Prioritize
A newly admitted client is suspected to have avian influenza (“bird flu”) due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?
A. Give first dose of oseltamivir (Tamiflu)
B. Instill 5% dextrose in water at 100 mL/hr
C. Collect blood and sputum specimens for testing
D. Start oxygen using a non-rebreather mask
What is start oxygen using a non-rebreather mask?
A child with fever has been admitted for several hours. Cooling measures are ordered by the physician in order for the client’s temperature to come down. Which task would be appropriate to delegate to the medical technician?
A. Prepare and administer a tepid bath
B. Assist the child in removing outer garments
C. Educate the need for giving cool fluids
D. Tell the parent to use acetaminophen (Tylenol) instead of aspirin
What is assist the child in removing outer garments?
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the medical technician? Select all that apply.
A. Assess for indicators of fluid imbalance.
B. Review fingerstick glucose results every hour.
C. Measure vital signs every 15 minutes.
D. Document intake and output every hour.
What is C & D; measure vital signs every 15 minutes and document intake and output every hour?
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately?
A. Decrease in pain level from 6 to 2 (on a scale of 10)
B. Heart rate of 90 to 100 beats/min
C. Request by the client that the room door be closed
D. Respiratory rate of 8 to 10 breaths/min
What is respiratory rate of 8 to 10 breaths/min?
A client is admitted to the unit with the diagnosis of Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be charged to a medical technician?
A. Administer intravenous (IV) fluids as prescribed by the physician.
B. Develop a plan for added fluid intake over 24 hours.
C. Provide straws and offer fluids between meals.
D. Complete initial family education on assisting the client with fluid intake.
What is provide straws and offer fluids between meals?
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?
A. Irregular apical pulse
B. Ecchymosis in the flank area
C. A deviated trachea
D. Unequal pupils
What is a deviated trachea?
The ambulance has transported a man with severe chest pain. As the man is being transferred to the emergency stretcher, the nurse assessed the following: unresponsiveness, cessation of breathing, and absence of palpable pulse. Which of the following tasks is proper to assign to the medical technician?
A. Aiding with oral intubation
B. Performing chest compressions
C. Administering aspirin
D. Starting bag valve mask ventilation
What is performing chest compressions?
The nurse is caring for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action can be delegated to the medical technician?
A. Implement contact precautions when caring for the client.
B. Monitor the results of ordered laboratory culture and sensitivity tests.
C. Teach the client and family members about means to prevent transmission of VRE.
D. Interact with other departments when the client is transported for ordered tests.
What is implement contact precautions when caring for the client?
The assigned medical technician of the unit reports to you that a client’s blood pressure and heart rate have decreased, and when her face is assessed, one side twitches. What is the most appropriate thing to do as a nurse?
A. Assess the client's pupillary reaction to light.
B. Obtain a neurologic exam request for the client.
C. Review the client's morning calcium level.
D. Perform orthostatic blood pressures.
What is review the client's morning calcium level?
An elderly maintenance staff is lying on the floor and the nurse responds to a call for help. List the order in which the nurse must carry out the following actions.
A. Instruct the med tech/nurse assistant to get the crash cart
B. Perform the chin lift or jaw thrust maneuver
C. Call for help and activate the code team
D. Initiate cardiopulmonary resuscitation (CPR)
E. Establish unresponsiveness
What is E, A, C, B, D?
Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation?
A. Give supplemental oxygen
B. Allow the student to breathe into a paper bag
C. Report to the physician immediately
D. Get an order for an anxiolytic medication
What is allow the student to breathe into a paper bag?
The nurse is caring for a client with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of the following nursing actions can a nurse assign to a properly trained medical technician?
A. Assess risk for further skin breakdown.
B. Collect wound cultures during dressing changes.
C. Create methods to improve the client's oral protein intake.
D. Educate the client about home care of the leg ulcer.
What is collect wound cultures during dressing changes?
A client who has frequent watery stool is admitted to the unit due to dehydration possibly caused by C. difficile. Which nursing action should the charge nurse delegate to a medical technician?
A. Giving the ordered metronidazole (Flagyl) 500 mg PO to the client.
B. Reconsidering the client's medical history for any risk factors for diarrhea.
C. Monitor the patients I/O’s every 4 hours.
D. Explaining the purpose of ordered stool cultures to the client family.
What is monitor the patients I/O’s every 4 hours?
The newly hired nurse is assigned by the charge nurse to care for a client with acute renal failure and hypernatremia. Which action can the nurse assign to the medical technician? Select all that apply.
A. Administer 0.45% saline by IV line
B. Complete daily weights and document for trends
C. Check for indications of dehydration
D. Render oral care every 3 to 4 hours
What is complete daily weights and document for trends and render oral care every 3 to 4 hours?
During the shift of a nurse the following clients arrive. Which client needs the most rapid response to protect other clients in the unit from infection?
A. A 72-year-old who must undergo tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight.
B. A 58-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection.
C. A 7-year-old who has a new pruritic rash and a possible chickenpox infection.
D. A 4-year-old who has paroxysmal coughing and whose sibling has pertussis..
What is a 7-year-old who has a new pruritic rash and a possible chickenpox infection?
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area?
A. Supply oxygen via nasal cannula
B. Place intravenous (IV) access
C. Notify the ED physician
D. Set the client on continuous electrocardiographic monitoring
What is supply oxygen via nasal cannula?
A 7-year-old girl who has just endured allogeneic stem cell transplantation will need protective environmental stimulation. Which nursing task should the nurse delegate to the medical technician? Select all that apply.
A. Educating the client on when and how to perform careful handwashing.
B. Communicating with the family members about the grounds for isolation.
C. Stock the client's room with the required PPE items.
D. Reminding the visitors to wear a face mask, gloves, and gown.
E. Posting the precautions for protective isolation on the door of the client's room.
What is stock the client's room with the required PPE items. Reminding the visitors to wear a face mask, gloves, and gown. And posting the precautions for protective isolation on the door of the client's room.
A 25-year-old client comes to the outpatient unit with complaints of diarrhea, abdominal pain, shortness of breath, and epistaxis. Which action should the nurse take first?
A. Learn whether the client has had recommended immunizations.
B. Ask the client about any recent travel to Asia or the Middle East.
C. Have the client pinch the anterior nares firmly for 5 minutes.
D. Request an ambulance to take the client quickly to the hospital.
What is ask the client about any recent travel to Asia or the Middle East?
The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first?
A. Place the client on airborne and contact precautions
B. Introduce normal saline at 75 mL/hr
C. Give methylprednisolone (SOLU-Medrol) 1 g intravenously (IV)
D. Take blood, urine, sputum cultures
What is place the client on airborne and contact precautions?
A 90-year-old client is confined to the unit for two weeks. He has been receiving antibiotics for more than a week and tells you that he is having frequent watery stools. Which action will you take first?
A. Place the client on contact precautions
B. Educate the client about correct hand washing
C. Notify the physician about the loose stools
D. Get stool specimens for culture
What is place the client on contact precautions?