The nurse calls a surgeon about a male client who is having abdominal pain after a bowel resection. He received hydromorphone 2 hours ago and is now
... [Show More] requesting additional pain medication. Vital signs include temperature 97.8 F, HR 112bpm, RR 24pm, and BP is 98/62 mmHg, which is lower from previous reading one hour ago. The client has a history of chronic atrial fibrillation and takes clopidogrel, which was continued until one day prior to surgery. The Nurse recommends that surgeon see the client immediately to evaluate the situation. What information makes this report complete?
The abdomen is rigid, tender to touch, and distended
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
A prescribed consultation
The client's vital signs
The client's name
The client's code status
The client's vital signs
A nurse is doing telephone triage at the clinic office. Which client is most acute and should be scheduled for the first available appointment?
A 21-year-old with a history of kidney transplant. Today the client complains of flu-like symptoms with a fever of 100.4°F
The nurse is calling for an older adult who was admitted with a urinary tract infection and is now exhibiting signs of severe inflammatory response syndrome (SIRS). Which collaborative care goals should the nurse include in the plan of care?
Decrease blood pressure
Reduce white blood cell count
Body temperature within normal limits
Negative urine culture
Incision free of exudate
Reduce white blood cell count
Body temperature within normal limits
Negative urine culture
Pt came off the PCA pump an hour ago and put on PO analgesic and he in a room with another patient and he was fussing and demanding the PCA back. Nurse was on the phone with the surgeon, what does she say to implement the recommendation of SBAR acronym?
Ask can pt PCA be reinitiated for 12 hours
When meeting with the client and the family, which nursing interventions demonstrate the nurse's role of collaborator of care?
Coordinating and educating about multidisciplinary services
It is most important to schedule a multi-disciplinary team meeting to discuss which client?
A woman who is pregnant with twins and whose due date is one week away.
A 2 year old who contracted Hep A while at a local daycare center
A business executive admitted with Gullain-Barre syndrome who has residual numbness in lower extremities
An elderly client admitted through ED with a broken hip whose blood glucose is 400 mg/dl
An elderly client admitted through ED with a broken hip whose blood glucose is 400 mg/dl
The charge nurse on a surgical unit is assessing the morning lab work on four clients. Which client's lab finding should be reported to HCP immediately?
A client scheduled for an elective transurethral resection of prostate that has an aPTT of 80 seconds
An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL and BUN of 84 mg/dL
An adolescent who had an emergency appendectomy yesterday and has a WBC of 12,000 mm3
A client scheduled for an elective transurethral resection of prostate that has an aPTT of 80 seconds (i think we picked this one)
An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL and BUN of 84 mg/dL
When triaging emergency-room clients, which client should the nurse assess first?
A female client with severe right lower abdominal pain who is febrile and vomiting
The nurse working on a medical unit is assigned to care for four clients. Which client should the nurse assess first?
A client who is quadriplegic and is complaining of severe headache
After receiving report, which client should the nurse assess first?
A client with O2 sat of 70% following bronchodilator therapy
The nurse is caring for several clients on the telemetry unit. Which client should the nurse assess first?
A client who is demonstrating: NSR and complaining of chest pain
After receiving morning report on an acute care unit, which client should the nurse assess first?
A client sitting close to the nurse's station who has been restrained for the past 6 hours
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
A client with a bowel obstruction due to a valvula's who is experiencing abdominal rigidity
A nurse working the 7 am-to-3 pm shift is reviewing the records of him/her assigned clients. Which client should the nurse assess first?
A client scheduled for hemodialysis at 10 am
A client scheduled for a nuclear scanning procedure at 10 am
A client scheduled for contrast computed tomography (CT) at noon
A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am
A client scheduled for hemodialysis at 10 am
A client in the intensive care unit needs to be transferred to the medical unit to make room for a client who is being admitted from the emergency department. Which client is best for the charge nurse to transfer? A client with:
Chronic emphysema that has an arterial blood gas PaO2 of 75mmHg (norm= 80-100mmHg)
After lumbar puncture, what position should the client be positioned in?
The client should be placed in supine position for 4 to 12 hours as prescribed
Nurse determines that an IV vesicant chemotherapy infusion is infiltrated. What should he/she do?
Apply COLD compress
You use warm for non-vesicant but for vesicant you use cold to constrict the blood vessels and stop it from going into tissues more
Also you want to raise the extremity if infiltration happens
Also vesicants should always run through a pump
Some vesicants have antidotes, so it is important to notify HCP right away so it can be ordered and administered if applicable
Which nurse's behavior is a breech of patient confidentiality according to HIPAA regulations?
Nurse takes home a daily report sheet with information on the team's client
While the registered nurse is appearing to take the vital signs of a newly admitted client who has a medical diagnosis of congestive heart failure. A practical nurse enters the client's room and reports to the RN that another client just pulled out his central venous catheter and the unlicensed assistive personnel is in the room with the client. The RN knows that the newly admitted client is to receive a stat dose of oral anti-anxiety medications. How should the RN assign the needed care?
The RN should provide care for the client who removed the central venous catheter while the PN administers a stat medication and the UAP obtains the newly admitted client's vital signs
Fire alarm is going off, what does the charge nurse tell the nurses to do?
Keep clients in rooms with doors closed
A fire is reported in the kitchen on the first floor of a three-floor community Hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. What intervention should the charge nurse implement?
Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits
At 2 a.m. the nurse phones the health-care provider to request a PRN medication for a client who is unable to sleep. The health-care provider is awakened, and gives the nurse a prescription for 4 times the normal dosage. When questioned by the nurse, the health-care provider responds in a sleepy voice "yeah okay" and hangs up the phone. What action should the nurse take first?
Call HCP back and report that the dosage described is 4 times the normal dose
The practical nurse caring for a client with acute congestive heart failure and pitting edema tells the charge nurse that a verbal prescription was obtained from the health-care provider for 1000 mL D5 % normal saline to be administered over 4 hours. What action should the charge nurse take?
Clarify the prescription with the HCP
A nurse is assisting a primary health care provider in assessing a hospitalized client. During the assessment, the primary health care provider is paged to report to the recovery room. The primary health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?
Asking the PCP to write the prescription in the client's chart before leaving the nursing unit
A primary health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the primary health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?
Discuss issue with nurse manager
A practical nurse (PN) is reluctant to use new blood glucose monitoring equipment despite having attended the mandatory in-service about the equipment. What action is best for the charge nurse to take?
Observe the PN while he uses the new equipment
A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply.
A client who is confused and requires assistance with a shower
A client requiring a bed bath and frequent ambulation with a cane
A client who must be accompanied to physical therapy twice during the shift
A client with a colostomy who requires reinforcement regarding the procedure for irrigation
A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours
A client with a colostomy who requires reinforcement regarding the procedure for irrigation
A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours
The nurse assigns collection of the sputum specimen to the unlicensed assistive personnel (UAP). Before delegating this task to the UAP, which action is most important for the nurse to implement?
Determine if the UAP has received training to collect sputum specimen
The registered nurse is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the ER nurse calls to report on a client with unstable angina that must be admitted immediately. A practical nurse (PN) and unlicensed assisted personnel (UAP) are available to assist the RN. How should the RN assign the necessary nursing actions?
Assign PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for the new admission
An unlicensed assistive personnel UAP who is working on a skilled nursing unit is diagnosed with hepatitis A HVA. Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. What action should the nurse-manager take next?
Refer the nurse to the employee health clinic for serological testing
An unlicensed assistive personnel UAP who is working on a skilled nursing unit is diagnosed with hepatitis A HVA. Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. What action should the nurse-manager take next?
Refer the nurse to the employee health clinic for serological testing
After receiving morning report on an acute care unit, which client should the nurse assess first?
A client sitting close to the nurses' station who has been restrained for the past six hours
What should UAP notify nurse about when putting SCD on legs?
Report any change in color in client's feet or legs
A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant?
Assisting a client with dysphagia to eat
A client has a prescription for 20 units of Novolin 70/30 insulin to be administered subcutaneously. The pharmacy has provided a vial of Novolin N insulin in a vial of Novolin R insulin. What action should the nurse implement?
Notify the pharmacy that the incorrect insulin has been delivered to the unit
Client is admitted and within chart there is a DNR
Confirm current resuscitation wishes with client and family
The nurse is giving change-of-shift report for four clients in the emergency center and reports the client with a terminal disease has a living will and a "Do not resuscitate" (DNR) order on file. Which client fits the criteria for a terminal illness?
2-year-old child with esophageal burns from drinking drain cleaner who now has a gastrostomy tube.
76-year-old female client with Alzheimer's disease who is pacing the halls and trying to "go home."
52-year-old male client who had a partial lobectomy and on a ventilator on the 2 postoperative day.
43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration.
43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration.
A primary health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The primary health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond?
Telling the physician that "slow codes" aren't acceptable
A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. What is the most appropriate action by the nurse?
The DNR request should be discussed with the provider, who will write the order
Nursing diagnosis within plan of care for Heart Failure?
Impaired gas exchange
Leukemia Precautions
Maintain private isolation if client is infectious
A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?
Non maleficence
Making assignments for the day, which info provided during change of shift report is most important for the charge nurse to consider?
Elderly female client who refuses to be cared for by a male nurse
To facilitate the initiation of a new fall prevention program, which action should the nurse manager implement?
Involve the staff in developing interventions for the program
Pertussis Precautions
Pertussis is spread by respiratory droplets
Ensure staff follow droplet precautions (including wearing a surgical mask) during close contact with cases
A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?
Pertussis
Needs Assess Equipment
Determine if other units can use equipment
Young adult woman with brain tumor refuses further treatment, die by natural causes; HCP does not agree and refuses...What action should be taken by nurse?
Initiate a review of the situation by the hospital's ethics committee
The charge nurse needs to determine if an additional nurse should be called to help staff in the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
The acuity level of the clients on the unit
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) inform the nurse that one of the visitors is lying on the client's bed. What action should the nurse implement?
Explain that the client has the right to have a visitor lie on the bed
To help prevent litigation by dissatisfied clients, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will:
Discuss how to handle complaints from the client and/or their families
The practical nurse reports that a client with a DVT was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
Monitor for signs of bleeding
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
Evaluate client for symptoms of drug interaction
New policy to prevent med errors
Examine med admin data to determine use of new procedure
Med error occurred filled out incident report, called doctor, notified manager...This is an example of
Emotional intelligence
Med Error Action
Assess pt, incident report, notify doctor, document amount prescribed and dosage given (do not place incident report in chart or make any reference to it in patient's medical record)
The nurse assigns collection of sputum specimen to a UAP. Before delegating this task to the UAP, which action is most important to the nurse to implement?
Determine if the UAP received training to collect sputum specimen
A nurse has delegated several nursing tasks to staff members. What is the nurse's primary responsibility after delegation of these tasks?
Following up with each staff member regarding the performance of the task and the outcomes r/t implementation of the task
The RN is assigned to care for 4 surgical clients. After receiving report, which client should the nurse see first?
The client who is: Three days postoperative resection, receiving transfusion of packed RBCs
The nurses caring for a group of clients on a surgical unit. What action should the nurse implement first?
Determine if the client scheduled for surgery is prepared to go to the operating room
In assigning client care to an RN and a licensed practical nurse, it is most important to assign which client to the RN?
A client who is: Exhibiting signs of Addison's crisis after corticosteroids were discontinued
A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant?
A client who needs frequent ambulation with a walker
A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (assistive personnel)? Select all that apply.
A client with a permanent tracheostomy
A client requiring a gastrostomy tube dressing change
A client who requires transport to the radiology department in a wheelchair
A client with a Foley catheter for whom a 24-hour urine collection is in progress
A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter
A client who requires transport to the radiology department in a wheelchair
A client with a Foley catheter for whom a 24-hour urine collection is in progress
The nurse is working at a diabetic clinic with a PN. Which nurse care is best to assign to PN?
Assess cause of nausea and vomiting for past 2 days
Describe meaning of hgb a1c result of 9.9%
Observe first attempt at self-administration of insulin
Perform dressing change stage 2 ankle ulcer
Perform dressing change stage 2 ankle ulcer
The home health nurse is planning care for a client with diabetes. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
Assist with bathing and other activities of daily living
The nurse is planning a diabetes education course for a group of clients newly diagnosed with diabetes mellitus. Which collaborative approach is the best use of interdisciplinary team members?
Invite the dietician to discuss the timing of meals and snacks
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take first?
Discuss with the client her meaning of heroic measures.
Obtain a DNR.
Set up a family conference to discuss the client.
Consult the palliative care team about the client's care.
Discuss with the client her meaning of heroic measures.
An older female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother's original request, which was executed when she was healthy. What information is best for the nurse to provide?
The family should be guided to support the client's current decision about the ventilato [Show Less]