Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX ® Examination Lacharity Chapters 1-21 (3rd Edition)

Which clients must be assigned to an experienced RN? (Select all that apply.) 1. Client who was in an automobile crash and sustained multiple injuries 2. Client with chronic back pain related to a workplace injury 3. Client who has returned from surgery and has a chest tube in place 4. Client with abdominal cramps related to food poisoning 5. Client with a severe headache of unknown origin 6. Client with chest pain who has a history of arteriosclerosis

1,3,5,6

You are working with a UAP to provide care for six patients. At the beginning of the shift, you carefully tell the UAP what patient interventions and tasks she is expected to perform. To be sure that your communication is appropriate, you refer to the "Four Cs." List the "Four Cs"

7. Ans: Clear, Concise, Correct, Complete Implementing the Four Cs of communication helps the nurse ensure that the UAP understands what is being said; that the UAP does not confuse the nurse's directions; that the directions comply with policies, procedures, job descriptions, and the law; and that the UAP has all the information necessary to complete the tasks assigned. Focus: Delegation, supervision

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? (Select all that apply.) 1. Surgical face mask 2. N95 respirator 3. Gown 4. Gloves 5. Goggles 6. Shoe covers

Ans: 2, 3, 4 2. N95 respirator 3. Gown 4. Gloves Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and will not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions. Focus: Prioritization

Which members of the health care team (advanced practice nurse, MD, RN, LPN/LVN) should perform the tasks related to care of patients who are at risk for breast cancer? (There may be more than one professional who could complete the task.) 1. Perform the clinical breast examination. _________________________________________ 2. Teach about breast self-examination. _________________________________________ 3. Make a nursing diagnosis based on the assessment data. _________________________________________ 4. Assess the patient's belief about and use of complementary and alternative therapies. _________________________________________ 5. Reinforce the importance of a baseline screening mammogram starting at age 40. _________________________________________ 6. Explain the results of the mammogram to the patient. _________________________________________

1. Advanced practice nurse, MD, 2. Advanced practice nurse, MD, RN, 3. Advanced practice nurse, RN, 4. Advanced practice nurse, MD, RN, 5. Advanced practice nurse, MD, RN, LPN/LVN, 6. MD Advanced practice nurses could do any of the tasks; however, explaining results of a mammogram may be handled by the supervising physician, especially if complex follow-up is needed (e.g., surgery). Physicians could do any of the tasks except they do not make nursing diagnoses. RNs could do tasks 2, 3, 4, and 5 but usually do not do clinical breast examination, unless specially trained, and do not interpret results of diagnostic tests for patients. LPNs/LVNs could reinforce standard information about screening recommendations. The RN should make the nursing diagnoses, and the LPN/LVN assists in planning and implementing the interventions.

A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional (RN, LPN/LVN, nurse practitioner,nutritionist) should be assigned responsibility for the following tasks? 1. Explain screening examinations and diagnostic testing for common cancers. ___________________________ 2. Discuss how to plan a balanced diet and reduce fats and preservatives. ___________________________ 3. Prepare a poster on the seven warning signs of cancer. ___________________________ 4. Discuss how to perform breast or testicular self-examinations. ___________________________ 5. Describe strategies for reducing risk factors such as smoking and obesity. ___________________________

1. Nurse practitioner, 2. Nutritionist, 3. LPN/LVN, 4. Nurse practitioner, 5. RN The nurse practitioner is often the provider who performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs. The RN has primary responsibility for educating people about risk factors.

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply.) 1. Client who needs preoperative teaching for the use of a PCA pump 2. Client with a leg cast who needs neurologic and circulatory checks and PRN hydrocodone 3. Client who underwent a toe amputation and has diabetic neuropathic pain 4. Client with terminal cancer and severe pain who is refusing medication 5. Client who reports abdominal pain after being kicked, punched, and beaten 6. Client with arthritis who needs scheduled pain medications and heat applications

2,3,6

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? (Select all that apply.) 1. Anxious client with chronic pain who frequently uses the call button 2. Client on the second postoperative day who needs pain medication before dressing changes 3. Client with human immunodeficiency virus (HIV) infection who reports headache and abdominal and pleuritic chest pain 4. Client with chronic pain who is to be discharged with a new surgically- implanted catheter 5. Client who is reporting pain at the site of a peripheral IV line 6. Client with a kidney stone who needs frequent PRN pain medication

2,5,6

You must rearrange the room assignments for several clients. Who could you put together? 1. 35-year-old woman with diarrhea and vomiting 2. 43 year old woman who underwent a cholecystectomy 2 days ago 3. a 52 year old woman with pain related to alcohol associated pancreatitis 4. .62 year old woman with colon cancer receiving chemo

2. 43 year old woman who underwent a cholecystectomy 2 days ago 3. a 52 year old woman with pain related to alcohol associated pancreatitis

You are preparing to teach a patient with a new diagnosis of osteoporosis about strategies to prevent falls. Which teaching points will you be sure to include? (Select all that apply.) 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 4. Expect a few bumps and bruises when you go home. 5. Rest when you are tired.

2. Ans: 1, 2, 3, 5 1. Wear a hip protector when ambulating. 2. Remove throw rugs and other obstacles at home. 3. Exercise to help build your strength. 5. Rest when you are tired. The purpose of the teaching is to help the patient prevent falls. The hip protector can prevent hip fractures if the patient falls. Throw rugs and obstacles in the home increase the risk of falls. Patients who are tired are also more likely to fall. Exercise helps to strengthen muscles and improve coordination. Focus: Prioritization

You are caring for an obese postop client who had a bowel resection. His wound eviscerated. What do you do? (in order). 1. Cover the intestine with sterile moistened gauze 2. Stay calm and stay with the client 3. Check the VS especially BP and HR 4. Have a colleague gather sterile supplies and contact the dr. 5. Put the client into semi-fowler's position with knees slightly flexed 6. Prep the client for surgery as ordered

253416 2. Stay calm and stay with the client 5. Put the client into semi-fowler's position with knees slightly flexed 3. Check the VS especially BP and HR 4. Have a colleague gather sterile supplies and contact the dr. 1. Cover the intestine with sterile moistened gauze 6. Prep the client for surgery as ordered

You are caring for a client who had abdominal surgery yesterday. The client is restless and anxious and tells you that the pain is getting worse despite the pain medication. Physical assessment findings include the following: temperature, 100.3° F (38° C); pulse rate, 110 beats/min; respiratory rate, 24 breaths/min; and blood pressure, 140/90 mm Hg. The abdomen is rigid and tender to the touch. You decide to notify the client's provider. Place the following report information in the correct order according to the SBAR format. 1. "He is restless and anxious: temperature is 100.3° F (38° C); pulse is 110 beats/min; respiratory rate is 24 breaths/min; blood pressure is 140/90 mm Hg. Abdomen is rigid and tender to touch with hypoactive bowel sounds." 2. "He had abdominal surgery yesterday. He is on PCA morphine, but he says the pain is getting progressively worse." 3. "I have tried to make him comfortable and he is willing to wait until the next scheduled dose of pain medication, but I think his pain warrants evaluation." 4. "Would you like to give me an order for any laboratory tests or additional therapies at this time?" 5. "Dr. S, this is Nurse J. I'm calling about Mr. D, who is reporting severe abdominal pain."_____, _____, _____, _____, _____

5,2,1,3,4

You have received the shift report from the night nurse. Prioritize the order in which you will check on the following clients. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. Elderly man who underwent total knee replacement surgery 2 days ago. He is using the patient-controlled analgesia (PCA) pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and needy. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Elderly woman with advanced Alzheimer disease who requires total care for all activities of daily living (ADLs). She struggles during any type of nursing care and it is difficult to assess her subjective symptoms. She is awaiting transfer to a long-term care facility. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. His chest tube will be removed and his PCA pump discontinued today. _____, _____, _____, _____, _____

5,3,1,2,4

Place the steps for performing a colostomy care in the right order. 1. Fit the pouch snugly around the stoma 2. assess the color and appearance of the stoma 3. wash the skin with mild soap and rinse with warm water 4. Apply a skin barrier to protect the peristomal skin 5. Dry the skin carefully 6. Don a pair of clean gloves and remove the old pouch

623541 6. Don a pair of clean gloves and remove the old pouch 2. assess the color and appearance of the stoma 3. wash the skin with mild soap and rinse with warm water 5. Dry the skin carefully 4. Apply a skin barrier to protect the peristomal skin 1. Fit the pouch snugly around the stoma

You're preparing to administer TPN on a central line. Place the following steps in the correct order. 1. use aseptic technique when handling the injection cap 2. Thread the IV tubing through an infusion pump 3. check the solution for cloudiness or turbidity 4. connect the tubing to the central line 5. select and flush the correct tubing and filter 6. Set the infusion pump at the prescribed rate 7. Confirm the order for TPN

7 3 5 2 1 46 7. Confirm the order for TPN 3. check the solution for cloudiness or turbidity 5. select and flush the correct tubing and filter 2. Thread the IV tubing through an infusion pump 1. use aseptic technique when handling the injection cap 4. connect the tubing to the central line 6. Set the infusion pump at the prescribed rate

In assisting clients with vertigo and balance problems, which team member (RN, LPN/LVN, MD, physical therapist, UAP), working under appropriate supervision, should be assigned to complete each task? 1. Assess and identify the cause of the vertigo. 2. Assist the client in routine position change and ambulation. 3. Administer antivertigo agents such as meclizine (Antivert). 4. Obtain informed consent for a labyrinthectomy. 5. Assess situations that lead to or exacerbate vertigo. 6. Review the need for adaptive aids such as a walker or cane.

Ans: 1. Assess and identify the cause of the vertigo. --MD, 2. Assist the client in routine position change and ambulation. --UAP, 3. Administer antivertigo agents such as meclizine (Antivert). --LPN/LVN or RN, 4. Obtain informed consent for a labyrinthectomy. --MD, 5. Assess situations that lead to or exacerbate vertigo.--RN, 6. Review the need for adaptive aids such as a walker or cane. --Physical therapist The physician is responsible for determining the medical diagnosis and for explaining the outcomes and risks of surgical procedures. A physical therapist evaluates movement and the need for adaptive equipment and teaches ambulation techniques; however, the UAP (under supervision) is able to help clients with routine ambulation and position changes. The LPN/LVN and RN are qualified to give medications. The RN should assess the client to identify situations associated with vertigo. Focus: Assignment

You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? (Select all that apply.) 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

Ans: 1, 2 1. Gown 2. Gloves A gown and gloves should be used when coming in contact with linens that may be contaminated by the client's wound secretions. The other PPE items are not necessary, because transmission by splashes, droplets, or airborne means will not occur when the bed is changed. Focus: Prioritization

25. A 23-year-old with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to delegate to an LPN/LVN whom you are supervising? (Select all that apply.) 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin (Dilantin) 200 mg by mouth (PO) three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications

Ans: 1, 2 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin (Dilantin) 200 mg by mouth (PO) three times a day Any nursing staff member who is involved in caring for the client should observe for the onset and duration of any seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice. Focus: Delegation

While admitting a client, you obtain this information about her cardiovascular risk factors: Her mother and two siblings have had myocardial infarctions (MIs). The client smokes and has a 20 pack-year history of cigarette use. Her work as a mail carrier involves a lot of walking. She takes metoprolol (Lopressor) for hypertension, and her blood pressure has been in the range of 130/60 to 138/85 mm Hg. Which interventions will be important to include in the discharge plan for this client? (Select all that apply.) 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk 3. Education about the need for a change in antihypertensive therapy 4. Assistance in reducing the stress associated with her cardiovascular risk 5. Discussion of the risks associated with having a sedentary lifestyle

Ans: 1, 2 1. Referral to community programs that assist in smoking cessation 2. Teaching about the impact of family history on cardiovascular risk The client's major modifiable risk factor is her ongoing smoking. The family history is significant, and she should be aware that this increases her cardiovascular risk. The goal when treating hypertension with medications is reduction of blood pressure to under 140/90 mm Hg. There is no indication that stress is a risk factor for this client. The client's work involves moderate physical activity; although leisure exercise may further decrease her cardiac risk, this is not an immediate need for this client. Focus: Prioritization

You have received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions will you give the student nurse who is assisting in the care of the infant? (Select all that apply.) 1. Cover the infant's eyes with a mask. 2. Monitor the infant's temperature closely. 3. Keep the infant "nothing by mouth" (NPO) during the treatment. 4. Apply ointment to the infant's skin prior to light exposure. 5. Offer the infant sterile water feedings during the treatment.

Ans: 1, 2 During phototherapy, the infant's eyes must be protected and the temperature carefully monitored to avoid both hypothermia and hyperthermia. Breastfeeding should be continued to avoid dehydration and to increase passage of meconium, which helps to excrete bilirubin. Ointments or lotions should not be applied to the skin during phototherapy as they may cause burns. Encouraging continued breast feeding and teaching the family the benefits of breast feeding in this scenario supports the Perinatal Core Measure of increasing the percentage of infants who are fed breast milk only. Focus: Assignment

You are acting as preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? (Select all that apply.) 1. 38-year-old with moderate persistent asthma awaiting discharge 2. 63-year-old with a tracheostomy needing tracheostomy care every shift 3. 56-year-old with lung cancer who has just undergone left lower lobectomy 4. 49-year-old just admitted with a new diagnosis of esophageal cancer 5. 76-year-old newly diagnosed with type 2 diabetes

Ans: 1, 2 The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly-diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with him or her in providing care for these patients with more complex needs. The newly-diagnosed diabetic patient will need much teaching as well as careful monitoring. Focus: Assignment, delegation, supervision

You are interviewing an elderly client who reports that "lately there has been a roaring sound in my ears." What additional assessments should you include? (Select all that apply.) 1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. 5. Ask about frequency of ear hygiene.

Ans: 1, 2, 3, 4 1. Obtain a medication history. 2. Ask about exposure to loud noises. 3. Observe the canal for earwax or foreign body. 4. Assess for signs and symptoms of ear infection. Medications such as aspirin or diuretics (and many others) can cause tinnitus (ringing in the ears). Loud noises, impacted earwax or foreign bodies in the ear canal, or ear infections can also cause tinnitus. Asking about frequency of hygiene is less relevant than asking about the method the client uses to clean the ears. For example, the insertion of cotton-tipped swabs may be contributing to the impaction of earwax. Focus: Prioritization

The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays

Ans: 1, 2, 3, 4 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.

You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by your physician.

Ans: 1, 2, 3, 4, 5 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization

You are teaching a patient how best to prevent renal trauma after an injury that required a left nephrectomy. Which points would you include in your teaching plan? (Select all that apply.) 1. Always wear a seat belt. 2. Avoid all contact sports. 3. Practice safe walking habits. 4. Wear protective clothing to participate in contact sports. 5. Use caution when riding a bicycle.

Ans: 1, 2, 3, 5 1. Always wear a seat belt. 2. Avoid all contact sports. 3. Practice safe walking habits. 5. Use caution when riding a bicycle. A patient with only one kidney should avoid all contact sports and high-risk activities to protect the remaining kidney from injury and preserve kidney function. All of the other points are key to preventing renal trauma. Focus: Prioritization

Which actions should you delegate to an experienced UAP when caring for a client with a thrombotic stroke who has residual left-sided weakness? (Select all that apply.) 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active ROM exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding

Ans: 1, 2, 3, 5 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active ROM exercises 5. Setting up meal trays and assisting with feeding An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. Assessing for redness and swelling (signs of deep venous thrombosis) requires additional education and skill, appropriate to the professional nurse. Focus: Delegation, supervision

As charge nurse, you assign the nursing care of a patient who has just returned from open carpal tunnel release surgery to an experienced LPN/LVN, who will perform under the supervision of an RN. Which instructions would you provide for the LPN/LVN? (Select all that apply.) 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 4. The patient will no longer need pain medication. 5. Check the neurovascular status of the fingers every hour.

Ans: 1, 2, 3, 5 1. Check the patient's vital signs every 15 minutes in the first hour. 2. Check the dressing for drainage and tightness. 3. Elevate the patient's hand above the heart. 5. Check the neurovascular status of the fingers every hour. Postoperatively, patients undergoing open carpal tunnel release surgery experience pain and numbness, and their discomfort may last for weeks to months. All of the other directions are appropriate for the postoperative care of this patient. It is important to monitor for drainage, tightness, and neurovascular changes. Raising the hand and wrist above the heart reduces the swelling from surgery, and this is often done for several days. Focus: Assignment, delegation, supervision

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs? (Select all that apply.) 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

Ans: 1, 2, 3, 5 While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Focus: Delegation, supervision

Which health care provider orders for the patient with Addison disease should you delegate to the experienced UAP? (Select all that apply.) 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 4. Monitor for cardiac dysrhythmias. 5. Administer oral prednisone 10 mg every morning. 6. Record intake and output.

Ans: 1, 2, 3, 6 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 6. Record intake and output. Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring also. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses. Focus: Delegation

An experienced LPN/LVN, 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/LVN? (Select all that apply.) 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

Ans: 1, 2, 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN. Focus: Delegation, supervision

You are preparing a care plan for a patient with Cushing disease. Which nursing diagnoses would you be sure to include? (Select all that apply.) 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 3. Imbalanced Nutrition: Less than Body Requirements 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection

Ans: 1, 2, 4, 5 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection A patient with Cushing disease experiences body changes affecting body image and is at risk for bruising, infection, and hypertension. Such a patient usually gains weight. Focus: Prioritization

You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (Select all that apply.) 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle

Ans: 1, 2, 4, 5 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. Focus: Prioritization

You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply.) 1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 3. Wash all bedding in cold water to reduce and destroy dust mites. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG).

Ans: 1, 2, 4, 5 Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma. Focus: Prioritization

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. Which actions would require immediate intervention by the supervising RN? (Select all that apply.) 1. Gently cleansing the amputated digits and the hand with a povidone-iodine (Betadine)/normal saline solution 2. Cleansing the amputated digits and placing them directly into an ice slurry 3. Wrapping the cleansed digits in saline-moistened gauze, sealing them in a plastic bag, and placing them in an ice slurry 4. Cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline 5. Placing the amputated digits in the correct anatomic position and then wrapping the hand and digits with sterile gauze.

Ans: 1, 2, 4, 5 The only correct intervention is to gently cleanse the digits with normal saline, wrap them in sterile gauze moistened with saline, and place them in a plastic bag or container. The container is then placed on ice. Focus: Supervision, knowledge

You are providing nursing care for a patient with acute kidney failure for whom a nursing diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? (Select all that apply.) 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 3. Administering furosemide (Lasix) 40 mg orally twice a day 4. Reminding the patient to save all urine for intake and output measurement 5. Assessing breath sounds every 4 hours 6. Ensuring that the patient's urinal is within reach

Ans: 1, 2, 4, 6 1. Measuring and recording vital sign values every 4 hours 2. Weighing the patient every morning using a standing scale 4. Reminding the patient to save all urine for intake and output measurement 6. Ensuring that the patient's urinal is within reach Administering oral medications is appropriate to the scope of practice for an LPN/LVN or RN. Assessing breath sounds requires additional education and skill development and is most appropriately within the scope of practice of an RN, but it may be part of the observations of an experienced and competent LPN/LVN. All other actions are within the educational preparation and scope of practice of an experienced UAP. Focus: Delegation, supervision

In the care of a patient with neutropenia, what tasks can be delegated to a UAP? (Select all that apply.) 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4° F (38° C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

Ans: 1, 2, 4, 6 Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

A nursing diagnosis for a patient with newly-diagnosed diabetes is Risk for Injury related to sensory alterations. Which key points should you include in the teaching plan for this patient? (Select all that apply.) 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 3. "Nylon socks are best to prevent friction on your toes from shoes." 4. "Only a podiatrist should trim your toenails." 5. "Report any nonhealing skin breaks to your health care provider."

Ans: 1, 2, 5 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 5. "Report any nonhealing skin breaks to your health care provider." Sensory alterations are the major cause of foot complications in diabetic patients, and patients should be taught to examine their feet on a daily basis. Properly-fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Patients, family, or health care providers may trim toenails. Focus: Prioritization

6. A 58-year-old with type 2 diabetes was admitted to your unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. When you prepare a care plan for this patient, what would you be sure to include? (Select all that apply.) 1. Fingerstick blood glucose checks before meals and at bedtime 2. Sliding-scale insulin dosing as ordered 3. Bed rest until the COPD exacerbation is resolved 4. Teaching about the Atkins diet for weight loss 5. Demonstration of the components of foot care

Ans: 1, 2, 5 1. Fingerstick blood glucose checks before meals and at bedtime 2. Sliding-scale insulin dosing as ordered 5. Demonstration of the components of foot care When a diabetic patient is ill, glucose levels become elevated, and administration of insulin may be necessary. Teaching or reviewing the components of proper foot care is always a good idea with a diabetic patient. Bed rest is not necessary, and glucose level may be better controlled when a patient is more active. The Atkins diet recommends decreasing the consumption of carbohydrates and is not a good diet for diabetic patients. Focus: Prioritization

You are caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

Ans: 1, 2, 5 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily. The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential in preventing VAP. Focus: Prioritization

Which actions should you delegate to the LPN/LVN for the care of a patient with hypothyroidism? (Select all that apply.) 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 3. Creating an individualized nursing care plan for the patient 4. Administering sedation medications every 6 hours 5. Checking blood pressure, heart rate, and respirations every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

Ans: 1, 2, 6 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort Assessment, auscultation, and reminding patients about information that has been taught to them are within the scope of practice of the LPN/LVN. Certainly the LPN/LVN could check the patient's vital signs, but this would be more appropriately delegated to the UAP. Creating nursing care plans falls within the scope of practice of the RN. The use of sedation is discouraged for patients with hypothyroidism because it may make respiratory problems more difficult. If sedation is used, dosage is reduced and it is not given around the clock. Focus: Delegation, supervision

You are caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? (Select all that apply.) 1. Hydrochlorothiazide (HCTZ) prescribed to control her diabetes 2. Weight gain of 6 pounds over the past month 3. Avoids consuming liquids in the evening 4. Blood pressure of 168/94 mm Hg 5. Urine output of 50 to 75 mL/hr

Ans: 1, 3 1. Hydrochlorothiazide (HCTZ) prescribed to control her diabetes 3. Avoids consuming liquids in the evening HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Weight loss (not weight gain) would be a symptom. While the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr is adequate. Focus: Prioritization

You have just received the morning report from the night shift nurse. List the order of priority for assessing and caring for the following patients. 1. A patient who developed tumor lysis syndrome around 5:00 AM 2. A patient with frequent reports of breakthrough pain over the past 24 hours 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours _______,_______, _______, _______

Ans: 1, 3, 2, 4 Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment, and the physician may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics.

You are the team leader RN working with a student nurse. The student nurse is to teach a patient how to use an MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient. 1. Remove the inhaler cap and shake the inhaler. 2. Open your mouth and place the mouthpiece 1 to 2 inches away. 3. Breathe out completely. 4. Hold your breath for at least 10 seconds. 5. Press down firmly on the canister and breathe deeply through your mouth. 6. Wait at least 1 minute between puffs. _____, _____, _____, _____, _____, _____

Ans: 1, 3, 2, 5, 4, 6 Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler. Focus: Prioritization

A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client

Ans: 1, 3, 4 1. Checking the client's skin for pressure from the device 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Delegation, supervision

You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environmental isolation. Which nursing tasks will you delegate to the UAP? (Select all that apply.) 1. Stocking the patient's room with the needed personal protective equipment items 2. Teaching the patient to perform thorough hand washing after using the bathroom 3. Reminding visitors to wear a respirator mask, gloves, and gown 4. Posting the precautions for protective isolation on the door of the patient's room 5. Talking to the family members about the reasons for the isolation

Ans: 1, 3, 4 Because all patient care staff members should be familiar with the various types of isolation, a UAP will be able to stock the room and post the precautions on the patient's door. Reminding visitors about previously taught information is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Patient teaching and discussion of the reasons for the protective isolation fall within the RN-level scope of practice. Focus: Delegation

Identify the five most critical elements in performing disaster triage for multiple victims. 1. Obtain past medical and surgical histories. 2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note color, presence of moisture, and temperature of the skin. 6. Obtain a history of allergies to food or medicine. 7. Check vital signs, including pulse and respirations. 8. Obtain a list of current medications. 9. Inquire about the last tetanus shot. _____, _____, _____, _____, _____

Ans: 2, 3, 4, 5, 7 These would be appropriate for disaster triage. The other items are important and would be addressed when the staff has time and resources to collect the additional information. (Note: During nondisaster situations, it would be appropriate to include all items.) Focus: Prioritization

Which statements by a new father indicate that additional discharge teaching is needed for this family, who had their first baby 24 hours ago? (Select all that apply.) 1. "We have a crib ready for our baby with lots of stuffed animals and two quilts that my mother made." 2. "My wife wants to receive the flu shot before she goes home." 3. "We will bring our baby to the pediatrician in 3 weeks." 4. "I will give the baby formula at night so my wife can rest. She will breast-feed in the daytime." 5. "We will always put our baby to sleep in a face-up position."

Ans: 1, 3, 4 It is recommended that a newborn be placed on the back in a crib with a firm mattress with no toys and a minimum of blankets as a safety measure for prevention of sudden infant death syndrome. A newborn discharged before 72 hours of life should be seen by an RN or MD within 2 days of discharge. Breast-feeding women should breast-feed at all feedings, especially in these early weeks of establishing breast feeding. This supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. A more appropriate response would be for the father to help with household chores to allow breast feeding to be established successfully. A flu shot in flu season is a recommended intervention for a new mother. Focus: Prioritization

A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.) 1. Check deep tendon reflexes. 2. Observe for vaginal bleeding. 3. Check the respiratory rate. 4. Note the urine output. 5. Monitor for calf pain

Ans: 1, 3, 4 Magnesium sulfate toxicity can cause fatal cardiovascular events and/or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis, but is not associated with magnesium sulfate therapy. Focus: Prioritization

The ED receives multiple individuals, mostly children, who were injured when the roof of a day-care center collapsed because of a heavy snowfall. Based on physiologic differences in children compared with adults, for which injuries and complications will the nurse assess first? (Select all that apply.) 1. Head injuries 2. Bradycardia or junctional arrhythmias 3. Hypoxemia 4. Liver and spleen contusions 5. Hypothermia 6. Fractures of the long bones 7. Lumbar spines injuries

Ans: 1, 3, 4, 5 Children have proportionately larger heads that predispose them to head injuries. Hypoxemia is more likely because of their higher oxygen demand. Liver and spleen injuries are more likely because the thoracic cage of children offers less protection. Hypothermia is more likely because of children's thinner skin and proportionately larger body surface area. They have strong hearts; therefore pulse rate will increase to compensate, but other arrhythmias are less likely to occur. Children have relatively flexible bones compared with those of adults. The most likely spinal injury in children is injury to the cervical area. Focus: Prioritization

People at risk are the target populations for cancer screening programs. Which of these asymptomatic patients need extra encouragement to participate in cancer screening? (Select all that apply.) 1. A 21-year-old white American woman who is sexually inactive, for a Pap test 2. A 30-year-old Asian-American woman, for an annual mammogram 3. A 45-year-old African-American man, for a prostate-specific antigen test 4. A 50-year-old African-American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy 6. A 70-year-old Asian-American woman with normal results on three previous Pap tests, for a Pap test

Ans: 1, 3, 4, 5 Women age 21 or over should have annual Pap smears, regardless of sexual activity. African-American men should begin prostate-specific antigen testing at age 45. Colonoscopy and annual fecal occult blood testing are recommended for those with average risk starting at age 50. Annual mammograms are recommended for women over the age of 40. Women age 65 or older who have normal results on previous Pap tests may forego additional screenings for cervical cancer.

A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization

All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to your home health agency. Which activities will you delegate to the UAP? (Select all that apply.) 1. Checking for orthostatic changes in pulse and blood pressure 2. Assessing for improvement in tremor after levodopa (l-dopa [Larodopa]) is given 3. Reminding the client to allow adequate time for meals 4. Monitoring for signs of toxic reactions to anti-Parkinson medications 5. Assisting the client with prescribed strengthening exercises 6. Adapting the client's preferred activities to his level of function

Ans: 1, 3, 5 1. Checking for orthostatic changes in pulse and blood pressure 3. Reminding the client to allow adequate time for meals 5. Assisting the client with prescribed strengthening exercises UAP education and scope of practice include taking pulse and blood pressure measurements. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice. Focus: Delegation

The UAP reports to you that a patient with type 1 diabetes has a question about exercise. What important points would you be sure to teach this patient? (Select all that apply.) 1. Exercise guidelines are based on blood glucose and urine ketone levels. 2. Be sure to test your blood glucose only after exercising. 3. You can exercise vigorously if your blood glucose is between 100 and 250 mg/dL. 4. Exercise will help resolve the presence of ketones in your urine. 5. A 5- to 10-minute warm-up and cool-down period should be included in your exercise.

Ans: 1, 3, 5 1. Exercise guidelines are based on blood glucose and urine ketone levels. 3. You can exercise vigorously if your blood glucose is between 100 and 250 mg/dL. 5. A 5- to 10-minute warm-up and cool-down period should be included in your exercise. Guidelines for exercise are based on blood glucose and urine ketone levels. Patients should test blood glucose before, during, and after exercise to be sure that it is safe. When ketones are present in urine, the patient should not exercise because they indicate that current insulin levels are not adequate. Vigorous exercise is permitted in patients with type 1 diabetes if glucose levels are between 100 and 250 mg/dL. Warm-up and cool-down should be included in exercise to gradually increase and decrease the heart rate. Focus: Prioritization

In the care of a patient with type 2 diabetes, which actions can you delegate to a UAP? (Select all that apply.) 1. Providing the patient with extra packets of artificial sweetener for coffee 2. Assessing how well the patient's shoes fit 3. Recording the liquid intake from the patient's breakfast tray 4. Teaching the patient what to do if dizziness or lightheadedness occurs 5. Checking and recording the patient's blood pressure

Ans: 1, 3, 5 1. Providing the patient with extra packets of artificial sweetener for coffee 3. Recording the liquid intake from the patient's breakfast tray 5. Checking and recording the patient's blood pressure Giving the patient extra sweetener, recording oral intake, and checking blood pressure are all within the scope of practice of the UAP. Assessing shoe fit and patient teaching are not within the UAP's scope of practice. Focus: Assignment

A 24-year-old G1P0 patient, who is receiving oxytocin (Pitocin), is in labor at 41 weeks' gestation. Which are appropriate nursing actions in the presence of late fetal heart rate decelerations? (Select all that apply.) 1. Discontinue the oxytocin. 2. Decrease the maintenance IV fluid rate. 3. Administer oxygen to the mother by mask. 4. Place the woman in high Fowler position. 5. Notify the provider.

Ans: 1, 3, 5 Late fetal heart rate decelerations can be an ominous sign of fetal hypoxemia, especially if repetitive and accompanied by decreased variability. Notification of the provider is indicated. Turning off the oxytocin and administering oxygen to the mother are recommended nursing interventions to improve fetal oxygenation. An increase in the IV rate can improve hydration, correct hypovolemia, and increase blood flow to the uterus. Putting the woman in a lateral position can increase blood flow to the uterus and increase oxygenation to the fetus. Promptly addressing fetal heart rate changes may allow intrauterine resuscitation and may decrease the need for cesarean section if those measures are effective. This supports the Perinatal Core Measure of reducing of cesarean section rates. Focus: Prioritization

A 26-year-old G1P1 patient who underwent cesarean section 24 hours ago tells the nurse that she is having some trouble breast-feeding. Which tasks could be appropriately delegated to the UAP on the postpartum floor? (Select all that apply.) 1. Providing the mother with an ordered abdominal binder 2. Assisting the mother with breast-feeding 3. Taking the mother's vital signs 4. Checking the amount of lochia present 5. Assisting the mother with ambulation

Ans: 1, 3, 5 The UAP could provide an abdominal binder, measure the vital signs of the patient, and assist her to ambulate. The RN would be responsible for evaluating the normality of the vital sign values. The UAP should be given parameter limits for vital signs and told to report values outside these limits to the RN. Assisting in breast feeding for a first-time mother is a very important nursing function, because the RN needs to give consistent, evidence-based advice to enhance success at breast feeding. A common complaint of postpartum patients is inconsistent help with and advice on breast feeding. The RN should also be the one to check the amount of lochia, because the evaluation requires nursing judgment. The use of the professionally educated RN to provide evidence-based and consistent information and assistance with breast feeding supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Focus: Delegation

As the charge nurse in the labor and delivery unit, you need to assign two patients to one of the RNs because of a staffing shortage. Normally on your unit the nurse-patient ratio is 1:1. Which two patients would you assign to the RN? 1. 30-year-old G1P0 woman, 40 weeks, 2 cm/90% effaced/-1 station 2. 25-year-old G3P2 woman, 38 weeks, 8 cm/100% effaced/0 station 3. 26-year-old G1P1 woman who delivered via normal vaginal delivery 15 minutes ago 4. 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks 5. 40-year-old G6P5 woman with contractions at 28 weeks who has not yet been evaluated by the provider _____, _____

Ans: 1, 4 Patient 1 is in the latent phase of labor with her first child; she typically will cope well at this point and will have many hours before labor becomes more active. Patient 4 would most likely be managed expectantly at this point and require observation and assessment for labor or signs of infection. Patient 2 can be expected to deliver soon and so requires intensive nursing care. Patient 3 is in the first hour of recovery and therefore requires frequent assessments, newborn assessments, and help with initiation of breast feeding if this is her chosen feeding method. Breast feeding in the first hour of life supports the Perinatal Core Measure of increasing the percentage of newborns who are fed breast milk only. Patient 5 could be in premature labor and require administration of tocolytic medications to stop contractions or preparation for a preterm delivery if dilation is advanced. Focus: Assignment

In the care of a client who has sustained recent blindness, which tasks would be appropriate to delegate to a UAP? (Select all that apply.) 1. Counseling the client to express grief or loss 2. Assisting the client with ambulating in the hall 3. Orienting the client to the surroundings 4. Encouraging independence 5. Obtaining supplies for hygienic care 6. Storing personal items to reduce clutter 7. Rearranging furniture to prevent falls

Ans: 2, 5 2. Assisting the client with ambulating in the hall 5. Obtaining supplies for hygienic care Assisting the client with ambulating in the hall and obtaining supplies are within the scope of practice of the UAP. Counseling for emotional problems, orienting the client to the room, and encouraging independence require formative evaluation to gauge readiness, and these activities should be the responsibility of the RN. Storing items and rearranging furniture are inappropriate actions, because the client needs be able to consistently locate objects in the immediate environment. Focus: Delegation

The LPN/LVN whom you are supervising comes to you and says, "I gave the client with myasthenia gravis 90 mg of neostigmine (Prostigmin) instead of the ordered 45 mg!" In which order should you perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the physician of the incorrect medication dose.

Ans: 1, 4, 3, 2 1. Assess the client's heart rate. 4. Notify the physician of the incorrect medication dose. 3. Ask the LPN/LVN to explain how the error occurred. 2. Complete a medication error report. The first action after a medication error should be to assess the client for adverse outcomes. You should evaluate this client for symptoms such as bradycardia and excessive salivation. These may indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The physician should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report. Focus: Prioritization

The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? (Select all that apply.) 1. "Take this medication in the morning." 2. "This medication should be taken in 2 divided doses when you get up and when you go to bed." 3. "Eat foods with extra sodium every day." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase."

Ans: 1, 4, 5 1. "Take this medication in the morning." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." HCTZ is a thiazide diuretic. It should not be taken at night because it will cause the client to wake up to urinate. This type of diuretic causes a loss of potassium, so you should teach the client about eating foods rich in potassium. Weight gain and increased edema should not occur while the client is taking this drug, so these should be reported to the prescriber.

You are caring for a diabetic patient admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a teaching plan for the patient and family before discharge? (Select all that apply.) 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1⁄4 cup of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away.

Ans: 1, 4, 5 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. Focus: Prioritization

3. The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to delegate to an experienced LPN/LVN who is working with you in the ED? (Select all that apply.) 1. Attaching cardiac monitor leads 2. Giving heparin 5000 units IV push 3. Administering morphine sulfate 4 mg IV 4. Obtaining a 12-lead electrocardiogram (ECG) 5. Asking the client about pertinent medical history 6. Having the client chew and swallow aspirin 162 mg

Ans: 1, 4, 6 1. Attaching cardiac monitor leads 4. Obtaining a 12-lead electrocardiogram (ECG) 6. Having the client chew and swallow aspirin 162 mg Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced ED LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Delegation

Place the following steps for ear irrigation in the correct order. 1. Use an otoscope to ascertain that the eardrum is intact and that there is no evidence of infection. 2. Place the tip of the syringe at an angle in the external canal. 3. Watch for fluid return and signs of cerumen. 4. If cerumen does not appear, wait 10 minutes and repeat the irrigation. 5. Fill a syringe with warm irrigating solution. 6. After completion of the irrigation, have the client turn the head to the side to facilitate drainage. 7. Apply gentle but continuous pressure to the syringe plunger.

Ans: 1, 5, 2, 7, 3, 4, 6 1. Use an otoscope to ascertain that the eardrum is intact and that there is no evidence of infection. 5. Fill a syringe with warm irrigating solution. 2. Place the tip of the syringe at an angle in the external canal. 7. Apply gentle but continuous pressure to the syringe plunger. 3. Watch for fluid return and signs of cerumen. 4. If cerumen does not appear, wait 10 minutes and repeat the irrigation. 6. After completion of the irrigation, have the client turn the head to the side to facilitate drainage. Use an otoscope to assess the ear first and then fill the syringe with warm fluid. Angle the syringe to allow the fluid to flow along the side of the ear canal, not directly at the eardrum. Flush with continuous pressure, rather than a pumping action. You should see fluid return with cerumen. If not, then wait at least 10 minutes and repeat. Tipping the head allows gravity drainage of fluid left in the ear canal. Focus: Prioritization

A 30-year-old G1P0 woman at 39 weeks experienced a fetal demise and has just delivered a female infant. Her husband is at the bedside. Which are appropriate nursing actions at this time? (Select all that apply.) 1. Offer the option of autopsy to the parents. 2. Stay with the parents and offer supportive care. 3. Place the infant on the maternal abdomen. 4. Clean and wrap the baby and offer the infant to the parents to view or hold when desired. 5. Ask the parents if there are any special rituals in their religion or culture for a baby who has died that they would like to have done.

Ans: 2, 4, 5 Staying with the parents at this moment and offering physical and emotional support is appropriate. It is also appropriate to prepare the infant in a way that demonstrates care and respect for the baby and to offer the parents the opportunity to view and/or hold the infant as they desire. The RN must ask the parents if there are cultural or religious rituals they would like for their child to ensure that they feel their infant has been treated properly with respect to their religion or culture. Autopsy should be discussed, but not at the very moments after birth. The infant should not be placed on the maternal abdomen until the nurse assesses the parents' wishes of when and how to view the infant. Focus: Prioritization

In a male patient who must undergo intermittent catheterization, you are preparing to insert a catheter to assess the patient for postvoid residual. Place the steps for catheterization in the correct order. 1. Assist the patient to the bathroom and ask the patient to attempt to void. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 3. Open the catheterization kit and put on sterile gloves. 4. Lubricate the catheter and insert it through the meatus of the penis. 5. Position the patient supine in bed or with the head slightly elevated. 6. Drain all the urine present in the bladder into a container. 7. Cleanse the glans penis starting at the meatus and working outward. 8. Remove the catheter, clean the penis, and measure the amount of urine returned. ____, ____, _____, _____, ____, ____, _____, _____

Ans: 1, 5, 3, 2, 7, 4, 6, 8 1. Assist the patient to the bathroom and ask the patient to attempt to void. 5. Position the patient supine in bed or with the head slightly elevated. 3. Open the catheterization kit and put on sterile gloves. 2. Retract the foreskin and hold the penis at a 60- to 90-degree angle. 7. Cleanse the glans penis starting at the meatus and working outward. 4. Lubricate the catheter and insert it through the meatus of the penis. 6. Drain all the urine present in the bladder into a container. 8. Remove the catheter, clean the penis, and measure the amount of urine returned. Before checking postvoid residual, you should ask the patient to void, and then position him. Next you should open the catheterization kit and put on sterile gloves, position the patient's penis, clean the meatus, then lubricate and insert the catheter. All urine must be drained from the bladder to assess the amount of postvoid residual the patient has. Finally, the catheter is removed, the penis cleaned, and the urine measured. Focus: Prioritization

A 79-year-old who has just returned to the surgical unit following a TURP reports acute bladder spasms. In which order will you perform the following prescribed actions? 1. Administer acetaminophen/oxycodone 325 mg/5 mg (Percocet) 2 tablets. 2. Irrigate the retention catheter with 30 to 50 mL of sterile normal saline. 3. Infuse 500 mL of 5% dextrose in lactated Ringer's solution over 2 hours. 4. Offer the client oral fluids to at least 2500 to 3000 mL daily. _____, _____, _____, _____

Ans: 2, 1, 3, 4 Bladder spasms after a TURP are usually caused by the presence of clots that obstruct the catheter, so irrigation should be the first action taken. Administration of analgesics may help to reduce spasm. Administration of a bolus of IV fluids is commonly used in the immediate postoperative period to help maintain fluid intake and increase urinary flow. Oral fluid intake should be encouraged once you are sure that the client is not nauseated and has adequate bowel tone. Focus: Prioritization

You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization

Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply.) 1. Checking fingerstick glucose results every hour 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes 4. Assessing for indicators of fluid imbalance 5. Notifying the provider of changes in glucose level

Ans: 2, 3 2. Recording intake and output every hour 3. Measuring vital signs every 15 minutes The UAP's training and education includes how to measure vital signs and record intake and output. Performing fingerstick glucose checks and assessing clients requires additional education and skill, as possessed by licensed nurses. Notifying the provider of glucose changes is within the scope of practice for licensed nurses. Some facilities may train experienced UAPs to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this task is beyond the normal scope of practice of a UAP.

A 36-year-old G1P0 patient has received an epidural anesthetic. Her cervix is 6 cm dilated. Her blood pressure is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? (Select all that apply.) 1. Place the patient in high Fowler position. 2. Turn the patient to a lateral position. 3. Notify the anesthesiologist. 4. Prepare for emergency cesarean section. 5. Decrease the IV fluid rate.

Ans: 2, 3 The patient may be experiencing supine hypotension caused by the pressure of the uterus on the vena cava and the effects of epidural medication. Maternal hypotension can cause uteroplacental insufficiency leading to fetal hypoxia. Placing the woman in lateral position can relieve the pressure on the vena cava. The anesthesiologist should be notified and may need to treat the patient with ephedrine to correct the hypotension. IV fluids are increased per protocol when supine hypotension occurs. The correction of common problems in labor supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization

You are supervising an RN who floated from the medical-surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.) 1. Position the patient supine and turned on his side. 2. Apply direct lateral pressure to the nose for 5 minutes. 3. Maintain standard body substance precautions. 4. Apply ice or cool compresses to the nose. 5. Instruct the patient not to blow the nose for several hours.

Ans: 2, 3, 4, 5 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Delegation, supervision, assignment

Which tasks are appropriate to delegate to an LPN/LVN who is functioning under the supervision of an RN? (Select all that apply.) 1. Assessing the sexual implications for a client with oculogenital-type Chlamydia trachomatis infection 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 5. Assessing nutritional factors for a client with age-related macular degeneration 6. Reviewing the health history of a client to identify risk for ocular manifestations 7. Performing a routine check of a client's visual acuity using the Snellen eye chart

Ans: 2, 3, 4, 7 2. Administering sulfacetamide sodium 10% (Sulf-10 Ophthalmic) to a child with conjunctivitis 3. Reviewing hand-washing and hygiene practices with clients who have eye infections 4. Showing clients how to gently cleanse eyelid margins to remove crusting 7. Performing a routine check of a client's visual acuity using the Snellen eye chart Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. Focus: Delegation

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? (Select all that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.

Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.

Which two cancer patients could potentially be placed together as roommates? 1. A patient with a neutrophil count of 1000/mm3 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who has undergone laminectomy for spinal cord compression _______,_______

Ans: 2, 4 Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with a low neutrophil count and the patient who has had a bone marrow transplantation need protective isolation.

A 22-year-old G1P0 woman is being given an epidural anesthetic for pain control during labor and birth. Which are appropriate nursing actions when epidural anesthesia is used during labor? (Select all that apply.) 1. Request the anesthesiologist to discontinue the epidural anesthetic when the patient's cervix is completely dilated to allow the patient to sense the urge to push. 2. Insert a Foley catheter, because the woman is likely to be unable to void. 3. Encourage pushing efforts when the cervix is completely dilated in the absence of an urge to push. 4. Encourage the patient to turn from side to side during the course of labor.

Ans: 2, 4 Insertion of a Foley catheter is indicated because the woman will usually be unable to void due to the effect of the anesthetic in the bladder area. Positioning the patient on her side enhances blood flow and helps to prevent hypotension. Changing maternal position encourages progress in labor. In management of the second stage of labor when epidural anesthesia is used, laboring down as opposed to immediately pushing without the urge to push is advocated. It is not recommended to routinely discontinue an epidural anesthetic at complete dilation. A continuous epidural infusion provides pain relief throughout labor and birth. Use of evidence-based practices with a laboring woman supports the Perinatal Core Measure of reducing the percentage of women who are delivered by cesarean section. Focus: Prioritization

You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a UAP to get the crash cart. _____, _____, _____, _____, _____

Ans: 2, 4, 1, 3, 5 Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. (Use a pocket mask or bag-valve mask.) CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team is present. Focus: Prioritization

You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula. _____, _____, _____, _____

Ans: 2, 4, 3, 1 2. Have the client sit down. 4. Administer PRN oxygen by nasal cannula. 3. Check the client's blood pressure. 1. Call the client's physician. The primary goal is to decrease the cardiac ischemia that may be causing the client's tachycardia. This would be most rapidly accomplished by decreasing the workload of the heart and administering supplemental oxygen. Changes in blood pressure indicate the impact of the tachycardia on cardiac output and tissue perfusion. Finally, the physician should be notified about the client's response to activity, because changes in therapy may be indicated. Focus: Prioritization

When you are developing the plan of care for a home health client who has been discharged after a radical prostatectomy, which activities will you delegate to the home health aide? (Select all that apply.) 1. Monitoring the client for symptoms of urinary tract infection 2. Helping the client to connect the catheter to the leg bag 3. Checking the client's incision for appropriate wound healing 4. Assisting the client in ambulating for increasing distances 5. Helping the client shower at least every other day

Ans: 2, 4, 5 Assisting with catheter care, ambulation, and hygiene are included in home health aide education and would be expected activities for this staff member. Client assessments are the responsibility of RN members of the home health care team. Focus: Delegation

You are caring for an older woman with hepatic cancer. The UAP informs you that the patient's level of consciousness is diminished compared to earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. 1. Take vital signs, including pulse, respirations, blood pressure, and temperature. 2. Check responsiveness and level of consciousness. 3. Obtain a blood glucose reading. 4. Check electrolyte values. 5. Check ammonia level. 6. Check the patency of existing IV lines. 7. Administer oxygen if needed and check pulse oximeter readings. _______, _______,_______, _______, _______, _______, _______

Ans: 2, 7, 1, 3, 6, 4, 5 Determine level of consciousness and responsiveness, and changes from baseline. Oxygen should be administered immediately in the presence of respiratory distress or risk for decreased oxygenation and perfusion. Pulse oximetry can be used for continuous monitoring. Adequate pulse, blood pressure, and respirations are required for cerebral perfusion. Increased temperature may signal infection or sepsis. Blood glucose levels should be checked even if the patient is not diabetic. Severe hypoglycemia should be immediately treated per protocol. A patent IV line may be needed for delivery of emergency drugs. Electrolyte and ammonia levels are relevant data for this patient, and abnormalities in these parameters may be contributing to change in mental status. (Note: Laboratory results [i.e., electrolytes and ammonia levels] may be concurrently available; however, you should train yourself to systematically look at data. Look at electrolytes first because these are more commonly ordered. In some cases, you may actually have to remind the physician to order the ammonia level if the patient with a hepatic disorder is having a change in mental status.)

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves. 4. Take off gown. 5. Perform hand hygiene.

Ans: 3, 2, 4, 1, 5 3. Remove gloves. 2. Take off goggles. 4. Take off gown. 1. Remove N95 respirator. 5. Perform hand hygiene. This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration. Focus: Prioritization

You are caring for a client with frostbite to the feet. Place the following interventions in the correct order. 1. Apply a loose, sterile, bulky dressing. 2. Give pain medication. 3. Remove the client from the cold environment. 4. Immerse the feet in warm water of 105° F to 115° F (40.6° C to 46.1° C). 5. Monitor for compartment syndrome. _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5 The client should be removed from the cold environment first, then the rewarming process can be initiated. It will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment. Focus: Prioritization

A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing. 7. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5, 6, 7 For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization

As charge nurse, you must rearrange room assignments to admit a new patient. Which two patients would be best suited to be roommates? 1. 58-year-old with urothelial cancer receiving multiagent chemotherapy 2. 63-year-old with kidney stones who has just undergone open ureterolithotomy 3. 24-year-old with acute pyelonephritis and severe flank pain 4. 76-year-old with urge incontinence and a UTI _____, _____

Ans: 3, 4 3. 24-year-old with acute pyelonephritis and severe flank pain 4. 76-year-old with urge incontinence and a UTI Both these patients will need frequent assessments and medications. The patient receiving chemotherapy and the patient who has just undergone surgery should not be exposed to any patient with infection. Focus: Assignment

You are performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps of the care plan in the order in which each should be accomplished. 1. Apply silver sulfadiazine (Silvadene) ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Debride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 1, 5 3. Administer morphine sulfate 10 mg IV. 4. Debride the wound of eschar using gauze sponges. 2. Obtain specimens for aerobic and anaerobic wound cultures. 1. Apply silver sulfadiazine (Silvadene) ointment. 5. Cover the wound with a sterile gauze dressing. Pain medication should be administered before changing the dressing, because changing dressings for partial-thickness burns is painful, especially if the dressing change involves removal of eschar. The wound should be debrided before obtaining wound specimens for culture to avoid including bacteria that are skin contaminants rather than causes of the wound infection. Culture specimens should be obtained prior to the application of antibacterial creams. The antibacterial cream should then be applied to the area after débridement to gain the maximum effect. Finally, the wound should be covered with a sterile dressing. Focus: Prioritization

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 5, 1 The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available. Focus: Prioritization

A client reports a sudden excruciating pain in the left eye with the visual change of colored halos around lights and blurred vision. Which interventions should you anticipate and perform for this emergency condition? (Select all that apply.) 1. Prepare the client for photodynamic therapy. 2. Instill a mydriatic agent, such as phenylephrine (Neo-Synephrine). 3. Instill a miotic agent, such as pilocarpine (Isopto Carpine). 4. Administer an oral hyperosmotic agent, such as isosorbide (Ismotic). 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client.

Ans: 3, 4, 5, 6 3. Instill a miotic agent, such as pilocarpine (Isopto Carpine). 4. Administer an oral hyperosmotic agent, such as isosorbide (Ismotic). 5. Apply a cool compress to the forehead. 6. Provide a darkened, quiet, and private space for the client. The client's symptoms are suggestive of angle-closure glaucoma. Immediate inventions include instillation of miotics, which open the trabecular network and facilitate aqueous outflow, and intravenous or oral administration of hyperosmotic agents to move fluid from the intracellular space to the extracellular space. Applying cool compresses and providing a dark, quiet space are appropriate comfort measures. Photodynamic therapy is a treatment for age-related macular degeneration. Use of mydriatics is contraindicated because dilation of the pupil will further block the outflow. Focus: Prioritization

As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should you take first? 1. Make a note in the nurse's file and continue to observe clinical performance. 2. Refer the new nurse to the in-service education department. 3. Quiz the nurse about knowledge of pain management and pharmacology. 4. Give praise for correctly charting the dose and time and discuss the deficits in charting.

Ans: 4 In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists. Focus: Supervision, delegation

After you receive the change-of-shift report, in which order will you assess these clients assigned to your care? 1. 22-year-old who has questions about how to care for the drains placed in her breast reconstruction incision 2. Anxious 44-year-old who is scheduled to be discharged today after undergoing a total vaginal hysterectomy 3. 69-year-old who reports level 5 pain (on a scale of 0 to 10) after undergoing perineal prostatectomy 2 days ago 4. Usually oriented 78-year-old who has new-onset confusion after having a bilateral orchiectomy the previous day _____, _____, _____, _____

Ans: 4, 3, 2, 1 The bilateral orchiectomy client needs immediate assessment, because confusion may be an indicator of serious postoperative complications such as hemorrhage, infection, or pulmonary embolism. The client who had a perineal prostatectomy should be assessed next, because pain medication may be needed to allow him to perform essential postoperative activities such as deep breathing, coughing, and ambulating. The vaginal hysterectomy client's anxiety needs further assessment next. Although the breast implant client has questions about care of the drains at the surgical site, there is nothing in the report indicating that these need to be addressed immediately. Focus: Prioritization

The following clients come to the ED reporting acute abdominal pain. Prioritize them for care in order of the severity of their conditions. 1. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. 40-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week 4. 65-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour 5. 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 6. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night _____, _____, _____, _____, _____, _____

Ans: 4, 5, 2, 3, 1, 6 The client with a pulsating mass has an abdominal aneurysm that may rupture, and he may decompensate suddenly. The woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider. Focus: Prioritization

After emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function. 1. Obtain an order for a chest radiograph to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral. 5. Check exhaled carbon dioxide levels. _____, _____, _____, _____, _____

Ans: 5, 3, 4, 2, 1 Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the midepigastric area, tube placement must be corrected immediately. Securing the tube can be performed after these assessments are performed. Finally, radiographic study will verify and document correct placement. Focus: Prioritization

You are working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 minutes 2. Firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to the hands and forearms 4. Teenager with a crushed leg that is very swollen who is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. 12-year-old with wheezing and very labored respirations unrelieved by an asthma inhaler _____, _____, _____, _____, _____, _____

Ans: 6, 2, 4, 3, 5, 1 Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, because CPR efforts have been prolonged. Focus: Prioritization

A patient needs Klonopin 1 mg PO. The pharmacy delivers clonidine 0.1 mg tablets. A nursing student asks you if Klonopin and clonidine are two different names for the same drug. Place the following steps in the correct sequence so that you can teach the nursing student how ti prevent medication errors. A. Advise the pharmacy of any corrections as appropriate B. Recognize the "look-alike, sound-alike" drugs increase the chances of error C. Consult a medication book to verify the purpose of the drugs and generic and brand names D. Check the original medication order to verify what was prescribed E. Write an incident report, as appropriate, if you believe that a system error is occurring F. Call the MD for clarification of the order as appropriate

B. Recognize the "look-alike, sound-alike" drugs increase the chances of error D. Check the original medication order to verify what was prescribed C. Consult a medication book to verify the purpose of the drugs and generic and brand names F. Call the MD for clarification of the order as appropriate A. Advise the pharmacy of any corrections as appropriate E. Write an incident report, as appropriate, if you believe that a system error is occurring

Several patients are taking antipsychotic medications and are having medication side effects. Place the following patients in priority order for additional assessment and appropriate interventions. A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000

C. A patient who is taking loxapine and has a protruding tongue with lip smacking and spastic facial distortions A. A patina who is taking trifluoperazine and has a temperature of 103.6 with tachycardia, muscular rigidity, and dysphagia D. A patient who is taking clozapine and reports a sore throat, fever, malaise, and flulike symptoms that began about 6 weeks ago after starting the new antipsychotic medication; WBC is 2000 B. A patient who is taking fluphenazine and has dry mouth and dry eyes, urinary hesitancy, constipation, and photosensitivity

An elderly man was admitted for palliative care of terminal pancreatic cancer. The wife stated, "We don't want hospice; he wants treatment." The patient requested discharge and home health visits. Several hours after discharge, the man committed suicide with a gun. Which people should participate in a root cause analysis if this sentinel event? (Select all that apply) A. The wife and all immediate family members B. Only the MD who discharged the patient C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient E. Only the RN who discharged the patient F. Any MD who has involved int eh care of this patient

C. Any nurse who cared for the patient during hospitalization D. The care manger who arranged home visits for the patient F. Any MD who has involved int eh care of this patient

You are reviewing the principle of "least restrictive" intervention with the staff. Place the following intervention in the correct ascending order from the least restrictive to the most restrictive. A. Escort the patient to a quite room for a time out B. Restrain the patient's arms and legs with soft cloth restraints C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard E. Restrain the patient's upper extremities with wrist restraints F. Place the patient in an isolation room with a mental health assistant observing

C. Verbally instruct the patient to stop the unacceptable behavior and move to another part of the day room D. Accompany the patient out into the garden courtyard A. Escort the patient to a quite room for a time out F. Place the patient in an isolation room with a mental health assistant observing E. Restrain the patient's upper extremities with wrist restraints B. Restrain the patient's arms and legs with soft clothrestraints