Detailed Rationales for Guaranteed First-Attempt
Success
BP increases stroke risk. Seizure Disorder -
ANSWER//UAP should secure side rails with blankets.
Major Depressive Disorder - ANSWER//Immediate
follow-up needed for purposeless life description.
Ovarian Cancer Evaluation - ANSWER//Negative Pap
smear may still require further surgical evaluation.
Tracheostomy Discharge - ANSWER//Teach tracheal
suctioning techniques. Partial Rebreather Mask -
ANSWER//Document findings of bag not deflating fully
and normal respiratory rate. EKG Monitoring Alarm -
ANSWER//Investigate respiratory apnea alarm first.
Elderly Fall - ANSWER//First check for lacerations or
fractures. Pre-C-Section Coffee - ANSWER//Inform
anesthesia care provider about client's coffee intake.
Heart Auscultation - ANSWER//Use bell to listen for S3
heart sound. Health Insurance Referral - ANSWER//Refer
retiring client to Medicare for health insurance needs.
Tetracycline Administration - ANSWER//Instruct client to
take tetracycline with toasted wheat bread and jelly.
Complication - ANSWER//Indicated by headache
worsening when sitting up post-lumbar puncture Clean
catch mid-stream specimen - ANSWER//Action for an
elderly client with confusion, nausea, dysuria, and
urgency Phenylketonuria (PKU) contraindicated foods -
ANSWER//Foods sweetened with aspartame for a child
with PKU Surgical hand scrub duration -
, ANSWER//Response to a scrub nurse asking about
adequacy of a 3-minute scrub Osteoporosis dietary
management - ANSWER//Breakfast choice indicating
understanding of nurse's instructions Registered nurse
assignment - ANSWER//Client prioritization based on
care needs in a critical care unit Rusty nail injury -
ANSWER//Initial action for a child with a nail through
the foot Athlete's foot treatment - ANSWER//Instruction
for a mother applying antibiotic ointment with no
improvement Levothyroxine sodium dosage -
ANSWER//Symptoms indicating excessive dosage for a
client with a simple goiter Assessment priority for heart
failure client - ANSWER//Key finding to assess in a client
with heart failure symptoms Isoproterenol infusion rate
- ANSWER//Calculation of ml/hour for IV solution based
on prescribed dosage Ascites pathophysiological
mechanisms - ANSWER//Factors responsible for ascites
in liver failure (select all that apply) Heart sounds
auscultation - ANSWER//Description documentation
during heart sounds assessment Murmur - ANSWER//A
swishing sound indicating heart or valvular defect
Ceftazidime - ANSWER//Antibiotic prescribed at 35mg
every 8 hours IM Hydromorphone - ANSWER//Potent
opioid analgesic affecting peristalsis End Stage
Pulmonary Disease - ANSWER//Client requests 'no
heroic measures' in medical record Enteral Tube Feeding
- ANSWER//Changing to half strength due to diarrhea
Hypothyroidism - ANSWER//Manifestations: coarse hair,
puffy eyes, missing eyebrows Ascites - ANSWER//Client
with malnutrition and fluid accumulation in the
abdomen Surgical Consent Form - ANSWER//Nurse's