Management of Care
Can unlicensed assistive personal assist with patient position change?
Yes
Place in order: 1. Bulb suction excessive mucus. 2. Assess newborn's airway and breathing. 3. Assess newborn's heart rate. 4. Administer sterile ophthalmic ointment containing 0.5% erythromycin. 5. Place identification bands on newborn and mom.
1. Assess newborn's airway and breathing. 2. Bulb suction excessive mucus. 3. Assess newborn's heart rate. 4. Place identification bands on newborn and mom. 5. Administer sterile ophthalmic ointment containing 0.5% erythromycin.
Which is best to take of telemetry? 1. Pacemaker with history of heart failure. 2. Colon resection with new onset a-fib. 3. Status post CABG with atrial flutter. 4. Chest pain with history of heart failure.
1. Pacemaker with history of heart failure.
Who oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
Case manager
What task by the RN should be performed first? 1. Changing a burn dressing that is scheduled every four hours. 2. Administering scheduled IV antibiotic. 3. Teaching a new diagnosed diabetic about diet and exercise. 4. Assessing a newly admitted client.
4. Assessing a newly admitted client. It is important to initiate the assessment and physical within one hour of being admitted to the unit or floor.
What department is responsible for specialized eating utensils for patients?
occupational therapy
Where should large amounts of patient cash be held?
In the hospital safe
A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.
Safe home environment
Who often performs the responsibilities of a case manager 1. Physical therapist 2. Social worker 3. Primary healthcare provider 4. Nurse 5. Unlicensed assistive personnel
2. Social worker 4. Nurse
Order the following: 1. UAP reports a heart rate of 40/min in a client. 2. The water seal chamber is empty in a client's closed chest drainage unit. 3. Client's tracheostomy needs to be suctioned. 4. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. 5. Client reporting urinary frequency and dysuria.
1. Client's tracheostomy needs to be suctioned. 2. The water seal chamber is empty in a client's closed chest drainage unit. 3. UAP reports a heart rate of 40/min in a client. 4. Client who is on bedrest due to a deep vein thrombus attempting to get out of bed. 5. Client reporting urinary frequency and dysuria.
A client with a history of peptic ulcer disease arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Which primary healthcare provider prescription will the nurse perform first? 1. Initiate oxygen at 2 liters/nasal cannula. 2. Start an IV of NS at 150 ml/hr. 3. Insert NG tube to low suction. 4. Attach client to the ECG monitor.
1. Initiate oxygen at 2 liters/nasal cannula. The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because of decreased blood volume.
A charge nurse is caring for clients when a new admit arrives on the unit. What action by the charge nurse is most appropriate? 1. Instruct the unlicensed assistive personnel (UAP) to complete emptying the catheter bag, and assess the new admission. 2. Send the UAP to take VS on the new admit and begin the history until she can get there. 3. Assign the new nurse on the floor to initiate the assessment process. 4. Ask the unit secretary to make the client and family comfortable until she can complete her present task.
3. Assign the new nurse on the floor to initiate the assessment process. The nurse is the only one who can assess.
A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.
3. Remove the occlusive dressing. The client has developed a tension pneumothorax as evidenced by these signs/symptoms. By removing the occlusive dressing the pressure pushing to the opposite side of the chest will stop.
The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40; arterial BP 98/44; oxygen saturation 82%; cardiac monitor sinus tachycardia at 138. What action should the nurse take 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 setting to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds.
4. Auscultate lung sounds. When an alarm sounds, the first action by the nurse should be to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary.
A nine year old child with ADHD is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with? 1. Ten year old with Crohn's disease. 2. Eight year old with a history of seizures. 3. Six year old admitted with asthma. 4. Seven year old with a urinary tract infection.
4. Seven year old with a urinary tract infection. It would be best to pair this child with the child with a urinary tract infection. They are close to the same age and this child's condition does not require a quiet environment that could be interrupted by a hyperactive child.