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Nursing Management, Delegation and Prioritization (PM)
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Question 1
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
Maintain the head of the bed at a 30 – to 45-degree angle
B
Hyperoxygenate the patient before suctioning
C
Administer ordered antibiotics as scheduled
D
Suction the airway when coarse crackles are audible
Question 1 Explanation:
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. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
Question 2
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 change my diet to include more foods rich in iron, protein, and vitamin C.”
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 continue to take my isoniazid until I am feeling completely well.”
Question 2 Explanation:
Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.
Question 3
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
Assess the client and let the other nurse know what should be done.
B
Ask the other nurse if she needs help.
C
Contact the nursing supervisor to address the situation.
D
Ask the client if he is satisfied with his care.
Question 3 Explanation:
The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
Question 4
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
Assist the patient with basic activities of daily living
B
Plan a nursing care regimen that gradually increases activity intolerance
C
Observe how well the patient performs pursed-lip breathing
D
Consult with the physical therapy department about reconditioning exercises
Question 4 Explanation:
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN.
Question 5
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
Cephalexin (Keflex) 250 mg PO
C
Morphine sulfate 2 to 4 mg IV
D
Heparin infusion at 900 units/hr
Question 5 Explanation:
Medication safety guidelines indicate that 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.
Question 6
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
There are multiple ecchymotic areas on the patient’s arms
B
The patient says that her right leg aches all night
C
The patient is unable to remember her husband’s first name
D
The right calf is warm to the touch and is larger than the left calf
Question 6 Explanation:
Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. 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.
Question 7
The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?
A
Heart rate of 92 beats/min
B
Blood pressure of 152/84 mm Hg
C
Oral temperature of 101.2 F (38.4C)
D
Respiratory rate of 27 breaths/min
Question 7 Explanation:
A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.
Question 8
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
Pneumonia
B
Pneumothorax
C
Bronchitis
D
Pulmonary embolus
Question 8 Explanation:
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
Question 9
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A
A client with diabetic foot ulcer that needs a dressing change.
B
A client with chronic bronchitis on nasal oxygen.
C
A client with syncope being discharged today.
D
A client scheduled for cardiac ultrasound this morning.
Question 9 Explanation:
A client with airway problems should be attended first.
Question 10
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
Complaints of a sore throat
B
Frequent swallowing
C
Heart rate of 112 beats/min
D
Hypotonic bowel sounds
Question 10 Explanation:
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
Question 11
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
A
Assisting the patient to sit up on the side of the bed
B
Auscultation of breath sounds every 4 hours
C
Teaching the patient to use incentive spirometry
D
Instructing the patient to cough effectively
Question 11 Explanation:
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
Question 12
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?
A
Lyme’s disease vaccine.
B
Hepatitis A vaccine.
C
Hepatitis B vaccine.
D
Pneumococcal vaccine.
Question 12 Explanation:
Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.
Question 13
Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:
A
Role modeling behaviors of the preceptor.
B
Lack of trust to the members of the healthcare team.
C
The philosophy of the new nurse’s school of nursing.
D
The orientation provided to the new nurse.
Question 13 Explanation:
Lack of trust is the common reason for reluctance in delegation of tasks.
Question 14
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
Marking the tube 1 cm from where it touches the incisor tooth or nares
B
Assessing for bilateral breath sounds and symmetrical chest movements
C
Ordering a chest radiograph to verify that tube placement is correct
D
Auscultating over the stomach to rule out esophageal intubation
Question 14 Explanation:
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. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.
Question 15
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
Insert an oral airway to prevent the patient from biting on the endotracheal tube
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
Reassure the patient that the ventilator will do the work of breathing for him
Question 15 Explanation:
Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.
Question 16
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 RN immediately?
A
Blood pressure of 168/90 mm Hg
B
Respiratory rate of 24 breaths/min
C
Tympanic temperature of 101.4 F (38.6 C)
D
Heart rate of 98 beats/min
Question 16 Explanation:
Infections are always a threat for 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.
Question 17
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 foods prepared with monosodium glutamate (MSG)
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
Avoid potential environmental asthma triggers such as smoke
E
Be sure to get at least 8 hours of rest and sleep every night.
Question 17 Explanation:
Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
Question 18
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
A
A 35-year-old male with tracheostomy and copious secretions
B
A teenager scheduled for physical therapy this morning.
C
A 78-year-old female client with pressure ulcer that needs dressing change.
D
A client with diabetes being discharged today.
Question 18 Explanation:
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Question 19
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 bronchoscopy and biopsy
C
A 69-year old with COPD who is ventilator dependent
D
A 72-year old who needs teaching about the use of incentive spirometry
Question 19 Explanation:
Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
Question 20
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 the patient be provided with an extra pillow
C
Suggest that a simple face mask be used instead of a nasal cannula.
D
Suggest that the patient sit up in a chair at the bedside
Question 20 Explanation:
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. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
Question 21
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
A
Place the patient in a private room to decrease the risk of further infection
B
Perform postural drainage and chest physiotherapy every 4 hours
C
Plan activities to allow at least 8 hours of uninterrupted sleep
D
Allow the patient to decide whether she needs aerosolized medications
Question 21 Explanation:
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
Question 22
You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
A
Chest tube drainage of 10 to 15 mL/hr
B
Chest tube dressing dated yesterday
C
Continuous bubbling in the water seal chamber
D
Complaints of pain at the chest tube site
Question 22 Explanation:
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. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. 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.
Question 23
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
A
reflexes and movement of extremities.
B
level of pain.
C
level of consciousness.
D
respiratory status.
Question 23 Explanation:
Assessing respiratory status is the first priority. Remember ABC.
Question 24
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
Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
B
Teaching the patient about the importance of adequate of fluid intake and hydration.
C
Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
D
Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
Question 24 Explanation:
A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into 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. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
Question 25
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.
Remove the inhaler cap and shake the inhaler
Open your mouth and place the mouthpiece 1 to 2 inches away
Tilt your head back and breathe out fully
Hold your breath for at least 10 seconds
Press down firmly on the canister and breathe deeply through your mouth
Wait at least 1 minute between puffs.
A
A, B, C, E, D, F
B
A, C, B, E, D, F
C
A, E, B, C, D, F
D
A, C, B, E, F, D
Question 25 Explanation:
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. As the patient begins to breathe in 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.
Question 26
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?
A
Theophylline (Theolair, Theochron)
B
Dexamethasone (Decadron)
C
Surfactant (Exosurf)
D
Albuterol (Proventil)
Question 26 Explanation:
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 show a significant decrease in the incidence of pneumothorax when it is administered.
Question 27
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 proved to the RN? (Select all that apply)
A
Position the patient supine and turned on his side
B
Maintain universal body substances precautions.
C
Apply ice or cool compresses to the nose
D
Instruct the patient not to blow the nose for several hours.
E
Apply direct lateral pressure to the nose for 5 minutes
Question 27 Explanation:
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
Question 28
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
A
Taking vital signs and pulse oximetry readings every 4 hours
B
Checking the ventilator settings to make sure they are as prescribed
C
Assessing the patient’s respiratory status every 4 hours
D
Observing whether the patient’s tube needs suctioning every 2 hours
Question 28 Explanation:
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. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
Question 29
After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
A
A 50-year old with asthma who complains of shortness of breath after using a bronchodilator
B
A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
C
A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D
A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
Question 29 Explanation:
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. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
Question 30
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
simple carbohydrates.
B
yogurt.
C
broccoli.
D
fiber.
Question 30 Explanation:
Broccoli are gas forming and therefore, should be avoided.
Question 31
Nurse Jason is planning care for a client who will undergo a colposcopy. Which of the following actions should Jason take first?
A
Give instructions regarding douching and sexual relations.
B
Discuss the client’s fear regarding potential cervical cancer.
C
Administer pain medications.
D
Assist with silver nitrate application to the cervix to control bleeding.
Question 31 Explanation:
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.
Question 32
You are acting as 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 49-year old just admitted with a new diagnosis of esophageal cancer.
B
A 56-year old with lung cancer who has just undergone left lower lobectomy
C
A 38-year old with moderate persistent asthma awaiting discharge
D
A 63-year old with a tracheostomy needing tracheostomy care every shift.
Question 32 Explanation:
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. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. 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.
Question 33
Nurse Pietro receives a 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
Check the child’s blood pressure, pulse, respiration, and temperature.
B
Call for a social worker to meet with the family.
C
Speak with the parents about how the fracture occurred.
D
Administer pain medications.
Question 33 Explanation:
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.
Question 34
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
Push the call button for help.
B
Turn the client face up to assess.
C
Determine the level of consciousness.
D
Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.
Question 34 Explanation:
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
Question 35
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
thrombophlebitis.
B
depression.
C
pain.
D
wound infection.
Question 35 Explanation:
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.
Question 36
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather 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
Call a code for respiratory arrest
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
Perform endotracheal intubation and initiate mechanical ventilation
Question 36 Explanation:
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to 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 health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
Question 37
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 sits up and leans over the night table.
B
The patient’s respiratory rate is 8 breaths/min
C
The patient has a large barrel chest.
D
The patient has fine bibasilar crackles
Question 37 Explanation:
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. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
Question 38
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
A
Changing the soiled tracheostomy ties and securing the tube in place
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
Suctioning the tracheostomy tube before performing tracheostomy care
Question 38 Explanation:
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.
Question 39
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that 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 dopamine.
B
Administer pain medications.
C
Administer oxygen via nasal cannula.
D
Administer IV fluids.
Question 39 Explanation:
Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Question 40
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
Monitoring cardiorespiratory response to activity
B
Instructing the patient to alternate rest and activity periods
C
Planning activities for periods when the patient has the most energy
D
Encouraging, monitoring, and recording nutritional intake
Question 40 Explanation:
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. Instructing patients and planning activities require more education and skill, and are appropriate to the RN’s scope of practice. 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
Question 41
A patient with a pulmonary embolus 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
Be sure the patient’s footwear has a firm sole when the patient ambulates
C
Use a soft-bristled toothbrush or tooth sponge for oral care
D
Use an electric razor when shaving the patient each day
E
Use a rectal thermometer to obtain a more accurate body temperature
Question 41 Explanation:
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). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
Question 42
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’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
C
The patient complains of sharp, stabbing chest pain with every deep breath
D
The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage
Question 42 Explanation:
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. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure
Question 43
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 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
Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
B
Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
C
Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
D
Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
Question 43 Explanation:
The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an 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. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
Question 44
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
A
The patient was on bed rest for 6 hours after a diagnostic procedure
B
The patient was recently in a motor vehicle accident
C
The patient gave birth to her youngest child 1 year ago
D
The patient participated in an aerobic exercise program for 6 months
Question 44 Explanation:
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
Question 45
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 (PCT)?
A
Remind the patient to sleep on his side instead of his back.
B
Discuss weight-loss strategies such as diet and exercise with the patient
C
Administer modafinil (Provigil) to promote daytime wakefulness
D
Teach the patient how to set up the BiPAP machine before sleeping
Question 45 Explanation:
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. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
Question 46
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
A
Ask the client what happened.
B
Establish whether the client is responsive.
C
Assist the client back to bed.
D
Call for help to get the client back in bed.
Question 46 Explanation:
Assess first for responsiveness.
Question 47
Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?
A
Decontaminate the open wound on the client’s thigh.
B
Decontaminate the client’s clothing.
C
Save the client’s vomitus for analysis by the radiation safety staff.
D
Decontaminate the examination room the client is placed in.
Question 47 Explanation:
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
Question 48
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
Initiate the nursing care plan
C
Evaluate the patient’s technique for using MDI’s
D
Complete in-depth admission assessment
E
Administer medications via metered-dose inhaler (MDI)
Question 48 Explanation:
The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. 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.
Question 49
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
A
Monitoring laboratory values for changes in oxygenation
B
Assessing for symptoms of respiratory failure
C
Evaluating the patient’s complaint of chest pain
D
Auscultating the lungs for crackles
Question 49 Explanation:
An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. 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.
Question 50
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on 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 who had a total hip replacement two days ago and needs blood glucose monitoring.
C
A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.
D
A client with balanced skeletal traction and needs assistance with morning care.
Question 50 Explanation:
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
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Nursing Management, Delegation and Prioritization (EM)
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Question 1
Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?
A
Cephalexin (Keflex) 250 mg PO
B
Heparin infusion at 900 units/hr
C
Morphine sulfate 2 to 4 mg IV
D
Warfarin (Coumadin) 1.0 mg by mouth (PO)
Question 1 Explanation:
Medication safety guidelines indicate that 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.
Question 2
The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?
A
Oral temperature of 101.2 F (38.4C)
B
Blood pressure of 152/84 mm Hg
C
Respiratory rate of 27 breaths/min
D
Heart rate of 92 beats/min
Question 2 Explanation:
A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.
Question 3
You are acting as 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 49-year old just admitted with a new diagnosis of esophageal cancer.
B
A 38-year old with moderate persistent asthma awaiting discharge
C
A 56-year old with lung cancer who has just undergone left lower lobectomy
D
A 63-year old with a tracheostomy needing tracheostomy care every shift.
Question 3 Explanation:
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. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. 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.
Question 4
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 client if he is satisfied with his care.
B
Ask the other nurse if she needs help.
C
Assess the client and let the other nurse know what should be done.
D
Contact the nursing supervisor to address the situation.
Question 4 Explanation:
The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
Question 5
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
Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
B
Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
C
Teaching the patient about the importance of adequate of fluid intake and hydration.
D
Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
Question 5 Explanation:
A nursing assistant can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into 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. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
Question 6
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
A
Place the patient in a private room to decrease the risk of further infection
B
Allow the patient to decide whether she needs aerosolized medications
C
Perform postural drainage and chest physiotherapy every 4 hours
D
Plan activities to allow at least 8 hours of uninterrupted sleep
Question 6 Explanation:
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
Question 7
To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?
A
Albuterol (Proventil)
B
Surfactant (Exosurf)
C
Dexamethasone (Decadron)
D
Theophylline (Theolair, Theochron)
Question 7 Explanation:
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 show a significant decrease in the incidence of pneumothorax when it is administered.
Question 8
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
thrombophlebitis.
B
wound infection.
C
depression.
D
pain.
Question 8 Explanation:
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.
Question 9
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 is unable to remember her husband’s first name
B
The patient says that her right leg aches all night
C
There are multiple ecchymotic areas on the patient’s arms
D
The right calf is warm to the touch and is larger than the left calf
Question 9 Explanation:
Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. 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.
Question 10
You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
A
Chest tube dressing dated yesterday
B
Continuous bubbling in the water seal chamber
C
Chest tube drainage of 10 to 15 mL/hr
D
Complaints of pain at the chest tube site
Question 10 Explanation:
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. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. 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.
Question 11
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 sit up in a chair at the bedside
B
Suggest that the patient be provided with an extra pillow
C
Suggest that a simple face mask be used instead of a nasal cannula.
D
Suggest that the patient’s oxygen be humidified
Question 11 Explanation:
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. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
Question 12
A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that 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 dopamine.
B
Administer pain medications.
C
Administer IV fluids.
D
Administer oxygen via nasal cannula.
Question 12 Explanation:
Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
Question 13
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
simple carbohydrates.
B
yogurt.
C
broccoli.
D
fiber.
Question 13 Explanation:
Broccoli are gas forming and therefore, should be avoided.
Question 14
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
Ordering a chest radiograph to verify that tube placement is correct
B
Assessing for bilateral breath sounds and symmetrical chest movements
C
Marking the tube 1 cm from where it touches the incisor tooth or nares
D
Auscultating over the stomach to rule out esophageal intubation
Question 14 Explanation:
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. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.
Question 15
The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
A
respiratory status.
B
level of pain.
C
reflexes and movement of extremities.
D
level of consciousness.
Question 15 Explanation:
Assessing respiratory status is the first priority. Remember ABC.
Question 16
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’s dressing at the thoracentesis site has 1 cm of bloody drainage
B
The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
C
The patient complains of sharp, stabbing chest pain with every deep breath
D
The patient starts crying and says she can’t go on with treatment much longer
Question 16 Explanation:
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. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure
Question 17
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
Maintain the head of the bed at a 30 – to 45-degree angle
B
Hyperoxygenate the patient before suctioning
C
Suction the airway when coarse crackles are audible
D
Administer ordered antibiotics as scheduled
Question 17 Explanation:
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. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
Question 18
A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
A
Instructing the patient to cough effectively
B
Teaching the patient to use incentive spirometry
C
Assisting the patient to sit up on the side of the bed
D
Auscultation of breath sounds every 4 hours
Question 18 Explanation:
Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of a nursing assistant. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
Question 19
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 being discharged today.
B
A teenager scheduled for physical therapy this morning.
C
A 78-year-old female client with pressure ulcer that needs dressing change.
D
A 35-year-old male with tracheostomy and copious secretions
Question 19 Explanation:
The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Question 20
You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.
Remove the inhaler cap and shake the inhaler
Open your mouth and place the mouthpiece 1 to 2 inches away
Tilt your head back and breathe out fully
Hold your breath for at least 10 seconds
Press down firmly on the canister and breathe deeply through your mouth
Wait at least 1 minute between puffs.
A
A, C, B, E, D, F
B
A, C, B, E, D, F
C
A, C, B, E, D, F
D
A, C, B, E, D, F
Question 20 Explanation:
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. As the patient begins to breathe in 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.
Question 21
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 proved to the RN? (Select all that apply)
A
Position the patient supine and turned on his side
B
Instruct the patient not to blow the nose for several hours.
C
Maintain universal body substances precautions.
D
Apply direct lateral pressure to the nose for 5 minutes
E
Apply ice or cool compresses to the nose
Question 21 Explanation:
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
Question 22
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
Ask the client what happened.
C
Establish whether the client is responsive.
D
Assist the client back to bed.
Question 22 Explanation:
Assess first for responsiveness.
Question 23
Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?
A
A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.
B
A client who had a total hip replacement two days ago and needs blood glucose monitoring.
C
A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
D
A client with balanced skeletal traction and needs assistance with morning care.
Question 23 Explanation:
A nurse from the medical-surgical floor floated to the orthopedic unit should be given clients with stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
Question 24
Nurse Jason is planning care for a client who will undergo a colposcopy. Which of the following actions should Jason take first?
A
Discuss the client’s fear regarding potential cervical cancer.
B
Administer pain medications.
C
Assist with silver nitrate application to the cervix to control bleeding.
D
Give instructions regarding douching and sexual relations.
Question 24 Explanation:
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.
Question 25
When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
A
“I will change my diet to include more foods rich in iron, protein, and vitamin C.”
B
“Everyone in my family needs to go and see the doctor for TB testing.”
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 continue to take my isoniazid until I am feeling completely well.”
Question 25 Explanation:
Patients taking isoniazid must continue the drug for 6 months. The other 3 statements are accurate and indicate understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.
Question 26
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
Monitoring cardiorespiratory response to activity
B
Encouraging, monitoring, and recording nutritional intake
C
Instructing the patient to alternate rest and activity periods
D
Planning activities for periods when the patient has the most energy
Question 26 Explanation:
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. Instructing patients and planning activities require more education and skill, and are appropriate to the RN’s scope of practice. 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
Question 27
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
Be sure to get at least 8 hours of rest and sleep every night.
B
Use the inhaler 30 minutes before exercising to prevent bronchospasm
C
Avoid potential environmental asthma triggers such as smoke
D
Avoid foods prepared with monosodium glutamate (MSG)
E
Wash all bedding in cold water to reduce and destroy dust mites.
Question 27 Explanation:
Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
Question 28
You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
A
Checking the ventilator settings to make sure they are as prescribed
B
Assessing the patient’s respiratory status every 4 hours
C
Observing whether the patient’s tube needs suctioning every 2 hours
D
Taking vital signs and pulse oximetry readings every 4 hours
Question 28 Explanation:
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. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
Question 29
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 RN immediately?
A
Blood pressure of 168/90 mm Hg
B
Tympanic temperature of 101.4 F (38.6 C)
C
Heart rate of 98 beats/min
D
Respiratory rate of 24 breaths/min
Question 29 Explanation:
Infections are always a threat for 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.
Question 30
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
Heart rate of 112 beats/min
D
Complaints of a sore throat
Question 30 Explanation:
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
Question 31
A patient with a pulmonary embolus 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 rectal thermometer to obtain a more accurate body temperature
B
Use an electric razor when shaving the patient each day
C
Use a lift sheet when moving and positioning the patient in bed
D
Be sure the patient’s footwear has a firm sole when the patient ambulates
E
Use a soft-bristled toothbrush or tooth sponge for oral care
Question 31 Explanation:
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). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
Question 32
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 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
Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
B
Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
C
Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
D
Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
Question 32 Explanation:
The patient’s history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an 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. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
Question 33
After 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 50-year old with asthma who complains of shortness of breath after using a bronchodilator
C
A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
D
A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
Question 33 Explanation:
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. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
Question 34
Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?
A
Decontaminate the client’s clothing.
B
Decontaminate the examination room the client is placed in.
C
Decontaminate the open wound on the client’s thigh.
D
Save the client’s vomitus for analysis by the radiation safety staff.
Question 34 Explanation:
Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
Question 35
Nurse Pietro receives a 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
Administer pain medications.
B
Check the child’s blood pressure, pulse, respiration, and temperature.
C
Call for a social worker to meet with the family.
D
Speak with the parents about how the fracture occurred.
Question 35 Explanation:
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.
Question 36
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
Assist the patient with basic activities of daily living
B
Observe how well the patient performs pursed-lip breathing
C
Consult with the physical therapy department about reconditioning exercises
D
Plan a nursing care regimen that gradually increases activity intolerance
Question 36 Explanation:
Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN.
Question 37
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 has a large barrel chest.
C
The patient’s respiratory rate is 8 breaths/min
D
The patient sits up and leans over the night table.
Question 37 Explanation:
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. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
Question 38
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
Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
B
Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
C
Insert an oral airway to prevent the patient from biting on the endotracheal tube
D
Reassure the patient that the ventilator will do the work of breathing for him
Question 38 Explanation:
Manual ventilation of the patient will allow you to deliver an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.
Question 39
You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
A
Changing the soiled tracheostomy ties and securing the tube in place
B
Removing old dressings and cleaning off excess secretions
C
Suctioning the tracheostomy tube before performing tracheostomy care
D
Replacing the inner cannula and cleaning the stoma site.
E
Removing the inner cannula and cleaning using universal precautions
Question 39 Explanation:
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.
Question 40
Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A
A client with diabetic foot ulcer that needs a dressing change.
B
A client scheduled for cardiac ultrasound this morning.
C
A client with chronic bronchitis on nasal oxygen.
D
A client with syncope being discharged today.
Question 40 Explanation:
A client with airway problems should be attended first.
Question 41
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
A
The patient was recently in a motor vehicle accident
B
The patient was on bed rest for 6 hours after a diagnostic procedure
C
The patient participated in an aerobic exercise program for 6 months
D
The patient gave birth to her youngest child 1 year ago
Question 41 Explanation:
Patients who have recently experienced trauma are at risk for deep vein thrombosis and pulmonary embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
Question 42
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?
A
Lyme’s disease vaccine.
B
Hepatitis A vaccine.
C
Hepatitis B vaccine.
D
Pneumococcal vaccine.
Question 42 Explanation:
Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.
Question 43
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather 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
Administer furosemide (Lasix) 100 mg IV push stat
C
Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
D
Call a code for respiratory arrest
Question 43 Explanation:
A non-rebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to 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 health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
Question 44
Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:
A
Role modeling behaviors of the preceptor.
B
The philosophy of the new nurse’s school of nursing.
C
Lack of trust to the members of the healthcare team.
D
The orientation provided to the new nurse.
Question 44 Explanation:
Lack of trust is the common reason for reluctance in delegation of tasks.
Question 45
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
Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.
B
Turn the client face up to assess.
C
Push the call button for help.
D
Determine the level of consciousness.
Question 45 Explanation:
Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
Question 46
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 (PCT)?
A
Remind the patient to sleep on his side instead of his back.
B
Teach the patient how to set up the BiPAP machine before sleeping
C
Administer modafinil (Provigil) to promote daytime wakefulness
D
Discuss weight-loss strategies such as diet and exercise with the patient
Question 46 Explanation:
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. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
Question 47
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 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
Question 47 Explanation:
Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
Question 48
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
Initiate the nursing care plan
C
Complete in-depth admission assessment
D
Administer medications via metered-dose inhaler (MDI)
E
Evaluate the patient’s technique for using MDI’s
Question 48 Explanation:
The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. 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.
Question 49
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 embolus
B
Pneumothorax
C
Bronchitis
D
Pneumonia
Question 49 Explanation:
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
Question 50
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
A
Monitoring laboratory values for changes in oxygenation
B
Evaluating the patient’s complaint of chest pain
C
Assessing for symptoms of respiratory failure
D
Auscultating the lungs for crackles
Question 50 Explanation:
An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. 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.
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1. A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
Perform postural drainage and chest physiotherapy every 4 hours
Allow the patient to decide whether she needs aerosolized medications
Place the patient in a private room to decrease the risk of further infection
Plan activities to allow at least 8 hours of uninterrupted sleep
2. A patient with a pulmonary embolus 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.
Use a lift sheet when moving and positioning the patient in bed
Use an electric razor when shaving the patient each day
Use a soft-bristled toothbrush or tooth sponge for oral care
Use a rectal thermometer to obtain a more accurate body temperature
Be sure the patient’s footwear has a firm sole when the patient ambulates
3. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather 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?
Perform endotracheal intubation and initiate mechanical ventilation
Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
Administer furosemide (Lasix) 100 mg IV push stat
Call a code for respiratory arrest
4. A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)?
Assisting the patient to sit up on the side of the bed
Instructing the patient to cough effectively
Teaching the patient to use incentive spirometry
Auscultation of breath sounds every 4 hours
5. 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 (PCT)?
Discuss weight-loss strategies such as diet and exercise with the patient
Teach the patient how to set up the BiPAP machine before sleeping
Remind the patient to sleep on his side instead of his back.
Administer modafinil (Provigil) to promote daytime wakefulness
6. After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
A 50-year old with asthma who complains of shortness of breath after using a bronchodilator
7. 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 RN immediately?
Heart rate of 98 beats/min
Respiratory rate of 24 breaths/min
Blood pressure of 168/90 mm Hg
Tympanic temperature of 101.4 F (38.6 C)
8. 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.
Auscultate breath sounds
Administer medications via metered-dose inhaler (MDI)
Complete in-depth admission assessment
Initiate the nursing care plan
Evaluate the patient’s technique for using MDI’s
9. 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 58-year old on airborne precautions for tuberculosis (TB)
A 68-year old just returned from bronchoscopy and biopsy
A 72-year old who needs teaching about the use of incentive spirometry
A 69-year old with COPD who is ventilator dependent
10. 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?
Reassure the patient that the ventilator will do the work of breathing for him
Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
Insert an oral airway to prevent the patient from biting on the endotracheal tube
11. 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?
Suggest that the patient’s oxygen be humidified
Suggest that a simple face mask be used instead of a nasal cannula.
Suggest that the patient be provided with an extra pillow
Suggest that the patient sit up in a chair at the bedside
12. 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?
Observe how well the patient performs pursed-lip breathing
Plan a nursing care regimen that gradually increases activity intolerance
Assist the patient with basic activities of daily living
Consult with the physical therapy department about reconditioning exercises
13. The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?
Blood pressure of 152/84 mm Hg
Respiratory rate of 27 breaths/min
Heart rate of 92 beats/min
Oral temperature of 101.2 F (38.4C)
14. To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?
Theophylline (Theolair, Theochron)
Surfactant (Exosurf)
Dexamethasone (Decadron)
Albuterol (Proventil)
15. When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
“Everyone in my family needs to go and see the doctor for TB testing.”
“I will continue to take my isoniazid until I am feeling completely well.”
“I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
“I will change my diet to include more foods rich in iron, protein, and vitamin C.”
16. When assessing a 22-year old patient who required emergency surgery and multiple transfusion 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?
Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status.
17. Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
Evaluating the patient’s complaint of chest pain
Monitoring laboratory values for changes in oxygenation
Assessing for symptoms of respiratory failure
Auscultating the lungs for crackles
18. Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?
Warfarin (Coumadin) 1.0 mg by mouth (PO)
Morphine sulfate 2 to 4 mg IV
Cephalexin (Keflex) 250 mg PO
Heparin infusion at 900 units/hr
19. You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.
Remove the inhaler cap and shake the inhaler
Open your mouth and place the mouthpiece 1 to 2 inches away
Tilt your head back and breathe out fully
Hold your breath for at least 10 seconds
Press down firmly on the canister and breathe deeply through your mouth
Wait at least 1 minute between puffs.
20. You are acting as 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 38-year old with moderate persistent asthma awaiting discharge
A 63-year old with a tracheostomy needing tracheostomy care every shift.
A 56-year old with lung cancer who has just undergone left lower lobectomy
A 49-year old just admitted with a new diagnosis of esophageal cancer.
21. Jenna is a nurse from the medical-surgical unit of a tertiary hospital. She was asked to float on the orthopedic in which she has no prior experience on working on. Which client should be assigned to her?
A client with a cast for a fractured femur and who has numbness and discoloration of the toes.
A client with balanced skeletal traction and needs assistance with morning care.
A client who had an above-the-knee amputation yesterday and has currently has a temperature of 101.4ºF.
A client who had a total hip replacement two days ago and needs blood glucose monitoring.
22. Sally is a nurse working in an emergency department and receives a client after a radiological incident. Which task is utmost priority for the nurse to do first?
Decontaminate the client’s clothing.
Decontaminate the open wound on the client’s thigh.
Decontaminate the examination room the client is placed in.
Save the client’s vomitus for analysis by the radiation safety staff.
23. The nurse plans care for a client in the post anesthesia care unit. The nurse should assess first the client’s:
respiratory status.
level of consciousness.
level of pain.
reflexes and movement of extremities.
24. 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:
fiber.
broccoli.
yogurt.
simple carbohydrates.
25. Nurse Jason is planning care for a client who will undergo a colposcopy. Which of the following actions should Jason take first?
Discuss the client’s fear regarding potential cervical cancer.
Assist with silver nitrate application to the cervix to control bleeding.
Give instructions regarding douching and sexual relations.
Administer pain medications.
26. Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first?
A client with diabetes being discharged today.
A 35-year-old male with tracheostomy and copious secretions.
A teenager scheduled for physical therapy this morning.
A 78-year-old female client with pressure ulcer that needs dressing change.
27. Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
Call for help to get the client back in bed.
Establish whether the client is responsive.
Assist the client back to bed.
Ask the client what happened.
28. Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:
Role modeling behaviors of the preceptor.
The philosophy of the new nurse’s school of nursing.
The orientation provided to the new nurse.
Lack of trust to the members of the healthcare team.
29. 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:
pain.
wound infection.
depression.
thrombophlebitis.
30. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that 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?
Administer pain medications.
Administer IV fluids.
Administer dopamine.
Administer oxygen via nasal cannula.
31. Nurse Pietro receives a 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?
Call for a social worker to meet with the family.
Check the child’s blood pressure, pulse, respiration, and temperature.
Administer pain medications.
Speak with the parents about how the fracture occurred.
32. Nurse Skye is on the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A client scheduled for cardiac ultrasound this morning.
A client with syncope being discharged today.
A client with chronic bronchitis on nasal oxygen.
A client with diabetic foot ulcer that needs a dressing change.
33. 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?
Determine the level of consciousness.
Push the call button for help.
Turn the client face up to assess.
Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician.
34. 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?
Ask the other nurse if she needs help.
Assess the client and let the other nurse know what should be done.
Ask the client if he is satisfied with his care.
Contact the nursing supervisor to address the situation.
35. Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns that which immunization is a priority for the client?
Hepatitis A vaccine.
Lyme’s disease vaccine.
Hepatitis B vaccine.
Pneumococcal vaccine.
36. You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
The patient was recently in a motor vehicle accident
The patient participated in an aerobic exercise program for 6 months
The patient gave birth to her youngest child 1 year ago
The patient was on bed rest for 6 hours after a diagnostic procedure
37. You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?
Assessing the patient’s respiratory status every 4 hours
Taking vital signs and pulse oximetry readings every 4 hours
Checking the ventilator settings to make sure they are as prescribed
Observing whether the patient’s tube needs suctioning every 2 hours
38. 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?
Administer ordered antibiotics as scheduled
Hyperoxygenate the patient before suctioning
Maintain the head of the bed at a 30 – to 45-degree angle
Suction the airway when coarse crackles are audible
39. 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?
The patient has fine bibasilar crackles
The patient’s respiratory rate is 8 breaths/min.
The patient sits up and leans over the night table.
The patient has a large barrel chest.
40. You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant?
Teaching the patient about the importance of adequate of fluid intake and hydration.
Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
Encouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession.
41. 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?
The patient says that her right leg aches all night
The right calf is warm to the touch and is larger than the left calf
The patient is unable to remember her husband’s first name
There are multiple ecchymotic areas on the patient’s arms
42. 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)
Avoid potential environmental asthma triggers such as smoke
Use the inhaler 30 minutes before exercising to prevent bronchospasm
Wash all bedding in cold water to reduce and destroy dust mites.
Be sure to get at least 8 hours of rest and sleep every night.
Avoid foods prepared with monosodium glutamate (MSG)
43. 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?
Pulmonary embolus
Bronchitis
Pneumothorax
Pneumonia
44. 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?
Instructing the patient to alternate rest and activity periods
Encouraging, monitoring, and recording nutritional intake
Monitoring cardiorespiratory response to activity
Planning activities for periods when the patient has the most energy
45. You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
Chest tube drainage of 10 to 15 mL/hr
Continuous bubbling in the water seal chamber
Complaints of pain at the chest tube site
Chest tube dressing dated yesterday
46. You are supervising a student nurse who is performing tracheostomy care for a patient. For which action by the student should you intervene?
Suctioning the tracheostomy tube before performing tracheostomy care
Removing old dressings and cleaning off excess secretions
Removing the inner cannula and cleaning using universal precautions
Replacing the inner cannula and cleaning the stoma site.
Changing the soiled tracheostomy ties and securing the tube in place
47. 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 proved to the RN? (Select all that apply)
Position the patient supine and turned on his side
Apply direct lateral pressure to the nose for 5 minutes
Maintain universal body substances precautions.
Apply ice or cool compresses to the nose
Instruct the patient not to blow the nose for several hours.
48. 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?
Assessing for bilateral breath sounds and symmetrical chest movements
Auscultating over the stomach to rule out esophageal intubation
Marking the tube 1 cm from where it touches the incisor tooth or nares
Ordering a chest radiograph to verify that tube placement is correct
49. 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?
The patient starts crying and says she can’t go on with treatment much longer
The patient complains of sharp, stabbing chest pain with every deep breath
The patient’s blood pressure is 100/48 mm Hg and her heart rate is 102 beats/ min
The patient’s dressing at the thoracentesis site has 1 cm of bloody drainage
50. 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?
Frequent swallowing
Hypotonic bowel sounds
Complaints of a sore throat
Heart rate of 112 beats/min
Answers and Rationales
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 the other activities. Although allowing more independent decision making is important for adolescents, the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath, it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
Answers: A, B, C, and E. 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). All of the other instructions are appropriate to the care of a patient receiving anticoagulants.
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 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 health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s work of breathing.
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. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate for a licensed nurse.
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. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can delegate administration of medication to an LPN/LVN.
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. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.
Answer: D. Tympanic temperature of 101.4 F (38.6 C). Infections are always a threat for 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.
Answers: A and B. The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. 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.
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 use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.
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 an FiO2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia.
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. Application of a water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.
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. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN.
Answer: D. Oral temperature of 101.2 F (38.4C). A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated but are not a cause for immediate concern.
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 show a significant decrease in the incidence of pneumothorax when it is administered.
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 understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing, and placing the tissues in plastic bags help prevent transmission of the causative organism. The dietary changes are recommended for patients with TB.
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. The maximum oxygen delivery with a nasal cannula is an 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. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
Answer: D. Auscultating the lungs for crackles. An LPN who has been trained to auscultate lungs sounds can gather data by routine assessment and observation, under supervision of an RN. 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.
Answer: A. Warfarin (Coumadin) 1.0 mg by mouth (PO). Medication safety guidelines indicate that 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.
Answer: A, C, B, E, D, F. 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. As the patient begins to breathe in 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.
Answers. A and 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. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. 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.
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 stable condition as those have care similar to her training and experience. A client who is in postoperative state is more likely to be on a stable condition.
Answer: B. Decontaminate the open wound on the client’s thigh. Decontaminating an open wound is the first priority for the client. This minimizes absorption of radiation in the client’s body.
Answer: A. respiratory status. Assessing respiratory status is the first priority. Remember ABC.
Answer: B. Broccoli. Broccoli are gas forming and therefore, should be avoided.
Answer: B. Assist with silver nitrate application to the cervix to control bleeding. 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.
Answer: C. A 35-year-old male with tracheostomy and copious secretions. The patient with problem of the airway should be given highest priority. Remember Airway, Breathing, and Circulation (ABC) is a priority.
Answer: B. Establish whether the client is responsive. Assess first for responsiveness.
Answer: D. Lack of trust to the members of the healthcare team. Lack of trust is the common reason for reluctance in delegation of tasks.
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.
Answer: D. Administer oxygen via nasal cannula. Promotion of adequate oxygenation is the most vital to life and therefore should be given highest priority by the nurse.
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.
Answer: C. A client with chronic bronchitis on nasal oxygen. A client with airway problems should be attended first.
Answer: A. Determine the level of consciousness. Assessing the level of consciousness should be the first action when dealing with clients that might have fell over.
Answer: D. Contact the nursing supervisor to address the situation. The nurse should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.
Answer: D. Pneumococcal vaccine. Pneumococcal vaccine is a priority immunization amongst elderly especially those with chronic illnesses. It is administered every five (5) years.
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 embolus. None of the other findings are risk factors for pulmonary embolus. Prolonged immobilization is also a risk factor for DVT and pulmonary embolus, but this period of bed rest was very short.
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. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN
Answer: C. Maintain the head of the bed at a 30 – to 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. The other actions are also appropriate for this patient but will not decrease the incidence of VAP
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. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema
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. Assisting the patient into 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. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill, and is within the scope of practice of the RN
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. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. 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.
Answer: A, B, D, and E. Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.
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
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. Instructing patients and planning activities require more education and skill, and are appropriate to the RN’s scope of practice. 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
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. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. 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.
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.
Answers: B, C, D, and E. 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
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. The other three actions are appropriate after endotracheal placement. The priority at this time is to verify that the tube has been correctly placed.
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. The other data indicate that the patient needs ongoing monitoring and/or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure
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