical unit after visiting her health care provider (HCP) because of shortness of breath and increased swelling in her ankles and calves. She is being admitted with a diagnosis of chronic kidney disease. Ms. J states that her symptoms have become worse over the past 2 to 3 months and that she uses the bathroom less often and urinates in small amounts. Her medical history includes hypertension (30 years), coronary artery disease (18 years), type 2 diabetes (14 years), appendectomy at age 28, cataract surgery to the left eye 2 years ago and right eye 1 year ago, and four pregnancies with healthy births. She also has gastroesophageal reflux disease (GERD), which is controlled with over-the-counter ranitidine 75 mg as needed. Ms. J's *vital sign values* on admission were as follows: -Blood pressure: 162/96 mm Hg -Heart rate: 88 beats/min -O2 saturation: 89% on room air -Respiratory rate:28 breaths/min -Temperature97.8° F (36.6° C) The patient is to be placed on oxygen at 2 L/min via nasal cannula. Admission laboratory tests for which patient samples are to be collected on the unit include serum electrolyte levels, kidney function tests, complete blood count, and urinalysis. A 24-hour urine collection for determination of creatinine clearance has also been ordered. Which patient admission tasks should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? *Select all that apply.* •Check vital signs every 4 hours •Record accurate intake and output •Place a saline lock in left forearm •Check oxygen saturation by pulse oximetry •Teach the patient the importance of keeping oxygen in place •Check and record the fingerstick blood glucose before lunch

•Hyperacute rejection •Hyperacute rejection occurs within 48 hours after transplant surgery. Increased temperature, increased blood pressure, and pain at the transplant site are manifestations.

Ms. J is admitted for a kidney transplantation 6 months later. Her son is the kidney donor. The RN is caring for Ms. J on the first day postoperatively after a kidney transplant. On assessment, her temperature is 100.4°F (38°C), her blood pressure is 168/92 mm Hg, and the patient tells the RN she has pain around the transplant site. What is the *best* interpretation of these findings? •Hyperacute rejection •Acute rejection •Chronic rejection •Transplant site infection

•"You must take the epoetin alfa three times a week by mouth to treat anemia." •Epoetin alfa is used to treat anemia and is given two to three times a week. However, it is given by either the IV or subcutaneous route. Most commonly epoetin alfa is given subcutaneously. All of the other statements about medications for patients with chronic kidney disease are accurate.

Ms. J is preparing for discharge. The RN is supervising a student nurse, who is teaching the patient about her discharge medications. For which statement by the student nurse will the RN intervene? •"Sevelamer prevents your body from absorbing phosphorus." •"Take your folic acid after dialysis on dialysis days." •"The docusate is to prevent constipation that may be caused by ferrous sulfate." •"You must take the epoetin alfa three times a week by mouth to treat anemia."

•Checking for residual urine with the bedside bladder scanner •Checking residual urine with a bedside bladder scanner is within the scope of practice of the LPN/LVN, who would remain under the supervision of the RN. Planning care and discussing options such as renal replacement therapies require additional education and training, which are within the scope of practice for the professional RN. Although in many acute care hospitals, LPN/LVNs auscultate breath sounds as a part of their observations, RNs follow up for overall assessment and synthesis of data. Because Ms. J is a potentially unstable patient with respiratory changes that may indicate worsening of her condition, the more appropriate person to assess her lung sounds would be the RN.

Ms. J states that she feels increasingly short of breath. The nurse team leader is supervising an LPN/LVN and a UAP. Which nursing care action for Ms. J should be *most* appropriately assigned to the LPN/LVN? •Checking for residual urine with the bedside bladder scanner •Planning restricted fluid amounts to be given with meals •Assessing breath sounds for increased bilateral crackles •Discussing renal replacement therapies with the patient

•Measure weight daily •Monitor daily intake and output •Restrict sodium intake with meals •Assess for crackles in the lungs every shift •Check for peripheral edema and note any increase •The usual fluid restriction for patients with chronic kidney failure is 500 to 700 mL plus urine output. All of the other actions are appropriate for a patient with fluid overload. Remember that it is essential for the nurse to compare findings with previous shifts and days to determine if symptoms are worsening.

Ms. J's care plan includes the nursing concern, excess fluid volume. What interventions are appropriate for this nursing concern? *Select all that apply.* •Measure weight daily •Monitor daily intake and output •Restrict sodium intake with meals •Restrict fluid to 1500 mL plus urine output •Assess for crackles in the lungs every shift •Check for peripheral edema and note any increase

•Reminding the client to remain on bed rest with the insertion site extremity straight •Measuring the client's vital signs every 15 minutes for the first hour •Assessing the catheter insertion site for bleeding or hematoma formation •Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs •Administering two tablets of acetaminophen for back pain •All of these interventions are within the scope of practice of an experienced LPN/LVN. The LPN/LVN would be instructed when to notify the RN or the HCP of any abnormal findings. Preparing a teaching plan requires additional education and is more suited to the RN's scope of practice. Taking vital signs and reminding the client about bed rest could also be delegated to the UAP.

Ms. S has returned from a cardiac catheterization and a percutaneous coronary intervention procedure. Which follow-up care orders should the nurse assign to an experienced LPN/LVN? *Select all that apply.* •Reminding the client to remain on bed rest with the insertion site extremity straight •Preparing a teaching plan that includes activity restrictions and risk factor modification •Measuring the client's vital signs every 15 minutes for the first hour •Assessing the catheter insertion site for bleeding or hematoma formation •Monitoring peripheral pulses, skin temperature, and skin color with each measurement of vital signs •Administering two tablets of acetaminophen for back pain

•Place the client on a cardiac monitor •Cardiac monitoring is the highest priority because the client's heart rate is rapid and irregular, and the client is experiencing chest pressure. The client is at risk for life-threatening dysrhythmias such as frequent premature ventricular contractions. Measuring vital signs every 2 hours, checking levels of cardiac markers, and recording a 12-lead ECG every 6 hours are important to accomplish, but cardiac monitoring takes first precedence.

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea. She started feeling ill about 10 hours before she called her daughter, who brought her to the ED for admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate that was in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She states, "It just gets worse and worse." Ms. S has been under a health care provider's (HCP's) care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker for 43 years but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed, and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU *vital sign values* on admission are as follows: -Blood pressure: 174/92 mm Hg -Heart rate: 120 to 130 beats/min, irregular -O2 saturation: 94% on room air -Respiratory rate: 30 to 34 breaths/min -Temperature: 99.8° F (37.7° C) (oral) Which action prescribed by the HCP for Ms. S takes *first priority* at this time? •Measure vital signs every 2 hours •Obtain a 12-lead ECG every 6 hours •Place the client on a cardiac monitor •Check levels of cardiac markers every 6 hours

•Hypertension for 12 years •Smoked for 43 years; quit smoking 1 year ago •Ms. S's father died at age 42 years from a heart attack •Client's weight is 278 lb (126 kg) •Diet includes fast foods three to five times a week •Risk factors for cardiac problems include hypertension, family history, obesity, and high-fat diets (which may cause elevation of cholesterol). Gallbladder surgery would not be a risk factor. Quitting smoking would be a risk factor, and the years that the client smoked would be a strong risk factor.

Ms. S is a 58-year-old African-American woman who is admitted to the coronary care unit (CCU) from the emergency department (ED) with reports of chest pressure and indigestion associated with nausea. She started feeling ill about 10 hours before she called her daughter, who brought her to the ED for admission. She told the nurse that she tried drinking water and took some bismuth subsalicylate that was in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She states, "It just gets worse and worse." Ms. S has been under a health care provider's (HCP's) care for the past 12 years for management of hypertension and swelling in her ankles. She was a smoker for 43 years but quit 1 year ago. In the ED, admission laboratory tests, including levels of cardiac markers, were performed, and a 12-lead electrocardiogram (ECG) was taken. Ms. S's CCU *vital sign values* on admission are as follows: -Blood pressure: 174/92 mm Hg -Heart rate: 120 to 130 beats/min, irregular -O2 saturation: 94% on room air -Respiratory rate: 30 to 34 breaths/min -Temperature: 99.8° F (37.7° C) (oral) Which risk factors from Ms. S's history would suggest a possible cardiac problem to the nurse? *Select all that apply.* •Hypertension for 12 years •Smoked for 43 years; quit smoking 1 year ago •Surgery for gallbladder removal 1 year ago •Ms. S's father died at age 42 years from a heart attack •Client's weight is 278 lb (126 kg) •Diet includes fast foods three to five times a week

•Administer morphine sulfate 2 mg IV push •Morphine sulfate has been ordered to relieve the chest discomfort that is common when a client has an acute myocardial infarction. Relief from the chest pain is the highest priority at this time. Ranitidine is a histamine2 blocker used to prevent gastric ulcers. Scheduling an ECG or drawing blood for coagulation studies, although important, will not help relieve chest discomfort.

Ms. S tells the nurse that she has worsening chest discomfort. The cardiac monitor shows ST-segment elevation, and the nurse notifies the HCP. Which prescribed action takes *priority* at this time? •Administer morphine sulfate 2 mg IV push •Schedule an ECG •Draw blood for coagulation studies •Administer ranitidine 75 mg PO every 12 hours

•Amiodarone IV push •With frequent PVCs, the client is at risk for life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Amiodarone is an antidysrhythmic drug used to control ventricular dysrhythmias. Nitroglycerin and morphine can be given for chest pain relief. Atenolol is a beta-blocker, which can be used to control heart rate and decrease blood pressure.

Ms. S's cardiac telemetry monitor shows a rhythm of sinus tachycardia with frequent premature ventricular contractions (PVCs). Which drug should the nurse be prepared to administer *first*? •Amiodarone IV push •Nitroglycerin sublingually •Morphine sulfate IV push •Atenolol IV push

•Chest pain episode occurring during morning care •Chest pain can be an indicator of additional myocardial muscle damage. Additional episodes of chest pain significantly affect the client's plan of care. Small increases in heart rate and blood pressure after activity are to be expected. The client's temperature, only 0.2°F (0.1°C) higher than at admission, is not a priority at this time.

Ms. S's condition is stable, and she has been transferred to the cardiac step-down unit. What should the step-down nurse instruct the UAP to report *immediately*? •Temperature of 99°F (37.2°C) with morning vital sign monitoring •Chest pain episode occurring during morning care •Systolic blood pressure increase of 8 mm Hg after morning care •Heart rate increase of 10 beats/min after ambulation

•"Thrombolytic agents, also called clot busters, are most effective when administered within the first 6 hours of a coronary event." •Thrombolytic therapy using fibrinolytics dissolves thrombi in the coronary arteries and restores myocardial blood flow. Intracoronary fibrinolytics may be delivered during cardiac catheterization. Thrombolytic agents are most effective when administered within the first 6 hours of a coronary event. They are used in men and women, young and old.

Ms. S's daughter asks the nurse why her mother did not receive a "clot-buster" drug. What is the nurse's *best* response? •"Thrombolytic agents, also called clot busters, are most effective when administered within the first 6 hours of a coronary event." •"Thrombolytic drugs are much more effective when used for clients who have had a recent stroke." •"Thrombolytic drugs work better for clients who have a heart attack at a much younger age." •"Contraindications for these drugs include recent surgeries, and your mother had gallbladder surgery a year ago."

•Measuring vital signs and postdialysis weight •Measuring vital signs and weighing the patient are within the education and scope of practice of the UAP. The UAP could remind the patient to request assistance when getting out of bed after the RN has instructed to patient to do so. Assessing the HD access site for bleeding, bruit, and thrill require additional education and skill and are appropriately performed by a licensed nurse.

Six months later, Ms. J is readmitted to the unit. She has just returned from HD. Which nursing care action should the nurse delegate to the UAP? •Measuring vital signs and postdialysis weight •Assessing the HD access site for bruit and thrill •Checking the access site dressing for bleeding •Instructing the patient to request assistance getting out of bed

•Monitoring the client for any form of bleeding •DAT is suggested for all clients with acute coronary syndrome, incorporating aspirin and either clopidogrel or ticagrelor. The major side effect for each of these agents is bleeding. Observe for bleeding tendencies, such as nosebleeds or blood in the stool. Medications will need to be discontinued if evidence of bleeding occurs.

The HCP orders DAT for Ms. S. What is the nurse's *priority* concern for this client? •Reminding the client to do no heavy lifting while hospitalized •Assessing the progression of walking in the halls •Teaching the client to apply oxygen for any shortness of breath •Monitoring the client for any form of bleeding

•Oral temperature of 103.5°F (39.7°C) •The heart rate and blood pressure are slightly increased from admission, and the respiratory rate is slightly decreased. The continued elevation in temperature indicates a probable respiratory tract infection that needs to be recognized and treated.

The UAP checks morning vital signs and immediately reports the following values to the nurse. Which takes *priority* when notifying the HCP? •Heart rate of 96 beats/min •Blood pressure of 160/90 mm Hg •Respiratory rate of 34 breaths/min •Oral temperature of 103.5°F (39.7°C)

•Hold the drug if the client's heart rate is less than 55 beats/min •Atenolol is a beta-blocker drug. Do not give beta-blockers if the pulse is below 55 or the systolic blood pressure is below 100 mm Hg without first checking with the HCP. The beta-blocking agent may lead to persistent bradycardia or further reduction of systolic blood pressure, leading to poor peripheral and coronary perfusion.

The HCP prescribes atenolol 50 mg each morning for Ms. S. Which instruction would the nurse provide for the LPN/LVN assigned to give this drug? •Hold the drug if the client's blood pressure is higher than 100/80 mm Hg •Give the drug if the client's respiratory rate is greater than 30 breaths/min •Hold the drug if the client's heart rate is less than 55 beats/min •Give the drug if the client's blood pressure is less than 90/50 mm Hg

•"Take your hydrochlorothiazide in the morning." •HCTZ is a thiazide diuretic used to correct edema and lower blood pressure, and it should be taken in the morning so that its diuretic effects do not keep the client up during the night. A side effect of HCTZ is loss of potassium, and clients may require potassium supplementation. Captopril is an angiotensin-converting enzyme inhibitor that lowers blood pressure. It is never appropriate to take twice the dose of this drug.

The HCP prescribes captopril 12.5 mg orally twice daily and hydrochlorothiazide (HCTZ) 25 mg orally daily. Which information would the nurse be sure to include when teaching Ms. S about these drugs? •"Take your hydrochlorothiazide in the morning." •"If you miss a dose of captopril, take two tablets next time." •"Avoid foods that are rich in potassium, such as bananas and oranges." •"You should expect an increase in blood pressure with these drugs."

•UAP •Assisting clients with activities of daily living such as feeding is most appropriate to the scope of practice of the UAP. The RN would be sure to instruct the UAP to avoid rushing the client and to report any difficulty with swallowing.

The HCP's prescribed interventions for Mr. R, who had a stroke 4 days ago, include assisting the client with meals. Which staff member would be *best* to assign this task? •Physical therapist •UAP •LPN/LVN •Occupational therapist

•"Keep Mr. R NPO, and I will contact his health care provider." •The client who has difficulty chewing or swallowing foods and liquids (dysphagia) is at risk for aspiration pneumonia. At this time, the best action is to keep the client NPO and contact the HCP. Attempting to give him oral foods, drugs, or fluids increases his risk for aspiration. Assessing his speech and tongue movement is important but not as urgent as keeping him NPO. The client likely will require screening or use of an evidence-based bedside swallowing screening tool to determine if dysphagia is present. A referral to a speech-language pathologist for a swallowing evaluation per stroke protocol is needed. If dysphagia is present, develop a collaborative plan of care to prevent aspiration and support nutrition and prevent constipation or dehydration.

The LPN/LVN reports to the RN that Mr. R was unable to take his oral medications because of difficulty swallowing. The RN assesses Mr. R and finds that he is having dysphagia. What is the RN's *best* instruction for the LPN/LVN? •"Keep Mr. R NPO, and I will contact his health care provider." •"Try giving his medications with applesauce or pudding." •"Check with the pharmacy to find out if they have liquid forms of Mr. R's medications." •"Assess Mr. R's ability to speak and move his tongue."

•"No, but try covering the lead wires with the sheet so that the client does not see them." •Standards of practice for the use of restraints require that nurses attempt alternative strategies before asking that a client be restrained. An HCP's written order is required for continued use of restraints but can be obtained after the fact if the client's actions endanger his or her well-being. Remember that when a client is restrained, a flow sheet should be at the bedside and the restraints frequently assessed (every 1-2 hours) and released (every 2 hours).

The LPN/LVN reports to the RN that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if the client can be restrained. What is the RN's *best* response? •"Yes, this client had a heart attack, and we must keep her on the cardiac monitor." •"Yes, but be sure to use soft restraints so that the client's circulation is not compromised." •"No, we must have a health care provider's order before we can apply restraints in any situation." •"No, but try covering the lead wires with the sheet so that the client does not see them."

•Discontinue the IV infusion •Serious side effects of cefotaxime include rashes, fever, and chills, as well as diarrhea, bruising, numbness, tingling, and bleeding. If the patient is taking this drug as an outpatient, the HCP should be notified immediately. Because the drug is being given IV, the first step would be to stop the infusion. The HCP should be notified, and the patient should be assessed for additional symptoms of a serious reaction to the drug.

The RN administers the patient's first dose of IV cefotaxime. Within 15 minutes, Mr. W develops a rash with fever and chills. What is the nurse's *first* action at this time? •Discontinue the IV infusion •Administer 2 tablets of acetaminophen •Measure the area of the rash •Check for numbness and tingling

•Enlarged neck muscles •Forward bent posture •Inspiratory and expiratory wheezes •Blue-tinged dusky appearance •The presence of wheezes, enlarged neck muscles, bluish dusky appearance, and forward bent posture are all classic manifestations in a patient with COPD. The respiratory rate is usually higher than normal and during an exacerbation can be as high as 30 to 40 breaths/min. Lung expansion in patients with COPD is usually asymmetrical.

The RN assesses Mr. W in the emergency department. Which assessment findings are consistent with a diagnosis of COPD? *Select all that apply.* •Enlarged neck muscles •Forward bent posture •Respiratory rate 15 to 25 breaths/min •Inspiratory and expiratory wheezes •Blue-tinged dusky appearance •Symmetrical lung expansion

•Check the patient's heart rate and blood pressure •Atenolol is a beta-blocker drug with actions that slow the heart rate and decrease the blood pressure. HCPs often have blood pressure (BP) and heart rate (HR) guidelines (e.g., low BP and/or HR) for when to give and when to hold these drugs. The nurse should instruct the patient to call for help getting out of bed when the drug is newly prescribed or if the drug results in dizziness and syncope symptoms. The other instructions and actions may be included in the patient's care but will not affect the administration of atenolol.

The RN team leader assigns the LPN/LVN to give Ms. J's 9:00 am oral medications. Which key instruction or action will be *most* important that the RN give the LPN/LVN regarding administering Ms. J's atenolol 50-mg tablet? •Give this drug with just a few swallows of water •Ask the patient if she has been taking a diuretic at home •Instruct the patient to use the bedside commode •Check the patient's heart rate and blood pressure

•"When did you first notice the chest pain?" •"Did your pain start suddenly or gradually?" •"How long has the chest pain lasted?" •"Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain ever?" •"What were you doing when the chest pain started?" •The RN should thoroughly evaluate the nature of the client's pain. Asking the client when the pain started focuses on the onset. Asking if the pain was sudden or slow in onset deals with the manner of onset. Asking how long the pain has lasted speaks to duration of symptoms. Having the client grade the pain on a scale of 1 to 10 evaluates the intensity. Asking what the client what he or she was doing when the pain started helps delineate factors that can lead to pain onset. Clients do not usually experience confusion or memory loss with cardiac pain.

The RN is assessing Ms. J's chest pain. Which questions would the RN be sure to ask the client? *Select all that apply.* •"When did you first notice the chest pain?" •"Did your pain start suddenly or gradually?" •"How long has the chest pain lasted?" •"Have you experienced confusion or loss of memory with the pain?" •"Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain ever?" •"What were you doing when the chest pain started?"

•Immediate removal of the transplanted kidney •The treatment for hyperacute rejection is immediate removal of the transplanted kidney and return to dialysis until another kidney becomes available. Increased doses of immunosuppressant drugs are used to treat acute rejection, conservative management is used for chronic rejection, and IV antibiotics are administered for infections.

The RN is caring for Ms. J on the first day postoperatively after a kidney transplant. On assessment, her temperature is 100.4°F (38°C), her blood pressure is 168/92 mm Hg, and the patient tells the RN she has pain around the transplant site. What intervention is required at this time? •Increased doses of immunosuppressive drugs •IV antibiotics •Conservative management including dialysis •Immediate removal of the transplanted kidney

•RN delegates fingerstick glucose check to newly hired UAP •The newly hired UAP would need to be taught how to use a glucometer and perform a fingerstick before having this task delegated to him or her. All of the other care tasks are appropriate to the staff members.

The RN is delegating and assigning care for Ms. J related to her type 2 diabetes. Which action by the RN indicates that the team leader needs to intervene? •RN delegates fingerstick glucose check to newly hired UAP •RN assigns administering morning dose of metformin to the LPN/LVN •RN refers the patient to a dietitian for education about a diabetic diet •RN assesses condition of patient's feet daily

•Drawing blood for laboratory studies from the temporary dialysis line •Temporary dialysis lines are to be used only for HD. The preceptor nurse should stop the new nurse before the temporary HD system is interrupted. Breaking into the system increases the risk for complications such as infection. The blood pressure should always be assessed on the nondialysis arm. Postoperative patients should always be monitored for bleeding. Acetaminophen with codeine, when ordered by the HCP, is an appropriate analgesic for moderate to severe pain.

The RN is precepting a new nurse orientating to the unit, who is providing care for Ms. J after her return from surgery to create a left forearm access for dialysis. Which action by the orienting nurse requires that the preceptor intervene? •Monitoring the patient's operative site dressing for evidence of bleeding •Obtaining a blood pressure reading by placing the cuff on the right arm •Drawing blood for laboratory studies from the temporary dialysis line •Administering acetaminophen with codeine PO for moderate postoperative pain

•Allow her to sleep for an hour or two while the other clients are assessed •Because Ms. S is not scheduled to be transferred until after lunch, it is not urgent to get her ready at this time. Allowing her to rest while the staff takes care of other clients whose needs are more urgent is acceptable. The RN could instruct the UAP to keep the client's breakfast tray and warm it up when she is ready to eat.

The RN is the leader of a team providing care for six clients. The team includes the RN, an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP) who is in his fourth week of orientation to the acute care unit. The clients are as follows: -Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning -Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is scheduled for a graded exercise test later today -Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago -Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction, and mild dementia -Mr. B, a 93-year-old newly admitted man from a long-term care facility, with decreased urine output, altered level of consciousness, and an elevated temperature of 99.5°F (37.5°C) -Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema During shift change report, the night RN informs the team that Ms. S is to be transferred back to her long-term care facility after lunch. What action should be taken for this client? •Instruct the UAP to awaken her for vital signs and breakfast •Allow her to sleep for an hour or two while the other clients are assessed •Assign the LPN/LVN to immediately pack up the client's belongings •Call the nursing home to find out if the transfer can wait until tomorrow

•Ms. J •Although it is important that the nurse see all of these clients, Ms. J's assessment takes priority. Her chest pain may indicate coronary artery blockage and acute heart attack. None of the other clients' needs is life threatening.

The RN is the leader of a team providing care for six clients. The team includes the RN, an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP) who is in his fourth week of orientation to the acute care unit. The clients are as follows: -Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning -Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is scheduled for a graded exercise test later today -Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago -Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction, and mild dementia -Mr. B, a 93-year-old newly admitted man from a long-term care facility, with decreased urine output, altered level of consciousness, and an elevated temperature of 99.5°F (37.5°C) -Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema Which client should the RN assess *first*? •Mr. C •Ms. J •Mr. B •Mr. L

•Mr. C •Mr. R •Ms. S •Mr. L •It is important to recognize that the RN continues to be accountable for the care of all clients by this team. Appropriate client assignments for the LPN/LVN include clients whose conditions are stable and not complex. Ms. J is currently experiencing chest pain, and Mr. B is a complex new admission.

The RN is the leader of a team providing care for six clients. The team includes the RN, an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP) who is in his fourth week of orientation to the acute care unit. The clients are as follows: -Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning -Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is scheduled for a graded exercise test later today -Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago -Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction, and mild dementia -Mr. B, a 93-year-old newly admitted man from a long-term care facility, with decreased urine output, altered level of consciousness, and an elevated temperature of 99.5°F (37.5°C) -Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema Which clients should the team leader assign to the LPN/LVN for nursing care, under the RN's supervision? *Select all that apply.* •Mr. C •Ms. J •Mr. R •Ms. S •Mr. B •Mr. L

•Checking vital signs on all six clients •Recording oral intake and urine output for Mr. B •Assisting Mr. L to walk to the bathroom •Helping Mr. R with morning care •Assessment and teaching are more appropriate to the educational preparation of licensed nursing staff. Checking vital signs, monitoring and recording intake and output, assisting clients to the bathroom, and helping clients with morning care are all within the educational scope of the UAP.

The RN is the leader of a team providing care for six clients. The team includes the RN, an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP) who is in his fourth week of orientation to the acute care unit. The clients are as follows: -Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching for a cardiac catheterization scheduled this morning -Ms. J, a 45-year-old woman who had chest pain during the night and is now experiencing chest pain. She is scheduled for a graded exercise test later today -Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago -Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction, and mild dementia -Mr. B, a 93-year-old newly admitted man from a long-term care facility, with decreased urine output, altered level of consciousness, and an elevated temperature of 99.5°F (37.5°C) -Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema Which tasks should the nurse delegate to the newly hired UAP? *Select all that apply.* •Asking Ms. S memory-testing questions •Teaching Ms. J about treadmill exercise testing •Checking vital signs on all six clients •Recording oral intake and urine output for Mr. B •Assisting Mr. L to walk to the bathroom •Helping Mr. R with morning care

•Instruct the patient about proper techniques for using an MDI •The patient is demonstrating improper use of the MDI by taking 2 puffs in rapid succession, which can lead to incorrect dosage and ineffective action of the albuterol. Teaching is the first priority. As the nurse works with this patient, it may be determined that he would benefit from the use of a spacer. Sitting up in a chair may also be useful, but these interventions are not the first priority. Notifying the provider that the patient needs to continue with nebulizer treatments is not within nursing scope of practice and does not address the problem, which is that the patient does not know how to properly use his MDI.

The RN observes the patient's use of the albuterol MDI. The patient takes 2 puffs from the inhaler in rapid succession. Which intervention takes *priority* at this time? •Call the pharmacy to request a spacer for the patient •Notify the provider that the patient will need to continue receiving nebulizer treatments •Ask the UAP to help get the patient into a chair •Instruct the patient about proper techniques for using an MDI

•Serum potassium level of 7.1 mEq/L (7.1 mmol/L) •A patient with a serum potassium level of 7 to 8 mEq/L (7-8 mmol/L) or higher is at risk for electrocardiographic changes and fatal dysrhythmias. The HCP should be notified immediately about this potassium level. Although the serum creatinine and blood urea nitrogen levels are high, these levels are commonly reached before patients experience symptoms of chronic kidney disease (CKD). The serum calcium level is low but not life threatening. Keep in mind that there is an inverse relationship between calcium and phosphorus, so when calcium is low, expect phosphorus to be high.

The RN reviews Ms. J's laboratory results. Which laboratory finding is of *most* concern? •Serum potassium level of 7.1 mEq/L (7.1 mmol/L) •Serum creatinine level of 7.3 mg/dL (645 μmol/L) •Blood urea nitrogen level of 180 mg/dL (64.3 mmol/L) •Serum calcium level of 7.8 mg/dL (1.95 mmol/L)

•"Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment." •Acute chest pain can indicate myocardial ischemia, coronary artery blockage, or myocardial damage. The UAP's question should be answered with the most accurate response. Although the unit may have protocols that the UAP should be familiar with, option 4 is not the most accurate response.

The UAP asks the RN why it is important to notify someone whenever a client with heart problems reports chest pain. What is the RN's *best* response? •"It's important to keep track of the chest pain episodes so we can notify the health care provider." •"The client may need morphine to treat the chest pain." •"Chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment." •"Our unit policy includes specific steps to take in the treatment of clients with chest pain."

•Oral temperature higher than 102°F (38.9°C) •A temperature elevation to 102°F (38.9°C) is likely an indicator of an infectious process. The other criterion parameters are near normal, and assessment or evaluation would instead be based on abnormalities from each client's baseline.

The UAP is delegated the task of measuring morning vital signs for all six clients. Which finding would the nurse instruct the UAP to report *immediately*? •Oral temperature higher than 102°F (38.9°C) •Blood pressure higher than 140/80 mm Hg •Heart rate lower than 65 beats/min •Respiratory rate lower than 18 breaths/min

•"Did you recently use your albuterol inhaler?" •A common side effect of beta-adrenergic agonists such as albuterol is increased heart rate. Drugs such as albuterol are commonly prescribed for clients with COPD to use as needed to dilate the airways when experiencing shortness of breath. Although the other factors are important and may be related to the client's COPD, they may not have contributed to the increase in heart rate.

The UAP reports that Mr. L's heart rate, which was 86 beats/min in the morning, is now 98 beats/min. What would be the *most* appropriate question for the nurse to ask Mr. L? •"Have you just returned from the bathroom?" •"Did you recently use your albuterol inhaler?" •"Are you feeling short of breath?" •"How much do you smoke?"

•Assess oxygen saturation by pulse oximetry •The nurse should gather more information before notifying the HCP. Pulse oximetry assessment provides information about the client's gas exchange and oxygenation status. Clients with chronic obstructive pulmonary disease (COPD) usually receive low-dose oxygen (1-3 L) because their stimulus for breathing is a low oxygen level. Coughing and deep breathing help mobilize secretions and can be helpful, but these are not the first priority.

The UAP reports to the RN that Mr. L, the client with chronic emphysema, says he is feeling short of breath after walking to the bathroom. What action should the RN take *first*? •Notify the HCP •Increase oxygen flow to 6 L/min via nasal cannula •Assess oxygen saturation by pulse oximetry •Remind the client to cough and deep-breathe

•"Remind the patient to take his time and not to rush his morning care." •The patient with COPD often has chronic fatigue and needs help with activities. Teaching the patient not to rush through activities is important because rushing increases dyspnea, fatigue, and hypoxemia. Reminding a patient of what has already been taught is within the scope of practice for a UAP. Patients with COPD should be kept on low-flow oxygen because their stimulus to breathe is a low arterial oxygen level.

The UAP tells the nurse that Mr. W is unable to complete his morning care without assistance and wonders if he is being lazy. What is the nurse's *best* response? •"Encourage the patient to do as much as he can as quickly as he can." •"If the patient is short of breath, increase his oxygen flow." •"Remind the patient to take his time and not to rush his morning care." •"He may not need as much help as he is asking for, so try to get him to do more."

•Contact the HCP to ask if the client should still have the GXT •The client had chest pain during the night and this morning. She may be experiencing acute coronary syndrome, a term used to describe clients who have either unstable angina or an acute myocardial infarction. In this situation, the best action by the RN is to contact the HCP and ask if the client's GXT should be cancelled. Sending her to take the GXT would increase the risk of cardiac damage and should not be done. Asking if the client is still having chest pain is important and may reinforce the need to cancel the test.

The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT). What is the nurse's *best* action? •Instruct the UAP to put the client in a wheelchair and take her to the lab •Call the cardiac lab and ask to delay the test until later in the day •Contact the HCP to ask if the client should still have the GXT •Ask the client if she is continuing to have chest pain

•"The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open." •The nurse's best response should be attentive to and answer the client's question. For the cardiac catheterization, the client is taken to a special lab where the cardiologist uses an invasive catheter with injectable dye to locate and diagnose narrowed sections of coronary arteries. For percutaneous coronary intervention, a catheter is placed with a balloon, which can be inflated to open the narrowed section, and a stent (an expandable metal mesh device) can be left in place to keep the artery opened. Options 1, 3, and 4 do not accurately answer the client's question about the procedure.

The client is scheduled for an emergent cardiac catheterization with possible percutaneous coronary intervention (PCI). Ms. S asks the nurse what is involved with this procedure. What is the nurse's *best* response? •"It is a procedure that is usually done on clients who have heart attacks to diagnose blockages in the arteries that feed the heart." •"The cardiologist will use a catheter to inject dye and locate narrowed arteries, then may inflate a balloon to open the artery and place a stent to keep it open." •"Cardiac catheterization is usually performed on an outpatient basis to determine whether or not you have had a heart attack." •"After the cardiac catheterization, you will come back to the coronary care unit, where you will be on bed rest for 6 to 8 hours, and we will check your vital signs often."

•Check blood pressure and heart rate •When the client experiences chest pain, vital signs should be checked immediately to establish a baseline. Nitroglycerin is usually tried every 5 minutes for three doses before morphine to relieve the chest pain. Hypotension is a side effect of nitroglycerin. Blood pressure and heart rate are monitored after each dose of nitroglycerin is administered. When nitroglycerin fails to relieve chest pain, IV morphine is the next action, and the HCP should be notified.

The health care provider's (HCP's) prescribed actions for Ms. J, who is currently experiencing chest pain, are as follows. Which intervention should be completed *first*? •Administer nitroglycerin 0.6 mg sublingually as needed for chest pain •Administer morphine 2 mg IV push as needed for chest pain •Check blood pressure and heart rate •Lab tests to include cardiac markers and daily electrocardiogram

•Speak to the UAP privately to determine why the values were not recorded •Measuring and recording vital sign values are within the scope of practice of the UAP. When the UAP makes a mistake, it is best to communicate specifically, stressing the importance of recording vital sign values after they have been obtained. Supervision should be done in a supportive rather than confrontational manner. Notifying the nurse manager is not appropriate at this time. Reprimanding the UAP in front of others also is not appropriate.

The nurse delegates to the UAP the task of taking Ms. S's vital signs every 4 hours and recording the vital sign values in the electronic chart. Later the nurse checks the client's chart and discovers that vital sign measurements have not been recorded. What is the nurse's *best* action? •Take the vital signs because the UAP is not competent to complete this task •Notify the nurse manager immediately •Reprimand the UAP at the nurses' station •Speak to the UAP privately to determine why the values were not recorded

•Administer furosemide 20 mg IV push now •Furosemide is a loop diuretic. The uses of this drug include treatment of pulmonary edema, which is most directly related to the new finding. Intake and output records and daily weights are important in documenting the effectiveness of the medication. A side effect of this drug is hypokalemia, and some patients are also prescribed a potassium supplement when taking this medication.

The nurse reports the morning assessment findings (crackles bilaterally) to the HCP. Which prescribed intervention is *most* directly related to the nurse's assessment findings? •Administer furosemide 20 mg IV push now •Keep accurate records of intake and output. •Administer potassium 20 mEq (20 mmol) orally every morning •Weigh the patient every morning

•Bladder infection •The client's temperature elevation indicates an infectious process. For older adult clients, changes in level of consciousness are frequently an early sign of bladder or urinary tract infections.

The oral temperature of Mr. B, the client newly admitted from a long-term care facility with decreased urine output and altered level of consciousness, is now 102.6°F (39.2°C). Which factor does the nurse suspect *most* likely precipitated Mr. B's elevated temperature? •Bladder infection •Increased metabolic rate •Kidney failure •Nosocomial pneumonia

•Notify the HCP •This client's temperature elevation is most likely caused by an infection. The HCP must be notified to modify the client's plan of care. Administering acetaminophen and removing extra blankets may decrease the client's temperature, but they will not treat the infection.

The oral temperature of Mr. B, the client newly admitted from a long-term care facility with decreased urine output and altered level of consciousness, is now 102.6°F (39.2°C). What is the nurse's *best* action? •Notify the HCP •Administer acetaminophen 2 tablets orally •Ask the LPN/LVN to give an acetaminophen suppository •Remove extra blankets from the client's bed

•Creatinine clearance is lower than normal •The normal creatinine clearance is 107 to 139 mL/min for men (1.78-2.32 mL/sec) and 87 to 107 mL/min (1.45-1.78 mL/sec) for women tested with a 24-hour urine collection. A low result indicates that the kidneys are functioning at a lower than expected level. The patient has chronic kidney disease.

The results of Ms. J's 24-hour urine collection reveals a creatinine clearance of 65 mL/min (1.09 mL/sec). How does the nurse *best* interpret this finding? •Creatinine clearance is lower than normal •Creatinine clearance is higher than normal •Creatinine clearance is within normal range •Creatinine clearance indicates adequate kidney function

•Checking vital signs after the patient has had something cold to drink •Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min •Checking vital signs usually includes measuring oral body temperature. Because the patient just finished drinking fluids, an oral temperature measurement would be inaccurate at this time. If the fluids were cold, the temperature would be falsely low; if the fluids were hot, the temperature would be falsely high. Changing the oxygen flow rate without prescription or instruction is not acceptable practice. All of the other actions are appropriate and within the scope of practice of the UAP. A UAP's scope of practice includes reminding patients of content that has already been taught.

The team leader RN observes the UAP perform all of these actions for Ms. J. For which actions must the RN intervene? *Select all that apply.* •Assisting the patient to replace her oxygen nasal cannula •Checking vital signs after the patient has had something cold to drink •Ambulating with the patient to the bathroom and back •Increasing the patient's oxygen flow rate by nasal cannula from 2 to 4 L/min •Washing the patient's back, legs, and feet with warm water •Reminding Ms. J to perform prescribed incentive spirometry every hour while awake

•Monitoring and recording the client's intake and output •Monitoring and recording intake and output are within the scope of practice for UAPs. Initiating telemetry, performing venipuncture, and obtaining ECGs require additional education and training and would not be delegated to a new UAP. Attaching ECG leads may be done by UAPs in some facilities, as may venipuncture and ECG recording. However, the UAPs performing these tasks would require additional specialized training. These actions are generally considered to be within the scope of practice of licensed nurses.

Which action is *best* for the nurse to delegate to a new unlicensed assistive personnel (UAP) orienting to the CCU when caring for Ms. S? •Placing the client on a cardiac telemetry monitor •Drawing blood to test cardiac marker levels and sending it to the laboratory •Obtaining a 12-lead ECG •Monitoring and recording the client's intake and output

•Assist with Ms. S's morning bath •Ambulate with Ms. S to the bathroom •Assist with progressive ambulation in the hall •Cardiac rehabilitation is the process of actively assisting the client with cardiac disease in achieving and maintaining a vital and productive life while remaining within the limits of the heart's ability to respond to increases in activity and stress. It can be divided into three phases. Phase 1 begins with the acute illness and ends with discharge from the hospital. Activities during this phase that could be delegated to a UAP include assisting with morning care such as a bath, assisting a client to the bathroom, and assisting with progressive ambulation in the hall. The nurse would be sure to instruct to UAP to stop any activity that caused chest pain or pressure and report this at once. Referrals, administering drugs, and assessing clients requires additional educational preparation and is suitable for professional nurses.

Which activities could the nurse delegate to UAP assisting Ms. S during phase 1 of cardiac rehabilitation? *Select all that apply.* •Assist with Ms. S's morning bath •Refer Ms. S to a monitored cardiac rehab program •Ambulate with Ms. S to the bathroom •Administer Ms. S's morning doses of captopril and HCTZ •Assist with progressive ambulation in the hall •Assess Ms. S for additional chest pain or pressure

•Patient cough productive of greenish-yellow sputum •The patient's temperature was elevated on admission, and his cough was productive. The changes in Mr. W's sputum could indicate an ongoing infection. The HCP needs to be notified and an appropriate treatment plan started. All of the other pieces of information are important but are not urgent. The patient's incontinence is not new.

Which assessment finding would the nurse instruct the UAP to report *immediately*? •Incontinence of urine and stool • 1-lb (0.45-kg) weight loss since admission •Patient cough productive of greenish-yellow sputum •Eating only half of breakfast and lunch

•Client will be prescribed dual antiplatelet therapy (DAT) •Without stent placement, the artery often reoccludes due to the artery's normal elasticity and memory. Clients who undergo percutaneous coronary intervention are required to take DAT consisting of aspirin and a platelet inhibitor to prevent recurrence of artery blockage, chest pain, and MI. Clients are not kept on bed rest for 24 hours; rather, they are instructed to do no heavy lifting for several days after this procedure, and they are often prescribed a beta-blocker to slow heart rate and lower blood pressure.

Which information is *most* important to prevent recurrence of reocclusion of the coronary artery, chest discomfort, or myocardial infarction (MI)? •Remain on bed rest for the next 24 hours •Client will be prescribed dual antiplatelet therapy (DAT) •Client should do no heavy lifting for 48 hours •HCP will prescribe a beta-blocker

•Increasing oxygen delivery to 2 L/min via nasal cannula •Increasing oxygen flow for a patient based on an HCP's prescription is within the scope of practice of LPN/LVNs. UAPs may measure vital signs. Arterial draws for laboratory tests are not within the LPN/LVN's scope of practice unless they have had additional special training. The RN would need to assess the LPN/LVN's skill before assigning this task. Hand-held nebulizers are usually operated by respiratory therapists.

Which intervention would the RN assign to an experienced LPN/LVN? •Drawing a sample for ABG determination •Administering albuterol by hand-held nebulizer •Measuring vital signs every 2 hours •Increasing oxygen delivery to 2 L/min via nasal cannula

•"You will have to stay almost flat in bed with limited position changes for 4 to 6 hours." •Cardiac catheterization is usually accomplished by inserting a large-bore needle into the femoral vein or artery (or both). Clients are routinely restricted to bed rest, with the affected extremity kept straight, for 4 to 6 hours after the procedure to prevent hemorrhage. Family members are usually permitted to visit as soon as the client returns to the room.

Which key point would the nurse be sure to include when teaching Mr. C about the postprocedure care for cardiac catheterization? •"There are no restrictions after the procedure." •"You will be able to get out of bed within 2 hours after the procedure." •"You will have to stay almost flat in bed with limited position changes for 4 to 6 hours." •"Family visitors will be restricted until the next day."

•Sodium polystyrene sulfonate 15 g PO •Sodium polystyrene sulfonate removes potassium from the body by exchanging sodium for potassium in the large intestine. Diuretics such as furosemide generally do not work well in chronic kidney failure. The patient may need a calcium supplement and subcutaneous epoetin alfa; however, these drugs do nothing to decrease potassium levels.

Which medication should the nurse be prepared to administer to lower the patient's potassium level? •Furosemide 40 mg IV push •Epoetin alfa 300 units/kg subcutaneously •Calcium 1 tablet PO •Sodium polystyrene sulfonate 15 g PO

•Hypertension •Type 2 diabetes •Coronary artery disease (CAD) •Major risk factors for CKD include hypertension and diabetes. CAD has a related pathophysiology to hypertension. Pregnancy, cataracts, and GERD are not risk factors for CKD.

Which risk factors in Ms. J's history indicate increased risk for chronic kidney disease (CKD)? *Select all that apply.* •GERD •Hypertension •Four pregnancies •Type 2 diabetes •Coronary artery disease (CAD) •Cataracts

•Ensuring that all of Ms. J's urine collected for the test is kept on ice •Teaching, instructing, and assessing are all functions that require additional education and preparation appropriate to the scope of practice for professional nurses. Providing the patient with ice for the urine collection and reminding the patient to collect her urine fit the scope of practice of the UAP. Remember that the UAP can remind a patient about anything that has already been taught.

Which task associated with the patient's 24-hour urine collection is appropriate for the nurse to delegate to the UAP? •Instructing Ms. J to collect all urine with each voiding •Teaching Ms. J the purpose of collecting urine for 24 hours •Ensuring that all of Ms. J's urine collected for the test is kept on ice •Assessing Ms. J's urine for color, odor, and sediment

•"Tell me some more about how you are feeling." •The RN should be supportive and nonjudgmental. Listening and encouraging the patient to verbalize her concerns (e.g., grief, feeling of failure) are essential at this time. Asking someone else to come in to talk with the patient is not responding to her concern. Suggesting that she can get on the transplant list again is not acknowledging Ms. J's grief for losing the transplanted kidney.

While making rounds, the RN finds Ms. J in tears and sobbing. She states, "I just don't want to have to go back to dialysis 3 days a week!" What is the nurse's *best* response? •"Would you like me to call someone to come in and sit with you?" •"You can always get on the list for another kidney transplant." •"Tell me some more about how you are feeling." •"Let me call your health care provider to come in and speak with you."