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Confirm current resuscitation wishes with client and family.
Give this one a try later!
27.An older woman with a long history of hypertension is transferred from a
long-term care facility to the hospital intensive care unit because of an
exacerbation of heart failure (HF). She has a signed and witnessed "do not
resuscitate" from in her record. Which action should the nurse take?
The abdomen is rigid, tender to touch, and distended
Give this one a try later!
, The nurse calls a surgeon about a male client who is having abdominal pain
after a bowel resection. He received hydromorphone 2 hours ago and is now
requesting additional pain medication. Vital signs include temperature 97.8 F
(36.6 C), heart rate 112 beats/minute, respirations 24 breaths/minute, and blood
pressure is 98/62 mmHg, which is lower from previous reading one hour ago.
The client has a history of chronic atrial fibrillation and takes clopidogrel,
which was continued until one day prior to surgery. The nurse recommends
that the surgeon see the client immediately to evaluate the situation. What
information makes this report complete?
o Nasogastric suction is draining bile-colored secretions
o Lungs are clear bilaterally and oxygen saturation is 97%
o The abdomen is rigid, tender to touch, and distended
o Client's history includes cardioversion and ablation therapy
admission assessment
Give this one a try later!
The charge nurse, along with one nurse, two practical nurses (PN), a unit
secretary, and two unlicensed assistive personal (UAP), is caring for 24 clients
on a medical surgical unit. Which task is best for the charge nurse to assign to
the nurse?
o The admission assessment of a client diagnosed with bacterial pneumonia
o The subclavian dressing change on a client diagnosed with inflammatory
bowel disease
o Transcription of the healthcare provider's treatment plan for a client
transferred from a critical care unit
o The insertion of a foley catheter for a client diagnosed with septicemia
Ensure the prescriptions or transfer include the client's end-of-life choice.
Give this one a try later!
, 18.A male client with metastatic lung cancer has requested that "no heroic
measures" are used to extend his life, so the healthcare provider prescribes
transferring the client to the palliative care
monitor urinary output hourly
Give this one a try later!
When assessing a client who is returned to the unit following a left
nephrectomy, the nurse notes a small amount of bloody drainage at the drain
site. Which intervention is most important for the nurse to include in this
client's plan of care?
o Document temperature every four hours o Turn, cough, deep breath
o Provide sips of water and ice chips
o Monitor urinary output hourly
3. Notify the physician.
The physician must determine patient competency before a DNR or DNI form can be
signed. Also, the DNR order must be signed by the physician in order to make it valid.
Give this one a try later!
An elderly patient with respiratory failure informs the nurse that she does not
want to be placed on a ventilator. What should the nurse do NEXT?
1) Consult with the patient's family
.2) Notify the hospice team
3) Notify the physician
4) Have the patient sign a DNR form.
, A 73 year old diagnosed with chronic obstructive pulmonary disease who has a pulse
oximeter reading of 84%ment before assessing the client
Give this one a try later!
34.The nurse manager decides to report a staff nurse to the Peer Review
Committee (PRC).
Assess warmth of extremities
Give this one a try later!
A client is admitted to the surgical intensive care unit following the removal of
a large portion of the intestines due to a gunshot wound to the abdomen. The
client begins to display signs of septic shock and a sepsis protocol is initiated.
Which intervention is most important for the nurse to include in the plan of
care?
o Keep head of bed raised 45 degrees
o Maintain strict intake and output
o Monitor blood glucose level
o Assess warmth of extremities
Confirm current resuscitation wishes with client and family
Give this one a try later!
Confirm current resuscitation wishes with client and family.
Give this one a try later!
27.An older woman with a long history of hypertension is transferred from a
long-term care facility to the hospital intensive care unit because of an
exacerbation of heart failure (HF). She has a signed and witnessed "do not
resuscitate" from in her record. Which action should the nurse take?
The abdomen is rigid, tender to touch, and distended
Give this one a try later!
, The nurse calls a surgeon about a male client who is having abdominal pain
after a bowel resection. He received hydromorphone 2 hours ago and is now
requesting additional pain medication. Vital signs include temperature 97.8 F
(36.6 C), heart rate 112 beats/minute, respirations 24 breaths/minute, and blood
pressure is 98/62 mmHg, which is lower from previous reading one hour ago.
The client has a history of chronic atrial fibrillation and takes clopidogrel,
which was continued until one day prior to surgery. The nurse recommends
that the surgeon see the client immediately to evaluate the situation. What
information makes this report complete?
o Nasogastric suction is draining bile-colored secretions
o Lungs are clear bilaterally and oxygen saturation is 97%
o The abdomen is rigid, tender to touch, and distended
o Client's history includes cardioversion and ablation therapy
admission assessment
Give this one a try later!
The charge nurse, along with one nurse, two practical nurses (PN), a unit
secretary, and two unlicensed assistive personal (UAP), is caring for 24 clients
on a medical surgical unit. Which task is best for the charge nurse to assign to
the nurse?
o The admission assessment of a client diagnosed with bacterial pneumonia
o The subclavian dressing change on a client diagnosed with inflammatory
bowel disease
o Transcription of the healthcare provider's treatment plan for a client
transferred from a critical care unit
o The insertion of a foley catheter for a client diagnosed with septicemia
Ensure the prescriptions or transfer include the client's end-of-life choice.
Give this one a try later!
, 18.A male client with metastatic lung cancer has requested that "no heroic
measures" are used to extend his life, so the healthcare provider prescribes
transferring the client to the palliative care
monitor urinary output hourly
Give this one a try later!
When assessing a client who is returned to the unit following a left
nephrectomy, the nurse notes a small amount of bloody drainage at the drain
site. Which intervention is most important for the nurse to include in this
client's plan of care?
o Document temperature every four hours o Turn, cough, deep breath
o Provide sips of water and ice chips
o Monitor urinary output hourly
3. Notify the physician.
The physician must determine patient competency before a DNR or DNI form can be
signed. Also, the DNR order must be signed by the physician in order to make it valid.
Give this one a try later!
An elderly patient with respiratory failure informs the nurse that she does not
want to be placed on a ventilator. What should the nurse do NEXT?
1) Consult with the patient's family
.2) Notify the hospice team
3) Notify the physician
4) Have the patient sign a DNR form.
, A 73 year old diagnosed with chronic obstructive pulmonary disease who has a pulse
oximeter reading of 84%ment before assessing the client
Give this one a try later!
34.The nurse manager decides to report a staff nurse to the Peer Review
Committee (PRC).
Assess warmth of extremities
Give this one a try later!
A client is admitted to the surgical intensive care unit following the removal of
a large portion of the intestines due to a gunshot wound to the abdomen. The
client begins to display signs of septic shock and a sepsis protocol is initiated.
Which intervention is most important for the nurse to include in the plan of
care?
o Keep head of bed raised 45 degrees
o Maintain strict intake and output
o Monitor blood glucose level
o Assess warmth of extremities
Confirm current resuscitation wishes with client and family
Give this one a try later!
