Prioritization
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
A. A client with pneumonia who is receiving IV antibiotics and reports chills
B. A client with a new tracheostomy who is having difficulty clearing secretions
C. A client with heart failure who gained 2 lbs overnight
D. A client who is 2 days postoperative and requesting pain medication
B. A client with a new tracheostomy who is having difficulty clearing secretions
A nurse is reviewing the medication administration record for a client prescribed digoxin. Which of the following findings should the nurse report before administering the medication?
A. Heart rate of 58 bpm
B. Potassium level of 4.0 mEq/L
C. Blood pressure of 130/80 mmHg
A. Heart rate of 58 bpm
What is the first step in donning PPE?
Hand hygiene
Normal range for adult temperature?
97.8–99.1°F
Can an LPN administer oral meds?
Yes
Who takes priority: the patient with a fever or the one with shortness of breath?
The one with shortness of breath.
A nurse is educating a client who is prescribed lisinopril. Which of the following statements by the client indicates a need for further teaching?
A. 'I will report a persistent dry cough to my provider.'
B. 'I will avoid potassium-containing salt substitutes.'
C. 'I can stop taking my medication once I feel better.'
D. 'I will rise slowly from sitting to prevent dizziness.'
C. 'I can stop taking my medication once I feel better.'
A nurse is preparing to care for a client on contact precautions. Which of the following conditions requires this type of isolation?
A. Measles
B. Tuberculosis
C. Methicillin-resistant Staphylococcus aureus (MRSA) wound infection
D. Influenza
C. Methicillin-resistant Staphylococcus aureus (MRSA) wound infection
How to verify NG tube placement?
Aspirate and check pH or confirm by X-ray
Can a UAP take vitals on a stable patient?
Yes
You are the charge nurse on a medical-surgical unit. After receiving shift report, which of the following clients should you assess first?
A. A 65-year-old with a history of COPD who is short of breath after walking to the bathroom and has an oxygen saturation of 89%
B. A 58-year-old with type 2 diabetes who has a blood glucose of 220 mg/dL and is scheduled for insulin
C. A 40-year-old who is 2 hours postoperative following a laparoscopic appendectomy and is requesting pain medication
D. A 72-year-old admitted for dehydration who has dry mucous membranes and reports dizziness when standing
A. A 65-year-old with a history of COPD who is short of breath after walking to the bathroom and has an oxygen saturation of 89%
What to assess before giving Digoxin?
Apical pulse
What to do if a med error is made?
Notify the provider and complete an incident report
What is orthostatic hypotension?
BP drop on standing
Who can assess new post-op patients?
The RN
A nurse is caring for a client recovering from abdominal surgery. Which of the following symptoms requires immediate intervention?
A. A temperature of 100.2°F (37.9°C)
B. Serosanguinous drainage on the surgical dressing
C. Abdominal distension with absent bowel sounds for 4 hours
D. A sudden burst of bright red blood soaking through the dressing
D. A sudden burst of bright red blood soaking through the dressing
What med class is Metoprolol?
Beta blocker
A nurse is caring for a client admitted with a diagnosis of pulmonary tuberculosis. Which of the following infection control precautions should the nurse implement?
A. Place the client in a private room with droplet precautions
B. Use a surgical mask when entering the client’s room
C. Place the client in a negative-pressure airborne isolation room
D. Wear gloves and gown only during procedures involving body fluids
C. Place the client in a negative-pressure airborne isolation room
Best position for aspiration risk?
Semi-Fowler’s
Can an LPN start an IV?
Depends on state—check scope of practice
A nurse is caring for four postoperative clients. Which finding requires the nurse to reassess care priorities immediately?
A. A client with a blood pressure of 150/88 mm Hg and a mild headache
B. A client requesting assistance to ambulate to the bathroom
C. A client who has not voided 6 hours after catheter removal
D. A client reporting new-onset shortness of breath and restlessness
D. A client reporting new-onset shortness of breath and restlessness
What is a key teaching point for Levothyroxine?
Take on an empty stomach in the morning
Best way to prevent falls in elderly?
Hourly rounding and call light within reach
What is the first step in a head-to-toe assessment?
Hand hygiene and patient identification
Can a UAP feed a stroke patient?
Only if swallowing has been evaluated and cleared