Prioritization

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply a.) Auscultate breath sounds b.) Administer medications via metered-dose inhaler (MDI) c.) Complete in-depth admission assessment d.) Initiate the nursing care plan e.) Evaluate the patient's technique for using MDI's

a.) Auscultate breath sounds b.) Administer medications via metered-dose inhaler (MDI)

A client with DM has an above-knee amputation because of severe peripheral vascular disease. Two days following surgery, when preparing the client for dinner, it is the nurse's primary responsibilities to: a.) Check the client's serum glucose level b.) Assist the client out of bed to the chair c.) Place the client in a high-Fowlers position d.) Ensure that the client's residual limb is elevated

a.) Check the client's serum glucose level

Jerod is experiencing an acute episode of ulcerative colitis. Which is priority for this patient? a.) Replace lost fluid and sodium. b.) Monitor for increased serum glucose level from steroid therapy. c.) Restrict the dietary intake of foods high in potassium. d.) Note any change in the color and consistency of stools.

a.) Replace lost fluid and sodium.

The nurse is caring for 4 clients and is preparing to do this initial rounds. Which client should the nurse assess first? a.) A client with diabetes being discharged today b.) A 35-year-old male with tracheostomy and copious secretions c.) A teenager scheduled for physical therapy this morning d.) A 78-year-old female client with pressure ulcer that needs dressing change

b.) A 35-year-old male with tracheostomy and copious secretions

The nurse receives change-of-shift report on the following 4 patients. Which patient should the nurse assess first? a.) A 23-year old patient with COPD who has pulmonary function testing scheduled b.) A 46-year old patient on bed rest who is complaining of sudden onset of shortness of breath c.) A 77-year old patient with TB who has 4 medications due in 15 minutes d.) A 35-year old patient who has admitted with pneumonia and has a temperature of 100.2 F (37.8 C)

b.) A 46-year old patient on bed rest who is complaining of sudden onset of shortness of breath

After receiving change-of-shift report on 4 patients admitted to a. heart failure unit, which patient should the nurse assess first? a.) A patient who reported dizziness after receiving the first of captopril b.) A patient who is cool and clammy, with new-onset confusion and restlessness c.) A patient who has crackles bilaterally in the lung bases and is receiving oxygen d.) A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

b.) A patient who is cool and clammy, with new-onset confusion and restlessness

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a.) A patient with loud expiratory wheezes b.) A patient with a respiratory rate of 38 breaths/min c.) A patient who has a cough productive of thick, green mucus d.) A patient with jugular venous distention and peripheral edema

b.) A patient with a respiratory rate of 38 breaths/min

A patient who has had an open reduction and internal fixation (ORIF) of a hip fracture tells the nurse that he is ready to get out of bed for the first time. Which action should the nurse take first? a.) Use a mechanical lift to transfer the patient from the bed to the chair b.) Check the postoperative orders for the patient's weight-bearing status c.) Avoid administration of pain medications before getting the patient up d.) Delegate the transfer of the patient to nursing assistive personnel (NAP)

b.) Check the postoperative orders for the patient's weight-bearing status

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? a.) Minimize O2 use to avoid O2 dependency b.) Maintain the pulse oximetry level at 90% or greater c.) Administer O2 according to the patient's level of dyspnea d.) Avoid administration of O2 at a rate of more than 2 L/min

b.) Maintain the pulse oximetry level at 90% or greater

The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? a.) Vitamin A b.) Vitamin B12 c.) Vitamin C d.) Vitamin E

b.) Vitamin B12

Which nursing action is the greatest priority in the plan of care for a patient recovering from an acute episode of COPD? a.) Assess nail beds every 2 hours for cyanosis b.) Assess orientation status every 4 hours c.) Monitor the respiratory rate and effort hourly d.) Monitor arterial blood gas (ABG) results as ordered

c.) Monitor the respiratory rate and effort hourly

The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which client problem is priority? a.) Body image disturbance b.) Impaired coping c.) Risk for infection d.) Self-care deficit

c.) Risk for infection

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? a.) A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab b.) A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation c.) A 70-year old with pneumonia who needs to be started on IV antibiotics d.) A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

d.) A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer? a.) Bradycardia b.) Numbness in the legs c.) Nausea and vomiting d.) A rigid, board-like abdomen

d.) A rigid, board-like abdomen

A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assess the client and notes that the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first? a.) Administer pain medications b.) Administer IV fluids c.) Administer dopamine d.) Administer oxygen via nasal cannula

d.) Administer oxygen via nasal cannula

Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first? a.) Call for help to get the client back in bed b.) Assist the client back to bed c.) Ask the client what happened d.) Establish whether the client is responsive

d.) Establish whether the client is responsive

Polyethylene glycol-electrolyte solution (GoLYTELY) is prescribed for the female client scheduled for colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate? a.) Start an IV infusion b.) Administer an enema c.) Cancel the diagnostic test d.) Explain that diarrhea is expected

d.) Explain that diarrhea is expected

Which condition would the nurse assess for first in a patient admitted to the emergency department because of multiple injuries after a motor vehicle crash? a.) Pain b.) Bleeding c.) Head injury d.) Respiratory distress

d.) Respiratory distress

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6L/min via nasal cannula. Which cation is most appropriate? a.) Increase the flow rate on the oxygen to 10L/min and reassess the patient after about 10 minutes. b.) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. c.) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. d.) Switch the patient to non-rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status

d.) Switch the patient to non-rebreather mask at 95% to 100% oxygen and call the physician to discuss the patient's status