Priority, Delegation & Management Questions (N460)

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?
1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.
2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale.
3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally.
4. The client who has been turning on the call light frequently and stating her care has been neglected.
1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.

This client may or may not be stable. The client may have “no complaints” at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first.

2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated and the pain was a 3. The nurse can evaluate the amount of pain relief after making sure that the ED admission is stable.
3. This client has been back from the procedure and a bilateral pedal pulse indicates the client is stable; therefore, this client does need to be seen first.
4. Psychological issues are important, but not more so than a physiological issue, and the client admitted from the ED may have a physiological problem.

The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
1. The cardiac glycoside to the client who has an apical pulse of 58.
2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L.
3. The antidysrhythmic to the client in ventricular fibrillation.
4. The calcium-channel blocker who has a blood pressure of 110/68.
3. The antidysrhytmic to the client in ventricular fibrilation.
The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first.
1. The cardiac glycoside, such as digoxin, should not be administered unless the apical pulse is 60 or above.
2. Because the client’s serum K+ level is already low, the nurse should question administering a loop diuretic.
4. The client’s blood pressure is above 90/60, so the calcium-channel blocker can be administered but it is not priority over a client who is in a life-threatening situation.
Which client should the telemetry nurse assess first after receiving the a.m. shift report?
1. The client diagnosed with deep vein thrombosis who has an edematous right calf.
2. The client diagnosed with mitral valve stenosis who has heart palpitations.
3. The client diagnosed with arterial occlusive disease who has intermittent claudication.
4. The client diagnosed with congestive heart failure who has pink frothy sputum.
4. The client diagnosed with CHF who has pink frothy sputum.
The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first.

1. The nurse would expect the client with a deep vein thrombosis to have an edematous right calf, so the nurse would not need to assess this client first.
2. The nurse would expect the client with mitral valve stenosis to have heart palpitations (sensa- tions of rapid, fluttering heartbeat).
3. The nurse would expect the client with arterial occlusive disease to have intermittent claudication (leg pain), so the nurse would not need to assess this client first.

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. The 75-year-old client scheduled for a cardiac catheterization.
A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab.
1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 4. This patient could be having a heart attack so not appropriate.
The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse?
1. Assign an RN to perform all sterile procedures.
2. Assign an LPN to give all IV medications.
3. Assign an UAP to complete the a.m. care.
4. Assign an LPN to write the care plans.
3. Assign a UAP to complete am care.
A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate. 4. Writing a care plan for a client requires nurs- ing judgment; therefore, an RN should be assigned this function.

1. An LPN can perform sterile procedures such as inserting indwelling catheters and IV catheters. An RN should perform the functions that require nursing judgment, such as planning and evaluating the care of the clients.
2. Although an LPN could administer most in- travenous piggyback (IVPB) medications, only qualified RNs may administer intravenous push (IVP) medications and chemotherapy.
4. Writing a care plan for a client requires nurs- ing judgment; therefore, an RN should be assigned this function.

The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?
1. Discuss personal information 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. Provide the case manager with any information that is required for continuity of care.
The case manager’s job is to ensure continuity and adequacy of care for the client. This individual has a “need to know.”

1. Unless the information shared is directly connected to healthcare issues, the nurse should not share confidential information with any- one else. The nurse should inform clients that information directly affecting the client’s healthcare will be shared on a need-to-know basis only.
3. The case manager is part of the healthcare team; therefore, information should be shared.
4. The client gave permission when being admit ted to the hospital for information to be shared among those providing care. The case manager does not need to obtain further consent.

The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?
1. Call a Code Blue immediately.
2. Check the client’s telemetry leads.
3. Find the nurse to check the client.
4. Remove the telemetry monitor.
2. Check the client’s telemetry leads.
The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system.

1. The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested.
2. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable.
3. The UAP can take care of this problem; there is no need for the primary nurse to check the client.
4. The strip indicates an artifact, but there is no indication that the client should be removed from telemetry.

The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department?
1. The nurse who has 4 years of experience on the cardiac unit.
2. The nurse who just transferred from critical care to the cardiac unit.
3. The nurse with 1 year of experience on the cardiac unit who has been on a week’s sick leave.
4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.
2. The nurse who just transferred from critical to the cardiac unit.
The nurse with critical care experience would be the best choice to float to the emergency department.

1. The nurse who just has surgical nursing expe- rience would not be the choice to float to the emergency department. 2. The nurse with critical care experience would be the best choice to float to the emergency department. 3. The nurse just returning from sick leave would not be a good choice to send to the emergency department, which may be very busy at times. 4. This nurse has not had experience in critical care; therefore, this nurse would not be the best choice to float to the emergency department.

The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?
1. The client with coronary artery disease who is complaining that the nurses are being rude and won’t answer the call lights.
2. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level.
3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.
4. The client 2 days’ postoperative coronary artery bypass who is being transferred to the cardiac unit.
1. The client with CAD who is complaining the nurses are being rude and won’t answer call lights.
The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening.
2. An elevated CPK-MB, cardiac isoenzyme, level is expected in a client with an acute myocardial infarction; therefore, the charge nurse would not see this client first.
3. The INR is within the normal limits of 2 to 3; therefore, this client does not need to be assessed first.
4. This client is being transferred to the cardiac unit; therefore, the client is stable and does not need intervention.
The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first?
1. Discontinue the client’s vasoconstrictor, dopamine.
2. Notify the client’s healthcare provider.
3. Administer the vasopressor hydralazine.
4. Assess client’s neurological status.
1. Discontinue the client’s vasoconstrictor, dopamine.
The nurse should first discontinue the medication that is causing the increase in the client’s blood pressure prior to doing anything else.
2. The nurse should notify the HCP but not prior to taking care of the client’s elevated blood pressure.
3. The client may need a medication to de crease the blood pressure but the nurse should first discontinue the medication causing the elevated blood pressure.
4. The nurse must first decrease the client’s blood pressure prior to assessing the client.
The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse?
1. The client with acute rheumatic fever carditis who does not want to stay on bed rest.
2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22.
3. The client who is showing multifocal premature ventricular contractions (PVCs).
4. The client diagnosed with angina who is scheduled for a cardiac catheterization. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit?
3. The client who is showing multifocal premature ventricular contractions (PVCs).
Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client.

1. The client with rheumatic heart fever is expected to have carditis and should be on bed rest. The nurse needs to talk to the client about the importance of being on bed rest but this client is not in a life-threatening situation and does not need the most experienced nurse.
2. These ABG values are within normal limits; therefore, a less experienced nurse could care for this client.
4. A cardiac catheterization is a routine procedure and would not require the most experienced nurse.

The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit?
1. The UAP is instructed to bathe the client who is on telemetry.
2. The UAP is requested to obtain a bedside glucometer reading.
3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic.
4. This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client.

1. All clients in the ICU are on telemetry, and the UAP could bathe the client. This would not warrant intervention by the charge nurse. 2. The UAP can perform glucometer checks at the bedside, and there is nothing that indi cates the client is unstable. This would not warrant intervention by the charge nurse. 3. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield.

The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication?
1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.
2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min.
3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.
1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.
The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice.
2. The apical heart rate should be greater than 60 beats/minute before administering the medication; therefore, the nurse would not question administering this medication.
3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be taken with foods to pre- vent gastric upset; therefore, the nurse would not question administering this medication.
4. The INR therapeutic level for warfarin (Coumadin), an anticoagulant, is 2 to 3; therefore, the nurse would not question administering this medication.
The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy?
1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit.
2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift.
3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated.
4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team.
2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift.
This is a win-win strategy that focuses on goals and attempts to meet the needs of both parties. The charge nurse keeps an experienced nurse and the staff nurse keeps her position. Both parties win

1. This is a win-lose strategy wherein, during the conflict, one party (charge nurse) exerts dominance and the other (staff nurse) submits.
3. This is negotiation in which the conflicting parties give and take on the issue. The staff nurse gets one more chance and the charge nurse’s authority is still intact.
4. This is not an example of a win-win strategy and is not an appropriate action for the staff nurse to take. The opinion of the staff should not influence the charge nurse’s action.

Which client warrants immediate intervention by the nurse?
1. The client diagnosed with pericarditis who has chest pain with inspiration.
2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse.
3. The client diagnosed with Marfan syndrome who has pectus excavatum (concave chest deformity).
4. The client diagnosed with atherosclerosis who has slurred speech and drooling.
4. The client diagnosed with atherosclerosis who has slurred speech and drooling.
Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.

1.The client with pericarditis is expected to have chest pain with inspiration; therefore, this client does not warrant immediate intervention. 2. The client with mitral valve regurgitation is expected to have thready peripheral pulses and cool, clammy extremities. Therefore, this client does not warrant immediate intervention. 3. The client with Marfan syndrome is expected to have a chest that sinks in or sticks out, known as funnel chest or pectus excavatum; therefore, this client does not warrant imme- diate intervention. 4. Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.

The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first?
1. Have the family bring food from home for the client. 2. Check to see what the client has eaten in the past 24 hours.
3. Tell the client that a low-sodium diet is an important part of the diagnosis.
4. Ask the dietician to discuss food preferences with the client.
2. Check to see what the client has eaten in the past 24 hours.
Assessing the client’s intake will help the nurse to determine the extent of the client’s complaints. This is the first intervention.
1. The family may be allowed to bring in food occasionally from home, but what they bring may not adhere to a low-sodium diet, and the family should not be required to provide three meals per day for the client. This is the facility’s responsibility. 3. This may be true but does not help the client adjust to a lack of sodium in the diet. 4. A referral to the dietician should be made after the nurse fully assesses the client.
The charge nurse on the cardiac unit is making shift assignments. Which client should 20. be assigned to the most experienced nurse?
1. The client diagnosed with mitral valve stenosis.
2. The client diagnosed with asymptomatic sinus bradycardia.
3. The client diagnosed with fulminant pulmonary edema.
4. The client diagnosed with acute atrial fibrillation.
3. The client diagnosed with fulminant pulmonary edema.
A client with fulminant pulmonary edema is experiencing an acute, life-threatening problem. The most experienced nurse should be assigned to this client.

1. The client with mitral valve stenosis can live with this diagnosis and it is not a life- threatening condition. 2. The client with asymptomatic sinus brady cardia is stable and because the client is not exhibiting any signs/symptoms, this client does not need to be assigned to the most experienced nurse. 4. A client with acute atrial fibrillation is not in a life-threatening situation; therefore, this client would not be assigned to the most experienced nurse.

The nurse and the UAP enter the client’s room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first?
1. Ask the UAP to check whether the client is asleep.
2. Tell the UAP to perform cardiac compressions.
3. Instruct the UAP to get the crash cart.
4. Request the UAP to put the client in a recumbent position.
3. Instruct the UAP to get the crash cart.
The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is deter mined, the nurse should not delegate any client care.

1. The first step in cardiopulmonary resuscitation according to the AHA guidelines is to establish unresponsiveness by “shaking and shouting.” If the client does not respond to being shaken, then the nurse can proceed to the next step, which is to “look, listen, and feel” for breaths. This is assessment and, according to AHA guidelines, the UAP could perform this function if alone. How ever, the nurse should assess the client before a UAP. 2. Administering chest compressions is per formed after establishing unresponsiveness and lack of respiration. 4. The nurse should place the client in the recumbent position before attempting to perform chest compressions; the nurse

The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client?
1. “Are you sexually active?”
2. “Can you still drive your car?”
3. “Do you have pain medications at home?”
4. “Do you know when to call your HCP?”
1. Are you sexually active?
The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client’s age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the question that should be asked because many clients may be embarrassed to bring up the subject.

2. The client should not drive a motor vehicle until released to do so by the healthcare provider (HCP). This is not an appropriate question at this time. 3. The client should be discharged with a prescription for oral pain medications to be taken as directed by the surgeon. The nurse should not encourage the client to use old medications the client may have at home. This is not an appropriate question. 4. The nurse is providing discharge instructions and should tell the client when to call the healthcare provider (HCP). This is not an appropriate question.

The nurse on the cardiac unit is discussing case management with a client who asks, “Why do I need a case manager for my heart disease?” Which statements are most appropriate for the nurse to respond? Select all that apply.
1.”Case management helps contain the costs of your healthcare.”
2.”It will help enhance your quality of life with a chronic illness.”
3. “It decreases the fragmentation of care across many healthcare settings.”
4. “Case management is a form of health insurance for clients with chronic illnesses.”
5. “We try to provide quality care along the healthcare continuum.”
1, 2, 3, 5.

1. Case managers help coordinate health care between multiple sources of healthcare attempting to contain healthcare cost. 2. The case manager is a client advocate and helps with communication between the client and healthcare providers, which, it is hoped, enhances the client’s quality of life. 3. The case manager coordinates out patient care and in-patient care, and helps with referrals for the client.5. The case manager is involved in assessing, planning, facilitating, and advocating for health services for a client, which, it is hoped, provide quality care. Trying to coordinate this is often exhausting and frustrating for the client and family.

4. Case management is not a form of health insurance.

The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy?
1. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early.
2. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week.
3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly.
4. The UAP is placed on 1-month probation, and any further occurrences will result in termination from this position.
3. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly.
This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses.

1. This is a win-win strategy that focuses on goals (to have adequate staff) and attempts to meet the needs of both parties. The director of nurses keeps an experienced nurse, and the UAP keeps her position. Both parties win. 2. This is a possible win-win strategy in which both parties win. The UAP keeps her job, and the director of nurses can hire a UAP who will be able to work the assigned hours. 4. This is a negotiation in which the conflicting parties give and take on the issues. The UAP gets one more chance, and the director of nurse’s authority is still intact.

The cardiac clinic nurse hears the UAP tell the client, “You have gained over 15 pounds since your last visit.” The scale is located in the office area. Which action should the clinic nurse implement?
1. Tell the UAP in front of the client to not comment on the weight.
2. Ask the UAP to put the client in the room and take no action.
3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA.
4. Report the UAP to the director of nurses of the clinic.
3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA.
The clinic nurse should correct the UAP’s behavior, but it should be done in private and with an explanation as to why the action is inappropriate. This is a violation of confidentiality because the scale is located in the office area and any client or visitor passing by, as well as other staff members, can hear the comment.

1. The clinic nurse should not correct the UAP in front of the client. This is embar- rassing to the UAP and makes the client uncomfortable. 2. The clinic nurse must correct the UAP’s be- havior. The client’s weight gain should not be announced in the office area so that all staff, clients, and visitors can hear. This is a violation of confidentiality. 4. The clinic nurse should handle this situation. If the UAP’s behavior shows a pattern of behavior, then it should be reported to the director of nurses.

The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first?
1. Tell the UAP to change it immediately.
2. Ask the UAP why the sharps container has not been changed.
3. Change the sharps container as per clinic policy.
4. Document the situation and place a copy of the documentation in the employee file.
3. Change the sharps container as per clinic policy.
A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behaviour

1. A full sharps container is a violation of Occupational Health and Safety Administra tion (OSHA) regulations, and because the UAP has not done it after being asked twice, a third request is not necessary. 2. The nurse should discuss why the sharps container has not been changed, but it is not the first intervention. 4. The situation should be documented because the UAP was told twice, but documentation is not the first intervention.

The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won’t go to the hospital. Which action should the nurse implement first?
1. Instruct the wife to call 911 immediately.
2. Tell the wife to have the client chew an aspirin.
3. Ask the wife what the client had to eat recently.
4. Request the husband talk to the clinic nurse.
2. Tell the wife to have the client chew an aspirin.
The AHA recommends the client having chest pain chew an aspirin to help de crease platelet aggregation. This is the first intervention the clinic nurse should tell the wife to do. The client is in dis tress; therefore, the nurse should have the wife do something.

1. The wife should call 911, but the American Heart Association recommends chewing a baby aspirin at the onset of chest pain. 3. This question could be asked to determine whether the pain is secondary to a gallblad- der attack or gastric irritation, but this is not the first intervention. 4. The clinic nurse could possibly talk to the client while the wife is getting an aspirin, but this is not the first intervention.

The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first?
1. The client diagnosed with hypertension who is reporting a BP of 148/92.
2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%.
3. The client diagnosed with congestive heart failure who has edematous feet.
4. The client diagnosed with chronic atrial fibrillation who is having chest pain.
4. The client with chronic atrial fibrillation is at risk for pulmonary emboli, a poten tially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first.

1. This blood pressure—148/92—is elevated, but it would not be life threatening for someone diagnosed with hypertension; therefore, the nurse would not contact this client first. 2. A pulse oximeter reading of 93% is low but still within normal limits, and a client with cystic fibrosis, a chronic respiratory condi- tion, would be expected to have a chronically low oxygen level. This client would not need to be contacted first. 3. The client with CHF would be expected to have edematous feet; this client would not need to be contacted first.

The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first?
1. Assist the client to a sitting position.
2. Assess the client’s vital signs.
3. Call 911 for the paramedics.
4. Auscultate the client’s lung sounds.
1. Assist client to a sitting position.
The nurse’s first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client’s respiratory distress.
2. The nurse should assess the client’s vital signs, but the first intervention is to help the client breathe. 3. The nurse should contact the paramedics if the client does not improve after being placed in a sitting position, but this is not the nurse’s first intervention. 4. The nurse should auscultate the client’s lungs, but the first intervention is to help the client breathe more easily.
The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse’s best response?
1. “I am so excited for you; he seems like a very nice young man.”
2. “You should not go out with him as long as she is a client of our agency.”
3. “I think you should tell the director of the HH care agency about this date.”
4. “You should never date someone you meet while taking care of a client.”
2. “You should not go out with him as long as she is a client of our agency.”
This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service.

1. This is professional boundary crossing. Even though the grandson is not the client, he is related to the client. The HH aide should not go out with him. 3. The nurse’s best response is to tell the HH aide the facts about dating relatives of clients. The director would tell the HH aide the same information. 4. The HH aide could date the grandson when the client is no longer on service. So this statement is not the nurse’s best response.

The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement?
1. Assess the client’s spiritual needs.
2. Assess the client’s financial situation.
3. Assess the client’s support system.
4. Assess the client’s medical diagnosis.
3. Assess the client’s support system.
The client’s support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client.

1. Assessment of the client’s spiritual needs in end-of-life issues is a key consideration but is the chaplain’s responsibility, when he/she is a member of the hospice team. 2. The client’s financial situation can be as- sessed, but it is not priority over the client’s spiritual needs when death is near. 4. The client’s medical diagnosis is important when addressing the grieving process but there is nothing the nurse can do about the medical diagnosis, which is why assessing, supporting, and addressing the client’s spiritual needs will be carried out prior to the medical diagnosis.

The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, “My wife is not breathing.” Which intervention should the nurse implement first?
1. Contact the client’s healthcare provider (HCP).
2. Notify the Rapid Response Team.
3. Stay with the client and her husband.
4. Instruct the UAP to perform post-mortem care.
3. Stay with the client and her husband.
The nurse should stay with the client and her husband and not make any life- rescuing interventions while the client is dying. The husband should not be left alone.

1. The client’s HCP will need to determine time of death but it is not the nurse’s first intervention. 2. The Rapid Response Team would not be notified because the client has a DNR. 4. The UAP can perform post-mortem care but it is not the first intervention when the client’s husband tells the nurse his wife has quit breathing.

The hospice nurse is triaging phone calls from clients. Which client should the nurse call first?
1. The client whose family reports the client is not eating.
2. The client who wants to rescind the out-of-hospital DNR.
3. The client whose pain is not being controlled with the current medications.
4. The client whose urinary incontinence has caused a Stage 1 pressure ulcer.
3. The client whose pain is not being controlled with the current medications.
One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately.

1. This client should be seen, but a client who is terminally ill and is refusing to eat is not an emergency situation. 2. The client has a right to rescind the out-of- hospital DNR but paperwork is not priority over a client who is in pain. 4. A Stage 1 pressure ulcer must be assessed and treatment started but this is not priority over pain control.

The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP?
1. Call the healthcare provider (HCP) and report the client’s chest pain.
2. Give a client some acetaminophen (Tylenol) while the nurse checks the client.
3. Get the client’s medical records and bring them to the client’s room.
4. Notify the client’s family of the onset of chest pain.
3. Get the client’s medical records and bring them to the client’s room.
The nurse should immediately go to the client’s room and assess the client. Sometimes the nurse may need the client’s chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room.

1. If the HCP is called, the nurse should per- form this task, not the UAP. A UAP cannot take a telephone order; only a licensed nurse can take telephone orders. 2. The UAP cannot administer a medication, not even Tylenol. 4. The UAP should not be asked to relay such information. This is the nurse’s or HCP’s responsibility.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? 1. Feed the client who has an IV in both forearms.
2. Assess the client diagnosed with stage IV heart failure.
3. Discharge the client who had a cardiac catheterization.
4. Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin).
2. Assess the client diagnosed with stage IV heart failure. The nurse cannot assign assessment. This is the inappropriate task to assign to the LPN

1. The LPN can feed a client who is stable but unable to feed him or herself because of medical equipment. This is an appropriate task to assign 3. The LPN can discharge a client who had a procedure and who does not require extensive teaching. 4. The LPN can administer a routine IVPB medication.

The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)?
1. Have the UAP call the operator and announce the code.
2. Tell the UAP to answer the other call lights on the unit.
3. Send the UAP to the room to start rescue breaths.
4. Ask the family to step out ofthe room during the code.
2. Tell the UAP to answer the other call lights on the unit. Answering the call lights of the other clients on the unit can be delegated to the UAP.

1. The nurse in the client’s room notifies the hospital operator of a code situation. 3. In a hospital, the respiratory therapist assumes the responsibility for ventilations. 4. The nursing supervisor is responsible for requesting the family to leave the room. The UAP does not have the authority to make this request.

The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first?
1. Place the client on a telemetry monitor and assess the client.
2. Call an ambulance to transfer the client to a charity hospital.
3. Have the client sign a form agreeing to pay the bill.
4. Ask the client why he chose to come to this hospital.
1. Place the client on a telemetry monitor and assess the client. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The nurse should initiate steps to assess the client.

2. The nurse must assess the client. If a transfer is made, it will be after the client has been stabilized and the receiving hospital has ac cepted the transfer. 3. Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The hospital will attempt to recover the costs after the client has been treated, 4. This is irrelevant information.

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

1. The client diagnosed with angina who is reporting chest pain.
2. The client diagnosed with CHF who has bilateral 4+ peripheral edema.
3. The client diagnosed with endocarditis who has a temperature of 100°F.
4. The client diagnosed with aortic valve stenosis who has syncope.

1. The client diagnosed with angina who is reporting chest pain. The client with angina should be asymptomatic; when the client is complaining of chest pain, this is abnormal data. Therefore, this client should be assessed first. Remember Maslow’s Hierarchy of Needs identifies physiological needs as priority and pain is priority.

2. In a client diagnosed with CHF, 4+ edema is expected. The nurse would not need to assess this client first. 3. The client diagnosed with endocarditis is expected to have a fever. The nurse would not need to assess this client first. 4. The client diagnosed with aortic valve stenosis has the classic triad of syncope, angina, and exertional dyspnea; therefore, this client would not be assessed first.

Which medication should the nurse administer first after receiving the morning 55. 56. 57. shift report?
1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today.
2. The antiplatelet medication to the client who had a myocardial infarction.
3. The coronary vasodilator patch to the client with coronary artery disease.
4. The statin medication to the client diagnosed with atherosclerosis.
1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today. First-dose intravenous antibiotic medications are priority medications and should be administered within 1 to 2 hours of when the order was written. This should be the first medication administered.

2. Antiplatelet medication, aspirin, is not a priority medication. 3. A coronary vasodilator patch, nitroglycerin, is not a priority medication. 4. A statin medication that decreases cholesterol level should be administered in the evening when the enzyme for cholesterol metabolism is at its highest peak.

The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP?
1. Monitor the client’s arterial blood gases.
2. Re-infuse the client’s blood using the cell saver.
3. Assist the client to take a sponge bath.
4. Change the client’s saturated leg dressing.
3. The UAP can assist with hygiene needs; this is one of the main tasks that may be delegated to UAPs.

1. The nurse and respiratory therapist, not the UAP, are responsible for monitoring the ABGs. 2. Infusion of blood and blood products, even the client’s own, cannot be delegated to a UAP. 4. The nurse must assess the surgical site for bleeding, infection, and healing. The UAP cannot perform assessments.

Which client should the cardiac nurse assess first after receiving the p.m. shift report?
1. The client who is completing the second unit of PRBCs.
2. The client who is crying after being informed of a terminal diagnosis.
3. The client who refused to eat the dietary tray but got food from home.
4. The client who became short of breath ambulating in the hallway.
2. The client who is crying after being informed of a terminal diagnosis. The client has been given devastating news. When all the information in the options is expected and not life threaten ing, then psychological issues have priority. This client should be seen first.

1. This client is being treated, and if the blood is almost finished, then it can be assumed that the client is tolerating the blood without incident. 3. The client has eaten. The nurse could arrange for the dietician to consult with the client about food preferences, but this client does not need to be assessed first. 4. Dyspnea on exertion is not priority if the client is exerting himself or herself.

The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement?
1. Continue to care for the client’s needs as usual.
2. Place notification of the DNR inside the client’s chart. 3. Refer the client to a hospice organization.
4. Limit visitors to two at a time, so as not to tire the client.
1. Continue to care for the client’s needs as usual.
The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client’s heart stops beating.
2. The information about the DNR status is already inside the chart. It may need to be placed on the outside of the chart and a special armband or other notification made to other healthcare personnel.
3. The client has a DNR order, but this does not imply that there may be 6 months or less life expectancy for the client. (Hospice care may be requested for clients with less than a 6-month life expectancy.) An order for hospice must be written by the attending healthcare provider before making this referral.
4. The client should be allowed as many visitors as the hospital policy allows.