Prioritization and Delegation
The nurse is caring for a client with a tooth abscess who is complaining of extreme pain in the mouth. The nurse takes the vital signs and completes an assessment. Which of the following assessment findings is expected for this client?
a. Increased blood pressure
b. Decreased heart rate
c. Decreased capillary refill
d. Change in level of consciousness
What is A.
Increased blood pressure
When a client is in extreme pain, this can raise blood pressure.
A client with a seizure disorder has been admitted to the hospital for surgery. The client has a seizure approximately once per month despite being on medications. This client is often triggered by environmental effects that can lead to a seizure. Which environmental condition is an example of a commonly reported seizure trigger with this disorder?
a. Use of cleaning products
b. A large meal
c. Consuming excess vitamin C
d. Stress
What is D. For some people who experience seizures due to epilepsy, a trigger in the environment may cause a seizure to occur. The person may eventually learn what situations act as triggers for seizures and how to avoid them. In cases of epilepsy, triggers may vary between people, but some situations are much more common among clients. Stress can lead to sleep deprivation and illness and may also be the most likely trigger for a seizure.
A home care nurse is working with a diabetic patient with poor tissue perfusion. Based on the nurse’s knowledge of this condition, which of the following effects would the nurse most likely see in the patient’s extremities?
a. Sweaty skin
b. Increased venous return
c. Poor hair and nail growth
d. 3+ peripheral pulses
What is c? "Poor hair and nail growth" is correct. A patient with poor tissue perfusion will likely demonstrate abnormal patterns of hair and nail growth on the hands and feet. This occurs because of peripheral arterial disease (PAD). PAD is a chronic disorder in which the lower extremities are deprived of nutrients and oxygen due to impaired arterial blood flow, resulting in tissue damage, pain, hair loss, dry skin, thickened toenails and cold skin in the lower extremities.
A client with cancer is starting to receive palliative care. Which of the following would be involved as part of the initial assessment?
a. The nurse's philosophy of care provision
b. The client's prognosis for the illness
c. The client's opinion of the nursing care received
d. Whether the client has a job or school responsibilities
What is B? Palliative care is designed to provide comfort for a client who is experiencing significant illness. Palliative care is not the same as hospice care, because a client can receive palliative care while still receiving treatment for the illness. During the initial assessment, the nurse would perform a comprehensive client assessment that would include all aspects of a basic health assessment. Aspects of the client assessment include prognosis, needs, and wishes.
A 59-year-old client has been diagnosed with alcohol abuse. Based on the nurse’s understanding of this condition, the nurse knows that alcohol abuse is defined as which of the following?
a. Increased need for the drug to achieve the same effect
b. The need for psychological therapy or medication as treatment for the drug
c. Negative symptoms that develop when the drug is stopped
d. Biological need for the drug to avoid physical withdrawal symptoms
What is D?
What are ways to give direction in communication with a UAP?
a. Explain which task is the priority
b. Give orders
c. Explain what you will be doing
d. Use manners
What is a? This helps give direction for the UAP to be able to prioritize their tasks appropriately.
A client has been brought in for care after suffering a basal skull fracture. The client has bruising noted around the bone behind the left ear. Which best describes this injury sign?
a. Aaron's sign
b. Beau's line
c. Elschnig's spots
d. Battle's sign
What is D. "Battle's sign" is correct. This is a manifestation of a basilar skull fracture that includes bruising on the mastoid process behind the ear. A basilar skull fracture involves a fracture at the base of the skull, and Battle's sign indicates trauma or bleeding into the tissue next to the fractured area.
A diabetic client in the care clinic is complaining of feeling anxious. The nurse notes that the client is sweaty, has tremors, and is tachycardic. Which intervention would the nurse most likely perform in response?
a. Give the client a drink of water
b. Check the client's blood glucose
c. Assist the client to lie down
d. Connect the client to a hemodynamic monitor
What is b?
A client who has bone cancer has a prescription for hydromorphone that is available in large amounts. The client tells the nurse that he is afraid of becoming addicted to the pain medications because it has been prescribed in such a large amount. Which response of the nurse is most appropriate?
a. If you take the minimal amount, you shouldn't have a problem
b. It is rare for clients with cancer to become addicted to pain medication when taken as prescribed
c. You cannot become addicted to this because you have cancer
d. I will tell the provider that you do not want the medication
What is B?
Many clients with cancer are prescribed pain medications that have the potential to be abused because they are controlled substances. A client may worry that he or she will use the pain medication inappropriately, even though cancer pain can require large amounts of medication. The nurse can help the client to consider how to use the medication appropriately, and can reassure the client that it is rare that a client with cancer becomes addicted to pain medication for treatment.
Which of the following best describes mindfulness as a method of stress management?
a. Practicing deep breathing and progressive muscle relaxation
b. Accepting reality for what it is
c. Intentionally focusing on and accepting the present moment
d. Meditating and focusing on positive aspects of the future
What is d?
The nurse is working on a busy unit with a nurse and a certified nursing assistant (CNA) who are available to help. Which of the following tasks is outside of the scope of practice for the CNA? Select all that apply.
a. Take the client by wheelchair to their ride at the front of the hospital after discharge
b. Reinforce a dressing that is leaking serosanguinous fluid
c. Assess a new client with jaundiced skin and abdominal pain
d. Obtain a full set of vitals on a client preparing for discharge
e. Administer 4 mg morphine to the client with chest pain
What is C and E.
The nurse is caring for a client with Parkinson’s disease. During the physical assessment, the nurse notes that which of the following signs and symptoms are consistent with this disease? Select all that apply.
a. Difficulty swallowing
b. Shuffling gait
c. Drooping of eyelids
d. Pill-rolling tremor
e. Tardive dyskinesia
What is a, b, and d?
A nurse is caring for a client that has an order for an insulin drip STAT. What kind of insulin can be safely administered intravenously? Select all that apply.
a. Lantus
b. Levemir
c. Regular
d. NPH
What is C?
The nurse is caring for a patient with breast cancer who underwent radiation therapy four weeks ago. The nurse should tell the patient to look for what potential late effects of radiation therapy following the treatment? Select all that apply.
a. Softer breast tissue
b. Lymphadema
c. Swelling of breast tissue
d. Delayed wound healing
e. Broken blood vessels under the skin
What is b, d, and e? Lymphadema", "Broken blood vessels under the skin" and "Delayed wound healing" are correct. Radiation side effects are divided into two categories: Acute effects (from treatment time to 2-3 weeks after treatment) and chronic effects (from 3 weeks after treatment to years later). Acute effects include mucositis or ulceration of mucous membranes, yeast or bacterial infections, dry or darkening skin, and temporary cessation of function to the sweat and oil glands. Chronic effects include lymphadema, broken blood vessels under the skin and delayed wound healing, as well as fibrotic muscle tissue in the area exposed to radiation. Dry mouth is a chronic effect if the radiation was placed near the neck.
A client is taking a monoamine oxidase inhibitor. Which of the following should the nurse teach the client to avoid? Select all that apply.
a. Tyramine containing foods
b. New hobbies
c. Alcohol
d. Caffeine
e. Psychotherapy
What is a, c, and d?
During a busy shift at the hospital, a nurse continually gets bogged down with extra tasks and is unable to keep up with the workload. Which of the following is an example of a barrier to setting priorities? Select all that apply.
a. The nurse prioritizes using the ABCs
b. The nurse groups tasks because a client is on isolation precautions
c. The nurse would rather do tasks than delegate them
d. The nurse responds to whatever crisis occurs first
e. The nurse feels obligated to consider family members opinions of priority
What is c, d, and e. "The nurse groups tasks because a client is on isolation precautions", and "The nurse prioritizes using the ABCs" are incorrect. These are examples of good principles of prioritization.
A nurse is caring for a client who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed. Which best describes the purpose of this test?
a. To check whether the client has a medical condition that causes swallowing problems
b. To determine the type of feeding tube that is most appropriate
c. To assess the amount of dysphagia present
d. To determine the nutrients needed to put in TPN
What is C. A swallowing test would help the provider to determine the amount, if any, of food and liquid that a client is able to swallow. A client who requires a dysphagia diet may eat from different levels of food consistency based on what they are able to swallow.
Which best describes the appearance of Charcot foot in a diabetic client?
a. Rocker-bottom appearance
b. Small, thin toes
c. Cracked and bleeding heels
d. Deformity of the lateral arch
What is A? Charcot foot is a complication of diabetes that may develop when tiny fractures in the bones of the feet cause structural changes. The client's arch may drop and the foot takes on a rocker-bottom, or rounded appearance. The condition can be very painful, but if a client has peripheral neuropathy, they may not be aware of the pain and may not notice the deformity.
The nurse is caring for a client who has just been diagnosed with an oligodendroglioma. The nurse knows that this is a type of cancer that effects which organ?
a. Brain
b. Skin
c. Gall bladder
d. Adrenal glands
What is a?
Oligodendrocytes are a type of cell in the brain and spinal cord. An oligodendroglioma is a tumor found in the central nervous system.
A client refuses to take prescribed antihypertensive medication and states, “I can’t swallow pills. They probably would not work anyway because my body is used to high blood pressure.” What defense mechanism is this client using?
a. Reaction formation
b. Sublimation
c. Rationalization
d. Intellectualization
What is C?
A nurse is working with a nursing assistant to care for six clients on the unit. The nurse wants to delegate certain tasks to the nursing assistant. What should the nurse consider when delegating tasks to unlicensed assistive personnel? Select all that apply.
a. Whether the nurse can delegate the specific task
b. If the nursing assistant is capable of creating nursing diagnoses
C. Whether the nurse has already assessed the client
D. If the nursing assistant has the capability to perform the tasks
E. Whether the nurse is available to supervise
What is A, C, and D.
"Whether the nurse can delegate the specific task", "Whether the nurse has already assessed the client", and "If the nursing assistant has the capability to perform the tasks" are correct. When a registered nurse decides to delegate to unlicensed assistive personnel, the 5 rights of Delegation are used as a guide for whether or not delegation is appropriate. The 5 rights include the right task, circumstance, person, direction, and supervision. "If the nursing assistant is capable of creating nursing diagnoses" is incorrect. Creating a nursing diagnosis is part of the nursing process, and cannot be delegated to a non-registered nurse. "Whether the nurse is available to supervise" is incorrect. The reason a nurse delegates tasks is to allow time for other high level tasks that must be done by the registered nurse. Supervision DURING a delegated task defeats the purpose of delegation. Rather than supervising the unlicensed assistive personnel, the nurse will assess the client later to ensure that the outcome of the task was sufficient.
A client is being seen in the emergency department after a spinal cord injury. The client initially states an inability to feel anything below the shoulders. At which point would this client need to be intubated with an endotracheal tube?
a. The point at which the client has a respiratory rate of 10/minute
b. The point at which the client has a Glasgow Coma Score of 8
c. The point at which the client's oxygen saturation is 88 percent on room air
d. Upon discovering that the client has a pneumothorax as seen on x-ray
What is b? A spinal cord injury produces paresthesia below the level of the injury; paraplegia indicates an injury in which the patient cannot move the lower extremities, while quadriplegia is a higher-level injury where the patient often cannot move the upper or lower extremities. With a higher-level injury, the patient may also need breathing support; if the spinal cord was injured above the level that stimulates breathing, the patient may need intubation. Respiratory failure is an indication for intubation, as is a GCS result of <9, which indicates a decreased level of consciousness.
The nurse has an order to given insulin to a client with acute renal failure. Which of the following is the purpose of giving insulin in this situation?
a. To move glucose out of cells
b. To increase bloodstream sodium
c. To move potassium into cells
d. To reduce hyperglycemia
What is C? Insulin administration in acute renal failure (ARF) helps to facilitate movement of potassium into the cells when potassium levels are dangerously high and dialysis is not immediately available. To prevent hypoglycemia for the client receiving insulin, IV glucose is also given.
A nurse is educating a client who is receiving external beam radiation to the chest while in the hospital. Which statement made by the client indicates proper understanding about care of the treatment site?
a. "I will avoid applying deodorant or powder while undergoing therapy"
b. "I can apply lotion to the treatment site if my skin becomes irritated"
c. "I will protect my site from sun exposure on the days I receive treatment"
d. "I'll stay six feet away from visitors until my treatment is complete"
What is A? "I will avoid applying deodorant or powder while undergoing therapy" is correct. There are various methods of radiation therapy, including external beam radiation (teletherapy), brachytherapy, unsealed, and sealed radiation sources. A client who receives external beam radiation receives a dose of radiation energy to a directed location on the body to treat cancer. It may cause skin rash and discomfort, but is not a risk to others. The client should be cautioned to avoid deodorant, powder, and cologne in the affected area, as well as lotions unless prescribed by the radiologist. The client must also avoid sun exposure to the irradiated area.
What is the purpose of a Mini-Mental Status Examination(MMSE)? Select all that apply.
a. To see which clients need to see a psychiatrist
b. To assess if the client understands your directions
c. To screen for possible cognitive dysfunction
d. To diagnose Alzheimer’s dementia
e. To see if the client can sign an informed consent form
What is b and c? The Mini-Mental Status Exam is a simple screen for cognitive dysfunction. It is not a psychiatric test nor can it diagnose Alzheimer’s dementia, which would require a complete clinical assessment of the client. It can help you understand if the client understands your instructions, and gives a baseline for cognitive function from which to work during the course of the client's stay.