Leadership/Delegation/Prioritization
A client has been admitted to the oncology unit and has a large amount of cash, several credit cards, and several pieces of expensive-looking gold jewelry in her possession. Which action by the nurse is MOST appropriate? (A) Tell the client to hide everything in her purse or a bag and put it in the closet. (B) Offer to take her belongings to the charge nurse's office where they can be locked up. (C) Suggest that the client put her valuables in a sock and place it in the bottom of the bedside table under some clothing. (D) Inform the client of the hospital policy regarding valuables an suggest that she give them to a trusted family member or to security for safekeeping.
D
Most hospitals provide security to lock up client valuables, along with a receipt or form for ID for claiming the items. All these items placed in security must be documented on the admission form and signed. The facility is not responsible for valuables left in the room by clients, and the nurse must inform the client of the policy and ensure understanding. (A, C - This still leaves the items subject to theft. B - This is not appropriate as it places the charge nurse in a position of responsibility.)
A patient is prescribed allopurinol (Zyloprim) for primary gout. Which of the following are therapeutic actions of the drug? (A) Analgesia. (B) Anti-inflammatory activity. (C) Cytotoxicity. (D) Enzyme inhibition.
D
Allopurinol reduces uric acid levels by inhibiting xanthine oxidase, the enzyme involved in the conversion of hypoxanthine to xanthine and of xanthine to uric acid. (A, B, C - Allopurinol has no analgesic, anti-inflammatory, or cytotoxic activity)
The patient asked for “some Tylenol for my headache.” The nurse looks at the medication order and it reads: “500 mg of acetaminophen TID PRN”. What is the nurse’s next step? (A) Administer the medication as ordered. (B) Call the physician for clarification of the order. (C) Double check the medication with a second nurse. (D) Explain to the patient that you don’t have an order for Tylenol.
B
The order is missing the route of administration; one of the five rights of medication. Any incomplete or unclear orders for medication must be questioned.
A nurse is caring for a client who has had thyroid surgery. The client’s calcium result has returned at 7.5 mg/dL. Which nursing interventions are the most appropriate based on this calcium level? Select all that apply. (A) Implement seizure precautions. (B) Assess for signs of hypocalcemia. (C) Administer intravenous furosemide. (D) Administer intravenous calcium gluconate. (E) Assess for signs of hypercalcemia.
A, B, D
(A) The client who has had thyroid surgery is at risk for hypocalcemia due to possible trauma to the parathyroid. Normal calcium levels are 8.4-10.2 mg/dL, so a level of 7.5 mg/dL indicates hypocalcemia. (B) The nurse should assess for signs of hypocalcemia, which include numbness or tingling of the face and extremities, muscle cramps and twitching, seizures, cardiac dysrhythmias, and a positive Chvostek's sign. Chvosteks' sign occurs when you tap the facial nerve and the facial muscle twitches on the respective side. (D) Calcium gluconate is given to increase the serum calcium level. We would not wait to treat this level, since we know the client is likely not going to be able to self-correct, and the consequences of hypocalcemia can be life-threatening. (C - IV diuretics can further lower serum calcium levels which is contraindicated in this client. E - The client has a low calcium level, not a high calcium level.)
A patient is not to eat or drink anything 24 hours before a colonoscopy. True or False
False
A patient may be instructed to not eat any solid foods up to 24 hours prior to a colonoscopy, however clear liquids (including a bowel prep) are typically allowed until midnight prior to the procedure up to a couple hours prior to the procedure. The nurse will need to verify the orders given by the physician.
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP? (A) A client whose IV infiltrated and needs replacing. (B) A client on BiPAP who needs arterial blood gases (ABGs) drawn. (C) A client with mild dementia who needs assistance with her food tray. (D) A client who needs a wet-to-dry dressing change on an abdominal incision.
C
This is an appropriate delegated task for a UAP. (A, B, D - UAPs may not provide direct nursing care or perform nursing interventions requiring specialized nursing knowledge, judgment, or skill. Assessing the IV site or inserting an IV are beyond the scope of a UAP. Drawing ABGs should be performed by either a licensed nurse or respiratory therapist per facility policy. Dressing changes should be performed by the licensed nurse.)
Which drug is used to treat amebas in the intestines? (A) Hydroxychloroquine (Plaquenil). (B) Paromomycin (Humatin). (C) Mefloquine (Lariam). (D) Rimantidine (Flumadine).
B
Paromomycin is an amebicide. (A, C - Hydroxychloroquine and Mefloquine are antimalarial drugs. D - Rimantidine is an antiviral drug.)
The regulatory agency for pharmaceuticals is: (A) ISMP. (B) OSHA. (C) TJC. (D) FDA
D
The U. S. Food and Drug Administration (FDA) has the goal of protecting the public by approving and regulating certain things like foods, cosmetics, medical devices, and medications: both prescription and over-the-counter. (A - The Institute for Safe Medication Practices (ISMP) provides accurate medication safety information but is not a regulatory agency. B - The Occupational Safety and Health Administration (OSHA) is a regulatory agency whose aim in healthcare is assuring worker safety. C - The Joint Commission (TJC) is an accrediting agency whose goal is to continuously improve healthcare for the public.)
A student nurse is reviewing electrolytes and understands that which of the following is the function of calcium in heart conduction? (A) Depolarize the cell. (B) Repolarize the cell. (C) Increase the strength of contraction. (D) Increase the heart rate.
C
(C) This is the function of calcium in the heart’s conduction. (A - Depolarizing the cell occurs when potassium exits the cell. B - This occurs when potassium reenters the cell. D - Calcium does not increase the heart rate.)
Which of the following lab tests would be considered Point of Care testing? (A) Urinalysis. (B) Sputum culture. (C) Complete metabolic panel. (D) Blood glucose.
D
Blood Glucose would be considered a Point of Care test as the test can be completed at the bedside with the result given immediately. (A, B, C - Urinalysis, Sputum Culture, or Complete Metabolic Panel would not be considered Point of Care tests because these tests need to be run in a laboratory setting with specialized equipment not available at the bedside.)
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see FIRST? (A) The client complaining of chest pain and nausea who is diaphoretic. (B) The client with a simple fracture of the radius from a fall on a staircase. (C) The client complaining of slight redness and itching at the IV site in his hand. (D) The client presenting with a sprained ankle from a tree branch falling on him.
A
Triage works on the principle that clients with the highest acuity have priority over clients with injuries or conditions that are not considered life-threatening. Chest pain, nausea, and diaphoresis indicate a possible myocardial infarction, which can be life-threatening and requires immediate intervention. (B, D - Fractures and sprains are nonurgent and can wait for treatment. C - Redness and itching at an IV site indicates a need to assess the site and remove/replace the IV, but it is not immediately life-threatening.)
A patient is scheduled to receive an initial dose of epoetin (Epogen). The nurse received report that the patient developed hives while receiving albumin the previous night. What is the nurse's best action? (A) Give the patient the scheduled diphenhydramine (Benadryl) before giving the epoetin. (B) Evaluate the patient's status, and hold the epoetin. (C) Administer the epoetin, and monitor the patient's BP before and after. (D) Consult the infectious disease team before administering the epoetin.
B
Epoetin should not be given to patients who have had a reaction to albumin because they may also react to epoetin. (A, C - Benadryl would be a good drug to administer to a patient who has had a reaction to albumin. BP should be monitored before and after epoetin administration. However, the epoetin should be held in this situation. D - Infectious disease would not be concerned with epoetin administration; it is a hematopoietic agent, not an anti-infective)
Following the steps of the nursing process, what is the FIRST step a nurse should take when administering an anti-hypertensive medication? (A) Evaluate the patient’s response to the medication. (B) Assess the patient and obtain vital signs. (C) Calculate the correct dose of medication. (D) Administer the medication utilizing the “five rights of medication administration”.
B
The five steps of the nursing process are: assess, diagnose, plan, implement, and evaluate. The first step of the nursing process is ‘assess’, so the nurse should perform a nursing assessment and obtain vital signs. With anti-hypertensive medications, a blood pressure and heart rate must be obtained before administration, and inform the prescriber of any abnormal findings.
A client has a calcium reading of 11 mg/dL. What does the nurse expect the clients phosphorus reading to be? (A) 2 mg/dL. (B) 3 mg/dL. (C) 4 mg/dL. (D) 5 mg/dL.
A
(A) Calcium and phosphorus have inverse relationships, therefore since the normal range for calcium is 8.4-10.2 mg/dL, it is high. Therefore the client will have a low phosphorus level. The normal phosphorus range is 3-4.5 mg/dL. (B and C are normal phosphorus levels. D - his is a high phosphorous level, and calcium and phosphorous have an inverse relationship, so if the calcium value is high, the phosphorous value will be low.)
A patient is to get an MRI of the abdomen. Which of the following instructions should the nurse give the patient? (A) Do not wear metal objects during the MRI, including jewelry. (B) Do not take oral medications up to 12 hours after the MRI. (C) Do not urinate prior to the MRI. (D) Do not eat solid foods 12 hours prior to the MRI.
A
Metal objects should not be used near an MRI. An MRI, or Magnetic Resonance Imaging device, will not function properly when magnetic objects, such as jewelry are nearby, and can cause harm to the patient through the MRI pulling the objects away from the patient. Patients should be assessed for metal materials within the body as well, such as joint replacement or spinal hardware. (B, C, D - Unless otherwise instructed, it is safe for a patient to take oral medications, eat solid foods, and urinate as usual prior to getting an MRI or following an MRI.)
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action? (A) Work closely with the UAP during the shift and observe for any signs of impairment. (B) Complete the bed bath without comment. The unit is already short one staff member. (C) Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired. (D) Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.
D
The professional nurse works under the framework of six ethical principles. Nonmaleficence emphasizes protecting the client from harm. Client safety is always a priority. Another nurse may step in and complete the bath, ensuring the client is not left alone with impaired personnel. The nurse has an ethical and legal duty to report situations that may cause client danger. Failure to do so may result in disciplinary action by the board of nursing for the nurse involved, regardless of whether harm comes to the client (A, B, C - This still allows the impaired UAP to remain on duty, possibly causing harm to the client.)
A patient identifies the potential side effects of fluconazole (Diflucan) from a list. Which side effect should be immediately reported to the health care provider? (A) Headache. (B) Diarrhea. (C) Dark urine. (D) Abdominal discomfort.
C
Dark urine may indicate a serious hepatic side effect of fluconazole. (A, B, D - None of these side effects need to be reported immediately)
A male patient asks about other ways he can help lower his blood pressure in addition to taking his beta-blocker. The nurse is CORRECT in explaining that: (A) “Relaxation and exercise are ways that can decrease your blood pressure.” (B) “You should increase your alcohol intake to decrease your blood pressure.” (C) “Medication is the only way you can decrease your blood pressure.” (D) “You should increase your intake of salt to decrease your blood pressure.”
A
Non-pharmacological methods to decrease blood pressure include a low-salt diet, relaxation techniques, exercise, decreased alcohol consumption (No more than 1 drink daily for females and 2 drinks daily for males), and smoking cessation. (B, D - An increase in alcohol and salt intake can increase blood pressure. C - While pharmacologic agents decrease blood pressure, there are non-pharmacologic methods that can be utilized as well as complementary therapy.)
A client has developed hyponatremia as a result of syndrome of inappropriate anti-diuretic hormone. Which type of IV fluid would the nurse most likely administer? (A) 0.45% NS. (B) 0.9% NaCl. (C) D5W. (D) D5LR.
D
(D) When a client has developed hyponatremia, he has a low level of sodium in the bloodstream. The nurse can increase sodium levels in circulation by providing hypertonic IV fluids. In this case, D5LR can help raise sodium levels transiently. Generally, water restrictions are put in place to aid in correction of hyponatremia. (A and C are hypotonic solutions. B is not a hypertonic solution and will not help raise the sodium level)
Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mmHg, O2Sat 96%, HCO3 24 mEq/L, and PaO2 94 mmHg? (A) Instruct the client to breathe into a paper bag. (B) Administer a prescribed decongestant. (C) Offer the client fluids frequently. (D) Administer prescribed supplemental oxygen.
A
The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to breathe into a paper bag to re-breathe exhaled CO2. (B, C, D - None of these options would raise the low PaCO2 level)
The nurse is working triage in the ED when four clients present at the same time. Which client should be seen FIRST? (A) A 45-year-old female on oral contraceptives with unusually heavy menstrual bleeding. (B) A 24-year-old with a dog bite to the leg from the family dog who is current on rabies shot. (C) An irritable 4-month-old with a petechial rash, nuchal rigidity, and a temperature of 103.4 degrees Farenheit. (D) A 16-year-old football player with a twisted ankle who has no deformity and a pedal pulse.
C
Petechial rash, nuchal rigidity, and fever are signs of meningitis, which is a medical emergency, especially in an infant. (A - The client with heavy menstrual bleeding is not as urgent as the infant. B - Dog bites from a known pet current on rabies shots are less urgent than bites from an animal with unknown rabies status. D - A twisted ankle with a pedal pulse and no deformity is not life-threatening and can be seen after more urgent clients.)
The nurse and respiratory therapist are collaboratively teaching the patient about the patient’s new albuterol inhaler. The respiratory therapist recognizes that the nurse needs more education when she states: (A) “Albuterol is a bronchodilator used to treat asthma symptoms.” (B) “An important assessment of a patient on albuterol is lung sounds and heart rate.” (C) “Side effects of albuterol include bradycardia and hypoglycemia.” (D) “A spacer may be used to improve the delivery of the drug into the lungs.”
C
The nurse needs more education on the side effects of albuterol, which are: restlessness, tremors, headache, dizziness, palpitations, tachycardia, rhinitis, hyperglycemia, nausea and bronchospasm. (A, B, C - These are correct. Albuterol is a bronchodilator used to treat asthma symptoms, a spacer can be used to improve drug delivery to the lungs, and it is important to assess lung sounds and heart rate prior to and after administration.)
A patient brings a bag with all his current medications to his appointment. The nurse talks with the patient about each medication and checks them with the patient’s current medication order list to make sure the list is current with no discrepancies. This process is known as: (A) Root cause analysis. (B) Five rights of medication administration. (C) Unit dose method. (D) Medication reconciliation.
D
The process the nurse is following is called ‘medication reconciliation’ and is a safety measure which can help prevent discrepancies that can lead to a medication error. It was created to provide drug continuity during care transitions.
A nurse is reviewing the laboratory results for a client and notes that the client has hyperkalemia. Which of the following EKG abnormalities would be consistent with this finding? Select all that apply. (A) Prolonged QT interval. (B) Peaked T waves. (C) U wave. (D) Atrial fibrillation. (E) Wide QRS.
B, E
(B, E) Since potassium plays a role in ventricular depolarization and repolarization, hyperkalemia will present with peaked T waves and a wide QRS. This means the process of allowing the ventricles to fully contract and relax is slower and longer because there is TOO much potassium present. (A - Hyperkalemia tends to cause a shortened QT interval because the ventricles are more active due to the excess potassium. C - U wave would be caused by hypokalemia, not hyperkalemia. D - Potassium abnormalities tend to cause ventricular dysrhythmias, NOT atrial ones.)
Which lab tests should the nurse expect to monitor for a patient receiving amikacin sulfate (Amikin)? (A) Hgb/WBC. (B) Creatinine/sodium. (C) ALT/PLT. (D) WBC/BUN.
D
Amikacin sulfate is used to fight infection. The nurse should follow the WBCs to evaluate the drug's effectiveness. Amikacin sulfate is an aminoglycoside and is nephrotoxic, which would prompt the nurse to follow the patient's renal status (BUN). (A, B, C - These lab tests do not address the primary concern of nephrotoxicity)