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Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #1 (25 Items)
- A. Perform postural drainage and chest physiotherapy every 4 hours.
- B. Allow the patient to decide whether she needs aerosolized medications.
- C. Place the patient in a private room to decrease the risk of further infection.
- D. Plan activities to allow at least 8 hours of uninterrupted sleep.
Correct Answer: A. Perform postural drainage and chest physiotherapy every 4 hours.
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over other activities. The Cystic Fibrosis Transmembrane Conductance Regulator defect causes mucus to become dehydrated. Secretions in cystic fibrosis are generally thick, sticky, and more difficult to clear. Frequent airway clearance is a mainstay in the treatment of acute exacerbations, as well as an integral part of health maintenance in cystic fibrosis.
- Option B: Although allowing more independent decision-making is important for adolescents, the physiologic need for an improved respiratory function takes precedence at this time. Collaborate with the client and staff to ensure that the schedule for therapy is amenable to all and does not interfere with meals, rest times, or medications.
- Option C: A private room may be desirable for the patient but is not necessary. Ensure that clients with CF are not cohorted. The cohorting of clients with CF is not recommended based on published CF Infection Control Consensus Guidelines.
- Option D: With increased shortness of breath, it will be more important that the patient has frequent respiratory treatments than 8 hours of sleep. Infection, inflammation, and mucous plugging will cause an increase in the respiratory effort to compensate for airway obstruction. As moving air into and out of the lungs becomes more difficult, the breathing pattern alters to include the use of accessory muscles and retractions.
A patient with a pulmonary embolism is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply.
- A. Use a lift sheet when moving and positioning the patient in bed.
- B. Use an electric razor when shaving the patient each day.
- C. Use a soft-bristled toothbrush or tooth sponge for oral care.
- D. Use a rectal thermometer to obtain a more accurate body temperature.
- E. Be sure the patient’s footwear has a firm sole when the patient ambulates.
Correct Answers: A, B, C, and E.
All of the other instructions are appropriate to the care of a patient receiving anticoagulants. Risk for bleeding may arise in any condition that disturbs the “close circuit” integrity of the circulatory system. Bleeding is the primary complication of anticoagulant therapy and is a risk of all anticoagulants even when maintained within the usual therapeutic ranges.
- Option A: Educate the at-risk patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. Information about precautionary measures lessens the risk for bleeding.
- Option B: Be careful when using sharp objects like scissors and knives. Use an electric razor for shaving (not razor blades). The patient needs to avoid situations that may cause tissue trauma and increase the risk for bleeding.
- Option C: Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use of toothpicks and dental floss. This method providing oral hygiene reduces trauma to oral mucous membranes and the risk for bleeding from the gums.
- Option D: While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). These invasive devices or medications may cause trauma to the mucous membranes that line the rectum or vagina.
- Option E: Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a health care provider reduces the risk for complications from blood loss.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
- A. Perform endotracheal intubation and initiate mechanical ventilation.
- B. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth.
- C. Administer furosemide (Lasix) 100 mg IV push stat.
- D. Call a code for respiratory arrest.
Correct Answer: A. Perform endotracheal intubation and initiate mechanical ventilation
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to the delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually, at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless healthcare care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
- Option B: To maintain oxygenation, ARDSnet recognizes the benefit of PEEP. The protocol allows for a low or a high PEEP strategy relative to FiO2. Either strategy tolerates a PEEP of up to 24 cm HO in patients requiring 100% FiO2. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS.
- Option C: The chief treatment strategy is supportive care and focuses on 1) reducing shunt fraction, 2) increasing oxygen delivery, 3) decreasing oxygen consumption, and 4) avoiding further injury. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional support until evidence of improvement is observed.
- Option D: The major cause of death in patients with ARDS was sepsis or multiorgan failure. While mortality rates are now around 9% to 20%, it is much higher in older patients. ARDS has significant morbidity as these patients remain in the hospital for extended periods and have significant weight loss, poor muscle function, and functional impairment.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant?
- A. Assisting the patient to sit up on the side of the bed.
- B. Instructing the patient to cough effectively.
- C. Teaching the patient to use incentive spirometry.
- D. Auscultation of breath sounds every 4 hours.
Correct Answer: A. Assisting the patient to sit up on the side of the bed.
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions.
- Option B: The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option C: Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
- Option D: Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant?
- A. Discuss weight-loss strategies such as diet and exercise with the patient.
- B. Teach the patient how to set up the BiPAP machine before sleeping.
- C. Remind the patient to sleep on his side instead of his back.
- D. Administer modafinil (Provigil) to promote daytime wakefulness.
Correct Answer: C. Remind the patient to sleep on his side instead of his back.
The nursing assistant can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. The right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe, and competent manner.
- Option A: Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care, and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
- Option B: The registered nurse must also ensure that the delegated tasks are permissible according to the nursing team members’ position description which is also referred to as the job description, and the particular facility’s specific policies and procedures relating to client care and who can and who cannot perform certain tasks.
- Option D: Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate the administration of medication to an LPN/LVN.
After a change of shift, you are assigned to care for the following patients. Which patient should you assess first?
- A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab.
- B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation.
- C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics.
- D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
Correct Answer: D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.
The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. In particular, a patient who is chronically on short-acting beta-2 agonists risks not achieving the same relief from their medicine as they once did. This phenomenon is called receptor downregulation. It happens because a portion of the receptors targeted end up being inactivated by the body due to overuse.
- Option A: The sterile sputum specimen of the patient should be sent to the laboratory for not more than 60 minutes, or it will not be acceptable. This is not an urgent case and can be done after the nurse sees the other patients.
- Option B: In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88–92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy
- Option C: The other patients need to be assessed as soon as possible, but none of their situations are urgent. Patients older than 60 years or younger than 4 years of age have a relatively poorer prognosis than young adults. If pneumonia is left untreated, the overall mortality may become 30%. The Pneumonia Severity Index (PSI) may be utilized as a tool to establish a patient’s risk of mortality.
After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately?
- 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)
Correct Answer: D. Tympanic temperature of 101.4ºF (38.6ºC)
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.
- Option A: The normal range used in an adult is between 60 to 100 beats/minute with rates above 100 beats/minute and rates below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The rate of the pulse is significant to measure for assessing the physiological and pathological processes affecting the body.
- Option B: The normal breathing rate is about 12 to 20 breaths per minute in an average adult. Tachypnea is described as a respiratory rate of more than 20 breaths per minute that could occur in physiological conditions like exercise, emotional changes, or pregnancy. Pathological conditions like pain, pneumonia, pulmonary embolism, asthma, foreign body aspiration, anxiety conditions, sepsis, carbon monoxide poisoning, and diabetic ketoacidosis can also present with tachypnea.
- Option C: Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the patient. Unfortunately, though, there are a lot of inter-person variabilities when measuring it. All healthcare providers should be aware of making sure all the essential prerequisites are met before checking the blood pressure of the patient.
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply.
- A. Auscultate breath sounds
- B. Administer medications via metered-dose inhaler (MDI)
- C. Complete in-depth admission assessment
- D. Initiate the nursing care plan
- E. Evaluate the patient’s technique for using MDI’s
Correct Answers: A and B.
Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team.
- Option A: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement, and evaluate care under the direct supervision and guidance of the registered nurse.
- Option B: Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
- Option C: Scopes of practice should be considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.
- Option D: The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others.
- Option E: Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient’s abilities require additional education and skills. These actions are within the scope of practice of the professional RN.
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
- A. A 58-year old on airborne precautions for tuberculosis (TB).
- B. A 68-year old just returned from a bronchoscopy and biopsy.
- C. A 72-year old who needs teaching about the use of incentive spirometry.
- D. A 69-year old with COPD who is ventilator dependent.
Correct Answer: C. A 72-year old who needs teaching about the use of incentive spirometry
Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care.
- Option A: To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. All healthcare facilities and agencies must assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience.
- Option B: The bronchoscopy patient needs a specialized procedure. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option D: The ventilator-dependent patient needs a nurse who is familiar with ventilator care. Some patients require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
- A. Reassure the patient that the ventilator will do the work of breathing for him.
- B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
- C. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning.
- D. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
Correct Answer: B. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
Manual ventilation of the patient will allow you to deliver a FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. Proper ventilation techniques with the BVM should consider safe ventilation parameters for each individual patient and their conditions.
- Option A: The patient may need reassurance, but this is not the priority nursing intervention. Indicators of appropriate ventilation include but are not limited to patient chest rise, skin color, electronic vital sign monitoring, resistance on bag squeeze according to patient lung pathology, CO2 monitoring, and a flashing light on the BVM for rate of breath delivery.
- Option C: Excessive volume, pressure or flow may result in morbidity from lung damage, stomach insufflation, or hemodynamic and pulmonary compromise. Lower tidal volumes are needed in ARDS to prevent regional overdistension.
- Option D: The patient may need insertion of an oral airway, but the first step should be an assessment of the reason for the high-pressure alarm and resolution of the hypoxemia. PEEP (5–20 cmH2O) is a key element of protective ventilation and is routinely applied in all patients with ARDS to facilitate adequate oxygenation and maintain alveolar recruitment.
The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?
- A. Suggest that the patient’s oxygen be humidified.
- B. Suggest that a simple face mask be used instead of a nasal cannula.
- C. Suggest that the patient be provided with an extra pillow.
- D. Suggest that the patient sit up in a chair at the bedside.
Correct Answer: A. Suggest that the patient’s oxygen be humidified.
When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. It is reasonable to use humidified oxygen for patients who require high-flow oxygen systems for more than 24 hours or who report upper airway discomfort due to dryness. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
- Option B: For patients wearing a nasal cannula for standard oxygen supplementation, switching to high-flow nasal cannula oxygen therapy (HNFC) may be a good alternative to combat the side effect of dry nose.
- Option C: Providing an extra pillow would not alleviate the dryness of the patient’s nose. Water-based lubricants, such as K-Y jelly, help prevent dryness, irritation, and cracking of the nose commonly associated with supplemental oxygen therapy, BiPAP, and CPAP by adding moisture to the affected area.
- Option D: Changing the patient’s position would not treat the dry nose. Medical oxygen contains no moisture, so regular or even occasional use can dry out the nasal passages. Nasal saline spray adds moisture to dry nasal passages and assists the nose’s natural cleaning system. It’s important to keep the nasal passages moist because bacterial infections can develop under the nasal crusts that develop inside dry nostrils.
When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
- A. “Everyone in my family needs to go and see the doctor for TB testing.”
- B. “I will continue to take my isoniazid until I am feeling completely well.”
- C. “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
- D. “I will change my diet to include more foods rich in iron, protein, and vitamin C.”
Correct Answer: B. “I will continue to take my isoniazid until I am feeling completely well.”
Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate an understanding of TB. Drug of choice is isoniazid. It is usually given with vitamin B6, pyridoxine (to prevent nerve damage). Isoniazid is recommended for Mantoux or quantiferon positive individuals and should be continued for 6 or 9 months.
- Option A: Family members should be tested because of their repeated exposure to the patient. Most people who develop tuberculosis do so after a long period of latency (usually several years after initial primary infection). This is known as secondary tuberculosis.
- Option C: Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. Although usually a lung infection, tuberculosis is a multi-system disease with protean manifestation. The principal mode of spread is through inhalation of infected aerosolized droplets.
- Option D: The dietary changes are recommended for patients with TB. Nutritional supplementation may help to improve outcomes in tuberculosis patients. A study found that nutritional counseling to increase energy intake combined with provision of supplements, when started during the initial phase of tuberculosis treatment, produced a significant increase in body weight, total lean mass, and physical function after six weeks.
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with respiratory distress syndrome (RDS)?
- A. Theophylline (Theolair, Theochron)
- B. Surfactant (Exosurf)
- C. Dexamethasone (Decadron)
- D. Albuterol (Proventil)
Answer: B. Surfactant (Exosurf)
Exosurf neonatal is a form of synthetic surfactant. An infant with RDS may be given two to four doses during the first 24 to 48 hours after birth. It improves respiratory status, and research has shown a significant decrease in the incidence of pneumothorax when it is administered.
- Option A: Theophylline is indicated for the treatment of asthma and COPD (bronchitis, emphysema). Theophylline relaxes the smooth muscles located in the bronchial airways and pulmonary blood vessels. It also reduces the airway responsiveness to histamine, adenosine, methacholine, and allergens.
- Option C: Dexamethasone has a wide variety of uses in the medical field. As a treatment, dexamethasone has been useful in the treatment of acute exacerbation of multiple sclerosis, allergies, cerebral edema, inflammation, and shock. It works by suppressing the migration of neutrophils and decreasing lymphocyte colony proliferation.
- Option D: Albuterol is often used for the treatment of pediatric acute asthma. Albuterol acts on beta-2 adrenergic receptors to relax the bronchial smooth muscle. It also inhibits the release of immediate hypersensitivity mediators from cells, especially mast cells.
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse?
- A. Give potassium 10 mEq orally
- B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
- C. Give spironolactone (Aldactone) 25 mg orally
- D. Assess electrocardiogram (ECG) strip for tall T waves
Correct Answer: B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally
Delegation, supervision. The normal range for potassium is 3.5 to 5 mEq/L. The client’s potassium level is high. Kayexalate eliminates potassium from the body through the gastrointestinal system. The right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job.
- Option A: Giving additional potassium may further increase the serum potassium level. The registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.
- Option C: Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.
- Option D: The beginning nursing student does not have the skill to assess ECG strips. Some client needs are relatively predictable; and other patient needs are unpredictable based on the changing status of the client. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?
- A. Observe how well the patient performs pursed-lip breathing.
- B. Plan a nursing care regimen that gradually increases activity intolerance.
- C. Assist the patient with basic activities of daily living.
- D. Consult with the physical therapy department about reconditioning exercises.
Correct Answer: A. Observe how well the patient performs pursed-lip breathing
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
- Option B: Planning requires additional education and skills, appropriate to an RN. The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option C: Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene.
- Option D: Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.
When assessing a 22-year old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
- A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
- B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
- C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
- D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
Correct Answer: D. Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. Patients are mechanically ventilated, guarded against fluid overload with diuretics, and given nutritional support until evidence of improvement is observed.
- Option A: The maximum oxygen delivery with a nasal cannula is a Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Interestingly, the mode in which a patient is ventilated affects lung recovery. Evidence suggests that some ventilatory strategies can exacerbate alveolar damage and perpetuate lung injury in the context of ARDS.
- Option B: Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. The chief treatment strategy is supportive care and focuses on 1) reducing shunt fraction, 2) increasing oxygen delivery, 3) decreasing oxygen consumption, and 4) avoiding further injury.
- Option C: Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. A lung-protective ventilatory strategy is advocated to reduce lung injury. Novel invasive ventilation strategies have been developed to improve oxygenation. These include airway pressure release ventilation (APRV) and high-frequency oscillation ventilation (children).
Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?
- A. Warfarin (Coumadin) 1.0 mg by mouth (PO)
- B. Morphine sulfate 2 to 4 mg IV
- C. Cephalexin (Keflex) 250 mg PO
- D. Heparin infusion at 900 units/hr
Correct Answer: A. Warfarin (Coumadin) 1.0 mg by mouth (PO)
Medication safety guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose, such as 10 mg. The order should be clarified before administration. The other orders are appropriate, based on the patient’s diagnosis.
- Option B: FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain.
- Option C: Cephalexin is an FDA-approved antibiotic. Cephalexin is a first-generation cephalosporin utilized in the treatment of urinary tract infections, respiratory infections, and other bacterial infections. Cephalexin is also commonly used in treating streptococcal and staphylococcal skin infections.
- Option D: Unfractionated heparin is an anticoagulant indicated for both the prevention and treatment of thrombotic events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) as well as atrial fibrillation (AF). Heparin is also used to prevent excess coagulation during procedures such as cardiac surgery, extracorporeal circulation, or dialysis, including continuous renal replacement therapy.
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use an MDI without a spacer. Put in the correct order the steps that the student nurse should teach the patient.
- 1. Remove the inhaler cap and shake the inhaler
- 2. Tilt your head back and breathe out fully
- 3. Open your mouth and place the mouthpiece 1 to 2 inches away
- 4. Press down firmly on the canister and breathe deeply through your mouth
- 5. Hold your breath for at least 10 seconds
- 6. Wait at least 1 minute between puffs
The correct order is shown above.
- Before each use, the cap is removed and the inhaler is shaken according to the instructions in the package insert.
- Next, the patient should tilt the head back and breathe out completely.
- Each inhaler consists of a small canister of medicine connected to a mouthpiece. The canister is pressurized. As the patient presses down on the inhaler, it releases a mist of medicine.
- As the patient begins to breathe deeply through the mouth, the canister should be pressed down to release one puff (dose) of the medication.
- The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs.
- The patient should wait for at least 1 minute between puffs from the inhaler.
You are acting as a preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? Select all that apply.
- A. A 38-year old with moderate persistent asthma awaiting discharge.
- B. A 63-year old with a tracheostomy needing tracheostomy care every shift.
- C. A 56-year old with lung cancer who has just undergone left lower lobectomy.
- D. A 49-year old just admitted with a new diagnosis of esophageal cancer.
Correct Answer: A and B.
- Option A: A patient who is waiting for discharge may be stable enough for the care of the student nurse. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs.
- Option B: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.
- Option C: The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
- Option D: The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs.
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic ward in which she has no prior experience working on. Which client should be assigned to her?
- A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
- B. A client with balanced skeletal traction and needs assistance with morning care.
- C. A client who had an above-the-knee amputation yesterday and currently has a temperature of 101.4ºF.
- D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
Correct Answer: D. A client who had a total hip replacement two days ago and needs blood glucose monitoring.
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with a stable condition as those who have care similar to her training and experience. A client who is in a postoperative state is more likely to be in a stable condition.
- Option A: The client may be experiencing compartment syndrome and would need the expertise of an orthopedic nurse. Acute compartment syndrome is a condition in which there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Without prompt treatment, acute compartment syndrome can lead to ischemia and eventually, necrosis.
- Option B: The care of a patient with skeletal traction would need a nurse who had experience with handling the apparatus. It requires frequent reassessment of neurovascular function of the extremity after application of the traction.
- Option C: A newly recovered postoperative patient should be monitored by an experienced ortho nurse. An above-knee amputation is associated with enormous morbidity; unlike a below-knee amputation, fitting a prosthesis for an above-knee stump is difficult.
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
- A. Evaluating the patient’s complaint of chest pain.
- B. Monitoring laboratory values for changes in oxygenation.
- C. Assessing for symptoms of respiratory failure.
- D. Auscultating the lungs for crackles.
Correct Answer: D. Auscultating the lungs for crackles.
An LPN who has been trained to auscultate lung sounds can gather data by routine assessment and observation, under the supervision of an RN. The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.
- Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option B: Part of supervision entails the ongoing evaluation of staff’s ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided.
- Option C: Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.
The nurse plans to care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first?
- A. Respiratory status
- B. Level of consciousness
- C. Level of pain
- D. Reflexes and movement of extremities
Correct Answer: A. Respiratory status
Assessing respiratory status is the first priority. Remember ABC. General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value.
- Option B: A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses.
- Option C: Pain is a common occurrence after most all types of surgical procedures and is probably the most significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a critical nursing intervention.
- Option D: Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip.
Nurse Jackie is reviewing the diet of a 28-year-old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. The nurse should tell the client to avoid:
- A. Fiber
- B. Broccoli
- C. Yogurt
- D. Simple carbohydrates
Correct Answer: B. Broccoli
Broccoli is known to be gas-forming which can lead to bloating and therefore, should be avoided. In general, gassy foods are those that contain certain sugars (fructose, lactose, raffinose, and sorbitol) and/or soluble fiber. These substances are not digested at the level of the stomach and thus make their way down to the intestines where bacteria break them down. The end result of this breakdown is the release of gas.
- Option A: One way to prevent uncomfortable intestinal gas is to slowly increase the fiber in the diet. Giving the body a chance to get used to processing the increase in fiber will make the transition easier and reduce the amount of intestinal gas to deal with.
- Option C: Plain yogurt can actually help the stomach because it contains probiotics, which are known to regulate digestion. However, if the patient is eating flavored yogurt that’s high in sugar, she’ll have more fermentation going on in her body, which means more gas and bloating.
- Option D: Complex Carbohydrate Intolerance (CCI) occurs because there is a lack of the enzyme necessary to digest complex carbohydrates. There is little gas production in the small intestine because the bacterial concentration is low. When the undigested carbohydrates reach the colon, the bacteria that normally live in the colon ferment them. This fermentation often results in the production of gas.
Nurse Jenny of Nurseslabs Medical Center is planning care for a client who had undergone colposcopy. Which of the following actions should the RN take first?
- A. Discuss the client’s fear regarding potential cervical cancer.
- B. Assist with silver nitrate application to the cervix to control bleeding.
- C. Give instructions regarding douching and sexual relations.
- D. Administer pain medications.
Correct Answer: B. Assist with silver nitrate application to the cervix to control bleeding.
Colposcopy is a procedure to examine the cervix, vagina, and vulva for signs of disease. The priority nursing action when caring for a client who underwent colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.
- Option A: Colposcopy is a procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. The indications for a colposcopy to be performed are risk-based. Women referred for colposcopy have a variety of underlying risks for cervical pre-cancer based on their cytological results, the HPV testing if it was performed, and personal history of cervical dysplasia.
- Option C: There is no required preparation for the patient having the colposcopy; however, it can be difficult to perform if she is on her menstrual cycle due to obscuring blood. Having the room with the proper equipment readily available will expedite the patient’s visit.
- Option D: The procedure is typically not painful. It does not require local or regional anesthesia. Slight discomfort may be felt when a speculum is inserted into the vagina, which can be minimized by deep breathing during the procedure.
Sally is a nurse working in an emergency department and receives a client after a radiological accident. Which task is the utmost priority for the nurse to do first?
- A. Decontaminate the client’s clothing.
- B. Decontaminate the open wound on the client’s thigh.
- C. Decontaminate the examination room the client is placed in.
- D. Save the client’s vomitus for analysis by the radiation safety staff.
Correct Answer: B. Decontaminate the open wound on the client’s thigh.
Decontaminating an open wound is the first priority for the client. This minimizes the absorption of radiation in the client’s body. A radiological accident is an event that involves the release of potentially dangerous radioactive materials into the environment. This release is usually in the form of a cloud or “plume” and could affect the health and safety of anyone in its path.
- Option A: Getting radioactive material off the body as soon as possible can lower a worker’s radiation dose from external contamination. Removing outer clothing and showering or, at a minimum, washing the face, hands, and any other exposed skin are essential decontamination steps.
- Option C: Decontamination of emergency response workers, their clothing, and any equipment, including PPE they may be using, is essential to limit radiation dose and prevent the spread of radioactive contamination outside of the response area.
- Option D: A prodromal period during which victims may experience loss of appetite, nausea, vomiting, fatigue, and diarrhea; after extremely high doses, additional symptoms such as fever, prostration (laying down), respiratory distress, and hyper-excitability can occur. In cases where the dose is not sufficient to cause rapid death, these symptoms usually disappear within 1-2 days.
Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #2 (25 Items)
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
- A. A client with diabetes was discharged today.
- B. A 35-year-old male with tracheostomy and copious secretions.
- C. A teenager scheduled for physical therapy this morning.
- D. A 78-year-old female client with a pressure ulcer that needs a dressing change.
Correct Answer: B. A 35-year-old male with tracheostomy and copious secretions.
The patient with an airway problem should be given the highest priority. The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.
- Option A: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.
- Option C: The teenager who will undergo physical therapy is under Maslow’s safety and physiological needs. The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security.
- Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
- A. Call for help to get the client back in bed
- B. Establish whether the client is responsive
- C. Assist the client back to bed
- D. Ask the client what happened
Correct Answer: B. Establish whether the client is responsive
Assess the client’s current level of consciousness first to determine whether the patient has had a loss of consciousness then do the remaining choices if possible. The initial step is to evaluate for reactivity using objective measures. Address the patient verbally, progress to light shaking, then progress to more intense mechanical stimulation.
- Option A: After establishing the client’s ABCs, the nurse may call for help. The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing airway patency and breathing pattern.
- Option C: If the client is stable and has been seen by a physician, the nurse may assist him back to his bed. The best practice for reporting level of responsiveness is to document specifically how the patient reacted to the external stimulus provided for testing.
- Option D: History regarding an unconscious patient is based on supplementary data. Questioning a person who has good knowledge of the recent history of the patient is preferable. The physical exam should be repeated at least daily, in a sequential fashion, and documented systematically.
Paige is a nurse preceptor who is working with a new nurse, Joyce. She notes that Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is most likely due to:
- A. Role modeling behaviors of the preceptor
- B. The philosophy of the new nurse’s school of nursing
- C. The orientation provided to the new nurse
- D. Lack of trust in the members of the healthcare team
Correct Answer: D. Lack of trust in the members of the healthcare team.
Lack of trust is the common reason for reluctance in a delegation of tasks. Some managers don’t delegate because they feel they can work better than others. Since ultimate responsibility is of the delegator, they prefer doing the work themselves rather than getting it done through others.
- Option A: Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences.
- Option B: Staff members differ in terms of their knowledge, skills, abilities and competencies. A staff member who has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill and competency as an experienced nursing assistant or registered nurse.
- Option C: Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so.
Nurse Paul is developing a care plan for a client after bariatric surgery for morbid obesity. The nurse should include which of the following on the care plan as the priority complication to prevent:
- A. Pain
- B. Wound infection
- C. Depression
- D. Thrombophlebitis
Correct Answer: B. Wound infection
Wound infection is the most common complication among obese clients who had undergone surgery. This is due to their poor blood supply in their adipose tissues. From a surgical standpoint, obesity is associated with a multitude of complications including impairments of cutaneous wound healing, total wound failure, and fascial dehiscence.
- Option A: A 2006 study of post bariatric patients found that over the ensuing six months after surgery, complication rates actually approached 40 percent. These complications included abdominal pain, nutritional deficiencies, endocrine or metabolic disorders, gastrointestinal disorders, and wound compromise.
- Option C: After bariatric surgery, improvements are significant in disease processes involving endocrine (diabetes), cardiovascular (hypertension, hyperlipidemia, and coronary artery disease), rheumatic, and hypercoagulation disorders (deep vein thrombosis and pulmonary embolism). Reductions in the severity of symptoms relating to sleep apnea and depression have also been observed.
- Option D: Compared with nonobese surgical patients, obese patients have an increased incidence of surgical complications, including atelectasis, thrombophlebitis, mortality, wound infection, and wound separation.
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes the following assessment cues: pale, diaphoretic, blood pressure of 90/60, respirations of 33. The client is also anxious and fearing death. Which action should the nurse take first?
- A. Administer pain medications
- B. Administer IV fluids
- C. Administer dopamine
- D. Administer oxygen via nasal cannula
Correct Answer: D. Administer oxygen via nasal cannula.
The promotion of adequate oxygenation is the most vital to life and therefore should be given the highest priority by the nurse. When the nurse needs to prioritize patients, Maslow’s hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow’s hierarchy of needs is airway, breathing, and circulation (ABC), which are physiological elements that are needed for the body to survive and help determine one’s level of health.
- Option A: The 2nd priority needs include MAAUAR which is mental status, acute pain, acute impaired urinary elimination, unresolved and unaddressed needs, abnormal diagnostic test results, and risks. The 3rd level priorities include all concerns and problems addressed with the 2nd level priority needs.
- Option B: Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority. Administering IV fluids belong in Maslow’s physical and biological needs, but still after airway.
- Option C: Dopamine (DA) is a peripheral vaso stimulant used to treat low blood pressure, low heart rate, and cardiac arrest, especially in acute neonatal cases via a continuous intravenous drip. For stimulation of the sympathetic nervous system, the indication is for a continuous intravenous drip administration.
Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?
- A. Call for a social worker to meet with the family.
- B. Check the child’s blood pressure, pulse, respiration, and temperature.
- C. Administer pain medications
- D. Speak with the parents about how the fracture occurred.
Correct Answer: D. Speak with the parents about how the fracture occurred.
In case of injury, especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse. The first step in any child protection response system is the identification of possible incidents of child maltreatment. Medical personnel, educators, childcare providers, mental health professionals, law enforcement personnel, the clergy, and other professionals are often in a position to observe and/or screen families and children to identify abuse or neglect when it occurs.
- Option A: An initial assessment or investigation is conducted on reports that are screened in during the intake process to identify whether the maltreatment can be substantiated. In addition to child protective services and law enforcement, other professionals such as medical and mental health personnel, teachers and childcare providers, and foster care or residential staff may play a role in the initial assessment.
- Option B: After initial screening for child abuse, the nurse may take the patient’s vital signs. State laws provide guidance to child protective services (CPS) agencies regarding identifying and reporting suspected child maltreatment, investigating to determine whether abuse occurred, and providing necessary services for children and youth and their families.
- Option C: Administering pain medications can be done after assessing the patient’s vital signs. Ibuprofen worked at least as well as acetaminophen with codeine for fracture pain control, and had fewer adverse effects. Children given ibuprofen were better able to eat and play than those given acetaminophen with codeine—an important patient-oriented functional outcome.
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
- A. A client scheduled for cardiac ultrasound this morning.
- B. A client with syncope being discharged today.
- C. A client with chronic bronchitis on nasal oxygen.
- D. A client with diabetic foot ulcer that needs a dressing change.
Correct Answer: C. A client with chronic bronchitis on nasal oxygen.
A client with airway problems should be attended first. When the nurse needs to prioritize patients, Maslow’s hierarchy of needs theory is used to decide which patient is to be seen first. A part of Maslow’s hierarchy of needs is airway, breathing, and circulation (ABC),which are physiological elements that are needed for the body to survive and help determine one’s level of health. Observing ABCs is a rapid assessment of life-threatening conditions in order of priority.
- Option A: Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical career to direct patient care and determine priorities. Analysis (interpreting what is going on with the patient through reviewing lab work, diagnostic testing, patient history, complaints and observations) comes after assessment.
- Option B: The client who was discharged today is not a priority because he is stable enough to be sent home. Maslow’s Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.
- Option D: The client needing a dressing change for her pressure ulcer belongs to Maslow’s physical and biological needs. Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?
- A. Determine the level of consciousness
- B. Push the call button for help
- C. Turn the client face up to assess
- D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician
Correct Answer: A. Determine the level of consciousness.
Assessing the level of consciousness should be the first action when dealing with clients that might have fallen over. The initial step is to evaluate for reactivity using objective measures. Address the patient verbally, progress to light shaking, then progress to more intense mechanical stimulation.
- Option B: After establishing the client’s ABCs, the nurse may call for help. The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing airway patency and breathing pattern.
- Option C: Refrain from moving the patient until a physician comes into the scene and assesses the overall condition. For patients with a pulse, who are breathing adequately, the evaluation shifts to a detailed neurological examination. The neurologic examination would serve to determine the location and nature of the neurological lesion and to determine prognosis.
- Option D: Do not leave the patient. A systematic evaluation of the unconscious patient is recommended. Because many cases of unconsciousness are reversible, the management of unconscious patients necessitates thorough history-taking, patient evaluation, stabilizing treatment, and diagnostic testing occurring simultaneously.
Nurse Adonai is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?
- A. Ask the other nurse if she needs help
- B. Assess the client and let the other nurse know what should be done
- C. Ask the client if he is satisfied with his care
- D. Contact the nursing supervisor to address the situation
Answer: D. Contact the nursing supervisor to address the situation
The nurse should use a proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team. Assessment and treatment of pain is often complex. The standard definition of pain is “whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffery, 1968, p. 65).
- Option A: Current health care requires effective collaboration among providers. Poor communication may lead to poor patient outcomes. Although emphasis has been placed on interprofessional communication (particularly between physicians and nurses) in the health system, little has been written about problems in communication within the medical profession.
- Option B: The problem of variability in clinical judgment occurs in virtually all medical fields. The type of workplace and the opportunity to discuss and receive advice about interpersonal issues appear to be important in dealing with some difficulties (e.g., overcoming misunderstandings).
- Option C: Patient feedback is an important source of information that should help staff implement changes that will improve care quality and patient safety. According to the NHS Confederation (2010), in some trusts, there have been “unspoken but widely held beliefs” that providing good patient experiences is “nice but not necessary” or “nice but too expensive”.
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client?
- A. Hepatitis A vaccine
- B. Lyme’s disease vaccine
- C. Hepatitis B vaccine
- D. Pneumococcal vaccine
Correct Answer: D. Pneumococcal vaccine
Pneumococcal vaccine is a priority immunization amongst the elderly, especially those with chronic illnesses. It is administered every five (5) years. A pneumococcal vaccine, PPSV23, is indicated in the United States for all adults 65 years of age and older, as well as younger patients with conditions that increase the risk for developing pneumococcal pneumonia or invasive pneumococcal disease.
- Option A: Hepatitis A vaccine is given to at-risk individuals to prevent infection from the hepatitis A virus (HAV). The Advisory Committee on Immunization Practices (ACIP)’s recommendations are to provide routine immunization for children aged 12 to 13 months for persons at high risk of having hepatitis A infection and or persons who wish to have immunity.
- Option B: Lyme disease, which is caused by the spirochetal agent Borrelia burgdorferi, is the most common vector-borne illness in the United States. In 1998, the US Food and Drug Administration approved a recombinant Lyme disease vaccine that was later voluntarily withdrawn from the market by the manufacturer.
- Option C: Hepatitis B vaccination is indicated to prevent active infection with the hepatitis B virus, which can lead to chronic liver failure and hepatocellular carcinoma. In addition to all infants and any yet unvaccinated children, the Advisory Committee on Immunization Practices recommends primarily vaccinating any adults who may have a higher risk for contracting or complication from hepatitis B.
You are admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism?
- A. The patient was recently in a motor vehicle accident
- B. The patient participated in an aerobic exercise program for 6 months
- C. The patient gave birth to her youngest child 1 year ago
- D. The patient was on bed rest for 6 hours after a diagnostic procedure
Correct Answer: A. The patient was recently in a motor vehicle accident
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolism. PE remains relatively common after trauma and occurs in the absence of lower extremity or spinal fractures. Although PE is usually thought to occur between days 5 and 7 after injury, data suggest that as many as 37% of pulmonary emboli occur early.
- Option B: The better the circulation is, the lower the chance of blood pooling up and clotting. Clotting is often caused by long periods of inactivity, so practicing a regular exercise routine can help reduce the risk of clots and other conditions related to blood clots, such as diabetes and obesity.
- Option C: Pulmonary embolisms (PE) typically occur during or shortly after the labor and delivery, and may be fatal for the mother if not treated immediately. The client gave birth a year ago, therefore eliminating the risk for pulmonary embolism.
- Option D: None of the other findings are risk factors for pulmonary embolism. Prolonged immobilization is also a risk factor for DVT and pulmonary embolism, but this period of bed rest was very short.
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
- A. Assessing the patient’s respiratory status every 4 hours
- B. Taking vital signs and pulse oximetry readings every 4 hours
- C. Checking the ventilator settings to make sure they are as prescribed
- D. Observing whether the patient’s tube needs suctioning every 2 hours
Correct Answer: B. Taking vital signs and pulse oximetry readings every 4 hours
The nursing assistant’s educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option A: Delegation should be done according to the differentiated practice for each of the staff members. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill.
- Option C: Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN. The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
- Option D: Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.
You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
- A. Administer ordered antibiotics as scheduled
- B. Hyperoxygenate the patient before suctioning
- C. Maintain the head of the bed at a 30 to a 45-degree angle
- D. Suction the airway when coarse crackles are audible
Correct Answer: C. Maintain the head of the bed at a 30 to a 45-degree angle
Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging early mobility of mechanically ventilated patients aid in the prevention of VAP.
- Option A: To reduce risk for VAP, the following nurse-led evidence-based practices are recommended: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suctioning, promote early mobility, and advocate for adequate nurse staffing and a healthy work environment.
- Option B: Aspiration of secretions that accumulate around the endotracheal tube of mechanically ventilated patients can lead to VAP. Subglottic secretion suctioning can be performed by both the nurse and respiratory therapist and can aid in prevention.
- Option D: A recent meta-analysis of 20 RCTs found that subglottic suctioning reduced the risk for VAP by 45% compared to patients who didn’t receive suctioning. Coordinating subglottic suctioning when conducting oral care may be a good mechanism to cluster care and ensure both of these practices are routinely delivered.
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.
Correct Answer: B. The patient’s respiratory rate is 8 breaths/min.
For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient’s oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest.
- Option A: The rest of the examination may range from prolonged expiration or wheezes on forced exhalation to increased resonance, indicating hyperinflation as the airway obstruction increases. Distant breath sounds, wheezes, crackles at the lung bases, and/or distant heart sounds are heard on auscultation.
- Option C: Patients with emphysema are typically referred to as “pink puffers,” meaning cachectic and non-cyanotic. Expiration through pursed lips increases airway pressure and prevents airway collapse during respiration, and the use of accessory muscles of respiration indicates advanced disease.
- Option D: A chest x-ray is only helpful in diagnosis if emphysema is severe, but it is usually the first step when suspecting COPD to rule out other causes. Destruction of alveoli and air trapping causes hyperinflation of the lungs with flattening of the diaphragm, and the heart appears elongated and tubular in shape.
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
- A. Teaching the patient about the importance of adequate fluid intake and hydration.
- B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed.
- C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake.
- D. Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
Correct Answer: C. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
A nursing assistant can remind the patient to perform actions that are already part of the plan of care. The right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe and competent manner.
- Option A: Teaching patients about adequate fluid intake requires additional education and skill and is within the scope of practice of the RN. Among the tasks that cannot be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.
- Option B: Assisting the patient in the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic nursing assistant. However, an experienced nursing assistant could assist the patient with positioning after the nursing assistant and the patient had been taught the proper technique. The nursing assistant would still be under the supervision of the RN.
- Option D: Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs.
You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
- A. The patient says that her right leg aches all night
- B. The right calf is warm to the touch and is larger than the left calf
- C. The patient is unable to remember her husband’s first name
- D. There are multiple ecchymotic areas on the patient’s arms
Correct Answer: C. The patient is unable to remember her husband’s first name
Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. Because of the reduced effectiveness of the antidote (e.g., protamine), bleeding complications can be severe and life-threatening.
- Option A: The right leg symptoms are consistent with a resolving deep vein thrombosis. Around half of people who have had a DVT will experience some degree of chronic discomfort and around 15% of people will experience moderate to severe chronic pain and swelling. This is called post-thrombotic syndrome (PTS) and is caused partly by damage or leftover scar tissue inside the vein.
- Option B: The patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The client may also wear graduated compression stockings. These specially fitted stockings are tight at the feet and become gradually loosened up on the leg, creating gentle pressure that keeps blood from pooling and clotting.
- Option D: The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the physician needs to be called.
You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? Select all that apply.
- A. Avoid potential environmental asthma triggers such as smoke.
- B. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
- C. Wash all bedding in cold water to reduce and destroy dust mites.
- D. Be sure to get at least 8 hours of rest and sleep every night.
- E. Avoid foods prepared with monosodium glutamate (MSG).
Correct Answer: A, B, D, and E.
Asthma comprises a range of diseases and has a variety of heterogeneous phenotypes. The recognized factors that are associated with asthma are a genetic predisposition, specifically a personal or family history of atopy (propensity to allergy, usually seen as eczema, hay fever, and asthma).
- Option A: Environmental control is vital if one wants to avoid recurrent attacks. Allergen avoidance can significantly improve the quality of life. This means avoiding tobacco, dust mites, animals, and pollen.
- Option B: Medical management includes bronchodilators like beta-2 agonists and muscarinic antagonists (salbutamol and ipratropium bromide respectively) and anti-inflammatories such as inhaled steroids (usually beclomethasone but steroids via any route will be helpful).
- Option C: Bedding should be washed in hot water to destroy dust mites. Put bed sheets, pillows cases, clothes, curtains, drapes, and other washable fabrics through a wash setting between 130° and 140°F (54° to 60°C) in order to kill them and remove their fecal matter and skin particles.
- Option D: Whether it’s due to the symptoms of asthma or just staying up too late, missing sleep can make asthma worse. Sleep loss promotes inflammation in the body and affects lung function, increasing the chances of an asthma attack.
- Option E: Foods that contain high concentrations of MSG include stock cubes, gravy, soy sauce and packet soups. Hydrolyzed vegetable protein is sometimes added to foods in place of MSG, and may trigger asthma in people who are sensitive to MSG.
You are providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal CPAP ventilation. What complications should you monitor for this infant?
- A. Pulmonary embolism
- B. Bronchitis
- C. Pneumothorax
- D. Pneumonia
Correct Answer: C. Pneumothorax
The most common complications after birth for infants with RDS is pneumothorax. Alveoli rupture and air leaks into the chest and compresses the lungs, which makes breathing difficult. Pulmonary air leak syndromes such as pneumothorax and pneumomediastinum may also present as respiratory distress, but the onset of symptoms may be more acute.
- Option A: Complications of neonatal respiratory distress syndrome are related mainly to the clinical course of RDS in neonates and the long term outcomes of the neonates. While surfactant therapy has decreased the morbidity associated with RDS, many patients continue to have complications during and after the acute course of RDS.
- Option B: Acute complications due to positive pressure ventilation or invasive mechanical ventilation include air-leak syndromes such as pneumothorax, pneumomediastinum, and pulmonary interstitial emphysema. There is also an increase in the incidence of intracranial hemorrhage and patent ductus arteriosus in very low birth weight infants with RDS, although independently linked to prematurity itself.
- Option D: BPD is a chronic complication of RDS. The pathophysiology of BPD involves both arrested lung development as well as lung injury and inflammation. Besides a surfactant deficiency, the immature lung of the premature infant has decreased compliance, decreased fluid clearance, and immature vascular development, which predisposes the lung to injury and inflammation, further disrupting the normal development of alveoli and pulmonary vasculature.
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given a nursing diagnosis of Activity Intolerance. Which action should you delegate to the nursing assistant?
- A. Instructing the patient to alternate rest and activity periods
- B. Encouraging, monitoring, and recording nutritional intake
- C. Monitoring cardiorespiratory response to activity
- D. Planning activities for periods when the patient has the most energy
Correct Answer: B. Encouraging, monitoring, and recording nutritional intake
The nursing assistant’s training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the nursing assistant can remind and encourage the patient to take-in adequate nutrition.
- Option A: Instructing patients requires more education and skill, and are appropriate to the RN’s scope of practice. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN.
- Option C: Monitoring the patient’s cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN’s scope of practice.
- Option D: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
You are supervising a nursing student who is providing care for a patient with thoracotomy with a chest tube. What findings would you clearly instruct the nursing student to notify you about immediately?
- A. Chest tube drainage of 10 to 15 mL/hr.
- B. Continuous bubbling in the water seal chamber.
- C. Complaints of pain at the chest tube site.
- D. Chest tube dressing dated yesterday.
Correct Answer: B. Continuous bubbling in the water seal chamber
Continuous bubbling indicates an air leak that must be identified. With the physician’s order you can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require you to notify the physician. If the air bubbling does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system, and you must assess the system carefully to locate the leak.
- Option A: Chest tube drainage of 10 to 15 mL/hr is acceptable. Alert physician if drainage greater than 100 mL per hour in an adult and 3 mL/Kg/hour in a 3 hour period or 5 to 10 mL/Kg in any 1 hour period in pediatric patients.
- Option C: The patient’s complaints of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak. Severe pain during chest drain therapy significantly influences the well being of the patient and leads to severe pathophysiological disorders. Early mobilization, sufficient coughing to mobilize secretions, and effective deep breathing are only possible with adequate pain management.
- Option D: Chest tube dressings are not changed daily but may be reinforced. In adults, chest tube dressing should be changed every other day and prn. In pediatric patients, if it is an uncomplicated chest tube insertion site, the dressing should be left as is until it is soiled or lifting. Changed ONLY when necessary and with a physician present.
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
- A. Suctioning the tracheostomy tube before performing tracheostomy care
- B. Removing old dressings and cleaning off excess secretions
- C. Removing the inner cannula and cleaning using universal precautions
- D. Replacing the inner cannula and cleaning the stoma site.
- E. Changing the soiled tracheostomy ties and securing the tube in place.
Correct Answer: C. Removing the inner cannula and cleaning using universal precautions
When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.
- Option A: Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment. It is recommended that the episode of suctioning (including passing the catheter and suctioning the tracheostomy tube) is completed within 5-10 seconds.
- Option B: The tracheal stoma in the immediate post-operative period requires regular assessment and wound management including once daily dressing change following cleaning of the stoma area or more frequently if required.
- Option D: Care of the stoma is commenced in the immediate postoperative period, and is ongoing. Clean stoma with cotton wool applicator sticks moistened with 0.9% sodium chloride. Use each cotton wool applicator stick once only taking it from one side of the stoma opening to the other and then discard in waste.
- Option E: The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation. This can vary depending on the patient’s individual needs and tracheostomy tube type. It is imperative that the first tracheostomy tube change is performed with both nursing and medical staff who are competent in tracheostomy management and the tracheostomy kit is available at the bedside.
You are supervising an RN who was pulled from the medical-surgical floor to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which of these directions would you clearly prove to the RN? Select all that apply.
- A. Position the patient supine and turn on his side.
- B. Apply direct lateral pressure to the nose for 5 minutes.
- C. Maintain universal body substances precautions.
- D. Apply ice or cool compresses to the nose.
- E. Instruct the patient not to blow the nose for several hours.
Correct Answers: B, C, D, and E.
Epistaxis (nasal bleeding) is relatively common but rarely fatal. Anterior bleeding is usually managed by digital pressure, gentle chemical cauterization, or nasal packing. Posterior bleeding, which is less common, is characterized by massive bleeding that’s initially bilateral; this bleeding may be more difficult to control.
- Option A: Have the patient sit upright with her head tilted forward, and instruct her to apply direct external digital pressure to the nares with her index finger and thumb. The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and avoid aspiration. All of the other instructions are appropriate according to best practice for emergency care of a patient with an anterior nosebleed.
- Option B: Tell her to breathe through her mouth while she holds firm pressure on the soft flesh of her nose for at least 10 minutes. If bleeding persists, cotton pledgets soaked in a vasoconstrictor and anesthetic will be placed in the anterior nasal cavity, and direct pressure should be applied at both sides of the nose.
- Option C: Put on protective gear, including gown, gloves, and face shields. Provide an emesis basin and tissues. Tell her to spit blood into the basin if necessary. This helps prevent nausea and vomiting and lets you estimate the amount of bleeding.
- Option D: Cooling the nape of the neck is said to induce reflex constriction of the mucosal vessels of the nose, but there is no general agreement in the literature on the benefit of an ice pack as an adjuvant treatment of epistaxis.
- Option E: The nasal packing will be left in place for 3 to 5 days. Instruct the patient to avoid exerting herself, forcefully blowing her nose, or bending over. She should also avoid NSAIDs, alcoholic beverages, and smoking for 5 to 7 days. Tell her to apply water-soluble ointment to her lips and nostrils while packing is in place and to use a cool-mist room humidifier. Advise her to take steps to prevent constipation and straining, which increases the risk of bleeding.
You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
- A. Assessing for bilateral breath sounds and symmetrical chest movements.
- B. Auscultating over the stomach to rule out esophageal intubation.
- C. Marking the tube 1 cm from where it touches the incisor tooth or nares.
- D. Ordering a chest radiograph to verify that tube placement is correct.
Correct Answer: C. Marking the tube 1 cm from where it touches the incisor tooth or nares
The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. If the patient has an endotracheal tube, check for tube slippage into the right mainstem bronchus, as well as inadvertent extubation.
- Option A: Auscultate over the epigastrium to assess for the absence of sounds in the stomach. The presence of an enlarging abdomen or audible air inflation into the stomach with each positive-pressure ventilation may be the initial sign of an ET tube in the esophagus or an esophageal intubation.
- Option B: Since the advent of ET intubation, the use of physical examination methods has been the mainstay for the initial evaluation of proper ET tube placement. Direct visualization of the insertion of the ET tube through the vocal cords and into the trachea is the first method to confirm proper ET tube placement.
- Option D: A chest X-ray is often acquired following placement of an endotracheal tube (ET tube) to determine the position of its tip. The priority at this time is to verify that the tube has been correctly placed. The trachea, carina and main bronchi are almost always identifiable on a chest X-ray image, as long as the image is viewed on a high quality screen in a darkened room.
You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
- A. The patient starts crying and says she can’t go on with treatment much longer.
- B. The patient complains of sharp, stabbing chest pain with every deep breath.
- C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min.
- D. The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage.
Correct Answer: C. The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this.
- Option A: A large build up of fluid can make it hard to breathe. Removing some fluid may make the person more comfortable. To remove this fluid for evaluation (testing) or improve a patient’s breathing, a procedure called a thoracentesis is done.
- Option B: Discomfort can result from the needle at the time it is inserted. Doctors try to lessen any pain or discomfort by giving a local numbing medicine (local anesthetic). The discomfort is usually mild and goes away once the needle or tube is removed.
- Option D: During insertion of the needle, a blood vessel in the skin or chest wall may be accidentally nicked. Bleeding is usually minor and stops on its own. Sometimes, bleeding can cause a bruise on the chest wall.
You have obtained the following assessment information about a 3-year old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?
- A. Frequent swallowing
- B. Hypotonic bowel sounds
- C. Complaints of a sore throat
- D. Heart rate of 112 beats/min
Correct Answer: A. Frequent swallowing
Frequent swallowing after a tonsillectomy may indicate bleeding. You should inspect the back of the throat for evidence of bleeding. The other assessment results are not unusual in a 3-year old after surgery.
- Option B: Hypoactive bowel sounds are normal during sleep. They also occur normally for a short time after the use of certain medicines and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation.
- Option C: It is common for the child to have a temporary sore throat for about 2-3 weeks after getting tonsils and adenoids removed. The pain will be most severe for the first week after surgery and will usually be gone in 2-3 weeks
- Option D: No strenuous exercise or activity – running, jumping, swimming or playing sports – until the child’s throat is fully healed. Anything that increases the child’s heart rate or blood pressure can increase the risk of bleeding. If this occurs, it may require another surgery to stop the bleeding.
Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #3 (25 Items)
After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention and those with less serious conditions.
- 1. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown.
- 2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job.
- 3. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis.
- 4. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue.
The correct order is shown above
- The abandoned person has symptoms of heat stroke, a medical emergency, which heightens the risk of brain damage. The sequelae of the insult may persist beyond the initial CNS dysfunction, involving injury to the gut, kidney, skeletal muscle, or other organ systems.
- The elderly traffic enforcer is at risk for heat syncope and should be instructed to relax in a cool environment and withdraw from approaching related circumstances. It represents a temporary, self-limited dizziness, weakness, or loss of consciousness during prolonged standing or positional changes in a hot environment, including physical activity.
- The sportsman is experiencing heat cramps, which can be treated with rest and fluids. This condition is due to a relative deficiency of sodium, potassium, chloride, or magnesium. Other symptoms may include nausea, vomiting, fatigue, weakness, sweating, and tachycardia.
- The homemaker is having heat exhaustion and management includes IV or oral fluids and settling in a cool area. External temperatures may be more moderate if associated with intense physical exertion. Survey-based data has shown that some of the most common symptoms are headache, exhaustion, or a combination of symptoms.
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 nursing assistant?
- A. Aiding with oral intubation
- B. Performing chest compressions
- C. Placing the defibrillator pads
- D. Starting bag valve mask ventilation
Correct Answer: B. Performing chest compressions
Basic cardiac life support is learned by nursing assistants so they can perform chest compressions. Certified nursing assistants deal directly with the patients so they must be cardiopulmonary resuscitation certified. It is the nursing assistant who witnesses the victims of cardiac arrests and becomes an immediate responder. A trained certified assistant can easily cater the instantaneous needs of the patient.
- Option A: The nurse or the respiratory therapist should provide assistance as needed during intubation. Assisting with tracheal intubation is an aspect of clinical practice that requires knowledge and skill if the procedure is to be carried out in a timely and safe manner.
- Option C: The defibrillator pads are accurately labeled; nevertheless, the responsibility of placing them should be done by the RN or physician because of the potential for skin damage and electrical arcing.
- Option D: The use of the bag valve mask demands practice, and normally, a respiratory therapist will implement this measure. If bag-valve-mask ventilation is used for a prolonged period of time or if improperly performed, air may be introduced into the stomach. If this occurs and gastric distention is noted, a nasogastric tube should be inserted to evacuate the accumulated air in the stomach.
A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are saying, “We were running around outside the school and he got hit in the abdomen with a stick!” Which statement should be a priority?
- A. “The stick was absolutely filthy and muddy.”
- B. “He has a family history of diabetes, so he requires attention right now.”
- C. “He pulled the stick out because it was too painful for him.”
- D. “There was plenty of blood so we used three gauzes.”
Correct Answer: C. “He pulled the stick out because it was too painful for him.”
An impaled object may be giving a tamponade effect, and removal can result in abrupt hemodynamic decompensation. Surgery is often required; impaled objects are secured in place so that they do not move and they should only be removed in an operating room.
- Option A: Penetrating trauma often causes damage to internal organs resulting in shock and infection. The severity depends on the body organs involved, the characteristics of the object, and the amount of energy transmitted.
- Option B: Information such as the dirt on the stick or history of diabetes, is significant in the overall treatment plan but can be addressed next. The indications for surgical intervention include a patient with hemodynamic instability, development of peritoneal findings such as involuntary guarding, point tenderness or rebound tenderness, and diffuse abdominal pain that does not resolve.
- Option D: Additional history including a more precise extent of blood loss, depth of penetration, and medical history should be collected. If the pancreas is injured, further injury occurs from autodigestion. Injuries of the liver often present in shock because the liver tissue has a large blood supply.
A mother is so worried that her son took an unknown amount of children’s chewable vitamins at an unknown time. While in the ED, the child is alert and asymptomatic. What information should be directly stated to the physician?
- A. The child was nauseated and vomited before arriving in the ED.
- B. The child has been managed multiple times for unexpected injuries.
- C. The child has been treated many times for the ingestion of toxic substances.
- D. The ingested children’s chewable vitamins contain iron.
Correct Answer: D. The ingested children’s chewable vitamins contain iron.
Iron is a toxic substance that can lead to severe bleeding, shock, hepatic failure, and coma. The antidote that can be used for severe cases of iron poisoning is deferoxamine. Iron poisoning is one of the most common toxic ingestion and one of the most deadly among children. Failure to diagnose and treat iron poisoning can have serious consequences including multi-organ failure and death.
- Option A: During the first stage (0.5 to 6 hours), the patient mainly exhibits gastrointestinal (GI) symptoms including abdominal pain, vomiting, diarrhea, hematemesis, and hematochezia. The second stage (6 to 24 hours) represents an apparent recovery phase, as the patient’s GI symptoms may resolve despite toxic amounts of iron absorption.
- Option B: This information needs further investigation but will not change the immediate diagnostic testing or treatment plan. Patients who have GI symptoms that resolve after a short period of time and have normal vital signs require supportive care and an observation period, as it may represent the second stage of iron toxicity.
- Option C: Patients who are symptomatic or demonstrate signs of hemodynamic instability require aggressive management and admission to an intensive care unit. Deferoxamine, a chelating agent that can remove iron from tissues and free iron from plasma, is indicated in patients with systemic toxicity, metabolic acidosis, worsening symptoms, or a serum iron level predictive of moderate or severe toxicity.
Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition.
- 1. A 68-year-old man with a pulsating abdominal mass and sudden onset of “tearing” pain in the abdomen and flank within the past hour.
- 2. A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant.
- 3. A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days.
- 4. A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week.
- 5. A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal.
- 6. A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night.
The correct order is shown above.
- The 68-year-old man with pulsating mass is experiencing abdominal aneurysm that may rupture, and he may abruptly deteriorate. Rupture of an abdominal aortic aneurysm is life-threatening. These patients may present in shock often with diffuse abdominal pain and distension. Most patients with a ruptured abdominal aortic aneurysm die before hospital arrival.
- The 25-year-old woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition.
- The 12-year-old girl needs evaluation to rule out appendicitis. Appendicitis is an acute inflammatory process involving the appendix. It is the number one surgical emergency and one of the most common causes of abdominal pain, particularly in children.
- The 42-year-old woman with vomiting needs evaluation for gallbladder problem, which seems to be worsening. Occlusion of the cystic duct or malfunction of the mechanics of gallbladder emptying is the pathophysiology of this disease. Cases of acute untreated cholecystitis could lead to perforation of the gallbladder, sepsis, and death.
- The 38-year-old man has food poisoning, which is usually self-limiting. Most food-borne illnesses are mild and improve without any specific treatment. Some patients have severe disease and require hospitalization, aggressive hydration, and antibiotic treatment.
- The 53-year-old man with mid-epigastric pain may have ulcer, but followup diagnostic testing and educating lifestyle modification can be scheduled with the primary health care provider. It is important to understand this disease process is both preventable and treatable. Patients may be treated differently depending on the etiology of their gastric ulcer.
The newly hired nurse is in his first week on the job in the ED. He used to be a traveling nurse for 5 years. Which area in his present job is the most appropriate assignment for him?
- A. Fast-track clinic
- B. Pediatric medicine team
- C. Trauma team
- D. Triage
Correct Answer: A. Fast-track clinic
The ambulatory or fast-track clinic deals with relatively stable clients. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.
- Option B: Few places are more hectic than a pediatric ward. Clearly, delegating important nursing tasks is the only plausible way for short-staffed emergency rooms to meet the challenges of providing quality patient care. All decisions related to delegation and assignment are based on the fundamental principles of protection of the health, safety, and welfare of the public.
- Option C: This area should be filled with nurses who are experienced with hospital routines and policies and have the ability to locate equipment immediately. There is both individual accountability and organizational accountability for delegation. Organizational accountability for delegation relates to providing sufficient resources, including sufficient staffing with an appropriate staff mix.
- Option D: The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.
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
Correct Answer: C. A deviated trachea
A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not managed. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and if the patient has a pulse.
- Option A: Assessment of circulation comes after the airway. The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need any immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?
- Option B: Ecchymosis can be a sign of internal bleeding, which belongs to assessment of circulation. If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.
- Option D: Anisocoria due to trauma may remain permanent but also may improve over time. Surgical management is rarely warranted. A referral to a neuro-ophthalmologist, ophthalmologist, or neurologist may be warranted in cases that do not resolve.
Several people were killed and injured in a recent industrial explosion. The victims are being interviewed and assessed by the nurses for possible psychiatric crises. Which client has the greatest risk for posttraumatic stress disorder?
- A. An individual who was injured and trapped for 8 hours before rescue.
- B. A person who saw the death of a co-worker during the blast.
- C. An individual who recently discovered that her daughter was killed in the incident.
- D. A person who repeatedly watched television coverage of the event.
Correct Answer: A. An individual who was injured and trapped for 8 hours before rescue
Any of these victims may need or require psychiatric counseling. There will be changes in previous coping skills and support groups; nevertheless, the individual who encounters a threat to his or her own life is at the greatest chance of having psychiatric difficulties following a disaster incident.
- Option B: It is important to remember that not everyone who lives through a dangerous event develops PTSD. In fact, most people will not develop the disorder. Not everyone with PTSD has been through a dangerous event. Some people develop PTSD after a friend or family member experiences danger or harm.
- Option C: Many factors play a part in whether a person will develop PTSD. Some examples are listed below. Risk factors make a person more likely to develop PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder.
- Option D: Anyone can develop PTSD at any age. This includes war veterans, children, and people who have been through a physical or sexual assault, abuse, accident, disaster, or other serious events.
When several areas of a daycare center collapsed due to an earthquake, children, especially injured ones, were brought to the ED. As a competent nurse, you know that children will be more predisposed to which of the following? Select all that apply.
- A. Bradycardia
- B. Fracture of the long bones
- C. Head trauma
- D. Hypothermia
- E. Hypoxemia
- F. Junctional arrhythmias
- G. Liver and spleen contusions
- H. Lumbar spine injuries
Correct Answer: C, D, E, and G
Children will be more prone to head trauma, hypothermia, hypoxemia, and liver and spleen injuries.
- Option A: Children have strong hearts; hence pulse rate will increase to compensate. A fast heart rate in children in most situations is a normal response to increased levels of activity or, occasionally, anxiety.
- Option B: They have almost flexible bones compared with those adults. A child’s bones are more flexible because their chemical composition is different from that of adult bones. This means a kid’s bone might bend or “bow” instead of breaking.
- Option C: They have proportionately larger heads that predispose them to head injuries or trauma. When one looks at an average growth chart for a child who has reached the age of 18, it can be seen that the steepest curve is from 0 to 2 years of age. From the ages of two to 18, a child experiences more growth in the size of their head, reaching its full size at anywhere from 54 to 60 cm.
- Option D: Hypothermia is more likely due to their thinner skin and proportionately larger body surface area. Newborns, infants, and young children are more likely to develop hypothermia because they have a larger surface area compared to body weight so they can lose body heat faster than older children and adults.
- Option E: Hypoxemia is more likely because of their higher oxygen demand. Neonates, infants, and children are at increased risk of hypoxemia because of smaller functional residual capacities, increased heart rates, and increased metabolic requirements compared with adults.
- Option F: Other arrhythmias are less likely to occur. In most cases an irregular heartbeat is abnormal. The most common cause of an irregular heartbeat in children is isolated premature beats. Both premature atrial contractions and premature ventricular contractions are relatively common in children. Fortunately, in many instances these can be completely benign.
- Option G: Liver and spleen injuries are more likely due to the thoracic cage of children giving less protection. The liver, spleen, and pancreas lie in the upper abdomen. They are partly protected by the ribs. This protection is less effective in children than in adults because the ribs are very pliable and because the liver and spleen may extend caudally beyond the ribs, especially in infants and toddlers. In addition, children have relatively larger viscera, less overlying fat, and weaker abdominal musculature.
- Option H: Injury to the cervical area is the most likely spinal injury in children. Majority of the pediatric cervical spine injuries (CSIs) occur between the skull and C4 vertebra; and around 10.8% to 38.7% of these injuries involve C1 and C2 vertebrae. Children suffer from atlanto-axial injuries 2.5 times more often than adults.
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed?
- A. Taking a full set of vital sign measurements.
- B. Completing a brief neurologic assessment.
- C. Monitoring pulse oximetry reading.
- D. Palpating and auscultating the abdomen.
Correct Answer: B. Completing a brief neurological assessment
A brief neurologic assessment to ascertain level of consciousness and pupil reaction is part of the primary survey. Once the patient is stabilized, a neurologic examination should be conducted. CT scan is the diagnostic modality of choice in the initial evaluation of patients with head trauma.
- Option A: Vital signs are considered part of the secondary survey. Avoid hypotension. Normal blood pressure may not be adequate to maintain adequate flow and CPP if ICP is elevated. Isolated head trauma usually does not cause hypotension. Look for another cause if the patient is in shock.
- Option C: Identify any condition which might compromise the airway, such as pneumothorax. The cervical spine should be maintained in-line during intubation. Nasotracheal intubation should be avoided in patients with facial trauma or basilar skull fracture.
- Option D: Assessment of abdomen is basically part of the secondary survey. The secondary survey is a rapid but thorough head to toe examination assessment to identify potential injuries. It should be performed after the primary survey and the initial stabilization is complete.
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
Correct Answer: B. Allow the student to breathe into a paper bag
The student is hyperventilating secondary to anxiety, and breathing into a paper bag will provide rebreathing of carbon dioxide. Encouraging slow breathing will also help. The idea behind breathing into a paper bag or mask is that rebreathing exhaled air helps the body put CO2 back into the blood.
- Option A: Acute anxiety may require treatment with a benzodiazepine. Chronic anxiety treatment consists of psychotherapy, pharmacotherapy, or a combination of both. Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.
- Option C: Report it to the physician once there is a recurrence or the breathing did not improve. Anxiety is one of the most common psychiatric disorders but the true prevalence is not known as many people do not seek help or clinicians fail to make the diagnosis. Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%.
- Option D: Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders.
The nurse is assigned to a small rural community hospital. Six clients have arrived at the ED because the local church is caught on deadly fire. More affected residents are expected to arrive soon and it is the only hospital in the nearby area. Arrange the following six clients in the order in which they should obtain medical attention utilizing disaster triage principles.
- 1. An 11-year-old boy wheezing and heavily labored breathing unrelieved by an asthma inhaler
- 2. A firefighter who is exhibiting combative behavior and has respiratory stridor
- 3. A 19-year-old anxious girl with a crushed leg that is very swollen and has tachycardia
- 4. A 62-year-old grandmother with full-thickness burns to the hands and forearms
- 5. A 5-year-old child with respiratory distress and burns over more than 70% of the anterior body.
- 6. A 50-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 30 minutes
The correct order is shown above.
- The 11-year-old may die if the nurse consumes too much time attempting to control the firefighter. First, initiate an albuterol treatment for the 11-year-old with asthma. This action is quick to perform, and the child or significant other can be instructed to hold the apparatus while the nurse attends to other clients.
- The firefighter is in greater respiratory distress than the 11-year-old; nevertheless, maintaining a strong combative client is demanding and time-consuming. If a patient is uncooperative or combative and it interferes with conducting a proper primary trauma survey then the patient should be sedated and intubated so that the exam may proceed.
- Next, attend to the 19-year-old with a crush injury. Anxiety and tachycardia may be due to the pain or stress; yet, the swelling hints of hemorrhage. Adequate circulation is required for oxygenation to the brain and other vital organs. Blood loss is the most common cause of shock in trauma patients.
- Take care of the grandmother with burns on the forearms next by providing dressings and pain management. By the end of the primary survey, the trauma patient should have received a well-organized resuscitation, and any immediately life-threatening condition should have been identified and addressed.
- Then, give comfort measures to the child with burns over more than 70% of the anterior body; however, the prognosis is very poor. In certain patients who are too unstable to move on from their primary survey and are unable to be resuscitated and stabilized, a secondary survey should not be performed.
- The prognosis of the client in cardiac arrest is also very poor, and the CPR attempts have been held. The only contraindication to the secondary survey would be if the patient succumbs to their injuries. Otherwise, the secondary survey must be completed on all trauma patients. If the patient is severely injured, they might not be capable of providing a history.
Identify the five most important elements in conducting disaster triage for multiple victims. Select all that apply.
- A. Assess level of consciousness
- B. Check airway, breathing, and circulation
- C. Monitor vital signs, including pulse and respirations
- D. Inquire about last tetanus shot
- E. Determine history of allergies to food or medicine
- F. Know the list of current medications
- G. Identify past medical and surgical history
- H. Note color, presence of moisture, and temperature of the skin
- I. Visually examine for gross deformities, bleeding, and obvious injuries
Correct Answers: A, B, C, H, and I
The following would be appropriate for disaster triage. The other options would be discussed when the staff has time and means to collect additional data. It would be appropriate to include all items during nondisaster circumstances.
- Option A: A rapid assessment of the patient’s neurologic status is necessary on arrival in the emergency department. This should include the patient’s conscious state and neurological signs. This is assessed by the patient’s Glasgow coma scale (GCS), pupil size and reaction, and lateralizing signs.
- Option B: The common acronym for performing the primary trauma survey is ABCDE, each letter representing an area of focus. If any abnormality is identified in one of the areas of focus, it should be resolved before a practitioner progresses further through the algorithm.
- Option C: Assess vital signs; A narrow pulse pressure and tachycardia indicate hypovolemic shock in a trauma setting until proven otherwise. Vital signs should be closely monitored and response to interventions should be assessed. In elderly population, normal vital signs should not be reassuring as hemodynamic changes such as tachycardia or hypotension may be delayed.
- Option D: Rendering care to a trauma patient can be a challenging endeavor due to the potential for numerous injuries. This part of evaluation should not be performed until the primary survey is completed.
- Option E: It should be performed after the primary survey and the initial stabilization is complete. The purpose of the secondary survey is to obtain pertinent historical data about the patient and his or her injury, as well as to evaluate and treat injuries not found during the primary survey.
- Option F: Patients who are hemodynamically unstable should be stabilized first before they are transferred to a trauma center. An attempt should be made to obtain the patient’s history regarding the mechanism of injury since certain mechanisms can raise suspicion for certain injuries.
- Option G: The purpose of the secondary survey is to obtain a detailed history, perform a head-to-toe physical exam, reassess all vital signs, and obtain pertinent lab and imaging studies to identify injuries and metabolic abnormalities.
- Option H: In this, visualize all possible areas of skin. This includes the locations of lacerations, abrasions, ecchymosis, hematoma, marks, or bruises. Pay attention to the hidden areas. Back should be evaluated by log-rolling the patient, and the spine should be palpated for step-offs or focal tenderness.
- Option I: The extremities should be assessed for fractures by carefully palpating each extremity over its entire length for tenderness and decreased the range of motion. Assess the integrity of uninjured joints by both active and passive movements. Injured joints should also be immobilized, and radiographs should be obtained if necessary.
A group of passengers enters the ED with complaints of cough, tightness in the throat, and extreme periorbital swelling. There is a strong odor exuding from their clothes. They report exposure to a “gas bomb” that was placed in the bus terminal. What is the priority action?
- A. Readily transfer clients and visitors from the area
- B. Check vital signs and auscultate lung sounds
- C. Assist clients in the decontamination area
- D. Direct clients to the cold or clean zone for immediate treatment
Correct Answer: C. Assist clients in the decontamination area
Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.
- Option A: Decontamination triage is especially important in mass casualty incidents and should not be confused with medical triage. Decontamination triage is the process of determining which victims require decontamination and which do not. Rapidly identifying victims who may not require decontamination can significantly reduce the time and resources needed for mass decontamination.
- Option B: Doing assessments and transferring others delay decontamination and do not protect the total environment. Set up or assign an area or building as a safe refuge/observation area for victims who do not require medical attention. Here they can be monitored for a delayed outbreak of symptoms or indications of residual contamination. Donning personal protective equipment and measures is vital before assisting with decontamination or assessing the clients.
- Option D: The clients must undergo decontamination before entering cold or clean zones. In mass casualty incidents, decontamination corridors can be set up that consist of high volume, low-pressure water deluges. Assign personnel to decontamination stations to control and instruct victims when they enter the decontamination area.
A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis?
- A. Risk for Nutritional Deficit related to chronic alcohol abuse
- B. Risk for Injury related to seizures
- C. Risk for Situational Low Self-Esteem related to police custody
- D. Risk for Other-Directed Violence related to hallucinations
Correct Answer: B. Risk for Injury related to seizures
Client safety is the priority because the driver exhibits neurologic hyperactivity and is on the verge of a seizure. Medications such as chlordiazepoxide (Librium) are needed to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to treat other problems.
- Option A: If withdrawal symptoms remain untreated, this can typically lead to DT. Additional evaluation of a patient with DT involves identifying electrolyte, nutrition, and fluid abnormalities. Most of these patients present with severe dehydration (up to 10 L fluid deficit) and severe electrolyte abnormalities, including hypoglycemia and severe hypomagnesemia and hypophosphatemia.
- Option C: Delirium tremens occur in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 48 hours. The initial minor withdrawal symptoms are characterized by anxiety, insomnia, palpitations, headache, and gastrointestinal symptoms. These symptoms usually occur as early as 6 hours after cessation of alcohol use. More than 50% of those with a history of alcohol abuse can exhibit alcohol withdrawal symptoms at discontinuing or decreasing their alcohol use.
- Option D: After 12 hours, minor withdrawal symptoms can progress to alcohol hallucinosis, a condition characterized by visual hallucinations. It can typically resolve in 24 to 48 hours, and may also be associated with auditory and tactile hallucinations.
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
Correct Answer: A. Supply oxygen via nasal cannula
Increasing myocardial oxygenation is the priority goal. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.
- Option B: Intravenous opioids (e.g., morphine) are the analgesics most commonly used for pain relief (Class IIa). The results from CRUSADE quality improvement initiative have shown that the use of morphine may be associated with a higher risk of death and adverse clinical outcomes.
- Option C: After providing initial treatment, the physician should be notified. Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consultation and workup. Patients with stable angina may be appropriate for outpatient workup.
- Option D: The other actions are also appropriate and should be done immediately. Electrocardiogram (ECG) preferably in the first 10 min of arrival, (consider serial ECGs). Patients with ST-elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI).
A child with fever has been admitted to the ED 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 nursing assistant?
- 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
Correct Answer: B. Assist the child in removing outer garments
The nursing assistant can assist with the elimination of outer garments, which enables the heat to dissipate from the child’s skin. The nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.
- Option A: Tepid baths are not usually given because of the potential for rebound and shivering. Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client’s laboratory values requires that the registered nurse report this to the nurse’s supervisor and doctor.
- Option C: Explaining is a teaching function only appropriate for a registered nurse. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option D: Advising is a teaching function that is the responsibility of the registered nurse. Delegation should be done according to the differentiated practice for each of the staff members.
A traveler’s feet suddenly become pale, turn red, and feel very cold. In just 30 minutes, the affected part became prickly and numb. Place the following interventions in the correct order for a client with frostbite.
- 1. Remove the client from the cold environment
- 2. Administer pain medication
- 3. Immerse the feet in warm water of 105°F to 115°F (40.6°C to 46.1°C)
- 4. Apply loose, sterile, bulky dressing
- 5. Monitor for compartment syndrome
The correct order is shown above.
Initially, the client should be removed from the cold environment. Pain medication should be given before immersing the feet in warm water to lessen the discomfort. The client should be monitored for compartment syndrome every hour after initial treatment.
- Patients should have protection from further injury by covering exposed areas. Remove patients from the wind. Remove wet clothing and replace it with dry clothing. Avoid vigorous rubbing as this can cause further damage.
- NSAIDS (ibuprofen) are indicated for controlling pain and preventing further inflammation, but stronger analgesics including narcotics may be necessary to achieve pain control. Frequent re-examination for sensation should accompany rewarming.
- The care of patients with frostbite begins with rewarming in the field if there is no anticipation of refreezing, as thaw-refreezing may worsen injuries. In-hospital management includes warm water baths, approximately 40-42 degrees C. Patients with systemic hypothermia should be managed by raising core temperature above 35 degrees C using warm IV fluids, and this should precede warming of the affected extremity.
- Apply a loose, bulky dressing to prevent infection. As with burn patients, particular care to prevent infections and dehydration should be a priority. Overly aggressive surgical debridement may remove skin that is otherwise viable, so complete rewarming should be achieved before surgical debridement.
- Signs of compartment syndrome (edema, pulselessness, extreme pain) should prompt urgent surgery. Delayed amputation (up to 6 weeks following injury) until the determination of tissue viability may prevent surgical morbidity from unnecessary procedures.
An elderly maintenance staff is lying on the floor and the ED nurse responds to a call for help. List the order in which the nurse must carry out the following actions.
- 1. Establish unresponsiveness
- 2. Call for help and activate the code team
- 3. Perform the chin lift or jaw thrust maneuver
- 4. Initiate cardiopulmonary resuscitation (CPR)
- 5. Instruct the nurse assistant to get the crash cart
The correct order is shown above
- First, establish unresponsiveness. (The patient may have fallen and sustained a minor injury.) The Code Blue will follow the AHA/HSFC ACLS/PALS guidelines. It is recommended all members have current ACLS/PALS training and certification.
- Get help and activate the code team if the client is unresponsive. Any individual may call a code blue and certified staff will initiate BLS and AED if available, until relieved by the Code Blue team.
- To open the airway, perform chin lift or jaw thrust maneuver. Place 1 hand on the casualty’s forehead and gently tilt their head back, lifting the tip of the chin using 2 fingers. This moves the tongue away from the back of the throat. Don’t push on the floor of the mouth, as this will push the tongue upwards and obstruct the airway.
- Then start CPR. CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. The Emergency Medical System (EMS) will be activated for all areas in the hospital not covered by the Code Blue team, as well as all arrests occurring outside the building. If the team is not able to transport the Code Blue Cart to the scene, the team will provide Basic Life Support (BLS) until EMS arrives.
- A crash cart should be present at the site when the code team arrives; however, basic CPR can be definitely performed until the team is present. The units where the Code Blue carts are located are only responsible for transporting the cart to the unit where a Code Blue has been called.
Which task is most appropriate to assign to the nursing assistant when an instantaneous death transpires in the ED? Select all that apply
- A. Assisting with postmortem care
- B. Escorting the family to a place of privacy
- C. Going with the organ donor specialist to talk to the family
- D. Helping the family to collect belongings
Correct Answer: A. Assisting with postmortem care
Postmortem care demands some turning, cleaning, lifting, and so on, and the nursing assistant is equipped and authorized to assist with these responsibilities. The use of NAPs increasingly demands registered nurses to delegate patient care tasks according to the principles of the ANA. These principles define nursing delegation as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.”
- Option B: The RN should be responsible for the other duties mentioned to help the family begin the grieving process. The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience, and facility/agency policies and procedures.
- Option C: Federal law mandates that only clinicians who completed certified training approach the family about organ donation. Physicians approaching families independently are associated with the lowest rate of consent. Hence, it is best practice for OPO staff to approach families together with the health care team.
- Option D: In case of uncertain death, belongings may be preserved for evidence, so the chain of custody would have to be maintained. One nurse shall enter items to be handed over in the valuables book in the presence of a second staff member, and wherever possible in the presence of the patient. This is to protect staff in the event of a dispute.
During the shift of a triage nurse in the Emergency Department (ED), the following clients arrive. Which client needs the most rapid response to protect other clients in the ED 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.
Correct Answer: C. A 7-year-old who has a new pruritic rash and a possible chickenpox infection
Varicella or chickenpox is spread by airborne means and could be quickly transmitted to other clients in the ED. The child with a rash should be immediately isolated from the other clients through placement in a negative-pressure room.
- Option A: The client who has been exposed to TB does not set other clients at risk for infection because there are no symptoms of active TB. In the past few decades, there has been a concerted global effort to eradicate TB. These efforts had yielded some positive dividends especially since 2000 when the World Health Organization (WHO, 2017) estimated that the global incidence rate for tuberculosis has fallen by 1.5% every year.
- Option B: Prevention and control of MRSA infections include necessary infection-control steps like strict hand hygiene and adequate contact precautions. Contact precautions include the use of gowns, gloves, and possibly masks during clinical encounters with patients with MRSA infection. Infection control also may include keeping patients in isolated rooms or the same rooms of other patients who have an MRSA infection.
- Option D: Droplet precautions should be instituted for the clients with possible pertussis, but this can be achieved after isolating the child with possible chickenpox. Strict isolation is important while the patient remains infectious. Pertussis is contagious throughout the catarrhal phase and for 3 weeks after the onset of the paroxysmal phase.
The nurse is assigned to a client who has a draining sacral wound infected by MRSA. Which personal protective equipment (PPE) will the nurse plan to use in preparing to change the linens of the client? Select all that apply.
- A. Gloves
- B. Goggles
- C. Gown
- D. N95 respirator
- E. Surgical mask
- F. Shoe covers
Correct Answer: A and C
Gloves and a gown should be applied when coming in contact with linens that may be contaminated by the client’s wound secretions. Contact precautions include the use of gowns, gloves, and possibly masks during clinical encounters with patients with MRSA infection. Infection control also may include keeping patients in isolated rooms or the same rooms of other patients who have an MRSA infection.
- Option B: Goggles are the primary protectors intended to shield the eyes against liquid or chemical splash, irritating mists, vapors, and fumes. They form a protective seal around the eyes, and prevent objects or liquids from entering under or around the goggles. This is especially important when working with or around liquids that may splash, spray, or mist.
- Option D: An N95 respirator protects against dust, fumes, mists, and other microorganisms. This can be used when working with live animals or infectious materials in BSL-2 level labs with known airborne transmissible disease (e.g. tuberculosis, also required for influenza (flu).
- Option E: Surgical masks protect against large droplets and splashes. It does not require fit-testing. This can be used when working with live animals; working with infectious material in BSL-2+ level labs but only protects your sample from you, not the other way around.
- Option F: A shoe cover is not necessary, because transmission by splashes, droplets, or airborne means will not occur when the bed is changed. The inclusion of protective shoe covers or footwear as a component of PPE for prevention of acquisition and dissemination of pathogenic microbial agents by healthcare staff derives from documentation of extensive floor contamination with bacterial pathogens.
Which action will the nurse take to most effectively reduce the incidence of hospital-related urinary tract infections (UTI)?
- A. Make sure that clients have an adequate fluid intake
- B. Educate assistive personnel on how to provide good perineal hygiene
- C. Restrict the use of indwelling catheters
- D. Perform dipstick urinalysis for clients with risk factors for UTI
Correct Answer: C. Restrict the use of indwelling catheters
The most effective way to lessen UTIs in the hospital setting is to avoid using retention catheters. Nurses are associated with promoting policies that lessen the unnecessary use of catheters because the use of catheters is the most common cause of hospital-acquired UTIs in the United States.
- Option A: Increase the patient’s fluid intake. This has been shown to decrease UTI incidence, possibly by diluting the urine and flushing out bacteria. In the past, catheter-associated UTIs were seen as an inevitable consequence of hospitalization. Now they’re considered unacceptable results of poor care.
- Option B: Perform meatal care twice daily using soap and water and working from the front to the back of the perineal area. Evidence shows no advantage to antiseptic use. Though some research suggests cleaning the catheter with povidone-iodine and applying antibiotic ointment at the insertion site may decrease bacteria, most studies show this practice has no benefit and may even lead to infection.
- Option D: The other options also reduce the risk for and/or detect UTIs, but avoidance of indwelling catheter use will be more effective. Urine may be assessed both at the bedside (dipstick) and in the laboratory (microscopy, culture, sensitivity and urinary electrolytes). Urine for laboratory analysis must be transferred quickly and at the correct temperature otherwise breeding ground for contaminants.
A 90-year-old client is confined to the unit for two weeks. He has been receiving antibiotics for more than a week and says 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
Correct Answer: A. Place the client on contact precautions
The client may have Clostridium difficile infection based on his age, history of antibiotic therapy, and watery stools. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients.
- Option B: General strategies such as early detection of the disease, placing the patient under isolation with a dedicated toilet and contact precautions, promoting hygiene measures such as improved hand hygiene, and environmental cleaning are effective measures in preventing infections from C. difficile infections.
- Option C: Watery diarrhea with mucus or occult blood, anorexia, nausea, vomiting, low-grade fever, and lower abdominal pain are the symptoms commonly associated with diarrhea and colitis caused by C. difficile.
- Option D: Patients with new-onset 3 or more loose or unformed stools in 24 hours with no obvious other etiology should be checked for testing for C. difficile infection. Stool examination for C. difficile toxins or toxigenic C. difficile bacillus is the commonly used diagnostic test used to diagnose C. difficile infection.
The nurse is assigned to a client with meningococcal meningitis. Which information about the client is the best indicator that the nurse can discontinue droplet precautions?
- A. Appropriate antibiotics have been given 24 hours
- B. Cough is productive of clear, nonpurulent mucus
- C. Pupils are equal and reactive to light
- D. Temperature is lower than 100°F (37.8°C)
Correct Answer: A. Appropriate antibiotics have been given 24 hours
Contemporary CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours.
- Option B: The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration. Meningococcal meningitis is a medical emergency presenting with severe sepsis syndrome, fever, petechiae, and ecchymosis requiring prompt resuscitation and antibiotic administration.
- Option C: A thorough neurologic exam should be performed looking for alteration in mental status, as well as any focal deficits. The classic triad of neck stiffness, fever, and altered mental status is a more specific sign for meningitis. Infants can present with a variety of non-specific symptoms, which include lethargy, irritability, and in some cases bulging fontanelles.
- Option D: The other information may mean that the client’s condition is improving but does not mean that droplet precautions should be stopped. Patients can present with abnormal vital signs, including fever, tachypnea, tachycardia, and hypotension. Hypotension with elevated pulse rate is suggestive of early vascular instability.
Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #4 (25 Items)
There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room?
- A. A client with a cough who may have tuberculosis
- B. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C)
- C. A client with diarrhea caused by C. difficile
- D. A client with a wound infected with Vancomycin-resistant enterococci (VRE)
Correct Answer: A. A client with a cough who may have tuberculosis
Private rooms should be occupied mainly for clients with infections that require airborne precautions such as TB. Despite the gains in tuberculosis control and the decline in both new cases and mortality, it still accounts for a huge burden of morbidity and mortality worldwide.
- Option B: Standard precautions are required for the client with toxic shock syndrome. Any source of bacteria such as tampons or nasal packing should immediately be removed. Emergent surgical consultation should be obtained for any wound debridement or surgical cause. This is critical in the early management of toxic shock syndrome.
- Option C: The primary mode of the disease transmission is the fecal-oral route. Effective prevention of C. difficile infection includes several generalized strategies and certain targeted strategies. General strategies such as early detection of the disease, placing the patient under isolation with a dedicated toilet and contact precautions, promoting hygiene measures such as improved hand hygiene, and environmental cleaning are effective measures in preventing infections from C. difficile infections.
- Option D: Clients with VRE infections that require contact precautions should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. The primary transmission of vancomycin-resistant Enterococcus in the hospital setting is through the hands of healthcare providers. Basic infection control prevention practices such as hand hygiene can help. Contact precautions such as wearing gowns and gloves also decrease transmission.
The nurse is assigned to a client who has been diagnosed with disseminated herpes zoster. Which PPE will the nurse plan to use when preparing to assess the client? Select all that apply.
- A. Gloves
- B. Goggles
- C. Gown
- D. N95 respirator
- E. Surgical face mask
- F. Shoe covers
Correct Answer: A, C, and D
The nurse should don an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves because herpes zoster (shingles) is spread through airborne means and by direct contact with lesions.
- Option B: Safety goggles protect the eyes, eye sockets, and the facial area immediately surrounding the eyes. Indirectly-vented or non-vented goggles prevent splashes, sprays, and respiratory droplets. Anti-fog safety goggles offer the most practical and reliable use.
- Option E: Surgical face masks filter particularly large particles and will not render protection from herpes zoster. A surgical mask is a loose-fitting disposable mask that protects the wearer’s nose and mouth from contact with droplets, splashes and sprays that may contain germs. A surgical mask also filters out large particles in the air.
- Option F: Shoe covers are not required for airborne or contact precautions. General occupational health guidance recommends shoe covers when there is a risk of splashing from infected body fluids. Further research is needed on whether shoe covers should be added to PPE.
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
Correct Answer: D. Start oxygen using a non-rebreather mask
The nurse’s first action should be to start oxygen therapy because the respiratory manifestations linked to avian influenza are most likely life-threatening. Patients with respiratory compromise should be placed on supplemental oxygen and monitored closely for signs of deterioration as these patients are at high risk of requiring intubation and mechanical ventilation.
- Option A: The World Health Organization released Rapid Advice Guidelines in 2007, outlining consensus treatment recommendations for H5N1 influenza outbreaks. Similar recommendations can likely be used in avian influenza outbreaks due to other strains of the virus. These recommendations include neuraminidase inhibitors (especially oseltamivir) for strongly suspected or confirmed cases of H5N1.
- Option B: Treatment of avian influenza usually consists of supportive care and antiviral medications. The majority of care should aim at managing the sequelae of infection. For instance, patients with volume loss or possible electrolyte imbalances should receive volume resuscitation and treatment to correct imbalances.
- Option C: The preferred source of a sample for testing is a nasopharyngeal swab or aspirate, but other body fluids are usable if the nasopharyngeal swab or aspirate is not available. Because the infection carries high mortality risk, a negative rapid antigen test should not rule out AIV infection when high suspicion exists.
The charge nurse is delegating tasks to her subordinates in the medical unit. Which infection control activity should she assign to an experienced nursing assistant?
- A. Asking clients about the use of immunosuppressant medications.
- B. Demonstrating correct hand washing to client visitors.
- C. Disinfecting blood pressure cuffs after clients are discharged.
- D. Screening clients for upper respiratory tract symptoms.
Correct Answer: C. Disinfecting blood pressure cuffs after clients are discharged
Nursing assistants can support agency policy to disinfect items that come in contact with intact skin such as blood pressure cuffs by cleaning with chemicals like alcohol. Depending on a nurse’s role, some tasks can be delegated to a CNA depending on their scope of practice. Essentially, a nurse can delegate tasks to a CNA anytime help is necessary.
- Option A: This task should be performed by licensed nurses. The practice of pervasive functions of critical decisions, nursing judgment, and clinical reasoning cannot be delegated. There should be no confusion between assignments and delegation.
- Option B: Also known as a certified nursing assistant, a CNA’s main role is to provide patients with basic care and assist them in their everyday activities, particularly when patients have a hard time doing a few activities on their own, such as bathing.
- Option D: Assessment for upper respiratory tract symptoms require further education and a broader scope of practice. A licensed nurse cannot delegate any activity involving critical decision-making or nursing judgment.
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 an LPN/LVN?
- 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.
Correct Answer: B. Collect wound cultures during dressing changes
Performing dressing changes and obtaining specimens for wound culture are part of the LPN/LVN education and scope of practice. LPN/LVN can perform routine procedures (ostomy care, catheter insertion, wound care, check blood glucose, obtaining EKG etc.).
- Option A: The scope of practice for LPN/LVN nurses includes observing patient data according to a list of set rules that they must follow unconditionally. Any abnormal findings that they observe must be reported to an RN. An LPN/LVN cannot perform a complete and exhaustive physical assessment. LPNs/LVN can suggest interventions but cannot implement them unless instructed and supervised.
- Option C: LPN/LVN assists with care plans by implementing the interventions (as within scope of practice) but does NOT develop the nursing diagnosis or interventions or evaluate the care plan.
- Option D: Education is a complex action that should be carried out by an RN. LPNs/LVNs may not become involved in teaching patients, although in some cases they can engage in basic teaching procedures under very specific guidelines. An LPN can for example teach a patient to do motion exercises. RNs have the sole responsibility when it comes to teaching patients.
The charge nurse from the unit receives a call from the pediatrician wanting to admit an 8-year-old child with rubeola (measles). Which of the following is of most concern in deciding whether to admit the child to the unit?
- A. The unit is not staffed with the usual number of RNs
- B. There are several children receiving chemotherapy on the unit.
- C. No negative-airflow rooms are available on the unit.
- D. The infection control nurse liaison is not on the unit today.
Correct Answer: C. No negative-airflow rooms are available on the unit.
The child cannot be admitted to the pediatric unit without the implementation of airborne precautions which is required for clients with rubeola. One of the components of airborne infection isolation (AII) is respiratory protection for health-care workers and visitors when entering AII rooms. Recommendations of the type of respiratory protection are dependent on the patient’s airborne infection (indicating the need for AII) and the risk of infection to persons entering the AII room.
- Option A: Staff reassignment can be done but this would not prevent the client’s admission. Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes. Twenty-four hour nursing care is one of the distinctive hallmarks of inpatient care in hospitals.
- Option B: Children undergoing cancer treatment are particularly vulnerable to illnesses such as measles, as chemotherapy greatly reduces their immunity and can make their previous vaccinations ineffective. However, the client with rubeola can be placed in an isolation room distant from the clients undergoing chemotherapy.
- Option D: The absence of the infection control nurse liaison would not prevent the admission of a client with rubeola. The infection control liaison nurse (ICLN) is a nurse in the ward, appointed to participate in education for infection control, and to liaise between the ward and the infection control nurse (ICN).
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 nursing assistant? Select all that apply.
- A. Educating the client to perform careful handwashing after using the bathroom.
- 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.
Correct Answer: C, D, and E
The nursing assistant is capable of stocking the room and posting the precautions on the client’s door because all staff who care for clients should be familiar with the various types of isolation. Reminding visitors about previously taught information is a task of the nursing assistant although the RN is responsible for the initial teaching.
- Option A: Education is a complex action that should be carried out by an RN. If a CNA does something that is not in their scope of work, the hospital is within their rights to dismiss them or at least issue them with a warning.
- Option B: Client discussion of the reason for the protective isolation falls within the RN-level-scope of practice. The scope of practice for a CNA includes tasks such as basic daily patient care including doing all of the things for the patient that they cannot do themselves. These tasks are classified as ADLs or activities of daily living and are called this because they need to be done daily.
- Option C: A CNA is allowed to stock the patient’s room with necessary equipment. In hospitals, certified nursing assistants are more likely to help a diverse patient population with a wide range of needs. Their patients could be young or old, and likely recovering from illness or surgery.
- Option D: Depending on daily needs, this can involve changing soiled sheets, cleaning up spills, changing bedpans, setting up equipment, and reducing the spread of germs and infection in the patient’s living area.
- Option E: CNAs are primarily responsible for helping patients with ADLs, such as bathing, grooming, toileting, eating, and moving. CNAs often measure a patient’s blood pressure, pulse, and temperature, and then record their findings and report them to a supervisor to determine whether action is necessary.
In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning?
- 1. Remove gloves
- 2. Take off gown
- 3. Take off goggles
- 4. Remove N95 respirator
- 5. Perform hand hygiene
The correct order is shown above.
This order will prevent contact of the contaminated gloves and gown with areas like the hair that cannot be readily cleaned after client contact and stop transmission of microorganisms to the nurse and the client. The correct order for donning and removal of PPE has been standardized by agencies such as the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration.
- Remove gown and gloves together. If gloves are removed first, hands must only touch uncontaminated surfaces of the gown, typically behind the neck (ties) and at the back of the shoulders.
- The gown is then peeled down off the body and arms, balling or rolling in the contaminated surfaces (front and sleeves). The preferred method for doffing a disposable gown and gloves is, therefore, to break the ties at the neck by pulling on the upper front portion of the gown with the hands still gloved, balling or rolling in the contaminated surfaces, and pulling the gloves off inside-out as the hands are withdrawn from the gown’s sleeves. The gown and gloves can then be placed in a disposal receptacle together.
- Remove eye protection. Remove from the back of the head by lifting headband or ear pieces. If reusable, place it in the designated reprocessing receptacle. If not, discard in the waste container.
- Remove mask/respirator. Grasp the bottom ties/elastics, then the top ones, and remove without touching the front of the mask. Discard in the waste container.
- Perform hand hygiene. Remember that all PPE is contaminated after use. Perform hand hygiene immediately after each step of doffing (Queensland DoH 2020).
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
Correct Answer: A. Place the client on airborne and contact precautions
SARS is considered deadly so the initial action is to protect other clients and healthcare workers by securing the client in isolation. If an airborne-agent isolation (negative-pressure) room is not yet available, droplet precautions should be initiated until the client can be moved to a negative-pressure room.
- Option B: Early in the pandemic, a combination of ribavirin and corticosteroids was adopted as the standard treatment in Hong Kong, Canada and elsewhere because of the apparent good results of the first few patients. Subsequent reports showed that ribavirin was associated with a high rate of toxicity and lacked in vitro antiviral effect on SARS-coronavirus (SAR-CoV).
- Option C: The timing and dosage regimens of steroids in the treatment of SARS are controversial. Pulse methylprednisolone 250 to 500 mg/day for 3 to 6 days has been reported to have some efficacy in a subset of patients with “critical SARS”, i.e., critically ill SARS patients with deteriorating radiographic consolidation, increasing oxygen requirement with PaO2 <10 kPa or SpO2 <90% on air, and respiratory distress (rate of 30/min).
- Option D: Handle these specimens using Universal Precautions, which includes use of gloves, gown, mask, and eye protection. Any procedure with the potential to generate fine-particulate aerosols (e.g., vortexing or sonication of specimens in an open tube) should be performed in a biological safety cabinet (BSC).
The nurse is caring for four clients receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection?
- A. A client who has a non-tunneled central line in the left internal jugular vein.
- B. A client with an implanted port in the right subclavian vein.
- C. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
- D. A client who has a midline IV catheter in the left antecubital fossa.
Correct Answer: A. A client who has a non-tunneled central line in the left internal jugular vein
Central lines are associated with a higher infection risk, the skin of the neck and chest have high numbers of microorganisms, and the line is non-tunneled: such factors increase the risk for infection. About half of nosocomial bloodstream infections occur in intensive care units, and the majority of them are associated with intravascular devices. Central-venous-catheter-related bloodstream infections (CRBSIs) are an important cause of healthcare-associated infections.
- Option B: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line. Inflow obstruction (7.6%) and infection (6.9%) were the main complications, followed by reflux (3.1%), subcutaneous masses (1.5%) and fistulae (1.5%). The median interval between port implantation and port complication was 5.4 months (range: 0.3–40.9 months).
- Option C: A peripherally inserted central catheter (PICC) infection occurs when bacteria enters the bloodstream through or around a central line catheter . A PICC is a long, thin tube that is inserted through a vein in the arm.
- Option D: Midline catheters are associated with a lower incidence of infection. Midline catheters (MCs) are peripheral IV access devices that may reduce the need for central lines and hence decrease central line-associated bloodstream infections.
The school nurse is asked which action will have the most impact on the incidence of infectious diseases in school. The correct response is:
- A. Granting written information about infection control to all parents.
- B. Ensure that students are immunized according to national guidelines.
- C. Make soap and water easily accessible in the classrooms.
- D. Educate students on how to cover their mouths when coughing.
Correct Answer: B. Ensure that students are immunized according to national guidelines.
The incidence of once-common infectious diseases like measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children. Infectious diseases that used to be common in children in the United States – including polio, diphtheria, pertussis (whooping cough), rubella (German measles), and chickenpox – are preventable with vaccines approved by the U.S. Food and Drug Administration (FDA).
- Option A: People are to be given information on the infectious disease hazards in their environment, the modes of transmission and appropriate control methods. This is best provided during induction and in ongoing training.
- Option C: Infectious disease can be spread via contaminated hands. Hand hygiene is one of the most important measures in preventing transmission of infection. Hands can become contaminated from touching contaminated surfaces or by being contaminated through coughing, sneezing, rubbing eyes etc. The infectious agent can then be passed on to others e.g. shaking hands and/or contaminating clean surfaces. Hand should be regularly washed with soap, running water and then dried.
- Option D: Respiratory hygiene is a set of routine practices to prevent potentially infectious secretions from the nose and mouth from contaminating others directly or indirectly via surfaces. Cough into a single use tissue or into the sleeve, never into the hands. Always turn to direct the cough away from others and away from surfaces or food sources.
The nurse is caring for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action can be delegated to the nursing assistant?
- 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.
Correct Answer: A. Implement contact precautions when caring for the client
Correct implementation of contact precautions should be well-known by the hospital staff. Depending on daily needs, this can involve changing soiled sheets, cleaning up spills, changing bedpans, setting up equipment, and reducing the spread of germs and infection in the patient’s living area.
- Option B: The key item identified by the American Nurses Association as being unable to be delegated is the nursing process itself. This notably includes any task that requires nursing judgment (or critical judgments) or decision making.
- Option C: Education is a complex action that should be carried out by an RN. If a CNA does something that is not in their scope of work, the hospital is within their rights to dismiss them or at least issue them with a warning.
- Option D: Appropriate delegation allows for responsibility transition in a consistent, safe manner. The RN transfers the performance of a procedure, skill, or activity to a CNA. However, the practice of pervasive functions of critical decisions, nursing judgment, and clinical reasoning cannot be delegated.
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 an LPN?
- 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. Doing ongoing assessments to determine the client’s hydration status.
- D. Explaining the purpose of ordered stool cultures to the client family.
Correct Answer: A. Giving the ordered metronidazole (Flagyl) 500 mg PO to the client.
LPN scope of practice and education include the administration of medications. Each state board of nursing regulates what the LPN can and cannot do. In general, LPN’s provide patient care in a variety of settings within a variety of clinical specializations. LPN’s can usually administer oral and intravenous medication.
- Option B: LPN’s are often the first point of contact that a hospital, doctor’s office, or other healthcare clinic has with patients. After patients are called back to be seen by a doctor, LPN’s record their medical history, known allergies, height, weight, internal body temperature, blood pressure, pulse, and breathing rate. These signs give doctors and registered nurses a good indication of patients’ overall health before any additional tests are administered.
- Option C: Assessment is not within the LPNs’ scope of practice. However, LPN’s can be asked to monitor their patients’ health throughout the course of their shift. Close monitoring is especially important after major surgeries, accidents, and when patients have received new medications. LPN’s are trained to quickly identify adverse reactions or complications and notify doctors and registered nurses immediately.
- Option D: Client and family education should be done by the RN. However, LPN’s are often tasked with providing a human touch to routine healthcare. They often teach patients and their family members how to administer medication, which symptoms to be aware of after the patient goes home, which activities to avoid, and how to adopt and maintain a healthy lifestyle.
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.
Correct Answer: B. Ask the client about any recent travel to Asia or the Middle East.
Based on the client’s manifestations, avian influenza (“bird flu”) is suspected. Outbreaks of bird flu have occurred in Asia or the Middle East. Airborne and contact precautions should be instituted immediately. Although adapted to birds, and often causing only mild illness, avian influenza viruses can be extremely dangerous with successful transmission to humans with a high percentage of confirmed cases requiring hospitalization and frequently intensive care unit (ICU) care.
- Option A: Any patient hospitalized with a suspected or confirmed diagnosis of avian influenza should have an infectious disease consultation to better direct care and minimize complications. While the recommendations presented here are necessary for any patient with suspected avian influenza, an infectious disease consultant may be able to better direct treatment for specific avian influenza strains and manage treatment and patient expectations more appropriately.
- Option C: After isolating the client accordingly, management of epistaxis may be done. Treatment for anterior bleeding can be started with direct pressure for at least 10 minutes. Have the patient apply constant direct pressure by pinching the nose over the cartilaginous tip (instead of over the bony areas) for a few minutes to try to control the bleed.
- Option D: When an outbreak is identified, it is crucial for public health officials to identify at-risk populations and to inform the public of risk factors and ways to detect infection. Because the presence of deadly diseases in a community can incite fear and panic, announcements should include which populations are at low risk for contracting avian influenza.
A mother of a 14-year-old client receiving chemotherapy for leukemia calls out to the unit concerning her other child having chickenpox. Which of these actions will the nurse anticipate taking next?
- A. Plan to admit the client to a private room in the hospital.
- B. Teach the mother about contact and airborne precautions.
- C. Educate the mother about the correct use of acyclovir (Zovirax).
- D. Administer varicella-zoster immune globulin to the client.
Correct Answer: D. Administer varicella-zoster immune globulin to the client
The development of varicella in high-risk clients can be prevented via administration of varicella-zoster immune globulin prescribed by the physician. Varicella zoster immunoglobulin (VZIG) is a scarce blood product that is offered to individuals at high risk of severe chickenpox following an exposure.
- Option A: Hospitalization may be required if the child develops a varicella-zoster virus infection. The incidence of varicella was higher in children with leukemia or lymphoma than in children with other types of cancer. Virus reactivation was uncommon and had a benign course. Varicella mortality in these children could be favorably modified through an active immunization of immunocompetent children.
- Option B: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. Contact Precautions only if Herpes simplex, localized zoster in an immunocompetent host or vaccinia viruses most likely.
- Option C: Acyclovir is a medication used in the management and treatment of infections caused by the herpes simplex virus (HSV). It is FDA approved to treat genital herpes and HSV encephalitis. Some off-label uses include cold sores, shingles, and chickenpox. It is in the antiviral class of medications.
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
Correct Answer: D. Respiratory rate of 8 to 10 breaths/min
A drop in respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. Signs and symptoms of an oxycodone overdose include bradycardia, hypotension, miosis, respiratory depression, somnolence, muscle flaccidity, cold and clammy skin, and death.
- Option A: Oxycodone is an opioid agonist prescription medication. The oxycodone immediate-release formulation is FDA-approved for the management of acute or chronic moderate to severe pain, for which other treatments do not suffice and for which the use of opioid medication is appropriate.
- Option B: A heart rate of 100/min is slightly higher than normal, therefore this should still be reported to the RN. Patients taking oxycodone require monitoring for the presence of constipation, pain relief, other side effects, and appropriate usage. Their blood pressure, heart rate, and respiratory rate should also be monitored, especially for the first 24 to 72 hours after initiating therapy or increasing dosage.
- Option C: The student nurses should still inform the RN of the client’s wishes. Due to the high misuse potential and possibly fatal results of an oxycodone overdose, prescriptions should be written for the lowest therapeutic dose and only for the period the patient is expected to be in pain. Close follow-up should be arranged.
The nurse just received the client’s morning laboratory results. Which of these results is of most concern?
- A. Serum sodium level of 134 mEq/L
- B. Serum potassium level of 5.2 mEq/L
- C. Serum magnesium level of 0.8 mEq/L
- D. Serum calcium level of 10.6 mg/dL
Correct Answer: C. Serum magnesium level of 0.8 mEq/L
With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias. Normal serum magnesium levels are between 1.46 and 2.68 mg/dL. Hypomagnesemia can be attributed to chronic disease, alcohol use disorder, gastrointestinal losses, renal losses, and other conditions. Signs and symptoms of hypomagnesemia include anything from mild tremors and generalized weakness to cardiac ischemia and death.
- Option A: Hyponatremia is defined as a serum sodium concentration of less than 135 mEq/L but can vary to some extent depending upon the set values of varied laboratories. Patients with mild-to-moderate hyponatremia (greater than 120 mEq/L) or gradual decrease in sodium (greater than 48 hours) have minimal symptoms.
- Option B: Hyperkalemia is defined as a serum or plasma potassium level above the upper limits of normal, usually greater than 5.0 mEq/L to 5.5 mEq/L. While mild hyperkalemia is usually asymptomatic, high levels of potassium may cause life-threatening cardiac arrhythmias, muscle weakness or paralysis.
- Option D: Hypercalcemia is defined as serum calcium concentration two standard deviations above the mean values. The normal serum calcium ranges from 8.8 mg/dL-10.8 mg/dL. Primary hyperparathyroidism and malignancy accounts for 90% of the cases of hypercalcemia.
The assigned LPN 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. Retake the client’s blood pressure and heart rate.
Correct Answer: C. Review the client’s morning calcium level.
Facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear is a positive Chvostek sign. It is a neurologic manifestation of hypocalcemia.
- Option A: Pupillary light reflex is used to assess the brain stem function. Abnormal pupillary light reflex can be found in optic nerve injury, oculomotor nerve damage, brain stem lesions, such as tumors, and medications like barbiturates.
- Option B: The neurological examination is an assessment tool to determine a patient’s neurologic function. It is beneficial in a variety of ways as it allows the localization of neurologic diseases and helps in ruling in or ruling out differential diagnoses.
- Option D: The LPN is experienced and holds the skills to carefully and accurately measure vital signs. The clinical manifestations of hypocalcemia can range from no symptoms if it is mild to life-threatening symptoms like seizures, heart failure, or laryngospasm if it is severe. Also, the clinical manifestation depends on the rate of development of hypocalcemia and its chronicity.
A client going through intense chemotherapy treatment is admitted to the unit. Which of these would the nurse instruct the nursing assistant to report to prevent an acid-base imbalance?
- A. Hair loss during the morning bath.
- B. Complaints of pain associated with exertion.
- C. Failure to eat all the food on the breakfast tray.
- D. Prolonged episodes of nausea and vomiting.
Correct Answer: D. Prolonged episodes of nausea and vomiting.
Repeated nausea and vomiting can lead to an acid base deficit and metabolic alkalosis. Other causes of metabolic alkalosis include the loss of hydrochloric acid from the stomach through vomiting, potassium depletion due to the use of diuretics for hypertension, and the excessive use of laxatives.
- Option A: Chemotherapy drugs are powerful medications that attack rapidly growing cancer cells. Unfortunately, these drugs also attack other rapidly growing cells in the body — including those in the hair roots. Fortunately, most of the time hair loss from chemotherapy is temporary.
- Option B: Chemotherapy or radiation induced pain is most often a form of nerve pain. It can cause peripheral neuropathy (painful numbness of the extremities), or paresthesia (numbness and tingling of hands, feet or any extremity of the body).
- Option C: Cancer treatments may lower appetite or change the way food tastes or smells. Side effects such as mouth and throat problems, or nausea and vomiting can also make eating difficult. Cancer-related fatigue can also lower the appetite.
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 nursing assistant? Select all that apply.
- A. Administer 0.45% saline by IV line
- B. Assess daily weights for trends
- C. Check for indications of dehydration
- D. Render oral care every 3 to 4 hours
Correct Answer: D. Render oral care every 3 to 4 hours
The nursing assistant can provide oral care to the client. This is within the scope of practice of nursing assistants. The scope of practice for a CNA includes tasks such as basic daily patient care. This includes activities such as bathing, eating and dressing, but also smaller things such as grooming.
- Option A: Appropriate delegation allows for responsibility transition in a consistent, safe manner. The RN transfers the performance of a procedure, skill, or activity to a CNA. However, the practice of pervasive functions of critical decisions, nursing judgment, and clinical reasoning cannot be delegated.
- Option B: RNs cannot delegate any activity including the nursing judgment that involves critical decision making. When specific aspects of nurse care need to be delegated beyond the traditional assignments and roles of care providers, the delegation process and state NPA or nurse practice act must be understood clearly so that it is effectively and safely carried out.
- Option C: Monitoring clients demand the additional education and skills of the RN. A CNA’s main role is to provide patients with basic care and assist them in their everyday activities, particularly when patients have a hard time doing a few activities on their own, such as bathing.
The nurse is caring for a client diagnosed with diabetic ketoacidosis. Which action should you delegate to the nursing assistant? 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.
Correct Answer: C and D
A well-trained and educated nursing assistant is knowledgeable in measuring vital signs and recording intake and output. In addition to helping patients with daily tasks, CNAs spend time taking vital signs and recording information about a patient’s condition. As a result, a CNA serves as an invaluable link between a patient and the rest of their healthcare team.
- Option A: RNs cannot delegate any activity including the nursing judgment that involves critical decision making. Validation competency needs to be specific to the skill and knowledge necessary to safely perform responsibilities delegated as well as to the level of the CNA to whom the procedure, skill, or activity has been delegated.
- Option B: Performing fingerstick glucose checks demands further education and skill, as possessed by licensed nurses. The practice of pervasive functions of critical decisions, nursing judgment, and clinical reasoning cannot be delegated.
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 nursing assistant?
- 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. Educate family members to assist the client with fluid intake.
Correct Answer: C. Provide straws and offer fluids between meals.
Additional fluid intake can be reinforced by the nursing assistance once it is part of the care plan. A CNA’s main role is to provide patients with basic care and assist them in their everyday activities, particularly when patients have a hard time doing a few activities on their own, such as bathing.
- Option A: In some hospitals, a CNA will administer a patient’s medication. Usually, however, this depends on the CNA’s level of experience and training, as well as the regulations of the state.
- Option B: Among the tasks that CANNOT be legally and appropriately delegated to nursing assistants include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care.
- Option D: Educating families demand further education and skills that are within the field of practice of an RN. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.
A group of nursing students is assigned to care for a client with a nasogastric tube connected to a wall suction. One student asks why the client’s respiratory rate has decreased. Choose the best response.
- A. “Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps fix the problem.”
- B. “The client is hypoventilating because of anxiety, and we will have to stay observant for the development of respiratory acidosis.”
- C. “It’s common for clients with uncomfortable equipment such as nasogastric tubes to have a lower rate of breathing.”
- D. “The client may have a metabolic alkalosis due to the nasogastric suctioning, and the decreased respiratory rate is a compensatory mechanism.”
Correct Answer: D. “The client may have a metabolic alkalosis due to the nasogastric suctioning, and the decreased respiratory rate is a compensatory mechanism.”
Nasogastric suctioning can result in a decrease in acid components and a metabolic alkalosis. The client’s decrease in rate and depth of ventilation is an attempt to compensate by retaining carbon dioxide. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCl). Whenever a hydrogen ion is excreted, a bicarbonate ion is gained in the extracellular space.
- Option A: Metabolic alkalosis causes hypoventilation, which may cause hypoxemia, especially in patients with poor respiratory reserve, and it may impair weaning from mechanical ventilation.
- Option B: Hypoventilation develops because of inhibition of the respiratory center in the medulla. Symptoms of hypocalcemia (eg, jitteriness, perioral tingling, muscle spasms) may be present.
- Option C: This response may be right, but it does not discuss all the components of the question. As a compensatory mechanism, metabolic alkalosis leads to alveolar hypoventilation with a rise in arterial carbon dioxide tension (PaCO2), which diminishes the change in pH that would otherwise occur.
A 56-year-old male is newly admitted to the medical unit. Which factor alerts the nurse that this client has a risk for acid-base imbalances?
- A. The client takes antacids for occasional indigestion.
- B. The client gets short of breath with extreme exertion.
- C. The client has a history of myocardial infarction 1 year ago.
- D. The client has chronic renal insufficiency.
Correct Answer: D. The client has chronic renal insufficiency.
Chronic renal disease and pulmonary disease are risk factors for acid-base imbalances in the older adult. Renal failure patients have an altered acid-base balance; most commonly, a mixed type of metabolic acidosis (hyperchloremic, and of a high anion gap) is observed.
- Option A: Although antacid abuse is a risk factor for metabolic alkalosis, occasional antacid use will not cause imbalances. Antacid use won’t normally lead to metabolic alkalosis. But if the patient has a weak or failing kidneys and uses a nonabsorbable antacid, it can bring on alkalosis. Nonabsorbable antacids contain aluminum hydroxide or magnesium hydroxide.
- Option B: A typical respiratory response to all types of metabolic alkalosis is hypoventilation leading to a pH correction towards normal. Increases in arterial blood pH depress respiratory centers. The resulting alveolar hypoventilation tends to elevate PaCO2 and restore arterial pH toward normal.
- Option C: MI is not related to metabolic alkalosis. Metabolic alkalosis is caused by too much bicarbonate in the blood. It can also occur due to certain kidney diseases. Hypochloremic alkalosis is caused by an extreme lack or loss of chloride, such as from prolonged vomiting.
The monitor watcher from the telemetry units informs the assigned nurse that the client developed prominent U waves. Which laboratory value should the nurse monitor?
- A. Sodium level
- B. Potassium level
- C. Calcium level
- D. Magnesium level
Correct Answer: B. Potassium level
The nurse should immediately check the client’s potassium level for hypokalemia. Common ECG changes with hypokalemia include ST depression, inverted T waves, and prominent U waves. Heart block may also transpire to clients with hypokalemia.
- Option A: Increased and decreased serum sodium levels do not have any effect on the ECG, nor cardiac rhythm, or impulse conduction.
- Option C: Common ECG changes due to hypercalcemia include shortened QT interval, lengthened QRS duration, and bradycardia may also occur. Hypocalcemia may cause lengthened QT interval and shortened QRS duration.
- Option D: Hypermagnesemia is rare but severe hypermagnesemia may cause atrioventricular and intraventricular conduction disturbances, which may culminate in third-degree AV block or asystole.