PDM: Chapter 3

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? 1. Assess the client for abnormal bleeding. 2. Instruct the client to stop taking the aspirin. 3. Recommend the client take an enteric-coated aspirin. 4. Instruct the client to notify the HCP.

1. Assess the client for abnormal bleeding.

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? 1. Clean the dog bite with soap and water and apply antibiotic ointment. 2. Obtain the phone number and contact the client's veterinarian. 3. Contact the HH care agency and complete an occurrence report. 4. Ask the client whether the dog has had all the required vaccinations.

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

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? 1. Collect data. 2. Identify the problem. 3. Select an alternative. 4. Implement a plan.

1. Collect data.

The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is refusing to eat the high protein meal. 2. The client with varicose veins who is refusing to wear thromboembolic hose. 3. The client with arterial occlusive disease who is refusing to elevate their legs. 4. The client with deep vein thrombosis who is refusing to stay in the bed.

1. The client with a venous stasis ulcer who is refusing to eat the high protein meal.

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? 1. Purchase at least one smoke detector for the client's home. 2. Notify the HH care agency social worker to discuss the situation. 3. Ask the client whether a family member could buy a smoke detector. 4. Contact the local fire department to see if they can provide smoke detectors for the client.

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

. Which medication is most appropriate for the nurse to assign to the LPN to administer? 1. The intravenous push antiemetic to the client who is nauseated and vomiting. 2. The subcutaneous low-molecular-weight heparin to the client with a pulmonary embolus. 3. The PO pentoxifylline (Trental) to the client who has intermittent claudication. 4. The sublingual nitroglycerin to the client who is complaining of chest pain.

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

The nurse is caring for clients on a vascular surgical floor. Which client should be assessed first? 1. The client who is 2 days postoperative right below-the-knee amputation who has phantom pain in the right foot. 2. The client who is 1 day postoperative abdominal aortic aneurysm who is complaining of numbness and tingling of both feet. 3. The client with superficial thrombophlebitis of the left arm who is complaining of tenderness to the touch. 4. The client with arterial occlusive disease who is complaining of calf pain when ambulating down the hall.

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

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? 1. Notify the clinic HCP immediately. 2. Ask the client how long the leg has been hurting. 3. Complete a neurovascular assessment on the leg. 4. Place the client's right leg on two pillows.

1. Notify the clinic HCP immediately.

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? 1. Plan to allow the daughter to see the client in the room. 2. Take the client to the morgue for the daughter to view. 3. Request the family call the daughter and tell her not to come. 4. Explain to the daughter that the unit is too busy for family visitation.

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

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? 1. Provide indwelling catheter care to a client on bed rest. 2. Evaluate the client's 8-hour intake and output. 3. Give a bath to the client who is third-spacing. 4. Administer a cation-exchange resin enema to a client

1. Provide indwelling catheter care to a client on bed rest.

Which client should the nurse assess first after receiving the shift report? 1. The client with a right above-the-knee amputation who is complaining of right foot pain. 2. The client with arterial hypertension who is complaining of a severe headache. 3. The client with lymphedema who has 4+ pitting edema of the left lower leg. 4. The client with gangrene of the right foot who has a foul-smelling discharge.

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

Which client should the nurse on the vascular unit assess first after receiving the shift report? 1. The client with lymphedema whose ABG results are pH 7.33, PaO2 89, PaCO2 47, HCO3 25. 2. The client with Raynaud's phenomenon who has bluish cold upper extremities. 3. The client with chronic venous insufficiency who has an ulcerated area on the right foot. 4. The client receiving intravenous heparin infusion who has a PTT on 78.

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

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. Tell the UAP to obtain the glucometer reading of the client who is dizzy and lightheaded. 2. Request the UAP to elevate the feet of the client with chronic venous insufficiency. 3. Ask the UAP to take the vital signs of the client who has numbness of the right arm. 4. Instruct the UAP to administer a tap water enema to the client with an aorta aneurysm.

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

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? 1. Refuse to take the assignment and leave the hospital immediately. 2. Tell the supervisor that he or she is concerned about the unsafe assignment. 3. Document his or her concerns in writing and give it to the supervisor. 4. Take the assignment for the shift but turn in his or her resignation.

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

The nurse is teaching the client diagnosed with arterial occlusive disease. Which statement indicates the client needs more teaching? 1. "I will wash my legs and feet daily in warm water." 2. "I should buy my shoes in the afternoon." 3. "I must wear knee-high stockings." 4. "I should not elevate my legs."

3. "I must wear knee-high stockings."

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 bilateral sequential compression devices to the client with deep vein thrombosis. 2. Accompany the client with thromboangiitis obliterans outside to smoke a cigarette. 3. Elevate the leg of the client who is one day postoperative femoral-popliteal bypass. 4. Perform Doppler studies on the client with right upper extremity lymphedema.

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

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? 1. Assess the client who will be transferred to the medical unit in the morning. 2. Administer a unit of blood to the client who is 1 day postoperative. 3. Hang the bag of heparin for a client diagnosed with a pulmonary embolus. 4. Assist the HCP with the insertion of a client's Swan-Ganz line.

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

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)? 1. The client with arterial occlusive disease who must dangle the legs off the side of the bed. 2. The client with congestive heart failure who is angry about the family not visiting. 3. The client with an above the knee amputation who needs a full body lift to get in the wheelchair. 4. The client with Buerger's disease who is particular about the way things are done.

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

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? 1. Notify the healthcare provider immediately. 2. Have the UAP recheck the client's vital signs manually. 3. Place the client in Trendelenburg position. 4. Assess the client's cardiovascular status.

4. Assess the client's cardiovascular status.

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? 1. Have the client sign the surgical operative permit. 2. Assess the client's neurological status. 3. Ask when the client last took a drink of water or ate anything. 4. Call a time out until clarifying which leg is having the vein ligation.

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

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? 1. Encourage the visitor to push the button for the client. 2. Ask the nurse to step into the hallway to discuss the situation. 3. Discuss the hospital protocol for the use of PCA pumps. 4. Continue to perform the charge nurse's other duties.

4. Continue to perform the charge nurse's other duties.

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? 1. Assess the client's vital signs. 2. Notify the HCP. 3. Maintain a patent IV line. 4. Stop the transfusion at the hub.

4. Stop the transfusion at the hub.

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? 1. Tell the LPN to take the client's blood pressure. 2. Take no action since this is appropriate behaviour. 3. Show the LPN where to find pudding for the client. 4. Tell the LPN this medication cannot be crushed.

4. Tell the LPN this medication cannot be crushed.

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? 1. Support the medical treatment, and recommend the client have the amputation. 2. Recommend the client talk to his wife and children about his decision. 3. Explain to the client that he has a right to a second opinion if he doesn't want an amputation. 4. Tell the client she will go with him to discuss his decision with the doctor.

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

The nurse is reviewing 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? 1. The article in which the study was conducted by the manufacturer of the product used. 2. The research article that included 10 subjects participating in the study. 3. The review-of-literature article that cited ambiguous statistics about the product. 4. The review-of-literature article that cited numerous studies supporting the product.

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

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?

50 gtt/min

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? 1. "Be sure to show me any lab information that is called in to the unit." 2. "Make sure to file the reports on the correct client's chart." 3. "Do not take any laboratory reports over the telephone." 4. "Verify all telephone reports by calling back to the lab."

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

. 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? 1. "I take a baby aspirin every day at breakfast." 2. "I have ordered myself a medical alert bracelet." 3. "I eat spinach and greens at least twice a week." 4. "I got a new recliner so I can elevate my legs."

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

The nursing staff confronts the hospice nurse overseeing the care of a client in a longterm 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? 1. Check with the client to see whether or not the client wants to go to a hospital. 2. Explain that the client can be kept comfortable at the long-term care facility. 3. Discuss the hospice concept of comfort measures only with the staff. 4. Call a client care conference immediately to discuss the conflict.

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

The fire alarm starts going off in the family practice clinic. Which action should the nurse take first? 1. Determine whether there is a fire in the clinic. 2. Evacuate all the people from the clinic. 3. Immediately call 911 and report the fire. 4. Instruct clients to stay in their rooms and close the doors.

1. Determine whether there is a fire in the clinic.

The client complains of chest pain on deep inspiration. Which intervention should the nurse implement first? 1. Place the client on oxygen. 2. Assess the client's lungs. 3. Notify the respiratory therapist. 4. Assess the client's pulse oximeter reading

1. Place the client on oxygen.

The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse must notify the significant other. Which statement made by the nurse is the best over the telephone? 1. "I am sorry to tell you, but your loved one has died." 2. "Could you come to the hospital? The client is not doing well." 3. "The HCP has asked me to tell you of your family member's death." 4. "Do you know whether the client wished to be an organ donor?"

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

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? 1. "You should be able to determine why the research was done." 2. "You should look to find out how much money was used for the study." 3. "You should evaluate which research method was used for the study." 4. "You should read the method section to find out what setting was used."

2. "You should look to find out how much money was used for the study." 3. "You should evaluate which research method was used for the study." 4. "You should read the method section to find out what setting was used."

The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate? 1. Request the LPN to escort the client to the examination room. 2. Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client. 3. Instruct the RN to administer the tetanus shot to the client. 4. Tell the clinic secretary to call in a new prescription for a client.

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

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. 1. Hang a bag of D5NS to keep open (TKO). 2. Change the blood administration set. 3. Check the client's current vital signs. 4. Assess for allergies to blood products. 5. Obtain a blood warmer for the blood.

2. Change the blood administration set. 3. Check the client's current vital signs.

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? 1. Tell another UAP to put the SCDs on the client. 2. Demonstrate the procedure for applying the SCDs. 3. Perform the task and apply the SCDs to the client. 4. Request the UAP watch the video demonstrating this task.

2. Demonstrate the procedure for applying the SCDs.

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

3, 2, 1, 4, 5

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? 1. Document the objective findings in the client's chart. 2. Tell the client she must talk about the situation with the nurse. 3. Report the situation to the Adult Protective Services. 4. Take photographs of the bruises and cigarette burns.

3. Report the situation to the Adult Protective Services.

The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse? 1. The client whose INR is 2.3. 2. The client whose H&H is 11 g/dL and 36%. 3. The client whose platelet count is 65,000 per milliliter of blood. 4. The client whose red blood cell count is 4.8 × 10 mm6.

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

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? 1. "I will talk to the intern and tell him to stop." 2. "Did anyone hear the intern asking you out?" 3. "He asks everyone out; that is just his way." 4. "You should inform the clinic's director of nurses."

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

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? 1. Discuss the client's comment with the UAP. 2. Retake the BP and inform the client of her BP reading. 3. Explain that the UAP knows how to take a BP reading. 4. Ask the UAP to demonstrate taking a BP reading.

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

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with arterial occlusive disease who has intermittent claudication. 2. The client on strict bed rest who is complaining of calf pain and has a reddened calf. 3. The client who complains of low back pain when lying supine in the bed. 4. The client who is upset because the food doesn't taste good and is cold all the time.

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

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? 1. The UAP instructs the client to sit in the chair when applying the stockings. 2. The UAP cannot insert one finger under the proximal end of the stocking. 3. The UAP ensures the toe opening is placed on the top side of the feet. 4. The UAP checked to make sure the client's toes were warm after putting the stockings on.

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

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?

2050 mL

The nurse is caring for a client receiving heparin sodium via constant infusion. The 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?

20mL/hr

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? 1. "The night shift often has trouble answering the lights promptly." 2. "I am sorry that happened and I will answer your lights promptly today." 3. "I will notify my charge nurse to come and talk to you about the situation." 4. "There might have been an emergency situation so your light was not answered."

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

The unlicensed assistive personnel (UAP) is caring for a client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. The UAP assists the client to apply compression stockings. 2. The UAP elevates the client's leg while sitting in the recliner. 3. The UAP assists the client to the bathroom for a.m. care. 4. The UAP is cutting the client's toenails after soaking the client's feet in tepid water.

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

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? 1. The client with the femoral-popliteal bypass who has paraesthesia of the foot. 2. The client with an abdominal aortic aneurysm who is complaining of low back pain. 3. The client newly diagnosed with chronic venous insufficiency who needs teaching. 4. The client with varicose veins who is complaining of deep, aching pain of the legs.

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

The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse? 1. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT). 2. The hemoglobin 11.4 for a client diagnosed with Raynaud's phenomenon. 3. The white blood cell (WBC) count of 11,000 for a client with a stasis venous ulcer. 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN).

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

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

1, 4, 3, 2, 5

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? 1. "The UAP will be practicing on my brand-new nursing license." 2. "I will still retain accountability for what I delegate to the UAP." 3. "I must make sure the UAP to whom I delegate is competent to perform the task." 4. "When I delegate, I must follow up with the UAP and evaluate the task."

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

Which laboratory data should the nurse in the long-term care unit notify the healthcare provider about? 1. The client receiving digoxon who has a digoxin level of 2.6. 2. The client receiving enoxaparin (Levonox) who has a PT of 12.9 seconds. 3. The client receiving ticlopidine (Ticlid) who has a platelet count of 160,000. 4. The client receiving furosemide (Lasix) who has a potassium level of 4.2 mEq/L.

1. The client receiving digoxon who has a digoxin level of 2.6.

A client is 2 days postoperative abdominal aortic aneurysm repair. Which data require immediate intervention from the nurse? 1. The client refuses to take deep breaths and cough. 2. The client's urinary output is 300 mL in 8 hours. 3. The client has hypoactive bowel sounds. 4. The client's vital signs are T 98, P 68, R 16, and BP 110/70.

1. The client refuses to take deep breaths and cough.

The nurse just received the a.m. shift report. Which client should the nurse assess first? 1. The client who is 6 hours post-op vein ligation who has absent pedal pulses. 2. The client diagnosed with deep vein thrombosis who is complaining of calf pain. 3. The client with Raynaud's disease who has throbbing and tingling in the extremities. 4. The client with Buerger's disease who has intermittent claudication of the feet and arms.

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

The nurse has received the shift report. Which client should the nurse assess first? 1. The client with a deep vein thrombosis who is complaining of dyspnea and coughing. 2. The client diagnosed with Buerger's disease who has intermittent claudication. 3. The client diagnosed with an aortic aneurysm who has an audible bruit. 4. The client with acute arterial ischemia who has bilateral palpable pedal pulses

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

The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering? 1. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8. 2. Propranolol (Inderal), a beta-adrenergic, to a client with arterial hypertension. 3. Nifedipine (Procardia), a calcium channel blocker, to a client with Raynaud's disease. 4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with a sodium level of 138 mEq/L.

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

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? 1. "If you cry every time a client dies, you won't last long on the unit." 2. "It can be difficult when a client dies. Would you like to take a break?" 3. "You need to stop crying and go on about your responsibilities." 4. "Did you not realize that clients die in a healthcare facility?"

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

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? 1. "My legs start to hurt when I walk to check my mail." 2. "My legs were so cold I had to put a heating pad on them." 3. "I hang my legs off the side of my bed when I sleep." 4. "I noticed that the hair on my feet and up my leg is gone."

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

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? 1. Document the result of the INR in the client's chart. 2. Contact the client and ask whether or not she has any abnormal bleeding. 3. Notify the client's healthcare provider of the INR results. 4. Schedule an appointment with the client to draw another INR.

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

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? 1. Discuss the importance of the client adhering to a low-salt diet. 2. Explain the need for the client to take antihypertensive medications as prescribed. 3. Tell the client to check and record their blood pressure readings daily. 4. Encourage the client to walk at least 30 minutes three times a week.

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

The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first? 1. Ask the HCP to order a stat lung scan. 2. Place oxygen on the client via nasal cannula. 3. Prepare to administer intravenous heparin. 4. Tell the client not to ambulate and remain in bed.

2. Place oxygen on the client via nasal cannula.

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? 1. Tell the pharmaceutical representative the staff nurse's statement was inappropriate. 2. Report this behavior to the clinic's director of nurses immediately. 3. Do not take any action and wait for the food to be delivered. 4. Inform the HCP of the staff nurse's and pharmaceutical representative's behaviors.

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

The nurse is admitting a client with an abdominal aortic aneurysm who is a member of the Church of Jesus Christ of Latter-Day Saints (Mormon). Which action by the nurse indicates cultural sensitivity to the client? 1. The nurse does not insist on administering a blood transfusion. 2. The nurse pins the client's amulet to the client's pillow. 3. The nurse keeps the client's undershirt on during the bath. 4. The nurse notifies the client's curandero of the admission.

2. The nurse pins the client's amulet to the client's pillow.

Which of the staff nurse's personal attributes is an important consideration for the unit manager when discussing making an experienced nurse a preceptor for new graduates? Select all that apply. 1. The nurse's need for the monetary stipend. 2. The nurse's ability to organize the work. 3. The ability of the nurse to interact with others. 4. The quality of care the nurse provides. 5. The nurse's willingness to be a preceptor.

2. The nurse's ability to organize the work. 3. The ability of the nurse to interact with others. 4. The quality of care the nurse provides. 5. The nurse's willingness to be a preceptor.

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? 1. Place the severed fingers in a sterile cloth and then in an ice chest. 2. Instruct the client to elevate the right arm over the heart. 3. Don non-sterile gloves on both hands. 4. Apply direct pressure to the right radial pulse.

3. Don non-sterile gloves on both hands.

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? 1. Write the order in the chart with the words "per telephone order (TO)." 2. Request another nurse to verify the HCP's order on the phone. 3. Read back the order to the HCP before hanging up the phone. 4. Transcribe the order to the medication administration record.

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

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? 1. Place a nasogastric feeding tube and feed the client. 2. Discuss why the client does not want to eat anymore. 3. Arrange for the family to bring food for the client. 4. Allow the client to refuse to eat if he wants to.

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