1137 Midterm

The client diagnosed with peptic ulcer disease has a blood pressure of 88/42 and an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis” altered tissue perfusion related to decreased circulatory volume.” Which intervention should the nurse implement first?
1. Notify the laboratory to draw a type and crossmatch
.2. Assess the client’s abdomen for tenderness.
3. Insert an 18-gauge catheter and infuse lactated Ringer’s.
4. Check the client’s pulse oximeter reading.
3. Insert an 18-gauge catheter and infuse lactated Ringer’s.
The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client’s circulatory volume
The 7:00 PM .to 7:00 AM.nurse has received the shift report from the outgoing nurse. Which client should the nurse assess first?
1. The male client who has just been brought to the floor from the emergency department (ED) with no report of complaints.
2. The female client who received pain medication 30 minutes ago for pain that was a level “8” on a 1-to-10 pain scale.
3. The male client who had a cardiac catheterization in the morning and has been allowed to use the bathroom one time.
4. The female client who has been turning on the call light frequently and stating that her care has been neglected.
1. This client may or may not be stable. Hemay have “no complaints” at this time,but the nurse must assess this client first to determine that whatever the complaint was that brought him to the ED has stabilized. This client should be seen first
The client diagnosed with breast cancer who is positive for then BRCA gene is requesting advice from the nurse about treatment options. Which statement is the nurse’s best response?
1. “If it were me in this situation, I would consider having a bilateral mastectomy.”
2. “What treatment options has your health-care provider (HCP) discussed with you?”
3. “You should discuss your treatment options with your HCP.”
4. “Have you talked with your significant other about the treatment options available to you?”
2. The nurse must assess what information the client actually needs. To do this, the nurse must know what treatment options have been suggested to the client. Assessment is the first step in thenursing process
The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first?
1. The client diagnosed with pneumonia who has bilateral crackles.
2. The client on strict bed rest who is complaining of calf pain.
3. The client who complains of low back pain when sitting in a chair.
4. The client who is upset because the food is cold all the time.
2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs;therefore, this client should be assessed first.
The nurse is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
1. The intravenous (IV) proton-pump inhibitor medication to a client who is to be given nothing by mouth (NPO).
2. The loop diuretic to a client with a serum K
+level of 3.2 mEq/L.
3. The rapid-acting insulin Humalog to a client who has the breakfast tray in the room.
4. The stimulant laxative to a client who has not had a bowel movement in3 days.
3. Rapid-acting insulin, such as Humalog,peaks in 15 to 20 minutes and should beadministered when or immediately before the client eats the food on thetray; therefore, this medication shouldbe administered first
The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse?
1. The client diagnosed with a myocardial infarction who has an elevated troponin level.
2. The client receiving the IV anticoagulant heparin who has a partial thromboplastintime (PTT) of 68 seconds.
3. The client diagnosed with end-stage liver failure who has an elevated ammonia level.
4. The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL
4. The therapeutic range for Dilantin is 10-20 mg/dL. This client’s higher level warrants intervention because the serum level is above therapeutic range
The nurse is caring for clients on a medical unit. Which intervention should the nurse implement first?
1. Change the leg wound dressing for a client who has ambulated in the hall.
2. Discuss the correct method of obtaining a blood glucose level with the unlicensed assistive personnel (UAP).
3. Check on the male client who called the desk to say he has just vomited.
4. Place a call to the extended care facility to give the report on a discharged client.
3. This client has experienced a physiologic problem, and the nurse must assess the client and the emesis to decide on possible interventions
The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus (upper gastrointestinal [GI] system). Which intervention isthe priority for this client?
1. Obtain informed consent from the client for the diagnostic procedure.
2. Discuss the need to increase oral fluid intake after the procedure.
3. Explain that the client will have to drink a white, chalky substance.
4. Tell the client not to eat or drink anything prior to the procedure
4. The test is a barium study of the upper GI system and requires the client’s upper GI system to be empty. This client should be made NPO at least 8 to 10 hours before the test.
The nurse is administering medications for clients on a medical unit. Which medication should the nurse administer first?
1. The narcotic pain medication to a client complaining that his pain is an “8.”
2. A loop diuretic to a client diagnosed with heart failure who has 3 + pitting edema.
3. An anti cholinesterase medication to a client diagnosed with myasthenia gravis.
4. An antacid to a client with pyrosis who has called several times over the intercom.
3. Anti-cholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. This is the priority medication.
The nurse is caring for clients on a medical unit. Which laboratory data warrants immediate intervention by the nurse?
1. The PTT of 98 seconds with a control of 36 on a client diagnosed with deep vein thrombosis (DVT).
2. The hemoglobin and hematocrit (H&H) of 10.4/31 for a client diagnosed with a bleeding gastric ulcer.
3. The white blood cell (WBC) count of 4800 for a client diagnosed with leukemia.
4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN).
1. Therapeutic levels for PTT should be1-1/2 to 2 times the control—that is, 54 to 72 seconds when the control is 36; therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the facility protocol.
The nurse and a UAP are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
1. The assistant places the gait belt around the client’s waist prior to ambulating.
2. The assistant places the client on the abdomen with the client’s head to the side.
3. The assistant places her hand under the client’s right axilla to help the client move up in bed.
4. The assistant praises the client for attempting to perform activities of daily living independently.
3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client’s back or using a lift sheet
The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
1. The elderly client who is experiencing a stroke in evolution.
2. The client diagnosed with a transient ischemic attack 48 hours ago.
3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
4. The client with Alzheimer’s disease who is wandering in the halls
1. Because the client is having an evolving stroke, the client is experiencing a worsening of signs and symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse.
The nurse and the UAP are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia.
2. Request the UAP turn and position the 89-year-old client with a pressure ulcer.
3. Tell the UAP to assist the 54-year-old client with toilet training activities.
4. Ask the UAP to obtain vital signs on a 72-year-old client diagnosed with pneumonia
1. The nurse should not delegate to the UAP feeding a client who is at risk for complications during feeding as a result of dysphagia. This requires judgment that the assistant is not expected to possess.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
1. The 44-year-old client diagnosed with a myocardial infarction.
2. The 65-year-old client admitted with unstable angina.
3. The 75-year-old client scheduled for a cardiac catheterization.
4. The 50-year-old client complaining of chest pain
3. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab.
The charge nurse is making assignments for a 30-bed medical unit that is staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and threeUAPs. Which assignment is most appropriate?
1. Assign the RN to perform all sterile procedures.
2. Assign the LPN to give all IV medications.
3. Assign the UAP to complete the AM care.
4. Assign the LPN to write the care plans
3. The UAP is capable of performing the morning care. This is an appropriate nursing task to delegate
The UAP tells the nurse that the client has a blood pressure (BP) of 78/46 and apulse of 116 using a vital signs machine. Which intervention should the nurse imple-ment first?
1. Notify the HCP immediately.
2. Have the UAP recheck the vital signs manually.
3. Place the client in reverse Trendelenburg’s position.
4. Assess the client’s cardiovascular status
4. The nurse should immediately go tothe client’s room to assess the client
The charge nurse on a medical unit is working with a new unit secretary. Which statement concerning laboratory data is most important for the charge nurse to tell the secretary?
1. “Be sure to show me any lab information that is called in to the unit.”
2. “Make sure to file the reports on the correct client’s chart.”
3. “Do not take any laboratory reports over the telephone.”
4. “Verify all telephone reports by calling back to the lab.”
1. Because laboratory values called into a unit usually include critical values, the charge nurse should tell the unit secretary “to show me any lab information that is called in immediately.” The charge nurse must evaluate this information immediately
The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the UAP?
1. Administer a pain medication 30 minutes before therapy.
2. Give the client a washcloth to wash his or her face before walking.
3. Check to make sure the client has been offered the use of the bathroom.
4. Find a walker that is the correct height for the client to use
3. The client should be ready to work on therapy when the physical therapist arrives. The UAP should make sure that the client has used the bathroom or has not been incontinent before the therapist arrives, thus making the most efficient use of the therapist’s time
The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first?
1. The HCP.
2. The unit manager.
3. The respiratory therapist.
4. The case manager
3. Respiratory therapists listen to and treat clients with lung problems multiple time severy day. Therefore, this is the best person to consult when the nurse needs helpi dentifying a respiratory problem
An RN is working with an LPN and a UAP to care for a group of clients. Which nursing task should not be delegated or assigned?
1. The routine oral medications for the clients
2. The bed baths and oral care.
3. Evaluating the client’s progress.
4. Transporting a client to dialysis
3. The nurse cannot delegate or assign tasks that require nursing judgment, such as evaluating a client’s progress
The female volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client’s condition. Which information should the nurse discuss with the volunteer?
1. Determine how well she knows the client before talking with the volunteer.
2. Tell the volunteer the client’s condition in layman’s terms.
3. Ask the client if it is all right to talk with the volunteer.
4. Explain that client information is on a need-to-know basis only
4. The nurse should remind the volunteer of the HIPAA and confidentiality rules that govern any information concerning clients in a health-care setting
The nurse on a medical unit is discussing a client with the case manager. Which information should the nurse share with the case manager?
1. Discuss personal information that the client shared with the nurse in confidence.
2. Provide the case manager with any information that is required for continuity of care.
3. Explain that client confidentiality prevents the nurse from disclosing information.
4. Ask the case manager to get the client’s permission before sharing information.
2. The case manager’s job is to ensure continuity and adequacy of care for the client. This individual has a “need to know.
The staff nurse is concerned about the documentation form for blood administration. The nurse thinks it is unclear and time consuming. The nurse has discussed this with the charge nurse and other staff members who agree the documentation is cumbersome and needs to be revised. Which action would be most appropriate for the staff nurse to implement first?
1. Discuss the blood administration flow sheet with the chief nursing officer.
2. Contact an individual to help design a new blood transfusion flow sheet.
3. Learn to adapt to the present form and do not take any further action.
4. Volunteer to be on an ad hoc committee to research alternate flow sheets
4. The staff nurse should be a part of the solution to a problem; volunteering to be on a committee of peers is the best action to effect a change
The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure?
1. The cardiac catheterization department
2. The dietary department.
3. The nuclear medicine department.
4. The hospital laboratory department
2. The client must be NPO for 8 to 10 hours before the procedure. Therefore, the dietary department should be notified to hold the meal trays
The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system?
1. It guarantees that unions will not be able to come into the hospital.
2. It makes the manager responsible for sharing information with the staff.
3. It involves staff nurses in the decision-making process of the unit.
4. It is a system used to represent the nurses in labor disputes
3. Shared governance is an organizationalframework in which the nurse hasautonomy over his or her own prac-tice. The nurse is given direct input into the working of the unit
The staff nurse answers the telephone on a medical unit and the caller tells the nurse that he has planted a bomb in the facility. Which actions should the nurse implement? Select all that apply.
1. Do not touch any suspicious object.
2. Call 911, the emergency response system.
3. Try to get the caller to provide additional information.
4. Immediately pull the red emergency wall lever.
5. Write down exactly what the caller says
1, 3, and 5 are correct.
1. The nurse should begin a systematic search of the unit after activating the bomb scare emergency plan, and if any suspicious objects are found the nurse should not touch and should notify the bomb squad.
3. The nurse should stay calm and try to keep the caller on the telephone. The nurse should attempt to get as much information from the caller as possible. The nurse can jot a note to someone nearby to initiate the bomb scare procedure
5. The nurse should try to transcribe exactly what the caller says; this may help identify who is calling and wherea bomb might be placed
The male visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse’s best initial response?
1. “If you don’t stop shouting, I will have to call security.”
2. “I hear that you are frustrated. Can we discuss the issues calmly?”
3. “Sir, you are disrupting the unit. Calm down or leave the hospital.”
4. “This type of behavior is uncalled for and will not resolve anything.”
2. The nurse should remain calm and try to allow the client to vent his frustrations in a more acceptable manner. The nurse should repeat calmly in a low voice any instructions given to the client.
The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first?
1. Confront the charge nurse with the suspicions.
2. Talk with the night supervisor about the concerns.
3. Ignore the situation unless the nurse cannot do her job.
4. Ask to speak to the nurse educator about the problem.
2. The night supervisor or the unit manager has the authority to require the charge nurse to submit to drug screening. In this case, the supervisor on duty should handle the situation
The experienced male nurse has recently taken a position on a medical unit in acommunity hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would bemost appropriate for the nurse to take when attempting to resolve the issue?
1. Immediately give a 2-week notice and find a different job.
2. Discuss the situation with the manager who interviewed him.
3. Talk with the other employees about the staffing situation.
4. Tell the charge nurse the staffing is not what was explained to him
2. The nurse should give the manager a chance to discuss the situation before quitting. A temporary problem, such a sillness, may be affecting staffing
The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the new graduate nurse?
1. The client who has received 3 units of packed red blood cells (RBCs).
2. The client going for an esophagogastroduodenoscopy in the morning.
3. The client diagnosed with hyperosmolar hyperglycemic non ketotic syndrome.
4. The client who has just returned from a cardiac catheterization.
2. This client is being prepared for a test in the morning and is the least acute of the clients listed. The new graduate should be assigned to this client.
Which client should the medical unit nurse assess first after receiving the shift report?
1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless.
2. The 25-year-old client diagnosed with cellulitis of the left arm who has 2 +edema.
3. The 56-year-old client diagnosed with diverticulitis who has cramp left lower quadrant pain.
4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose.
1. Elderly clients diagnosed with pneumonia may not present with the “normal” symptoms, such as fever. The client’s becoming restless may indicate a decrease in oxygen to the brain. This client should be seen first
The nurse is completing a head-to-toe assessment on a client diagnosed with breast cancer and notes a systolic murmur that the nurse was not informed of duringreport. Which action should the nurse implement first?
1. Notify the HCP about the new cardiac complication.
2. Document the finding in the client’s chart and tell the charge nurse.
3. Check the chart to determine whether this is the first time a murmur has been identified.
4. Ask the client whether she has ever been told she has an abnormal heartbeat
3. Although the client was not admitted for a cardiac problem, she may have had a murmur for a while, and the previous nurse did not pick it up or did not mention it in the report because it was a long-standing physiologic finding in this client. The nurse should research the chart for a current history and physical to determine whether the HCP is aware of the condition.
A major disaster has been called, and the charge nurse on a medical unit must recommend clients to discharge to the medical discharge officer on rounds. Which client should not be discharged?
1. The client diagnosed with chronic angina pectoris who has been on new medication for 2 days.
2. The client diagnosed with DVT who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days.
3. The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant
Staphylococcus aureus
(MRSA) infection.
4. The client diagnosed with COPD who has the following arterial blood gas (ABG)levels: pH, 7.34; PCO2, 55; HCO, 28; PaO2, 89
3. Because resistant infections are very difficult to treat, this client should remain in the hospital for the required IVPB medication
The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN?
1. Feed the client who is being allowed to eat for the first time.
2. Administer the client’s anticoagulant subcutaneously.
3. Check the client’s neurologic signs and limb movement.
4. Teach the client to turn the head and tuck the chin to swallow
2. The LPN could administer routineparenteral medications. This is thebest task to assign to the LPN
The client diagnosed with lung cancer has a hemoglobin and hematocrit (H&H) of 13.4 mg/dL and 40.1, a WBC count of 7800, and a neutrophil count of 62%. Which
action should the nurse implement?
1. Place the client in reverse isolation
2. Notify the HCP.
3. Make sure no flowers are taken into the room.
4. Continue to monitor the client.
4. This client’s lab work is within normal limits. The nurse should continue to monitor the client
The nurse has been named in a lawsuit concerning the care provided. Which actionshould the nurse take first?
1. Consult with the hospital’s attorney.
2. Review the client’s chart.
3. Purchase personal liability insurance.
4. Discuss the case with the supervison
2. The nurse should be familiar with the chart and the situation so that details can be remembered. This should be the nurse’s first action.
The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee?
1. Discuss the nurse’s actions with the unit manager.
2. Confront the nurse about the behavior.
3. Do not allow the nurse to take breaks alone.
4. Prepare an occurrence report on the employee
1. Usually, the charge nurse should attempt to settle a conflict at the lowest level possible, in this case, confronting the nurse. However, the charge nurse does not have the authority to require a drug screen, which is the intervention needed in this situation. The nurse should notify the unit manager.
The charge nurse observes two UAPs arguing in the hallway. Which action should the nurse implement first in this situation?
1. Tell the manager to check on the UAPs.
2. Instruct the UAPs to stop arguing in the hallway.
3. Have the UAPs go to a private room to talk.
4. Mediate the dispute between the UAPs
2. The first action is to stop the argument from occurring in a public place. The charge nurse should not discuss the UAPs’ behavior in public
The graduate nurse is working with a UAP who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first?
1. Tell the charge nurse the UAP will not do tasks as delegated by the nurse.
2. Write up a counseling record with objective data and give it to the manager.
3. Complete the delegated tasks and do nothing about the insubordination.
4. Address the UAP to discuss why the tasks are not being done as requested
4. The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks.
A male HCP frequently tells jokes with sexual undertones at the nursing station. Which action should the female charge nurse implement?
1. Tell the HCP that the jokes are inappropriate and offensive.
2. Report the behavior to the medical staff committee.
3. Discuss the problem with the chief nursing officer.
4. Call a Code Purple and have the nurses surround the HCP.
1. Telling jokes with sexual innuendoscreates a “hostile work environment”and should be addressed with the HCP. This is a courtesy to the HCP to allow him to correct the behavior without being embarrassed
The new graduate nurse is having difficulty in completing the workload in a timely manner. Which suggestion could the preceptor make to help the new graduate become more organized?
1. Take a break whenever the nurse feels overwhelmed with the tasks.
2. Start the shift with a work organization sheet for assigned clients.
3. Take five deep breaths at the beginning of the shift and then begin
4. Review each day’s assignments and organize the work for the new nurse
2. The preceptor should recommend that the new graduate use some tool to organize the work so that important tasks, such as medication administration and taking vital signs, are not missed
The nurse is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering?
1. Levothyroxine (Synthroid), a thyroid hormone, to a client diagnosed with hypothyroidism.
2. Propranolol (Inderal), a beta-adrenergic, to a client diagnosed with hyperthy-roidism.
3. Nifedipine (Procardia), a calcium channel blocker, to a client with hypotension.
4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with diabetes
3. Procardia decreases blood pressure; therefore, the nurse should question administering this medication to a client with hypotension.
The nurse has received the shift report. Which client should the nurse assess first?
1. The client diagnosed with a DVT who is complaining of dyspnea and coughing.
2. The client diagnosed with gallbladder ulcer disease who refuses to eat the foodserved.
3. The client diagnosed with pancreatitis who wants the nasogastric tube removed.
4. The client diagnosed with osteoarthritis who is complaining of stiff joints
1. This client is exhibiting signs and symptoms of a potentially fatal complication of DVT pulmonary embolism. The nurse should assess this client first
The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first?
1. The elderly client diagnosed with a left fractured hip who is crying and is frightened about the surgery.
2. The school-aged client who has an open reduction and internal fixation of the right ulna with 1+edema.
3. The middle-aged client who is 1 day postoperative for abdominal surgery and who has a rigid, hard abdomen.
4. The adolescent client who is 2 days postoperative for an emergency appendectomy and who is complaining of abdominal pain and rating it as an “8.”
3. A hard, rigid abdomen indicates peritonitis, which is a life-threatening emergency. This client should be assessed first.
The client is diagnosed with laryngeal cancer and is scheduled for a laryngectomy next week. Which intervention would be priority for the clinic nurse?
1. Assess the client’s ability to swallow.
2. Refer the client to a speech therapist.
3. Order the client’s preoperative lab work.
4. Discuss the client’s operative permit
2. The client will not be able to speak after the removal of the larynx; there-fore, referral to a speech therapist who will be able to discuss an alternatemeans of communication is priority
The client who is 2 days postoperative for a left pneumonectomy has an apical pulse(AP) of 128 and a blood pressure (BP) of 80/50. Which intervention should the nurseimplement first?
1. Notify the health-care provider (HCP) immediately.
2. Assess the client’s incisional wound.
3. Prepare to administer dopamine, a vasopressor.
4. Increase the client’s intravenous (IV) rate
4. Increasing the IV rate will provide theclient with circulatory volume immedi-ately. Therefore, this is the first intervention
The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone?
1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm.
2. The client who is 1 day postoperative for total knee replacement (TKR) with a hemoglobin and hematocrit (H&H) of 12/36.
3. The client who is 4 days postoperative for coronary artery bypass surgery whose fasting glucose is 180 mg/dL.
4. The client who is 8 hours postoperative for exploratory laparotomy whose potassium (K+) is at 4.5 mEq/L
1. Because a client undergoing an elective procedure such as a gastric lap banding is usually healthy prior to the surgery, an elevated postoperative WBC count— which this client has—may indicate infection and, therefore, requires notifying the HCP
The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications?
1. The 17-year-old client scheduled for left knee arthroscopy who reports chewing
tobacco several times a day.
2. The 48-year-old client scheduled for surgery for an abdominal aortic aneurysm(AAA) who has a history of high blood pressure.
3. The 55-year-old client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day.
4. The 25-year-old client scheduled for a dilatation and curettage (D&C) who smokes marijuana on a daily basis.
3. The location of the incision for a cholecystectomy, the general anesthesia needed, and a heavy smoking history makes this client high risk for pulmonary complications.
The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first?
1. The narcotic analgesic morphine IV infusion to the client who is 8 hours postoperative and who is complaining of pain and rating it as a “7.”
2. The aminoglycoside antibiotic vancomycin intravenous piggy back (IVPB) to the client with an infected abdominal wound.
3. The proton-pump inhibitor pantoprazole (Protonix) IVPB to the client who is at risk for developing a stress ulcer.
4. The loop-diuretic furosemide (Lasix) intravenous push (IVP) to the client who has undergone surgical débridement of the right lower limb
1. The client who is in pain is priority. None of the other clients has a life-threatening condition. Pain is considered the fifth vital sign
The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon?
1. The client who is 2 days postoperative for bowel resection and who refuses to turn,cough, and deep breathe
2. The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a “pop” and then her pain went away.
3. The client who is 2 hours postoperative for TKR and who has 400 mL in thecell-saver collection device.
4. The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign
2. Feeling a “pop” after an abdominal hysterectomy may indicate possible wound dehiscence, which is a surgical emergency and requires the nurse to notify the surgeon via telephone
The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority.
1. Cleanse the stomal site with mild soap and water.
2. Assess the stoma for a pink, moist appearance.
3. Monitor the drainage in the ostomy drainage bag.
4. Apply stoma adhesive paste to the skin around the stoma.
5. Attach the ostomy drainage bag to the abdomen.
3, 2, 1, 4, 5.
3 The nurse must first assess the drainage in the bag for color, consistency, and amount. 2 After removing the bag, the nurse should assess the site to ensure circulation to the stoma. A pink, moist appearance indicates adequate circulation.1 The nurse should cleanse the area with a mild soap and water to ensure that the skin is prepared for the adhesive paste. 4.The nurse should then apply adhesive paste to the clean, dry skin.5 The ostomy drainage bag is attached last.
The nurse is transcribing the HCP’s orders for a client who is scheduled for an emergency appendectomy and who is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first?
1. Obtain the client’s informed consent.
2. Administer IV morphine 2 mg, every 4 hours, prn.
3. Shave the lower right abdominal quadrant.
4. Administer the on-call IVPB antibiotic
1. The nurse must first obtain the operative permit or determine whether it has been signed by the client prior to implementing any other orders
The nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention?
1. The UAP empties the indwelling catheter bag for the client with transurethral resection of the prostate (TURP).
2. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall. 3. The UAP provides apple juice to a client who has just been advanced to a clear liquid diet.
4. The UAP applies moisture barrier cream to the elderly client who has an excoriated perianal area
2. The client who received a narcoticanalgesic 30 minutes ago is at risk for falling because of the effects of themedication; therefore, the UAP shouldnot ambulate this client. The nurseshould intervene
The charge nurse is making shift assignments to the surgical staff, which consists of two registered nurses (RNs), two licensed practical nurses (LPNs), and two UAPs. Which assignment would be most appropriate by the charge nurse?
1. Instruct the RN to administer all prn medications.
2. Instruct the UAP to clean the recently vacated room.
3. Assign the LPN to administer routine medications.
4. Request the LPN to complete the admission for a new client
3. The LPN can administer most routine medications; therefore, this would be the most appropriate assignment for the LPN.
The nurse on the surgical unit is working with a UAP. Which task would be most appropriate for the nurse to delegate to the UAP?
1. Change an abdominal dressing on a client who is 2 days postoperative.
2. Check the client’s IV insertion site on the right arm.
3. Monitor vital signs on a client who has just returned from surgery.
4. Escort a client who has been discharged to the client’s vehicle
4. The UAP can escort the client to the vehicle after discharge
The charge nurse is making assignments for the surgical unit. Which client should be assigned to the new graduate nurse?
1. The 84-year-old client who has a chest tube that is draining bright red blood.
2. The 38-year-old client who is 1 day postoperative with a temperature of 101.2ºF.
3. The 42-year-old client who has just returned to the unit after a breast biopsy.
4. The 55-year-old client who is complaining of unrelenting abdominal pain
3. Of the four clients, the one who is most stable is the client who has just undergone a breast biopsy; therefore,this client would be the most appropriate to assign to a new graduate nurse.
The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the UAP to assist the client to the bathroom. Which action should the charge nurse implement?
1. Take no action because this is appropriate delegation.
2. Tell the UAP to obtain a bedside commode for the client.
3. Discuss the inappropriate delegation of the nursing task.
4. Document the situation in an adverse occurrence report.
1. The primary nurse’s instruction to the UAP to assist the client to the bathroom is an appropriate delegation that ensures the safety of the client. It requires no action by the charge nurse
The HCP writes an order for the client with a fractured right hip to ambulate with a walker four times per day. Which action should the nurse implement?
1. Tell the UAP to ambulate the client with the walker.
2. Request a referral to the physical therapy department.
3. Obtain a walker that is appropriate for the client’s height.
4. Notify the social worker of the HCP’s order for a walker
2. According to the National Council of State Boards of Nursing (NCSBN), collaboration with interdisciplinary team members is part of the management of care. Physical therapy is responsible for management of the client’s ability to move and transfer
Which task would be most appropriate for the nurse to delegate to the UAP working on a surgical unit?
1. Escort the client to the smoking area outside.
2. Obtain vital signs on a newly admitted client.
3. Administer a feeding to the client with a gastrostomy tube.
4. Check the toes of a client who just had a cast application
2. The UAP can take vital signs on a newly admitted client.
The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse?
1. The client who had surgery for an inguinal hernia and who is being prepared for discharge.
2. The client who is in the preoperative area and who is scheduled for laparoscopic cholecystectomy.
3. The client who has completed scheduled chemotherapy treatment and who is receiving 2 units of blood.
4. The client who has end-stage renal disease and who has had an arteriovenous fistula created
1. The most experienced nurse should be assigned to the client who requires teaching and evaluation of knowledge for home health care, because the client is in the surgery center for less than 1 day.
The LPN is working in a surgical rehabilitation unit. Which nursing task would be most appropriate for the LPN to implement?
1. Bathe the client who is incontinent of urine.
2. Document the amount of food the client eats.
3. Conduct the afternoon bingo game in the lobby.
4. Perform routine dressing changes on assigned clients.
4. The LPN scope of practice allows routine sterile procedures on the client who is stable, such as clients in a surgical rehabilitation facility.
The nurse is completing the admission assessment on the client scheduled for cystectomy with creation of an ileal conduit. The client tells the nurse, “I am taking saw palmetto for my enlarged prostate.” Which action should the nurse implement first?
1. Notify the client’s HCP to write an order for the herbal supplement.
2. Ask the client why he is taking an herb for his enlarged prostate.
3. Consult with the pharmacist to determine any potential drug interactions.
4. Look up saw palmetto in the Physician’s Desk Reference (PDR)
3. According to the NSCBN NCLEX-RN test plan, collaboration with interdisciplinary team members is part of the management of care. The nurse should first consult with the pharmacist to determine whether the client is taking any medications that could interact with the saw palmetto
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
1. The client who is 1 day postoperative for mastectomy and who is refusing toperform arm exercises.
2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain and rating it as a “5.”
3. The client who is 12 hours postoperative for adrenalectomy and who has vomited100 mL of dark green bile.
4. The client who is 2 days postoperative for hiatal hernia repair and who is complaining of feeling constipated
3. The client who has had nothing by mouth (NPO) at least 20 hours (8 hours before surgery and 12 hours postoperative) and has started vomiting dark green bile is priority. If the nurse were to rate nausea on a 1 to 10 scale, the active vomiting would be a “10” and this client would be seen first.
The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations(Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first?
1. Increase the client’s oxygen rate via nasal cannula.
2. Notify the respiratory therapist to draw arterial blood gases
.3. Tilt the head back and push forward on the angle of the lower jaw.
4. Obtain an intubation tray and prepare for emergency intubation
3, The client is exhibiting signs/symptomsof hypopharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage. The ABC of car-diopulmonary resuscitation is Airway, Breathing, and Circulation
The day surgery admission nurse is obtaining operative permits for clients having sur-gery. Which client should the nurse question signing the consent form?
1. The 84-year-old client diagnosed with chronic obstructive pulmonary disease(COPD).
2. The 16-year-old married client who is diagnosed with an ectopic pregnancy.
3. The 50-year-old client who admits to being a recovering alcoholic.
4. The 39-year-old client diagnosed with paranoid schizophrenia
4. An incompetent client cannot sign the consent form. An incompetent client is an individual who is not autonomous and cannot give or withhold consent, for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. The client may be able to sign the permit, but the nurse should question the client’s ability to sign the permit because paranoid schizophrenia is a mental illness
The female client in the preoperative holding area tells the nurse that she had a reaction to a latex diaphragm. Which intervention should the nurse perform first?
1. Notify the operating room personnel.
2. Label the client’s chart with the allergy.
3. Place a red allergy band on the client.
4. Inform the client to tell all HCPs of the allergy
1. Because the client is in the preoperative holding area, the immediate safety need for the client is to inform the operating room personnel so that no latex gloves or equipment will come into contact with the client. Person-to-person communication for a safety issue ensures that the information is not overlooked
The nurse is caring for clients in the PACU. Which client would require immediate intervention by the PACU nurse?
1. The client who is exhibiting masseter rigidity.
2. The client who has not urinated for 2 hours after surgery.
3. The client who is sleepy but arouses easily to verbal stimuli.
4. The client who has hypoactive bowel sounds
1. Masseter rigidity is a sign of malignant hyperthermia, which is a life-threatening complication of surgery. The client will also exhibit tachycardia (a heart rate greater than 150 bpm), hypotension,decreased cardiac output, and oliguria.It is a rare muscle disorder chemically induced by anesthesia.
The night nurse walks into the client’s room and finds the client crying. The client asks the nurse “Am I dying? I think something bad is wrong but they aren’t telling me.” The nurse knows the client has cancer and has less than 6 months to live. Which response is an example of the ethical principle of veracity?
1. “You are concerned they are not telling you something is wrong.”
2. “I am sorry to tell you but you have cancer and less than 6 months to live.”
3. “If you think something is wrong you should speak with your doctor in the morning.”
4. “What makes you think there is something wrong and you are dying?”
2. The ethical principle of veracity is the duty to tell the truth
The female client tells the clinic nurse her stomach hurts after she takes her morning medications. The MAR indicates the client is taking an antibiotic, a daily aspirin, and a stool softener. Which intervention should the nurse implement first?
1. Assess the client for abnormal bleeding.
2. Instruct the client to quit taking the aspirin.
3. Recommend the client take an enteric-coated aspirin.
4. Instruct the client to notify the HCP
3. After assessing the MAR, the nurse should realize the stomach discomfort is probably secondary to daily aspirin,and entericcoated aspirin would be most helpful to decrease the stomach discomfort and allow the client to stay on the medication
EBP
The nurse is reviewing the literature to identify evidenced-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse’s proposal for a change in the procedure?
1. The article in which the study was conducted by the manufacturer of the product used.
2. The research article that included 10 subjects participating in the study.
3. The review-of-literature article that cited ambiguous statistics about the product.
4. The review-of-literature article that cited numerous studies supporting the product
4. The more research articles that su-port a change proposal, the more valid the information, which increases the possibility for change to be considered by the health-care facility
The nurse is discharging the 72-year-old client who is 5 days postoperative for repair of a fractured hip with comorbid medical conditions. At this time, which referral would be the most appropriate for the nurse to make for this client?
1. To a home health-care agency.
2. To a senior citizen center.
3. To a rehabilitation facility
.4. To an outpatient physical therapist.
3. The rehabilitation facility will provide intensive therapy and address the comorbid conditions 24 hours a day. This will assist in the client’s recovery
The nurse is working in the emergency department (ED) of a children’s medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day care center.
3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active
3. The child hit by a car should be assessed first because he or she may have life-threatening injuries that must be assessed and treated promptly
The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?
1. Administer 6 L of oxygen via nasal cannula.
2. Assess the client’s neurologic status.
3. Administer a narcotic analgesic by intravenous push (IVP).
4. Increase the client’s intravenous (IV) rate
2. Because the client is complaining of a headache, the nurse should first ruleout cerebrovascular accident (CVA) by assessing the client’s neurologic status and then determine whether it is a headache that can be treated with medication
The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse’s assistance. The child starts crying because the pinwheel won’t spin. Which action should the nurse implement first?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry.
3. Encourage the child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it
1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked
The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
1. The child diagnosed with type 1 diabetes who has a blood glucose level of 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of 100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%
4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first
The nurse enters the client’s room and realizes the 9-month-old infant is not breath-ing. Rank in order of priority. Which interventions should the nurse implement?
1. Perform cardiac compression 30:2.
2. Check the infant’s brachial pulse.
3. Administer two puffs to the infant.
4. Determine unresponsiveness.
5. Open the infant’s airway
In order of priority: 4, 5, 3, 2, 1
4. The nurse must first determine the infant’s responsiveness by thumping the baby’s feet.
5. The nurse should then open the child’s airway using the head-tilt chin-lift technique, with care taken not to hyperextend the neck. Then the nurse should look, listen, and feel for respirations.
3. The nurse then administers quick puffs of air while covering the child’s mouth and nose, preferably with a rescue mask.
2. The nurse should determine whether the infant has a pulse by checking the brachial artery.
1. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2
The nurse on a pediatric unit has received the
AM.shift report and tells the UAP to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?
1. Determine what the UAP did not understand about the instruction
2. Tell the HCP that the UAP did not follow the nurse’s direction.
3. Ask the mother why she was feeding her child if the child was NPO.
4. Notify the dietary department to hold the child’s meal trays.
1. Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child’s receiving food; therefore, this action should be implemented first
Which client should the charge nurse on the pediatric unit assign to the most experienced nurse?
1. The 4-year-old child diagnosed with hemophilia receiving factor VIII.
2. The 8-year-old child with headaches who is scheduled for a CT scan.
3. The 6-year-old child recovering from a sickle cell crisis.
4. The 11-year-old child newly diagnosed with rheumatoid arthritis
4. The child newly diagnosed with a chronic disease, which will have acute exacerbations, requires extensive teaching; therefore, the most experienced nurse should be assigned to this child and family
Which client should the postpartum nurse assess first after receiving the AM.shift report?
1. The client who is complaining of perineal pain when urinating.
2. The client who saturated multiple peri-pads during the night.
3. The client who is refusing to have the newborn in the room.
4. The client who is crying because the baby will not nurse
2. Saturating multiple peri-pads indicates heavy bleeding, which may indicate hemorrhaging. The nurse should assess this client first
Which newborn infant would warrant immediate intervention by the nursery nurse?
1. The 1-hour-old newborn who has abundant lanugo.
2. The 6-hour-old newborn whose respirations are 52.
3. The 12-hour-old newborn who is turning red and crying
.4. The 24-hour-old newborn who has not passed meconium.
4. The newborn who has not passed meconium 24 hours after birth must be evaluated for intestinal obstruction or a congenital abnormality. This could be caused by an imperforate anus, Hirschsprung’s disease, cystic fibrosis,or several other possibilities. This new-born warrants immediate intervention
The client in labor is showing late decelerations on the fetal monitor. Which interven-tion should the nurse implement first?
1. Notify the health-care provider (HCP) immediately.
2. Instruct the client to take slow, deep breaths.
3. Place the client in the left lateral position.
4. Prepare for an immediate delivery of the fetus
3. The left lateral position will improve placental blood flow and oxygen supply to the fetus. This should be the nurse’s first intervention