320 questions

Which items need to be considered when incorporating the right of delegation circumstance? SATA

a) Client needs
b) Available resources
c) Required supervision
d) Competency level
e) Degree of directions

a) Client needs
b) Available resources
c) Required supervision
d) Competency level

The N320 family is visiting the clinic for the first time and will be seen by the nurse practitioner for the initial screening. Given the initial information provided by each patient, prioritize the order in which each member is seen by the NP.

a) Frank: 82 years old has a history of arthritis with a recent diagnosis of skin cancer
b) Eleanor: 78 years old and has pre-diabetes and smokes 1 pack of cigarettes a day - blood sugar 190 mg/dL
c) Carlos: 48 years old has a history of pre-hypertension controlled by diet and weight control and BP is 160/95
d) Debbie: 45 years old reports fatigue and recent weight loss despite not exercising

First: Carlos, due to high BP
Second: Debbie, due to unexplained symptoms that could indicate illness or disease of unknown severity
Third: Eleanor, due to high blood sugar (but not high enough to require immediate emergency treatment)
Last: Frank, due to lack of immediately emergent or urgent symptoms

An adult patient is brought in by ambulance after a motor vehicle accident. The patient is unconscious, on a backboard with the neck immobilized and is bleeding profusely after a large gash in the head. What action should the nurse take first?

a) Stop the bleeding
b) Check airway
c) Take vital signs
d) Verify neurological status

b) Check airway

ABCs - ALWAYS establish airway first. If question clearly specified that patient had a clear airway, stop the bleeding would be the answer.

Which tasks are appropriate to delegate to the UAP? SATA.

a) Taking vital signs on the patients on the unit
b) Monitoring intake and output on the patient administered with dehydration
c) Asking the patient if Tylenol relieved the headache
d) Transporting the patient to radiology for a radiation treatment

a) Taking vital signs on the patients on the unit
d) Transporting the patient to radiology for a radiation treatment

A UAP (tech, CNA) can record output (e.g. foley/urinal voiding), but cannot monitor or evaluate I&Os
The UAP cannot assess or monitor pts pain

Which task is most appropriate for the RN to delegate to the UAP?

a) Checking the post-op patient for chest pain after ambulating to the bathroom
b) Obtain the pulse ox on a patient who became short of breath while ambulating in the hallway
c) Determine when it is appropriate for the patient to rest during ambulation
d) Reinforce with the patient the need to balance rest with activity

b) Obtain the pulse ox on a patient who became short of breath while ambulating in the hallway

UAPs cannot assess patients, make clinical decisions, or provide patient education. The RN should instruct the UAP on when to provide rest during ambulation.

The nurse is starting the 7AM-3PM shift. Which action takes priority?

a) Bathing the patient scheduled for the OR in an hour
b) Checking on the patient who was admitted for chest discomfort and received Nitroglycerin 15 minutes ago
c) Consulting with physical therapy on a patient who underwent a knee replacement yesterday
d) Teaching insulin administration to a newly diagnosed patient with diabetes

b) Checking on the patient who was admitted for chest discomfort and received Nitroglycerin 15 minutes ago

A nurse is caring for a group of patient on the medical-surgical unit with the help of one float RN, one UAP, and one LPN/LVN. Which assignment, if delegated by the nurse, would be inappropriate?

a) Delegate the LPN to assess the bowel sounds on a post-op patient
b) Assign the LPN to administer the daily antihypertensive meds to a patient scheduled for an ultrasound
c) Assign the float RN to a patient with diabetes and urinary frequency
d) Request the UAP check the abdominal dressing after the patient took a shower

d) Request the UAP check the abdominal dressing after the patient took a shower

The RN is working with a UAP and LPN. Which assignment is most appropriate to assign to the LPN?

a) Emptying a urine catheter bag on a immobile patient
b) Assessing the lungs on a patient with leg cellulitis
c) Taking vital signs on a post-op patient
d) Teaching a newly diagnosed patient about diabetes

b) Assessing the lungs on a patient with leg cellulitis

LPNs can perform focused assessments on stable patients.

Which patient task can the registered nurse assign to the UAP?

a) Assist a client with a new tracheostomy to complete trach care
b) Obtain a sputum sample from a patient reporting a productive cough
c) Obtain a urine sample from an indwelling catheter
d) Obtain a diet history from a patient complaining of decreased appetite

b) Obtain a sputum sample from a patient reporting a productive cough

UAPs cannot perform sterile procedures or assess patients, which includes history taking

The RN requests the UAP ambulate a patient with orthostatic hypotension and weakness up and down the hall after breakfast and lunch for 10 minutes and to report back when the task is completed. Which right of delegation did the RN violate?

a) Right task
b) Right circumstance
c) Right direction
d) Right supervision

b) Right circumstance

A 58 year old patient presents in the ER with a history of eating leftover foods last evening and now reports weakness, irritability, abdominal pain, vomiting, and diarrhea. Which category should the nurse assign to this patient?

a) Urgent
b) Non-urgent
c) Emergent
d) Semi-urgent

a) Urgent

This is not an emergency that is potentially fatal without immediate intervention. However, it does need to be addressed promptly due to potential fluid or acid-base imbalance, which is a circulatory issue (ABCs)

Which patient should the emergency room nurse list as urgent?

a) Patient A admitted to the ER with chest discomfort and shortness of breath
b) Patient B admitted with altered mental status and vomiting after being hit in the head with a baseball
c) Patient C admitted with diabetes, blood sugar is 350 and patient is reporting polyuria and polydipsia
d) Patient D admitted with sinus congestion and temperature 100F

c) Patient C admitted with diabetes, blood sugar is 350 and patient is reporting polyuria and polydipsia

a) and b) are emergent. c) is non-urgent.

A triage nurse working in the emergency room received four admissions. Which patient should the nurse see first?

a) A 40 year old client who is diaphoretic and complains of chest pain after mowing the lawn
b) An 18 year old client who thinks he might have a fractured arm after playing football. Arm is swollen and painful.
c) A 35 year old client who has a leg laceration from construction work after a metal pole fell on upper thigh
d) A 60 year old client with peanut allergy who is experiencing stridor and swollen mouth after eating food made in peanut oil.

d) A 60 year old client with peanut allergy who is experiencing stridor and swollen mouth after eating food made in peanut oil.

Stridor and swelling indicate a potential for airway obstruction, which takes priority over chest pain (ABCs - chest pain is circulatory)

The RN is working with an LPN and a UAP. Which action by the RN violates the 5 rights of delegation?

a) The RN asks the UAP to take vital signs on the patient returning from a radiation treatment
b) The RN asks the LPN to administer Motrin PO to the patient who complained of a sore ankle
c) The RN asks the UAP to take the urine specimen to the lab
d) The RN asks the LPN to check on the patient's pain who received nitroglycerin for complaint of chest discomfort

d) The RN asks the LPN to check on the patient's pain who received nitroglycerin for complaint of chest discomfort

The charge nurse is working with an LPN, UAP, and another RN. Which patient assignment is appropriate to delegate to the other RN?

a) Patient A with an arm fracture needs assisting with feeding and bathing
b) Patient B with diabetes and a wound infection that needs daily insulin injection
c) Patient C needs his chest pain re-assessed before giving a second dose of medication
d) Patient D with chronic bronchitis needs transportation to radiology for a chest X-ray

c) Patient C needs his chest pain re-assessed before giving a second dose of medication

Patient A can be delegated to the UAP.
Patient B can be delegated to the LPN.
Patient D can be delegated to the UAP.

The chronic pain patient reports to the charge nurse that the nurses have not been responding to requests for pain medication. Which action should the charge nurse take first?

a) Check the MARs and nurses notes for the past several days
b) Request the nurse educator provide an in-service about pain medication
c) Perform a complete pain assessment and history on the patient
d) Have a conference with the nurses responsible for the patient's care

d) Have a conference with the nurses responsible for the patient's care

Unless there is an emergency, the first step to responding to problems should discussion with the RN/UAP/LPN responsible for the patient

How should assessment findings of blanched cool skin and leaking fluid at a peripheral infusion site be documented?

a) Infiltration
b) Infection
c) Extravasation
d) Phlebitis

a) Infiltration

Fluid that has leaked into surrounding tissue (infiltration) will result in cool blanched skin. These are not signs of infection or inflammation. Blisters are seen with extravasation.

Which of the following describes infiltration?

a) Coolness at sight
b) Red streaks along arm
c) Blistering and necrosis of tissue

a) Coolness at sight

Which of the following describes extravasation?

a) Coolness at sight
b) Red streaks along arm
c) Blistering and necrosis of tissue

c) Blistering and necrosis of tissue

Which of the following describes phlebitis?

a) Coolness at sight
b) Red streaks along arm
c) Blistering and necrosis of tissue

b) Red streaks along arm

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

a) A postoperative client preparing for discharge with a new medication
b) A client requiring daily dressing changes of a recent surgical incision
c) A client scheduled for a chest x-ray after insertion of a nasogastric tube
d) A client with asthma who requested a breathing treatment during the previous shift

d) A client with asthma who requested a breathing treatment during the previous shift

Airway is always the highest priority - request of a breathing treatment may indicate the client is experiencing difficulty breathing. Clients A-C would be intermediate priority.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

a) A client complaining of muscle aches, a headache, and history of seizures
b) A client who twisted her ankle when rollerblading and is requesting medication for pain
c) A client with a minor laceration on the index finger sustained while cutting an eggplant
d) A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

d) A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Clients with chest pain are always high priority

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

a) A client who is ambulatory demonstrating a steady gait
b) A postoperative client who has just received an opioid pain medication
c) A client scheduled for physical therapy for the first crutch-walking session
d) A client with a white blood cell count of 14,000 mm^3 and a temperature of 38.4 C (101 F)

d) A client with a white blood cell count of 14,000 mm^3 and a temperature of 38.4 C (101 F)

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for a UAP?

a) A client requiring colostomy irrigation
b) A client receiving continuous tube feedings
c) A client who requires urine specimen collections
d) A client with difficulty swallowing foods and fluids

c) A client who requires urine specimen collections

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign 4 clients and has an LPN and 3 UAPs on a nursing team. Which client would the nurse most appropriately assign to the LPN?

a) A client who requires a bed bath
b) An older client requiring frequent ambulation
c) A client who requires hourly vital sign measurements
d) A client requiring abdominal wound irrigations and dressing changes every 3 hours

d) A client requiring abdominal wound irrigations and dressing changes every 3 hours

When a nurse administers the hypertonic solution such as 3% NaCl to a patient, what actions are essential? SATA.

a) Auscultate lung sounds
b) Monitor blood pressure
c) Monitor urine output
d) Check sodium level
e) Check for tetany

a) Auscultate lung sounds
b) Monitor blood pressure
c) Monitor urine output
d) Check sodium level

Hypertonic solution increases blood volume as fluid leaves the cells

Which fluid can the nurse anticipate when the physician orders a hypotonic solutions?

a) 0.45% NS
b) 0.9% NS
c) 3% NaCl
d) D10 ½ NS

a) 0.45% NS

Hypotonic \= less concentrated than body fluids

Which situation warrants action by the nurse? SATA.

a) The patient with a fluid volume deficit from hemorrhaging is ordered NSS
b) The patient with active seizures and a Na+ level of 158 is ordered 3% NaCl
c) The patient with head trauma is ordered D5W
d) The patient with Na+ level of 144 is ordered NSS

b) The patient with active seizures and a Na+ level of 158 is ordered 3% NaCl
c) The patient with head trauma is ordered D5W

Normal Na is 135-145, so a pt w/ Na level of 158 should not be given a hypertonic NaCl solution

Head trauma pts should not be given D5W since it becomes hypotonic when metabolized, causing fluid to enter the cells - risk for cerebral edema

The nurse is instructing a patient on the side effects of chemotherapy. Which instructions are important to provide to the patient? SATA.

a) Hair returning after experiencing alopecia will most likely be a different texture
b) Please report any elevated temperature to the physician
c) Excessive fatigue and sore throat can be anticipated
d) Take your antiemetic medication only if vomiting occurs

a) Hair returning after experiencing alopecia will most likely be a different texture
b) Please report any elevated temperature to the physician

Sore throat is not an expected side effect of chemo. Antiemetic medication should be taken to prevent nausea, even when the pt is not currently nauseous.

The student nurse is discussing brachytherapy to her peers during post-conference. Which statement by the student warrant further teaching by the instructor?

a) The two types of brachytherapy is low dose and high dose
b) Similar to external radiation, the patient does not give off radiation
c) The implants may be temporary or permanent
d) Discomfort at the brachytherapy site may occur

b) Similar to external radiation, the patient does not give off radiation

At first the body will emit low doses of radiation from the area being treated.

The patient is undergoing external radiation for lung cancer. Which patient statement warrants further intervention by the nurse?

a) I will continue to use my favorite soap.
b) The skin marks (radiation tattoo) will not be removed.
c) No swimming pools for me until my skin heals.
d) I will be careful not to put hot water on my skin during treatment

a) I will continue to use my favorite soap.

Which statement by the patient indicated teaching about chemotherapy was effective?

a) I know everyone loses their hair with chemo
b) I know it is important that I monitor my temperature
c) I know I should eat whatever I want so I don't lose weight while on chemo
d) I understand I skip a chemo treatment if I don't feel well

b) I know it is important that I monitor my temperature

What is the most specific method of diagnosing a malignancy?

a) Serum laboratory tests
b) MRI
c) CAT scan
d) Biopsy

d) Biopsy

The nurse is caring for a patient with neutropenia. Which tasks should the nurse assign to the UAP? SATA.

a) Take vital signs every 4 hours
b) Report temperature greater than 100.4F
c) Ask the patient about a sore throat or urinary burning
d) Gather supplies to prepare the protective isolation room
e) Report any superinfection such as thrush
f) Practice good hand-washing technique

a) Take vital signs every 4 hours
b) Report temperature greater than 100.4F
d) Gather supplies to prepare the protective isolation room
f) Practice good hand-washing technique

A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?

a) Charge nurse
b) Registered nurse (RN)
c) Practical nurse (LPN)
d) Assistive personnel (UAP)

b) Registered nurse (RN)

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to a UAP. Which of the following information should the nurse share with the UAP? SATA.

a) The roommate ambulates independently
b) The client ambulates wearing slippers over antiembolic stocking
c) The client uses a front-wheeled walker when ambulating
d) The client had pain medication 30 minutes ago
e) The client is allergic to codeine
f) The client ate 50% of breakfast this morning

b) The client ambulates wearing slippers over antiembolic stocking
c) The client uses a front-wheeled walker when ambulating
d) The client had pain medication 30 minutes ago

The UAP needs to make sure the client uses the walker, wears slippers, and may be feeling the effects of pain medication.

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to an LPN?

a) Creating a plan of care for a client who is recovering from a stroke
b) Assessing a pressure injury for a client who is on bed rest
c) Providing nasopharyngeal suctioning for a client who has pneumonia
d) Teaching a client who has asthma to use a metered-dose inhaler

c) Providing nasopharyngeal suctioning for a client who has pneumonia

TAPE acronym: Teaching, Assessing, Planning, Evaluating
TAPE tasks cannot be delegated and must be completed by the RN.
Creating a care plan, assessing a pressure injury, and teaching a client are all TAPE tasks
Suctioning can be delegated to the LPN since it is within their scope of practice

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? SATA.

a) Right place
b) Right supervision and evaluation
c) Right direction and communication
d) Right documentation
e) Right circumstances

b) Right supervision and evaluation
c) Right direction and communication
e) Right circumstances

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45m PaCO2 of 30, and HCO3 of 20. The nurse analyzes these results as indicating which condition?

a) Metabolic acidosis, compensated
b) Respiratory alkalosis, compensated
c) Metabolic alkalosis, uncompensated
d) Respiratory acidosis, uncompensated

b) Respiratory alkalosis, compensated

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

b) Metabolic alkalosis

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following?

a) A decreased pH and an increased PaCO2
b) An increased pH and a decreased PaCO2
c) A decreased pH and a decreased HCO3
d) An increased pH and an increased HCO3

d) An increased pH and an increased HCO3

Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, causing the pH and HCO3 to increase.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? SATA.

a) Respirations that are shallow
b) Respirations that are increased in rate
c) Respirations that are abnormally slow
d) Respirations that are abnormally deep
e) Respirations that cease for several seconds

b) Respirations that are increased in rate
d) Respirations that are abnormally deep

Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH 7.12, PaCO2 90, HCO3 22. The nurse interprets the results as indicating which condition?

a) Metabolic acidosis with compensation
b) Respiratory acidosis with compensation
c) Metabolic acidosis without compensation
d) Respiratory acidosis without compensation

d) Respiratory acidosis without compensation

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30. The nurse monitors the client for which clinical manifestations associated with these ABG results? SATA.

a) Nausea
b) Confusion
c) Bradypnea
d) Tachycardia
e) Hyperkalemia
f) Lightheadedness

a) Nausea
b) Confusion
d) Tachycardia
f) Lightheadedness

Manifestations of respiratory alkalosis: lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness/tingling in the extremities, hyperventilation (tachypnea)

A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and "not feeling well". The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

a) Obtain a specimen for culture
b) Apply a warm compress
c) Administer analgesics
d) Discontinue the infusion

d) Discontinue the infusion

The greatest risk to this client is further injury to the irritated vein. The first action is to stop the infusion and remove the catheter to prevent further harm.

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicated an understanding of the manifestations of infiltration? SATA.

a) The temperature around the IV site is cooler.
b) The rate of infusion increases.
c) The skin at the IV site is red.
d) The IV dressing is damp.
e) The tissue around the venipuncture site is swollen.

a) The temperature around the IV site is cooler.
d) The IV dressing is damp.
e) The tissue around the venipuncture site is swollen.

A nurse is caring for a client receiving dextrose 5% in 0.9& sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? SATA.

a) I feel lightheaded.
b) I feel as through my heart is racing.
c) I feel a little short of breath.
d) The nurse technician told me that my blood pressure was 150 over 90.
e) I think my ankles are less swollen.

b) I feel as through my heart is racing.
c) I feel a little short of breath.
d) The nurse technician told me that my blood pressure was 150 over 90.

Lightheadedness is a manifestation of hypotension.
Tachycardia - due to increased blood volume, causing the heart rate to increase
Dyspnea - due to increased amount of fluid entering the air spaces in the lungs, which reduces the amount of circulating oxygen

A nurse is obtaining arterial blood gases for a client who has vomited for 24 hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr?

a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis

d) Metabolic alkalosis

Excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis

A nurse is assessing a client who has pancreatitis. The client's arterial blood gases reveal metabolic acidosis. Which of the following are expected findings? SATA.

a) Tachycardia
b) Hypertension
c) Bounding pulses
d) Hyperreflexia
e) Dysrhythmia
f) Tachypnea

e) Dysrhythmia
f) Tachypnea

Tachycardia is an expected finding of respiratory acidosis or metabolic alkalosis
HTN is an expected finding of respiratory acidosis
Hyperreflexia is an expected finding of metabolic alkalosis

Which patient is most likely to have respiratory alkalosis?

a) Hypoxic patient
b) Patient with a body cast
c) Patient with a panic attack
d) A smoker who is obese and with chronic lung disease

c) Patient with a panic attack

A nurse is caring for a client diagnosed with respiratory acidosis. Which arterial blood gas findings should indicate to the nurse that the client's kidneys have compensated for the imbalance?

a) pH \= 7.45; CO2\=60; HCO3 \= 35
b) pH \= 7.35; CO2 \= 50, HCO3 \= 30
c) pH \= 7.50; CO2 \= 35, HCO3 \= 30
d) pH \= 7.44; CO2 \= 45, HCO3 \= 24

b) pH \= 7.35; CO2 \= 50, HCO3 \= 30

Which lab value is most important for the nurse to assess in a patient who is experiencing metabolic acidosis?

a) Sodium
b) Magnesium
c) Phosphorus
d) Potassium

d) Potassium

A recent GN is getting ready to take the NCLEX. She is nervous and slightly diaphoretic. Which ABG result is most likely?

a) pH 7.41, CO2 42, HCO3- 23
b) pH 7.30, CO2 38, HCO3- 20
c) pH 7.48, CO2 31, HCO3- 23
d) pH 7.37, CO2 55, HCO3- 30

c) pH 7.48, CO2 31, HCO3- 23

The nurse is completing a pre-op history on Frank. Which statements by Frank warrant further action by the nurse? Select all that apply.

a) I am scheduled to go to the dentist next week for my decayed cavity
b) My arthritis has been acting up so I restarted my over the counter pain meds
c) My last cigarette was about 40 years ago after I experienced bronchitis
d) The home remedies are the best for relaxation and stress

a) I am scheduled to go to the dentist next week for my decayed cavity
b) My arthritis has been acting up so I restarted my over the counter pain meds
d) The home remedies are the best for relaxation and stress

While under anesthesia, Frank starts to develop a temp of 102 and tachycardia. Which intervention should the OR circulating nurse anticipate?

a) Requesting a defibrillator
b) Administering an antibiotic
c) Obtaining a blood glucose level
d) Mixing Dantrolene

d) Mixing Dantrolene

Frank has entered the PACU. He is responsive, but sleepy and complains of nausea. His vital signs are BP 120/68, HR 86, RR 14, pulse ox 96% on 1L of oxygen.
The charge nurse is working with a new graduate nurse in the PACU. Which action by the new nurse warrants intervention by the charge nurse? Select all that apply.

a) The nurse is increasing the head of the bed for Frank
b) The nurse retakes vital signs every 5-10 minutes
c) The nurse assesses Frank's incision and ensures the Jackson Pratt drain is flowing by gravity
d) The nurse offers Frank a chance to ambulate to the bathroom

a) The nurse is increasing the head of the bed for Frank
c) The nurse assesses Frank's incision and ensures the Jackson Pratt drain is flowing by gravity
d) The nurse offers Frank a chance to ambulate to the bathroom

Frank is inquiring why he needs to ambulate several times a day. The nurse understands that her response will be based on the principles that ambulation can prevent which complication? Select all that apply.

a) Pneumonia
b) Deep vein thrombosis
c) Constipation
d) Urinary tract infections
e) Delayed wound healing
f) Muscle weakness
g) Depression

a) Pneumonia
b) Deep vein thrombosis
c) Constipation
d) Urinary tract infections
e) Delayed wound healing
f) Muscle weakness
g) Depression

The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

a) Urinary output of 20 mL/hr
b) Temperature of 37.6C (99.6F)
c) Blood pressure of 100/70 mm Hg
d) Serous drainage on the surgical dressing

a) Urinary output of 20 mL/hr

Urine output should be at a minimum of 30 mL/hr for an adult

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

a) Use of an incentive spirometer will help prevent pneumonia
b) Close monitoring of your oxygen saturation will detect hypoxemia
c) Administration of fluids will prevent or treat fluid imbalance
d) Early ambulation and administration of blood thinners will prevent pulmonary embolism

a) Use of an incentive spirometer will help prevent pneumonia

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery.

a) Avoid oral hygiene and rinsing with mouthwash
b) Verify that the client has not eaten for the last 24 hours
c) Have the client void immediately before going into surgery
d) Report immediately any slight increase in blood pressure or pulse

c) Have the client void immediately before going into surgery

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

a) Obtain a court order for the surgery
b) Have the charge nurse sign the informed consent immediately
c) Send the client to surgery without the consent form being signed
d) Obtain a telephone consent from a family member following agency policy

d) Obtain a telephone consent from a family member following agency policy

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

a) Inhale as rapidly as possible
b) Keep a loose seal between the lips and the mouthpiece
c) After maximum inspiration, hold the breath for 15 seconds and exhale
d) The best results are achieved when sitting up or with the head of the bed elevated to 45 to 90 degrees

c) After maximum inspiration, hold the breath for 15 seconds and exhale

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history or arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

a) Aspirin can cause bleeding after surgery.
b) Aspirin can cause my ability to clot blood to be abnormal.
c) I need to continue to take the aspirin until the day of surgery.
d) I need to check with my doctor about the need to stop the aspirin before the scheduled surgery.

c) I need to continue to take the aspirin until the day of surgery.

Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

a) Increasing restlessness
b) A pulse of 86 beats per minute
c) Blood pressure of 110/70 mm Hg
d) Hypoactive bowel sounds in all 4 quadrants

a) Increasing restlessness

Increasing restlessness could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.

a) Contact the surgeon
b) Instruct the client to remain quiet
c) Prepare the client for wound closure
d) Document the findings and actions taken
e) Place a sterile saline dressing and ice packs over the wound
f) Place the client in a supine position without a pillow under the head

a) Contact the surgeon
b) Instruct the client to remain quiet
c) Prepare the client for wound closure
d) Document the findings and actions taken

The nurse should place the client in low-Fowler's position and instruct the client to keep quiet and not cough.

The patient is experiencing primary polycythemia. Which action is most appropriate by the nurse?

a) Administer oxygen
b) Monitor the temperature frequently
c) Monitor for signs of bleeding
d) Encourage fluids

d) Encourage fluids

Fluids will decrease the viscosity of the blood and thus permit greater flow - this condition causes too many RBCs

The nurse is caring for the patient receiving chemotherapy. Which patient response indicates a potentially life-threatening situation?

a) Mucositis
b) Alopecia
c) 100F temperature
d) Fatigue

c) 100F temperature

Patients receiving chemo are at risk for bone marrow suppression and a low grade temp can be a sign of a life threatening infection/condition

Which is a priority diagnosis for a patient experiencing chemotherapy-induced anemia?

a) Risk of injury related to poor blood clotting
b) Fatigue related to decreased cellular oxygenation
c) Altered body image related to skin color changes
d) Imbalanced nutrition, less than requirements related to anorexia

b) Fatigue related to decreased cellular oxygenation

Determine the level of compensation in the following arterial blood gas:
7.49/39/94/30/95%

Uncompensated

This ABG is uncompensated because the CO2 is normal, while the pH and HCO3- are abnormal. This means the respiratory system is not attempting to compensate for this imbalance (metabolic alkalosis)

Format: pH/PaCO2/PaO2/HCO3-/SpO2
Normal pH: 7.35 - 7.45
Normal CO2: 35 - 45
Normal HCO3- (bicarb): 22 - 26

Which intervention should the nurse implement for the patient with respiratory alkalosis?

a) Administer bicarbonate
b) Encourage purse lip breathing
c) Administer antiemetic
d) Encourage breathing into a paper bag

d) Encourage breathing into a paper bag

Breathing into a paper bag will increase the uptake of CO2, which should treat the respiratory alkalosis by decreasing the pH (CO2 is acidic; lower pH \= more acid)

The patient lab results show an absolute neutrophil count (ANC) level of 400. Which interventions should the nurse implement? Select all that apply.

a) Encourage patient to use a soft toothbrush
b) Remove all fresh flowers from the room
c) Screen all visitors
d) Check stool for blood
e) Place patient in a private room
f) Encourage frequent rest periods

b) Remove all fresh flowers from the room
c) Screen all visitors
e) Place patient in a private room

Normal ANC: 2,500 - 6,000

Which acid base condition is reflected in the ABG:
7.32/58/93/24/95%

Respiratory acidosis, since the pH is decreased (acidosis), CO2 is increased, and HCO3- is normal (uncompensated)

Format: pH/PaCO2/PaO2/HCO3-/SpO2
Normal pH: 7.35 - 7.45
Normal CO2: 35 - 45
Normal HCO3- (bicarb): 22 - 26

Which are causes of respiratory acidosis? Select all that apply.

a) Over sedation
b) Hypoventilation
c) Anxiety
d) Pain

a) Over sedation
b) Hypoventilation

Respiratory acidosis \= accumulation of CO2

A nurse is caring for a patient with a platelet count of 20,000. Which of the following is the priority intervention?

a) Assess for spontaneous bleeding
b) Administer aspirin
c) Initiate neutropenic precautions
d) Restrict visitors

a) Assess for spontaneous bleeding

Which of the following is the most important nursing action when caring for a neutropenic patient?

a) Don a disposable mask in the room
b) Limit patient contact to 30 minutes at a time
c) Perform hand hygiene
d) Remove fresh flowers from the room

c) Perform hand hygiene

When is the best time to administer the antiemetic for the patient undergoing chemotherapy?

a) When the client begins to feel nauseated
b) After completion of the treatment regimen
c) At the same time as the chemotherapeutic agent
d) Thirty minutes before chemotherapy is started

d) Thirty minutes before chemotherapy is started

Which instruction is appropriate for the nurse to provide the patient with multiple myeloma who is scheduled for discharge?

a) Maintain bedrest to decrease oxygen demand
b) Restrict fluid to 1,000 mL/day
c) Maintain a low-fiber, high calorie diet with small frequent meals
d) Notify physician if nausea and constipation persist

d) Notify physician if nausea and constipation persist

The nurse is reviewing the complete blood count (CBC) for the patient admitted for knee arthroscopy. Which value is most important to report to the physician prior to surgery?

a) White blood count 16,000/mm3
b) Hematocrit 42%
c) Platelet count of 415,000/mm3
d) Hemoglobin 10.2 g/dL

d) Hemoglobin 10.2 g/dL

The patient with multiple myeloma becomes lethargic. The nurse would expect these manifestations may be explained by which condition?

a) Hyperkalemia
b) Hyperuricemia
c) Hypercalcemia
d) CNS myeloma

c) Hypercalcemia

Multiple myeloma pts are at risk for hypercalcemia due to calcium entering the blood as bones are broken down

The patient is undergoing brachytherapy for treatment of prostate cancer. Which action is most appropriate by the nurse?

a) Wear the radiology film badge when caring for this patient
b) Encourage family members to visit the patient
c) Review the patient skin care regarding the radiation field marks
d) Discuss with the patient strategies to deal with the expected alopecia

a) Wear the radiology film badge when caring for this patient

The charge nurse must assign an unlicensed assistive personnel (UAP) to help care for a patient with non-Hodgkin's lymphoma experiencing neutropenia. Which factor has the most impact in assigning a UAP to care for this patient? The nursing assistant...

a) Is in her first trimester of pregnancy
b) Has reported a scratchy throat for 2 days
c) Has no experience with this patient's specific care precautions
d) Has generalized fear of isolation clients

b) Has reported a scratchy throat for 2 days

Which patients experiencing cancer can be placed together as roommates? Select all that apply.

a) The patient who has a very low neutrophil count
b) The patient who underwent tumor shrinking to relieve pressure
c) The patient who just underwent a bone marrow transplantation
d) The patient who is undergoing brachytherapy for prostate cancer
e) The patient with terminal cancer who is receiving end-of-life care
f) The patient who had a laminectomy for spinal cord compression

b) The patient who underwent tumor shrinking to relieve pressure
f) The patient who had a laminectomy for spinal cord compression

What is the difference between infiltration and extravasation?

Infiltration is the leakage of IV fluids out of the vessel into surrounding tissues

Extravasation is specifically infiltration of a vesicant - it causes more severe damage than infiltration of non-vesicant solutions, such as blistering and tissue necrosis

Describe the movement of fluid in the body when administering hypotonic fluids.

Fluid moves INTO the cells (intracellular space) FROM the blood (intravascular space)

What are the contraindications for hypotonic fluid administration? Why is it contraindicated?

Increased intracranial pressure & cerebral edema - more fluid will enter brain cells, causing them to further swell
Burns and trauma - hypovolemia is already a risk for burns/hemorrhage due to trauma, hypotonic solutions increase that risk

What is the difference between tunneled and non-tunneled central catheters? When are they used?

Tunneled - the catheter is tunneled under the skin (subq tissue) after it exits the vein, then exits the skin at a more distal site. It is used as a CVAD when a patient requires long-term IV therapy such as hemodialysis since it lasts longer than a PICC line

Non-tunneled - the catheter exits the skin at the same place it exits the vein. It is only placed in emergency situations where peripheral IV sites can't be accessed

Should a central line be removed if pneumothorax or air embolism occurs on insertion?

NO - these are caused by complications of insertion, not by an issue with the catheter itself. If the catheter is placed correctly, it will not be removed so it can be used to administer IV meds

These symptoms describe which systemic IV therapy complication? (pneumothorax, circulatory overload, air embolism, or catheter related infection)

- Chest pain
- SOB
- Decreased BP
- Increased HR
- Cyanosis
- Anxiety
- Confusion

Air embolism

These symptoms describe which systemic IV therapy complication? (pneumothorax, circulatory overload, air embolism, or catheter related infection)

- Decreased or absent breath sounds
- Respiratory distress
- Distended unilateral chest

Pneumothorax

These symptoms describe which systemic IV therapy complication? (pneumothorax, circulatory overload, air embolism, or catheter related infection)

- Abrupt rise in temperature
- Severe chills
- Shaking
- Increased HR
- Increased RR
- Headache

Catheter related infection

These symptoms describe which systemic IV therapy complication? (pneumothorax, circulatory overload, air embolism, or catheter related infection)

- Increased BP
- Distended neck veins
- Shortness of breath

Circulatory overload

Normal RBC value

3.6 - 5.8 million/mm3

Normal hemoglobin

11.7 - 17.3 g/dL

Normal hematocrit

36 - 52%

Normal WBC

4,500 - 11,000 /mm3

Normal platelets

150,000 - 450,000 /uL

Normal erythrocyte sedimentation rate (ESR)

< 30 mm/hr

Normal bleeding time

3 - 8 minutes

What lab values are associated with aplastic anemia? Why do these values occur?

Pancytopenia - decreased RBCs, WBCs, and platelets
These are due to bone marrow suppression, often secondary to chemotherapy treatment

What lab values are associated with primary polycythemia/polycythemia vera? Why do these values occur?

Increased RBCs, WBCs, and platelets
These are due to a chromosomal mutation in stem cells