Delegation
The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP?
A. Checking to make sure that the patient's bath water is not too hot
B. Discussing community resources for diabetic outpatient care
C. Teaching the patient to perform daily foot inspection
D. Assessing the patient's technique for drawing insulin into a syringe
Ans: A
Checking to make sure the patient's bath water is not too hot is appropriate to delegate to the UAP. The other interventions are not.
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
A. A client complaining of muscle aches, a headache, and malaise
B. A client who twisted her ankle when she fell while rollerblading
C. A client with a minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that he just ate hot wings that was made with a very spicy sauce.
Ans: D
In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority.
You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection?
A. 3-year-old who has paroxysmal coughing and whose sibling has pertussis
B. 5-year-old who has a new pruritic rash and a possible chickenpox infection
C. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection
D. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight
Ans: B
Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/ or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization
The nurse at a family practice is responsible for reviewing home safety issues with all patients. She knows that there is an increased risk of falls in which of these two groups of patients?
A. The elderly and school-age children
B. Infants and toddlers
C. Toddlers and the elderly
D. Infants and the elderly
Ans: D.
Infants and the elderly both have increased risk of falls. Nurses should educate the parents and/or caregivers of infants about safe places for sleep and play to prevent a fall. In the elderly, nurses must consider age-related factors, both physical and cognitive that can increase the risk of falling.
A nurse is preparing to transfer a client who is 72 hours post-operative to a long-term care facility. Which of the following information is not necessary for the nurse to include in the transfer report?
A. Advance directives status
B. Vital signs on day of admission
C. Medical diagnosis
D. Need for specific equipment
Ans: B
The receiving nurse and facility do not need to know admission vital signs in order to provide care or address the client’s current needs. However, provide the most current set of vital signs in the report.
A student nurse is giving a child with suspected otitis media an ear examination. Which of the following actions, if taken by the student nurse, would require correction?
A. The student nurse allows the two-year-old to sit on her mother's lap during the exam.
B. The student nurse talks with the child as she looks into her ear.
C. The student nurse applies a disposable cover to the tip of the otoscope.
D. The student nurse gently pulls the pinna of the ear up and back to straighten the ear canal.
Ans: A
The student nurse gently pulls the pinna of the ear up and back to straighten the ear canal.
The student nurse should pull the pinna down and back in a child to straighten the ear canal. It's fine to talk with the child and sit them in the mother's lap, and the application of a disposable cover is a responsible action.
1. You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP?
A. Teaching the patient how to secure a clean-catch urine sample
B. Assessing the patient's urine for color, odor, and sediment
C. Reviewing the nursing care plan and add nursing interventions
D. Providing the patient with a clean-catch urine sample container
ANS: D
Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses.
After the respiratory therapist performs suctioning on a patient who is intubated, the RN measures vital signs for the patient. Which vital sign value should the RN be most concerned about?
A. Heart rate of 98 beats/min
B. Respiratory rate of 24 breaths/min
C. Blood pressure of 168/90 mm Hg
D. Tympanic temperature of 101.4ºF (38.6ºC)
Ans: D
Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
A. Surgical creation of a colostomy
B. First-degree burn on the back
C. Puncture of the foot by a nail
D. Paper cut on the finger
Ans: C
A. Surgery is conducted using sterile technique. In
addition, preoperative preparation of the bowel
helps to reduce the presence of organisms that
have the potential to cause infection.
B. There is no break in the skin in a first-degree
burn; therefore, there is less of a risk for a
wound infection than an example in another
option.
C. Of all the options, puncture of the foot
by a nail has the greatest risk for a wound
infection. A nail is a soiled object that has
the potential of introducing pathogens
into a deep wound that can trap them
under the surface of the skin, a favorable
environment for multiplication.
D. Paper generally is not heavily soiled and the
wound edges are approximated. This is less of
a risk than an example in another option.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
A. Restrain the client in bed.
B. Ask a family member to stay with the client.
C. Check the client every 15 minutes.
D. Use a bed exit safety monitoring device
Ans: D
Use a bed exit safety monitoring device.
Rationale: Option D is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option A can increase agitation and confusion and removes the client's independence. Option B would help but transfers the responsibility to the family member. Option C is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.
A charge nurse on the cardiac unit observes a new graduate nurse as she suctions a patient with a tracheostomy. What action, if performed by the graduate nurse, would require intervention from the charge nurse?
A. The graduate nurse hyperoxygenates the client for three minutes before suctioning.
B. The graduate nurse withdraws the catheter and intermittently applies suction for no longer than nine seconds.
C. The graduate nurse elevates the head of the bed to Semi-Fowler's position before beginning.
D. The graduate nurse withdraws the catheter and intermittently applies suction for no longer than fifteen seconds.
Ans: D
The graduate nurse withdraws the catheter and intermittently applies suction for no longer than fifteen seconds.
The nurse should suction a patient for no longer than ten seconds.
Which of the following must be performed by an RN and NOT a UAP (unlicensed assistive personnel)?
SELECT ALL THAT APPLY:
A. Ambulation post-op day 1. B. Patient teaching.
C. Ambulation post-op day 5.
D. Wound care.
E. Activities of daily living.
Ans:A, B, D
First time ambulation after surgery, any teaching, and special wound care may not be performed by a UAP.
When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/ LVN under the supervision of a team leader RN?
A. A patient with severe anemia secondary to GI bleeding
B. A patient who needs enemas and antibiotics to control GI bacteria
C. A patient who needs preoperative teaching for bowel resection surgery
D. A patient who needs central line insertion for chemotherapy
Ans: B
Administering enemas and antibiotics is within the scope of practice of LPNs/ LVNs. Although some states an facilities may allow the LPN/ LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the
A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first?
A. Start oxygen at 4 L/ min using a nasal cannula.
B. Obtain IV access with a large-bore IV catheter.
C. Give epinephrine (Adrenalin) 0.3 mL intramuscularly.
D. Administer 3 mL of nebulized albuterol (Proventil) 0.083%
Ans: C
Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention. Focus: Prioritization
The nurse understands that the factor that places a patient at the greatest risk for developing
an infection is:
A. Implantation of a prosthetic device
B. Presence of an indwelling urinary catheter
C. Burns more than twenty percent of the body
D. Multiple puncture sites from laparoscopic surgery
Ans: C
A. Although wound infections can occur when
prosthetic devices are implanted, they are
surgically implanted under sterile conditions
to minimize this risk.
B. Although urinary tract infections can occur
with an indwelling urinary catheter, even
though generally it is a closed system, an
example in another option places a person at a
greater risk for infection.
C. Burns more than 20% of a person's total
body surface generally are considered
major burn injuries. When the skin is
damaged by a burn, the underlying tissue
is left unprotected and the individual is at
risk for infection. The greater the extent
and the deeper the depth of the burn, the
higher the risk for infection.
D. Laparoscopic surgery is performed using
sterile technique to minimize the risk of
infection. An example in another option places
a person at a greater risk for infection.
Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?
A. Keep all of the side rails up.
B. Review prescribed medications.
C. Complete the "get up and go" test.
D. Place the bed in the lowest position.
ANS: D
Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option A can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option B is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option C would help the nurse to assess a client's risk for falling but would not prevent injury.
Which of the following situations is an example of negligence?
A. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown.
B. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water.
C. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair.
D. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization.
Ans: D
The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization.
The nurse in the outpatient care clinic cares for a client diagnosed with heart failure. Which of the following orders, if written by the physician, should the nurse question?
A. "Administer Lasix 40mg twice daily PO."
B. "Administer Potassium 40mEq tab once daily PO."
C. "Administer 0.9% NS solution IV at a rate of 125mL/hr."
D. "Administer Lactated Ringers solution IV at a rate of 50mL/hr."
Ans: C
"Administer 0.9% NS solution IV at a rate of 125mL/hr." The rate listed is too high for a heart failure patient, who cannot handle so much fluid on their cardiac system.
Which pediatric pain patient should be assigned to a newly-graduated RN?
A. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose
B. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures
C. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness
D. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful
Ans: B
The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding will require the most immediate action?
A. Blood pressure of 152/ 88 mm Hg
B. Heart rate of 134 beats/ min
C. Oxygen saturation of 91%
D. Chest pain level of 3 (on a scale of 10)
Ans: D
Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization
The physician orders a wound to be packed with a wet-to-damp gauze dressing. The nurse understands that this is done primarily to:
A. Minimize the loss of protein
B. Facilitate the healing process
C. Increase resistance to infection
D. Prevent the entry of microorganisms
Ans: B
A. Wet-to-damp packing of a wound is not
done to minimize the loss of protein from a
wound. Protein loss occurs until the wound
heals.
B. Packing a wound with wet-to-damp
dressings allows epidermal cells to migrate
more rapidly across the bed of the wound
surface than dry dressings, thereby
facilitating wound healing.
C. Although packing a wound with wet-to-damp
dressings will wick exudate up and away from
the base of the wound and therefore help to
increase resistance to a wound infection, it is
not the primary reason for its use.
D. This is not the primary purpose of a
wet-to-damp gauze dressing. Dry sterile
dressings are used to prevent the entry of
microorganisms into a wound.
The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.
A. Document the behavior(s) that require continued use of the restraints.
B. Ensure that the restraints are tied to the side rails.
C. Provide range-of-motion exercises when the restraints are removed.
D. Orient the client.
E. Assess the tightness of the restraints.
Ans: A, C, D, E
Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option B is inappropriate because it may cause injury if the side rail is lowered without untying the restraint.
An older client is admitted to the cardiac floor for new-onset atrial fibrillation. As the nurse is gathering admission history on the client, the client states, "Did you know that they can keep people alive even after they're brain dead? I never want to end up on those breathing machines." Which of the following questions should the nurse ask NEXT?
A. "Have you talked with your family about this?"
B. "I will make a note in your chart just in case."
C. "Do you have an advance directive?"
D. "Your lawyer can help you draft up papers to deal with this situation."
Ans: C
"Do you have an advance directive?"
An advance directive is a legal document that will ensure the patient's wishes are carried out, independent of what his family would like to do.
The nurse working on the diabetic specialty unit cares for four patients. A nursing assistant reports that each of the patients requires the nurse's attention. Which of the following patients, if described as detailed below by the nursing assistant, should be seen FIRST?
A. A diabetes type one patient who reported feeling weak and clammy and is now eating a simple-carbohydrate snack.
B. A diabetes type one patient who wants the nurse to change the dressing for his foot ulcer.
C. A diabetes type two patient who wants to know what to eat before she exercises.
D. A diabetes type two patient who reports headache, hot, dry skin and fruity odor to his breath.
Ans D:
A diabetes type two patient who reports headache, hot, dry skin and fruity odor to his breath.
The patient reporting hot, dry skin and fruity odor to breath shows signs of entering ketoacidosis and needs to be assessed immediately. The diabetes type one patient with low blood sugar (cool, clammy skin) is already eating a snack and should be seen second.
The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.)
A. Reminding the client to avoid commercial mouthwashes
B. Encouraging mouth rinsing with warm saline
C. Observing the lips, tongue, and mucous membranes D. Providing mouth care every 2 hours while the client is awake
E. Seeking a dietary consult to increase fluids on meal trays
ANS: A, B, C D
The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
A. The patient has fine bibasilar crackles.
B. The patient’s respiratory rate is 8 breaths/min.
C. The patient sits up and leans over the night table.
D. The patient has a large barrel chest.
Ans: B-
The oxygen flow is too high and is causing high serum oxygen level, which is decreasing the patient's respiratory drive. The oxygen flow needs to turned down.
ou are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions?
A. Remove N95 respirator.
B. Take off goggles.
C. Remove gloves.
D. Take off gown.
E. Perform hand hygiene. _____, _____, _____, _____,
Ans: C, B, D, A, E
This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration.
Focus: Prioritization
Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply.
A. Hire only competent nurses.
B. Improve the nurse's ability to multitask.
C. Establish a reporting system for "near misses."
D. Communicate effectively.
E. Create a culture of trust.
Ans: C,D,E
Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options A and B are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions.
A nurse observes a student nurse assess infants in the nursery. Which of the following, if observed by the nurse, would require an IMMEDIATE intervention?
A. The student nurse documents a negative red light reflex in a 2-day-old infant.
B. The student nurse notes the presence of overabundant lanugo in a preterm infant.
C. The student nurse lays an infant on his stomach to sleep.
D. The student nurse tests the rooting reflex by stroking the corner of the infant's mouth.
A. The student nurse documents a negative red light reflex in a 2-day-old infant.
Although sleeping on the stomach is not the recommended sleeping position, this does not require immediate correction. The more serious concern is the negative red light reflex. This reflex comes from the reflection of light off the inner retina. If absent, it indicates a severe neurological deficit, possibly caused by increased ICP and must be evaluated immediately.
The charge nurse is supervising the nursing care administered on a busy medical/surgical unit. Which of the following situations, if noticed, would require immediate intervention?
A. A UAP (unlicensed assistive personnel) changes the linens on the bed while the patient with Meniere's disease ambulates to the bathroom.
B. A nurse talks with a patient's family with the patient's direct permission.
C. An LPN (licensed practical nurse) gathers all necessary supplies before entering the room of a patient who needs a sterile dressing change.
D. An RN (registered nurse) dresses in a gown and gloves before entering the room of a patient with localized herpes zoster.
Ans: A
A UAP (unlicensed assistive personnel) changes the linens on the bed while the patient with Meniere's disease ambulates to the bathroom.
The UAP should walk hand in hand with the patient with Meniere's disease. The main characteristic of the disorder is attacks of dizziness that could cause a fall and injury. It is safest to ambulate with them.