Management Test #1

The client diagnosed with abdominal pain of unknown etiology has a NG tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's ABG values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs?

Check the amount of suction on the client's NG tube.

The ICU nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first?

Check the ventilator to resolve the problem.

The newly hired nurse manager has identified that whenever a specific staff member is unhappy with an assignment, the entire unit has a bad day. Which action should the unit manager take to correct this problem?

Discuss the staff member's attitude and the way it affects the unit.

The hospice nurse is discussing the clients' care with unlicensed assistive personnel (UAP). Which statement contains the best information about caring for a client with end-stage heart failure who is dying?

"Be careful not to promise to withhold healthcare information from the team."

The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first?

Immediately wash the area with soap and water.

The nurse is developing a nursing care plan for a client diagnosed with COPD. What should be the client's priority nursing diagnosis?

Impaired gas exchange.

The client who is 2 days post-op following a left pneumectomy has an apical pulse rate of 128 bpm and a BP of 80/50. Which intervention should the nurse implement first?

Increase the client's IV rate.

In the ICU, the critical care nurse assesses a client diagnosed with an asthma attack who has a respiration rate of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement first?

Increase the oxygen to 10L/min

The clinic nurse is evaluating vital signs for clients being seen in the outpatient clinic. Which client would require nursing intervention?

The 24-week gestational woman who has a BP of 142/96.

Ms. Gail is making shift assignments. Which client should be assigned to the most experienced RN?

The client whose pulse oximeter reading keeps decreasing after receiving high levels oxygen via nasal cannula.

The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first?

Check for any kinks in the tubing.

The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the home health nurse's best response?

This is normal at the end of life; the dehydration produces a type of euphoria.

The healthcare facility where the nurse works uses email to notify the staff of in-services and mandatory requirements. Which is important information for the nurse manager to remember when using email to disseminate information?

Make the email notices quick and easy to read.

The female nurse manager is discussing yearly performance evaluation with a male nurse. Which information regarding communication styles should the nurse manager employ when talking with the employee?

Men often see the work environment from a logical, focused perspective.

The charge nurse on the critical care respiratory unit is evaluating ABG values of several clients. Which client would require an immediate intervention by the charge nurse?

The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23.

The client involved in a motor vehicle accident is being prepped for surgery when the client asks the ED nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmaleficence?

"I will find out for you and let you know after surgery."

The hospice client asks the nurse, "What should I do about my house? My son and daughter are fighting over it." Which statement is the nurse's best response?

"What do you want to happen to your house? It's your decision."

The client has ABG values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement?

Administer oxygen 6L/min via nasal cannula.

The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client's drip rate should be decreased by 100 units per hour. The her pain comes prepared as 25,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should he nurse set the pump?

24 mL per hour

The respiratory unit nurse is calculating the shift intake and output for a client diagnosed with right-sided chest tube. The client has received 1500ml of D5W, IVPB of 100ml of 0.9% NS, 12oz water, 6oz milk, and 4oz chicken broth. The client has had a urinary output of 800ml and chest drainage of 125ml. What is the total intake and output for this client?

2160ml intake, 925ml output.

The client is getting out of bed, becomes very anxious, and has a feeling of impending doom. The nurse reports these findings to Ms. Gail. Which intervention should Ms. Gail tell the nurse to implement first after placing the client in the high-Fowler's position?

Administer oxygen via nasal cannula.

Allow the client to refuse to eat if he wants to.

A 90-year-old male client was recently widowed after more than 60 years of marriage. The client was admitted to a long-term care facility and is refusing to eat. Which intervention is an example of the ethical principle of autonomy?

The client refuses to take deep breaths and cough.

A client is 2 days postoperative abdominal aortic aneurysm repair. Which data require immediate intervention from the nurse?

"I will notify my charge nurse to come and talk to you about the situation."

A client on the vascular unit tells the day shift primary nurse that the night nurse did not answer the call light for almost 1 hour. Which statement would be most appropriate by the day shift primary nurse?

The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time?

A hospice agency.

The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client?

Are you sexually active?

The female charge nurse on the respiratory unit tells the male nurse, "you are really cute and have a great body. Do you work out?" Which action should be taken by the make nurse if he thinks he is being sexually harassed?

Ask the charge nurse to stop making comments like this.

In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse?

Ask the staff member not to discuss anything about the client.

The clinic nurse encounters a client who does not respond to verbal stimuli and initiates CPR. What should the nurse do? Prioritize the nurse's actions from first to last.

Assess the client for unresponsiveness. Perform compressions at a 30:2 rate. Open the client's airway. Pinch the nose and give 2 breaths. Check the client's carotid pulse.

The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first to last.

Assess the client's lung sounds. Make sure that the chest tube is securely taped. Check the chest tube dressing for drainage. Note the amount of suction being used. Place a bottle of sterile saline at the bedside.

The client with a right-sided chest tube is complaining of pain rated 6 on a pain scale of 1 to 10. Which intervention should the nurse implement first?

Assess the client's respiratory status and chest tube insertion site.

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse?

Auscultate the client's posterior breath sounds.

At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client's chart. Which is the most appropriate response by the charge nurse?

Call the lab and have the lab supervisor talk with the HCP.

The hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take?

Continue to allow the husband to answer the wife's questions.

The client in the ICU is on a ventilator. Which interventions should the nurse implement?

Ensure there is a manual resuscitation bag at the bedside. Assess the client's respiratory status every 2 hours. Check the ventilator settings every 4 hours. Collaborate with the respiratory therapist.

The nurse is working with a LPN and a UAP to care for a group of clients. Which nursing task should not be delegated or assigned?

Evaluating the client's progress

Which task is most appropriate for the home health nurse to delegate to the UAP?

Getting the client up in a chair three times a day.

The nurse is teaching the parents of a child diagnosed with CF. Which information is priority to teach the parents?

Give pancreatic enzymes with every meal.

The UAP is bathing the client diagnosed with adult acute respiratory distress syndrome who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take?

Give the UAP praise for performing the bath safely.

The UAP tells the clinic nurse that the male client in room 1 is "really breathing hard and can't seem to catch his breath." Which instruction should the nurse give to the UAP?

Go with the nurse to the client's room.

The ED nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure?

Have the client sit upright and bend over the bed table.

The client's ABG results are pH 7.34, PaCO2 50, HCO3 24, PO2 87. Which intervention should the nurse implement first?

Have the client turn, cough, and deep breathe.

The 92-year old client has a hospital bed in the home and is on strict bed rest. The UAP cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse?

I don't give her a lot of fluids so she won't wet the bed.

The UAP enters the elderly female client's room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP?

Instruct the UAP to give the bath after the program.

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is the most important for the nurse to ask the client?

Is there any chance you may be pregnant?

The home health nurse is visiting the client diagnosed with end-stage COPD while the UAP is providing care. Which action by the UAP would warrant intervention by the nurse?

Keeping the bedroom at a warm temperature.

The client who is 1 day post-op following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first?

Notify the rapid response team.

The husband of a client diagnosed with terminal lung cancer asks the nurse "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate?

Notify the social worker about the husband's concerns.

The client diagnosed with a community-acquired pneumonia is being admitted to the unit. Which HCP order should be implemented first?

Obtain a sputum specimen for culture and sensitivity.

The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority?

Obtain a tracheostomy tray for a client who is exhibiting air hunger.

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider's order should be implemented first?

Obtain sputum for gram stain and culture.

Which tasks are appropriate to assign to the UAP? Select all that apply.

Perform mouth care on the client with pneumonia. Take the empty blood bag back to the laboratory.

Ms. Gail is discussing the care of a client with a right-sided chest tube secondary to a pneumothorax with a graduate nurse. Which interventions should Ms. Gail discuss with the graduate nurse? Select all that apply.

Place the client in the high-Fowler's position. Ensure the tubing has no dependent loops. Mark the collection chamber for drainage every shift.

The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?

Place the client in the orthopedic position.

The client in the ICU has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next?

Placement of a tracheostomy.

The client diagnosed with acute respiratory distress syndrome is having increased difficulty breathing. The ABG indicates an arterial oxygen level of 54% on O2 at 10L/min. Which intervention should the ICU nurse implement first?

Prepare the client for intubation.

The clinic nurse is scheduling a 14-year-old for a tonsillectomy. Which intervention should the clinic nurse implement?

Request the lab to draw a PT and PTT.

While the nurse is caring for a client on a ventilator the ventilator alarm sounds. What is the first action taken by the nurse?

Silence the ventilator alarm.

The client is admitted to the ED with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first?

Start 2 IVs with large-bore catheters.

The client in a critical care unit died. What action should the nurse implement first?

Stay with the significant other.

The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement?

Tell the LPN to notify the clinic healthcare provider (HCP)

The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)?

Tell the UAP to answer the other call lights on the unit

The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won't go to the hospital. Which action should the nurse implement first?

Tell the wife to have the client chew an aspirin.

The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form?

The 39-year-old client diagnosed with paranoid schizophrenia.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?

The 75-year-old client scheduled for a cardiac catheterization

Which client should the medical unit nurse assess first after receiving the shift report?

The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless.

The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization?

The Commission reviews facilities for compliance with standards of care.

Which medication should he nurse administer first after receiving the morning shift report?

The IVPB antibiotic to the client with endocarditis admitted at 0530 today.

The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel. Which delegation task warrants intervention by the charge nurse of the cardiac unit?

The UAP is told to feed a client who is dysphagic.

One of Ms. Gail's staff nurses is preparing to administer morning medications to clients. Which medication should the nurse question administering to the client?

The aminoglycoside antibiotic to the client with an elevated trough level.

The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering?

The anti platelet ticlopidine (Ticlid) to a client being prepared for surgery.

The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?

The antidysrhythmic to the client in ventricular fibrillation.

The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?"Which statement is the nurse's best response?

The best way to prevent getting influenza is get a yearly flu vaccine.

Tell the supervisor that he or she is concerned about the unsafe assignment.

The charge nurse in the vascular intensive care unit assigns three clients to the staff nurse. The staff nurse thinks this is an unsafe assignment. Which action should the staff nurse implement first?

"It can be difficult when a client dies. Would you like to take a break?"

The charge nurse observes the unlicensed assistive personnel (UAP) crying after the death of a client. Which is the charge nurse's best response to the UAP?

The client with an above the knee amputation who needs a full body lift to get in the wheelchair.

The charge nurse of a long-term care facility is making assignments. Which client should be assigned to the most experienced unlicensed assistive personnel (UAP)?

Continue to perform the charge nurse's other duties.

The charge nurse on a vascular postsurgical unit observes a new graduate telling an elderly client's spouse not to push the client's patient-controlled analgesia (PCA) pump button. Which action should the charge nurse implement.

Place the client on oxygen.

The client complains of chest pain on deep inspiration. Which intervention should the nurse implement first?

The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication?

The client complains of painful leg cramps.

The nurse is assessing clients on a respiratory unit. Which client should be the nurse's first priority?

The client diagnosed with CF who has a pulse oximeter reading of 91%.

"Could you come to the hospital? The client is not doing well."

The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse most notify the significant other. Which statement made by the nurse is the best over the telephone?

Which client warrants immediate intervention by the nurse?

The client diagnosed with atherosclerosis who has slurred speech and drooling.

Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation?

The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing.

The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first?

The client diagnosed with chronic atrial fibrillation who is having chest pain.

Which client should the telemetry nurse assess first after receiving the a.m. shift report?

The client diagnosed with congestive heart failure who has pink, frothy sputum.

Which client should the charge nurse assign to the new graduate on the respiratory unit?

The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine.

The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective?

The client has bilateral breath sounds.

Call a time out until clarifying which leg is having the vein ligation.

The client in the day surgical unit is scheduled to have vein ligation on the right leg. The client states, "I am having surgery on my left leg." Which intervention should the nurse implement first?

50 drops per minute

The client on a surgical unit is scheduled to receive an antibiotic piggyback over 1 hour. The piggyback is prepared in 150 mL of solution. At what rate should the nurse set the piggyback if the administration set delivers 20 drops per mL?

Which client should Ms. Gail assign to the LPN?

The client who had a laryngectomy 2 days ago and has crepitus.

The clinic nurse is reviewing lab results for a client seen in the clinic. Which client requires additional assessment by the nurse?

The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%.

The charge nurse in the ICU asks a nurse to float from the med-surg unit to the ICU. Which client should the charge nurse assign to the float nurse?

The client who is diagnosed with bacterial pneumonia.

Ms. Gail is making client assignments. Which client should Ms. Gail assign to the LPN?

The client who is scheduled for a bronchoscopy to rule out lung cancer.

The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select all that apply.

The client who will be moved to the ICU when a bed is available. The client who is on multiple IV medications needed to be titrated.

Ms. Gail and the UAP are caring for the following clients. Which information provided by the UAP requires immediate intervention by Ms. Gail?

The client with a left-sided pneumothorax has 200ml of blood in the collection chamber of the Pleuravac.

The nurse is working in an outpatient clinic along with a LPN. Which client should the nurse assign to the LPN?

The client with acute bronchitis who has a chronic clear mucous cough and low fever.

Which client requires the immediate attention of the ICU nurse?

The client with acute respiratory distress syndrome who has difficulty breathing.

The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?

The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights.

The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first?

The elderly client with pneumonia who reports being dizzy when getting up.

2,050 mL

The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 950 mL of D5W, 2 IVPB of 100 mL of 0.9% NS, 16 ounces of water, 8 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 2,200 mL. What is the total intake for this client?

Tell the client she will go with him to discuss his decision with the doctor.

The male client with peripheral vascular disease tells the nurse, "I know my foot is really bad. My doctor told me I don't have any choice and I must have an amputation, but I don't want one." Which action supports the nurse being a client advocate?

Elevate the leg of the client who is one day postoperative femoral-popliteal bypass.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a vascular unit. Which task should the nurse delegate to the UAP?

1. Apply pressure directly to the bleeding site. 2. Assist the client to a recumbent position in the bed. 3. Redress the site with a sterile dressing. 4. Notify the surgeon of the fall and the bleeding. 5. Make out an occurrence report and document the fall.

The male post-op femoral popliteal client notifies the desk via the intercom system he has fallen and is now bleeding. Which interventions should the nurse implement? Rank in order of performance.

Plan to allow the daughter to see the client in the room.

The matriarch of a family has died on the vascular unit. The family tells the nurse the daughter is coming to the hospital from a nearby city to see the body. Which intervention should the nurse implement?

The client with varicose veins who is complaining of deep, aching pain of the legs.

The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse?

The client with deep vein thrombosis who is refusing to stay in bed.

The nurse has just received the a.m. shift report.. Which client would the nurse assess first?

The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of effective group process?

The nurse involves all committee members in the discussion.

Stop the transfusion at the hub.

The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?

Report the situation to the Adult Protective Services.

The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arms. The client states she fell on an ashtray and doesn't want to talk about it. Which nursing intervention is priority?

"I take a baby aspirin every day at breakfast."

The nurse is admitting a client diagnosed with deep vein thrombosis (DVT) in the right leg. Which statement by the client warrants immediate intervention by the nurse?

The nurse keeps the client's undershirt on during the bath.

The nurse is admitting a client with an abdominal aortic aneurysm who is am ember of the Church of Jesus Christ of Latter-Day Saints (Mormon). Which action by the nurse indicates cultural sensitivity to the client?

The client in the post-anesthesia care unit has noisy and irregular respirations with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first?

Tilt the head back and push forward on the angle of the lower jaw.

20 mL/hour

The nurse is caring for a client receiving heparin sodium via constant infusion. This heparin protocol reads to increase the IV rate by 100 units/hour if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 20 mL per hour. At what rate should the nurse set the pump?

The home health client is diagnosed with chronic obstructive disease. The UAP tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP?

To allow the client to sleep in a recliner.

The client who is 1 day postoperative abdominal aortic aneurysm who is complaining of numbness and tingling of both feet.

The nurse is caring for clients on a vascular surgical floor. Which client should be assessed first?

Request the UAP to elevate the feet of the client with chronic venous insufficiency.

The nurse is caring for clients on a vascular unit. Which nursing task is most appropriate to delegate to an unlicensed assistive personnel (UAP)?

1. Have the client sign the permit to receive blood products. 2. Start an IV access with normal saline at a keep-open rate. 3. Obtain the unit of blood from the blood bank. 4. Check the unit of blood with another nurse at the bedside. 5. Initiat th transfusion at a slow rate for 15 minutes.

The nurse is preparing to administer a unit of packed red blood cells to an elderly client who is 1 day postoperative abdominal aortic aneurysm. Which interventions should the nurse implement? List in order of performance.

"My legs were so cold I had to put a heating pad on them."

The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants immediate intervention by the nurse?

Change the blood administration set. Check the client's current vital signs.

The nurse is preparing to administer the third unit of packed red blood cells (PRBCs) to a client with a ruptured aortic aneurysm. Which interventions should the nurse implement? Select all that apply.

"I must wear knee-high stockings."

The nurse is teaching the client diagnosed with arterial occlusive disease. Which statement indicates the client needs more teaching?

The client who is 6 hours post-op vein ligation who has absent pedal pulses.

The nurse just received the a.m. shift report. Which client should the nurse assess first?

Tell the LPN this medication cannot be crushed.

The nurse observes an LPN crushing nifedipine (Procardia XL) before administering the medication to a client with arterial hypertension who has difficulty swallowing pills. Which intervention should the nurse implement first?

The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated on the emergency department?

The nurse who just transferred from critical care to the cardiac unit.

Check with the client to see whether or not the client wants to go to a hospital.

The nursing staff confronts the hospice nurse overseeing the care of a client in a long-term care facility. The nursing staff wants to send the client who is diagnosed with gangrene of the left leg secondary to peripheral occlusive disease to the hospital for treatment. Which intervention should the nurse implement first?

The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first?

The patient diagnosed with a DVT who is requesting an anti-anxiety medication.

Collect data.

The unit manager on the vascular unit is planning a change in the way post-mortem care is provided. Which is the first step in the change process?

The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first?

The respiratory therapist.

"You should look to find out how much money was used for the study."

The staff nurse on a vascular disorder unit asks the charge nurse, "What should I be looking for when I read a research article?" Which response indicates the charge nurse does not understand how to read a nursing research article?

The UAP is cutting the client's toenails after soaking the client's feet in tepid water.

The unlicensed assistive personnel (UAP) is caring for a client diagnosed with chronic venous insufficiency. Which action should warrant immediate intervention from the nurse?

The client with a right above-the-knee amputation who is complaining of right foot pain.

Which client should the nurse assess first after receiving the shift report?

The client with lymphedema whose ABG results are pH 7.33, PaO2 89, PaCO2 47, HCO3 25.

Which client should the nurse on the vascular unit assess first after receiving the shift report?

The nurse's ability to organize the work. The ability of the nurse to interact with others. The quality of care the nurse provides. The nurse's willingness to be a preceptor.

Which of the staff nurse's personal attributes is an important consideration for the unit manager when discussing making an experienced nurse a preceptor fo new graduates? Select all that apply.

The client diagnosed with active tuberculosis tells the public health nurse, "I am not going to take any more medications. I am tired of them." Which statement is the nurse's best response?

You must take your TB medications. It is not an option.

Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client.

The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate?

Report this behavior to the clinic's director of nurses immediately.

The clinic nurse overhears another staff nurse telling the pharmaceutical representative, "If you bring us lunch from the best place in town, I will make sure you get to see the HCP." Which action should the clinic nurse take?

Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing?

Inform the agency of the times of the client's scheduled visits

The nurse is preparing to administer two units of PRBCs to a client diagnosed with congestive heart failure (CHF). Which HCP order should the nurse question?

Administer each unit over 2 hours

The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse?

"I drink grapefruit juice every morning with my breakfast."

The nurse delegates post-mortem care to the unlicensed assistive personnel (UAP). The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP?

"It can be uncomfortable. I will go with you and show you what to do."

The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurses's best response?

"You should not go out with him as long as she is a client of our agency."

The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first?

Place sublingual nitroglycerin 1/150 g under the tongue

The nurse on the cardiac unit is discussing case management with a client who asks "Why do I need a case manager for my heart disease?" Which statements are most appropriate for the nurse to respond? Select all that apply

1) "Case management helps contain the costs of your healthcare." 2) "It will help enhance your quality of life with a chronic illness." 3) "It decreases the fragmentation of care across many healthcare settings." 4) "We try to provide quality care along the healthcare continuum."

While ambulating int he hallway with the nurse, the client diagnosed with myocardial infarction complains of chest pain. Which interventions should the nurse implement? Select all that apply

1) Administer nitroglycerin 0.4 mg sublingual STAT 2) Take the client's vital signs. 3) Place the client on supplemental oxygen

The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance.

1) Draw up the medication in a tuberculin syringe. 2) Dilute the medication with normal saline. 3) Check the client's identification band. 4) Clamp the primary tubing distal to the port. 5) Administer the medication over 5 minutes.

The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply

1) Notify the healthcare provider (HCP) if the client gains more than 2 lbs in one day. 2) Keep the head of the bed elevated when sleeping. 3) Teach the client which foods are high in sodium and should be avoided. 4) Perform isotonic exercises at least once a day.

The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement. Rank in order of priority.

1) Obtain informed consent for the unit of blood from the client. 2) Assess the client's vital signs and lung sounds, and assess for a rash. 3) Initiate Y-tubing with normal saline via an 18-gauge angiocatheter. 4) Check the unit of blood and the client's blood band with another nurse. 5) Infuse the unit of blood at 20 gtts/min the first 15 minutes.

The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority

1) The 29-year-old client diagnosed with septicemia who called to require more blankets because of being cold. 2) The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually 3)The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 4) The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday 5) The 37-year-old who has a Stage 4 pressure sore and the dressing needs to be changed this morning.

The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first?

Place the client on a telemetry monitor and assess the client.

The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement?

Continue to care for the client's needs as usual.

The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering?

Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L.

The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first?

Discontinue the client's vasoconstrictor, dopamine.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task shouldn't be assigned to the LPN?

Assess the client diagnosed with stage IV heart failure

The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement?

Assess the client's support system

The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse?

Assign a UAP to complete the a.m. care.

The client is diagnosed with end-stage congestive heart failure. The nurse find the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first?

Assist the client to a sitting position.

The home health (HH) nurse is caring for an elderly client. Which nursing task should the nurse delegate to the HH aide?

Assist the client to sit on the front porch.

The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP?

Assist the client to take a sponge bath.

Notify the clinic HCP immediately.

The clinic nurse is assessing a client who is complaining of right leg calf pain. The right calf is edematous and warm to the touch. Which intervention should the nurse implement first?

The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first?

Change the sharps container as per clinic policy

The nurse assess erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?

Check the client's telemetry leads.

The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive-heart failure who is on a low-sodium diet is complaining that the food in inedible. Which intervention should the nurse implement first?

Check to see what the client has eating in the past 24 hours.

The cardiac clinic nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the front office area. Which action should the clinic nurse implement?

Explain to the UAP, in private, that this is an inappropriate comment and violates HIPPA.

The elderly client on the cardiac unit was found on the floor by the bed. Which information should the nurse document in the client's chart?

Found on floor. No complaints of pain. Able to move all extremities.

The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP?

Get the client's medical record and bring them to the client's room.

The nurse and the UAP enter the client's room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first?

Instruct the UAP to get the crash cart

The client on the cardiac unit is has a cardiac arrest. Which is the administrative supervisor nurse's first intervention during the code?

Make sure all the jobs are being done.

The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first?

Obtain the latest PTT results on the client with a heparin drip.

The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client's family is at the bedside. Which intervention should the HH nurse implement first?

Pronounce the client's death

The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?

Provide the case manager with any information that is required for continuity of care.

The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement?

Refer the client to a cardiac rehabilitation unit

The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first?

Review the client's referral form/pertinent data.

The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer?

Sit with the client while he or she reminisces about life experiences.

The husband of a client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, " My wife is not breathing." Which intervention should he nurse implement first?

Stay with the client and her husband

The female family member of the client experiencing cardiac arrest refuses to leave the client's room. Which intervention should the administrative supervisor implement?

Stay with the family member and explain what the team is doing.

The nurse at a disaster site is triaging victims when a woman states "I am a certified nurse aide. Can I do anything to help?" Which action should the nurse implement?

Tell the woman to try and keep the victims calm.

The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 am to 7:00 pm shift. Which conflict resolution uses a win-win strategy?

The charge nurse discovered that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 am to 9:00 pm shift.

"Be sure to show me any lab information that is called in to the unit."

The charge nurse on a vascular unit is working with a new unit secretary. Which statement concerning laboratory data is most important for the charge nurse to tell the unit secretary?

The client whose platelet count is 65,000 per milliliter of blood.

The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse?

The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first?

The client diagnosed with angina who is reporting chest pain.

The charge number on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse?

The client diagnosed with fulminant pulmonary edema.

The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication?

The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?

The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.

The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse?

The client who has serum digoxin level of 2.6 mg/dL

Which client should the cardiac nurse first assess after receiving the p.m. shift report?

The client who is crying after being informed of a terminal diagnosis

The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse?

The client who is showing multifocal premature ventricular contractions (PVCs).

The hospice nurse is triaging phone calls from clients. Which client should the nurse call first?

The client whose pain is not being controlled with the current medications.

The surgical nurse is admitting a client having heart surgery to the operation groom. Which information would require the nurse to call a time-out?

The consent form states mitral valve replacement and the client states aortic valve replacement.

The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy?

The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly.

Place oxygen on the client via nasal cannula.

The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first?

Assess the client for abnormal bleeding.

The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first?

Retake the BP and inform the client of her BP reading.

The female client tells the charge nurse the unlicensed assistive personnel (UAP) did not know how to take her blood pressure. Which action should the charge nurse implement first?

"You should inform the clinic's director of nurses."

The female unlicensed assistive personnel (UAP) tells the clinic nurse, "One of the medical interns asked me out on a date. I told him no but he keeps asking." Which statement is the nurse's best response?

Determine whether there is a fire in the clinic.

The fire alarm starts going off in the family practice clinic. Which action should the nurse take first?

Clean the dog bite with soap and water and apply antibiotic ointment.

The home health (HH) nurse enters the yard of a client and is bitten on the leg by the client's dog. Which intervention should the nurse implement first?

Contact the local fire department to see if they can provide smoke detectors for the client.

The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home. The client tells the nurse they just cannot afford them. Which action should the nurse implement first?

Contact the client and ask whether or not she has any abnormal bleeding.

The home health (HH) nurse in the office is notified the female client on warfarin (Coumadin), an oral anticoagulant, has an International Normalized Ratio (INR) of 3.8. Which action should the HH nurse implement first?

Explain the need for the client to take antihypertensive medications as prescribed.

The home health (HH) nurse is caring for a client with arterial hypertension who has had a cerebrovascular accident. Which priority intervention should the nurse discuss with the client when teaching about arterial hypertension?

Provide indwelling catheter care to a client on bed rest.

The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate?

Demonstrate the procedure for applying the SCDs.

The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take?

Read back the order to the HCP before hanging up the phone.

The nurse calls the HCP for an order for pain medication for a client who is 2 days postoperative aortic aneurysm repair. The HCP gives the nurse an order for "Demerol 50 mg IVP now and then every 4 hours as needed." Which action should the nurse implement first?

"The UAP will be practicing on my brand-new nursing license."

The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching?

The client on strict bed rest who is complaining of calf pain and has a reddened calf.

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first?

The client with a deep vein thrombosis who is complaining of dyspnea and coughing.

The nurse has received the shift report. Which client should the nurse assess first?

Hang the bag of heparin for a client diagnosed with a pulmonary embolus.

The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN?

The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT).

The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse?

The review-of-literature article that cited numerous studies supporting the product.

The nurse is revving the literature to identify evidence-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse's proposal for a change in the procedure?

Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8.

The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering?

Don non-sterile gloves on both hands.

The occupational nurse is caring for the client who just severed two fingers from the right hand. Which intervention should the occupational nurse implement first?

Assess the client's cardiovascular status.

The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first?

The UAP checked to make sure the client's toes were warm after putting the stockings on.

Which action by the unlicensed assistive personnel (UAP) indicates to the nurse the UAP understands the correct procedure for applying compression stockings to the client recovering from a pulmonary embolus?

The client receiving digoxin who has a digoxin level of 2.6

Which laboratory data should the nurse in the long term care unit notify the healthcare provider about?

The PO pentoxifylline (Trental) to the client who has intermittent claudication.

Which medication is most appropriate for the nurse to assign to the LPN to administer?