See/ Do First
The nurse on the cardiac unit has received shift report from the outgoing nurse. Which client should the RN assess first?
A. The client who has just been brought to the unit from the emergency department (ED) with no reports of complaints.
B. the client who received pain medication 30 minutes ago for chest pain that was a 3 on a 1-10 scale.
C. the client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally.
D. the client who has been turning on the call light frequently and stating her care has been neglected.
Answer A: this client may or may not be stable, but the nurse must assess this client first to determine.
“when in doubt, check it out!”
The nurse can evaluate the amount of pain relief after first checking on the ED pt.
Is there an unexpected finding?
Is there an indication that a client is unstable?
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
A. the client diagnosed with a myocardial infarction
B. the client admitted with unstable angina
C. the client scheduled for a cardiac catheterization
D. the client complaining of chest pain
Answer: C
the new grad should be able to complete a pre-procedural checklist and get the client to the cath lab
The most stable client should be assigned to the least experienced nurse.
Is there an unstable client?
Where is the risk for most harm? Most complications?
The charge nurse is making assignments for a 30 bed cardiac unit staffed with 3 RN’s, 3 LPN’s and 3 UAP’s. which assignment is most appropriate by the charge nurse?
A. assign a RN to perform all sterile procedures
B. assign a LPN to give all IV medications
C. assign a UAP to complete the a.m. care
D. assign an LPN to write the care plans
1. an LPN can perform sterile procedures, a RN should perform the functions such as planning and evaluating the care of the client
2. there are some IV meds only a RN can perform such as chemo, and IVP medications, the word ALL here makes it incorrect.\
4. writing a care plan requires nursing judgment to plan, and implement an individualized plan of care
This term is used to describe what the body does to the drug.
What is pharmacokinetics?
This term is used for the cessation of bleeding.
What is Hemostasis?
Which client should the telemetry nurse assess first after receiving the a.m. shift report?
A. the client diagnosed with a deep vein thrombosis who has an edematous right calf.
B. the client diagnosed with mitral valve stenosis who has heart palpitations.
C. the client diagnosed with arterial occlusive disease who has intermittent claudication.
D. the client diagnosed with congestive heart failure who has pink frothy sputum.
Answer: D the nurse would not expect pink frothy sputum, this is a sign of pulmonary edema and a complication of chf
Is there expected findings? Unexpected findings?
Must know your medical-surgical material.
The calf red and edematous with a DVT is expected.
Clients with mitral valve stenosis have palpitations.
The nurse would expect intermittent claudication (leg pain)
The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (uap). Which task warrants intervention by the charge nurse on the telemetry unit?
1. the UAP is instructed to bathe the client who is on telemetry
2. the UAP is requested to obtain a bedside glucometer reading
3. the UAP is asked to assist with a portable chest x-ray
4. the UAP is told to feed a client who is dyphagic
Answer: D the client is at risk for choking and is not stable. The charge nurse should not let the uap feed
I knew you wouldn’t like this one!!!
Some questions to ponder….
Can the UAP perform tasks?
Most cardiac patients are on telemetry. These would be considered a routine task.
In most places a UAP cannot perform an accucheck. But if you look at the criteria. It is considered data collection. There is “EAT” involved.
What can cause the most harm?
Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply
1. perform mouth care on the client with pneumonia
2. apply oxygen via nasal cannula to the client
3. empty the trashcans in the client’s rooms
4. take the empty blood bag back to the laboratory
5. show the client how to ambulate on the walker
Answer: 1 and 4
The UAP can perform tasks on a client who is stable. The UAP can also take the blood bag to the lab.
Remember you are managing the floor, cost effectiveness, put your UAP to good work. The housekeeping staff can empty the trash cans.
Oxygen is a medication and the nurse cannot delegate medication administration.
The nurse also cannot delegate teaching.
Prior to running two IV drugs simultaneously, the RN knows to do this first.
This type of cell is responsible for blood clotting.
What is a thrombocyte?
The nurse on the cardiac unit is preparing to administer medications after receiving morning change of shift report. Which medication should the nurse administer first?
A. the cardiac glycoside to the client who has an apical pulse of 58.
B. the loop diuretic to a client with a serum K+ of 3.2 mEq/L.
C. the antidysrhythmic to the client in ventricular fibrillation.
D. the calcium-channel blocker to the client with a BP 110/68.
Answer C.ventricular fibrillation is a life-threatening arrhythmia
You must know your medications, SE and expected effects.
You must know your normal lab results.
A cardiac glycoside is digoxin, you would hold for a HR<60
The potassium is low, the nurse should question giving this.
The blood pressure is normal, so not a priority.
The RN is working with the UAP and the LPN in providing care to a group of clients. Which tasks should the RN plan to delegate? SATA
1. LPN to administer IM and oral medications
2. UAP to perform Chest Tube Dressings
3. LPN to initiate DC paperwork for two clients
4. UAP to empty and record urinary catheter bag drainage.
Answer: 1 and 4
1. it is in the LPN's scope of practice to give oral and IM medications
2. It is not acceptable for UAP to complete complex dressing changes
3. It is not within the LPN's scope to initiate discharge.
4. It is acceptable practice for the UAP to empty and record urinary catheter bag drainage.
The nurse is assigning tasks to the UAP. Which tasks best demonstrate proper delegation?
1. Bathe 30 clients while working the day shift.
2. Insert an NG tube to administer feeding.
3. Answer the client's question about a medication
4. Ambulate the client who had a thoracotomy 3 days ago
1. May be unreasonable to expect the UAP to sufficiently bathe 30 clients in 1 shift
2. UAP may not insert NG tube
3. RN may not delegate teaching to UAP
4. Client may be safely ambulated by 3rd day following a thoracotomy
A secondary, typically undesirable effect of a drug or medical treatment.
What is a side effect?
This is the term used for blood formation and maturation.
What is hematopoiesis?
The Uap working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first?
A. have the family bring food from home for the client.
B. check to see what the client has eaten in the past 24 hours.
C. tell the client that a low-sodium diet is an important part of the diagnosis.
D. ask the dietician to discuss food preferences with the client.
Answer B. assessing the client’s intake will help the nurse determine the extent of the complaints
One of the basic guidelines to apply is the nursing process.
If a priority setting question asks the test taker which step to implement first, the test taker should look for an answer that would assess first.
There are numerous words such as “check” that can be used to indicate assessment.
Do no discard an option because the word “assess” is not an option.
Alternatively do not assume the option is correct because it says “assess.”
The client on a telemetry unit has a BP of 88/40mmHg, a HR of 44 bpm, feels faint, and is pale and confused. When caring for this client, which tasks should the RN delegate to the NA? SATA
1. Paging for the charge nurse
2. Paging for the RT
3. Securing an Automatic BP machine
4. Placing an oxygen facemask at 2L/min
5. Obtaining a printed cardiac rhythm strip
1,3,5
The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first?
A. the elderly client with pneumonia who reports being dizzy when getting up.
B. the client with cystic fibrosis who needs a prescription for pancreatic enzymes.
C. the client with lung cancer on chemotherapy who reports nausea.
D. the client with pertussis who reports coughing spells so severe that they cause vomiting.
Answer A. this client needs further assessment
Think safety. Need to determine if medication cause, dehydration and are they at risk for injury? What client is at risk for most harm?
A pain medication delivery system where the client presses a button for medication delivery.
What is a PCA (Patient-Controlled Analgesia) pump.
This molecule gives blood its red color.
The client who is 1 day post-op following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first?
A. assess the client’s pulse oximeter reading
B. notify the rapid response team
C. place the client in the Trendelenburg position
D. check the client’s surgical dressing
Answer B. the rapid response team was mandated by the joint commission.
It is a team of healthcare professionals who respond to clients who are breathing but who the nurse thinks are in an emergency situation.
The client is in distress. Therefore the nurse most “do something.” There is already enough assessment data in the stem.
What is Trendelenburg?
The RN is working with the experienced LPN. Which client should the RN assign to the LPN?
1. The 1 year old who is scheduled to receive chemo.
2. The 2 year old who has orders for a platelet transfusion.
3. The 3 year old who has loose stools and is incontinent.
4. The 4 year old admitted with lethargy who has a temperature of 101F.
It is not in the LPN's scope of practice to administer chemo or blood products. The 4 year old may need frequent observations, so would not be appropriate for the LPN.
The nurse manager is reviewing assignments for an evening shift. The manager should intervene if the experienced LPN is assigned to what action?
1. Complete a foot soak for a client who has an infected heel ulcer in isolation for VRE.
2. Assist the client who had a hysterectomy 6 hrs ago to sit at the edge of the bed for a few minutes then ambulate.
3. Discharge a 34 yo who had a right mastectomy 4 days ago and needs discharge incision teaching.
4. Perform intermittent urinary catheterization for residual urine for the client who had an abdominal hysterectomy 2 days ago.
3. RNs should assess the client's readiness for discharge and complete any discharge teaching.
The nurse knows that when managing a patient on this type of medication, the nurse should:
Check vital signs and labs
Observe for signs of bleeding
Review bleeding protocol
Avoid aspirin and green leafy vegetables.
What are anticoagulants?
This is the term used for the desire to eat items with no traditional value (like dirt).
What is Pica?