1.ID: i9476872990
A iregistered inurse i(RN) ion ithe i7 ia.m.–3 ip.m. ishift iis iplanning iclient
i assignments ifor ithe iday. iWhich iclients iwould ibe iappropriate ifor ithe iRN ito
assign ito ithe ilicensed ipractical inurse i(LPN)? iSelect iall ithat iapply.
A. A iclient iwho ihad ia imastectomy i2 idays iago iCorrect
B. A iclient iwith itype i1 idiabetes imellitus iwho ihas ia ifoot iulcer iCorrect
C. A iclient iwith ileft-side iweakness iwho iwill ineed iassistance iwith
personal icare iCorrect
D. A inewly iadmitted iclient iwith ichronic iobstructive ipulmonary idisease
(COPD)
E. A iclient ibeing itransferred iin ifrom ithe iintensive icare iunit iwith ia ideep
vein ithrombosis iand ia iheparin idrip
Rationale: iWhen ia inurse idelegates iaspects iof ia iclient’s icare ito ianother istaff
i member, ithe inurse iassigning ithe itask iis iresponsible ifor iensuring ithat ieach itask
is iappropriately iassigned ion ithe ibasis iof ithe ieducational ilevel iand icompetency
i
of ithe istaff imember. iThe iclient iwith iCOPD iwho iwas iadmitted iduring ithe inight
i
i will ineed iclose imonitoring iof ithe irespiratory istatus. iAn iLPN imay inot iadminister
most ihigh-risk iintravenous imedications, iincluding iheparin. iThe iclient iwho ihas
i
i had ia imastectomy iand ithe iclient iwith ia ifoot iulcer iwill ilikely irequire idressing
i changes, ian iactivity ithat iis iwithin ithe iscope iof ipractice iof ithe iLPN. iThe iclient
i with ileft-side iweakness irequiring ipersonal icare iassistance icould ialso ibe
assigned ito ithe iLPN.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe isubject,
i assignment ito ithe iLPN. iRecalling ithat ian iLPN imay inot iadminister ihigh-risk
i intravenous imedications iwill iassist iyou iin ieliminating ithis ioption. iEliminate ithe
i newly iadmitted iclient iwith iCOPD, inoting ithat ithis iclient iwill irequire ia ihigher ilevel
of imonitoring. iReview ithe iprinciples iof idelegating itasks iif iyou ihad idifficulty
i
with ithis iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Planning
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iSafety
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iSafety
Reference: iZerwekh, iJ., i& iZerwekh, iA. i(2015). iNursing itoday: iTransition iand
trends i(8th ied., ipp. i305, i308). iSt. iLouis: iElsevier
iAwarded i3.0 ipoints iout iof i3.0 ipossible ipoints.
2.ID: i9476871061
A ihome icare inurse iis iassigned ito ivisit ia iprenatal iclient iwith ia idiagnosis iof
i hyperemesis igravidarum i(HEG). iDuring iphysical iassessment iof ithe iclient, ithe
nurse ishould ifirst:
A. Weigh ithe iclient
, B. Assess ithe iclient’s iintake iand ioutput iCorrect
C. Encourage ithe iclient ito iverbalize iher ifeelings iabout ithe idiagnosis
D. Review ithe iresults iof ithe ihemoglobin iand ihematocrit
determinations
Rationale: iHEG iis ipersistent, iuncontrolled ivomiting ithat ibegins ibefore ithe i20th
week iof ipregnancy. iIt ican ihave iserious iconsequence, iincluding iloss iof i5% iof
i
i prepregnancy iweight, idehydration, iketosis, iacid-base iimbalance, iand
i electrolyte iimbalances. iPhysical iassessment ibegins iwith idetermining ithe
i client’s iintake iand ioutput, ibecause ithese idata iprovide iinformation iregarding
i hydration iand ithe inutritional istatus iof ithe iclient. iThe iclient’s iweight iwould ibe
i obtained iand ithe ibaseline ivalue icompared iwith iprevious iand isubsequent
i values. iAdditionally, ithe inurse iwould iinstruct ithe iclient iin ihow ito iaccurately
i check iand imonitor iher iweight. iLaboratory idata imay ineed ito ibe ievaluated;
i increased ihemoglobin iand ihematocrit ivalues imay ioccur ias ia iresult iof
i dehydration. iEncouraging ithe iclient ito iverbalize iher ifeelings iabout ithe
i diagnosis iis ia icomponent iof ithe iplan iof icare ibut iis inot ithe ifirst iintervention
during iphysical iassessment.
Test-Taking iStrategy: iNote ithe istrategic iword i“first.” iUse iMaslow’s iHierarchy iof
Needs itheory ito ieliminate ithe ioption ithat iindicates iencouraging ithe iclient ito
i
i verbalize iher ifeelings, irecalling ithat iphysiological ineeds iare ithe ipriority. iTo
i select ifrom ithe iremaining ioptions, irecall ithe idescription iof iHEG; ithis iwill idirect
i you ito ithe icorrect ioption. iReview ithe ipriority iphysical iassessment itechniques iin
this idisorder iif iyou ihad idifficulty iwith ithis iquestion.
Level iof iCognitive iAbility: iAnalyzing
iClient iNeeds: iPhysiological iIntegrity
Integrated iProcess: iNursing iProcess/Assessment
Content iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iNutrition
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iNutrition
Reference: iMcKinney, iE., iJames, iS., iMurray, iS., iNelson, iK. i& iAshwill, iJ. i(2013).
Maternal-child inursing i(4th ied., ipp. i589-590). iSt. iLouis: iElsevier.
iAwarded i1.0 ipoints iout iof i1.0 ipossible ipoints.
3.ID: i9476869315
A iregistered inurse i(RN) ion ithe inight ishift ihas ia ilicensed ipractical inurse i(LPN)
and ian iunlicensed iassistive ipersonnel i(UAP)on ithe iteam iand iis iplanning ithe
i
i client iassignments ifor ithe inight. iWhich iclient idoes ithe iRN iassign ito ithe iLPN?
Select iall ithat iapply.
A. A iclient iwho iundergoing ia i24-hour iurine icollection
B. A iclient iwith ia inasogastric itube iwho iunderwent ibowel iresection i2
days iago iCorrect
C. A iclient iwith iurinary ifrequency iwho ineeds iassistance iin igetting ito
the ibathroom
i
, D. A iclient ischeduled ifor irenal idialysis iin ithe imorning iwho ineeds
assistance iwith ihygiene
i
E. A iclient iwho ihas ibeen ifitted iwith iskeletal itraction iof ithe iright ileg
after ian iopen ireduction imeasuresCorrect
Rationale: iWhen ia inurse idelegates iaspects iof ia iclient’s icare ito ianother istaff
i member, ithe inurse iassigning ithe itask iis iresponsible ifor iensuring ithat ieach itask
is iappropriately iassigned ion ithe ibasis iof ithe ieducational ilevel iand icompetency
i
i of ithe istaff imember. iAn iLPN imay iperform icertain iinvasive iprocedures. iA iclient
i with ia inasogastric itube iwho iunderwent ibowel iresection i2 idays iago iand ia iclient
in iskeletal itraction ito ithe iright ileg iafter iopen ireduction imay isafely ibe iassigned ito
i
the iLPN, ibecause ithe iLPN iis icapable iof iperforming ithe inasogastric itube icare,
i
dressing ichanges, iand imonitoring ifor ipostoperative icomplications ithat itheiclients
i
will irequire. iInterventions isuch ias iassisting iclients iwith iambulation iand ihygiene
i
measures iand iperforming inoninvasive iprocedures i— ithe itypes iof itasks
i
identified iin ithe iother ioptions i— imay ibe iassigned ito ia inursing iassistant.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe isubject,
i assignment ito ian iLPN. iEliminate ithe ioptions ithat iare icomparable ior ialike iin ithat
they iare inoninvasive iprocedures. iAlso inote ithat ithe iremaining ioptions iinvolve
i
i routine icare iof ithe ipostoperative iclient iand iactivities ithat iare iwithin ithe iscope iof
practice ifor ithe iLPN. iReview ithe iprinciples iof idelegation iif iyou ihad idifficulty iwith
i
this iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Planning
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iSafety
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iSafety
Reference: iPotter, iP., iPerry, iA. iG., iStockert, iP. iA., i& iHall, iA. iM. i(2013).
Fundamentals iof inursing. i(8thed., ipp. i262, i281-283). iSt. iLouis: iMosby.
iAwarded i2.0 ipoints iout iof i2.0 ipossible ipoints.
4.ID: i9476867243
A inurse iis imonitoring ia iclient iwith ipreeclampsia iwho iis ireceiving iintravenous
magnesium isulfate ito iprevent iseizures. iThe inurse inotes ithat ithe iclient’s
i
respiratory irate iis i10 ibreaths/min. iOn ithe ibasis iof ithis ifinding, ithe inurse ifirst:
A. Takes ithe iclient’s ivital isigns ihealth icare iprovider
B. Contacts ithe ihealth icare iprovider
C. Discontinues ithe imagnesium isulfate iCorrect
D. Checks ithe imost irecent iserum imagnesium isulfate ilevel
Rationale: iA irespiratory irate islower ithan i12 ibreaths/min iis ia isign iof imagnesium
toxicity. iOther isigns iinclude ithe iabsence iof ideep itendon ireflexes, ialtered
i
i sensorium, ihypotension, iand ia iserum imagnesium ilevel iabove ithe itherapeutic
i range iof i5 ito i8 img/dL i(2.05 ito i3.29 immol/L). iIn ithis isituation, ithe inurse iwould
i first idiscontinue ithe imagnesium isulfate. iThe inurse iwould ithen itake ithe iclient’s
, vital isigns iand icontact ithe ihealth icare iprovider ihealth icare iproviderThe imost
i recent iserum imagnesium ilevel imay ibe ichecked; ihowever, ia icurrent iserum ilevel
would iprovide imore iuseful idata.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe idata iin ithe
question. iRecalling ithat ia irespiratory irate islower ithan i12 ibreaths/min iis ia isign iof
i
magnesium itoxicity iwill idirect iyou ito ithe icorrect ioption. iReview ithese isigns
i
and ithe iappropriate inursing iinterventions iif iyou ihad idifficulty iwith ithis iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Implementation
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iClinical iJudgment, iSafety
HESI iConcepts: iClinical iDecision-Making/Clinical iJudgment, iSafety
Reference: iMcKinney, iE., iJames, iS., iMurray, iS., iNelson, iK. i& iAshwill, iJ. i(2013).
Maternal-child inursing i(4th ied., ip. i595). iSt. iLouis: iElsevier.
iAwarded i1.0 ipoints iout iof i1.0 ipossible ipoints.
5.ID: i9476864338
A iclient iwho ihas ijust iundergone iabdominal isurgery icalls ithe inurse iand istates, i“I
feel ias iif iI ijust isplit iopen.” iThe inurse ichecks ithe iabdominal iincision iand ifinds
i
wound ievisceration. iThe inurse iimmediately:
A. Documents ithe ifindings
B. Notifies ithe ioperating iroom
C. Takes ithe iclient’s ivital isigns
D. Contacts ithe ihealth icare iprovider iCorrect
Rationale: iWound ievisceration iis ithe itotal iseparation iof ia isurgical iincision ior
i wound iwith iextrusion iof ithe iinternal iorgans ior iviscera ithrough ithe iopen iwound.
When ievisceration ioccurs, ithe inurse iimmediately icalls ifor ihelp iand ihas ithe
i
i health icare iprovider inotified. iThe inurse istays iwith ithe iclient iand ipositions ithe
i client iwith ithe ihips iand iknees ibent. iThe inurse ithen icovers ithe iabdominal iwound
with ia isterile idressing imoistened iwith isterile isaline isolution. iThe inurse iwould
i
then itake ithe iclient’s ivital isigns iand idocument ithe ioccurrence. iSince ithisiis ia
i
surgical iemergency, ithe ioperating iroom iwould ibe inotified ibut ithis iwould inot
i
be idone iuntil idirected ito ido iso iby ithe isurgeon.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination iand iyour iprioritizing iskills.
i Note ithe istrategic iword i“immediately.” iRecalling ithat iwound ievisceration iis ia
i surgical iemergency iwill idirect iyou ito ithe icorrect ioption. iReview ithe inursing
i actions ito ibe itaken iimmediately iin ithe ievent iof iwound ievisceration ioccurs iif iyou
had idifficulty iwith ithis iquestion.
iLevel iof iCognitive iAbility: iApplying
iClient iNeeds: iPhysiological iIntegrity
Integrated iProcess: iNursing iProcess/Implementation
Content iArea: iDelegating/PrioritizingGiddens iConcepts: iClinical iJudgment,
Caregiving
HESI iConcepts: iClinical iDecision-Making/Clinical iJudgment, iCargiving
A iregistered inurse i(RN) ion ithe i7 ia.m.–3 ip.m. ishift iis iplanning iclient
i assignments ifor ithe iday. iWhich iclients iwould ibe iappropriate ifor ithe iRN ito
assign ito ithe ilicensed ipractical inurse i(LPN)? iSelect iall ithat iapply.
A. A iclient iwho ihad ia imastectomy i2 idays iago iCorrect
B. A iclient iwith itype i1 idiabetes imellitus iwho ihas ia ifoot iulcer iCorrect
C. A iclient iwith ileft-side iweakness iwho iwill ineed iassistance iwith
personal icare iCorrect
D. A inewly iadmitted iclient iwith ichronic iobstructive ipulmonary idisease
(COPD)
E. A iclient ibeing itransferred iin ifrom ithe iintensive icare iunit iwith ia ideep
vein ithrombosis iand ia iheparin idrip
Rationale: iWhen ia inurse idelegates iaspects iof ia iclient’s icare ito ianother istaff
i member, ithe inurse iassigning ithe itask iis iresponsible ifor iensuring ithat ieach itask
is iappropriately iassigned ion ithe ibasis iof ithe ieducational ilevel iand icompetency
i
of ithe istaff imember. iThe iclient iwith iCOPD iwho iwas iadmitted iduring ithe inight
i
i will ineed iclose imonitoring iof ithe irespiratory istatus. iAn iLPN imay inot iadminister
most ihigh-risk iintravenous imedications, iincluding iheparin. iThe iclient iwho ihas
i
i had ia imastectomy iand ithe iclient iwith ia ifoot iulcer iwill ilikely irequire idressing
i changes, ian iactivity ithat iis iwithin ithe iscope iof ipractice iof ithe iLPN. iThe iclient
i with ileft-side iweakness irequiring ipersonal icare iassistance icould ialso ibe
assigned ito ithe iLPN.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe isubject,
i assignment ito ithe iLPN. iRecalling ithat ian iLPN imay inot iadminister ihigh-risk
i intravenous imedications iwill iassist iyou iin ieliminating ithis ioption. iEliminate ithe
i newly iadmitted iclient iwith iCOPD, inoting ithat ithis iclient iwill irequire ia ihigher ilevel
of imonitoring. iReview ithe iprinciples iof idelegating itasks iif iyou ihad idifficulty
i
with ithis iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Planning
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iSafety
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iSafety
Reference: iZerwekh, iJ., i& iZerwekh, iA. i(2015). iNursing itoday: iTransition iand
trends i(8th ied., ipp. i305, i308). iSt. iLouis: iElsevier
iAwarded i3.0 ipoints iout iof i3.0 ipossible ipoints.
2.ID: i9476871061
A ihome icare inurse iis iassigned ito ivisit ia iprenatal iclient iwith ia idiagnosis iof
i hyperemesis igravidarum i(HEG). iDuring iphysical iassessment iof ithe iclient, ithe
nurse ishould ifirst:
A. Weigh ithe iclient
, B. Assess ithe iclient’s iintake iand ioutput iCorrect
C. Encourage ithe iclient ito iverbalize iher ifeelings iabout ithe idiagnosis
D. Review ithe iresults iof ithe ihemoglobin iand ihematocrit
determinations
Rationale: iHEG iis ipersistent, iuncontrolled ivomiting ithat ibegins ibefore ithe i20th
week iof ipregnancy. iIt ican ihave iserious iconsequence, iincluding iloss iof i5% iof
i
i prepregnancy iweight, idehydration, iketosis, iacid-base iimbalance, iand
i electrolyte iimbalances. iPhysical iassessment ibegins iwith idetermining ithe
i client’s iintake iand ioutput, ibecause ithese idata iprovide iinformation iregarding
i hydration iand ithe inutritional istatus iof ithe iclient. iThe iclient’s iweight iwould ibe
i obtained iand ithe ibaseline ivalue icompared iwith iprevious iand isubsequent
i values. iAdditionally, ithe inurse iwould iinstruct ithe iclient iin ihow ito iaccurately
i check iand imonitor iher iweight. iLaboratory idata imay ineed ito ibe ievaluated;
i increased ihemoglobin iand ihematocrit ivalues imay ioccur ias ia iresult iof
i dehydration. iEncouraging ithe iclient ito iverbalize iher ifeelings iabout ithe
i diagnosis iis ia icomponent iof ithe iplan iof icare ibut iis inot ithe ifirst iintervention
during iphysical iassessment.
Test-Taking iStrategy: iNote ithe istrategic iword i“first.” iUse iMaslow’s iHierarchy iof
Needs itheory ito ieliminate ithe ioption ithat iindicates iencouraging ithe iclient ito
i
i verbalize iher ifeelings, irecalling ithat iphysiological ineeds iare ithe ipriority. iTo
i select ifrom ithe iremaining ioptions, irecall ithe idescription iof iHEG; ithis iwill idirect
i you ito ithe icorrect ioption. iReview ithe ipriority iphysical iassessment itechniques iin
this idisorder iif iyou ihad idifficulty iwith ithis iquestion.
Level iof iCognitive iAbility: iAnalyzing
iClient iNeeds: iPhysiological iIntegrity
Integrated iProcess: iNursing iProcess/Assessment
Content iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iNutrition
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iNutrition
Reference: iMcKinney, iE., iJames, iS., iMurray, iS., iNelson, iK. i& iAshwill, iJ. i(2013).
Maternal-child inursing i(4th ied., ipp. i589-590). iSt. iLouis: iElsevier.
iAwarded i1.0 ipoints iout iof i1.0 ipossible ipoints.
3.ID: i9476869315
A iregistered inurse i(RN) ion ithe inight ishift ihas ia ilicensed ipractical inurse i(LPN)
and ian iunlicensed iassistive ipersonnel i(UAP)on ithe iteam iand iis iplanning ithe
i
i client iassignments ifor ithe inight. iWhich iclient idoes ithe iRN iassign ito ithe iLPN?
Select iall ithat iapply.
A. A iclient iwho iundergoing ia i24-hour iurine icollection
B. A iclient iwith ia inasogastric itube iwho iunderwent ibowel iresection i2
days iago iCorrect
C. A iclient iwith iurinary ifrequency iwho ineeds iassistance iin igetting ito
the ibathroom
i
, D. A iclient ischeduled ifor irenal idialysis iin ithe imorning iwho ineeds
assistance iwith ihygiene
i
E. A iclient iwho ihas ibeen ifitted iwith iskeletal itraction iof ithe iright ileg
after ian iopen ireduction imeasuresCorrect
Rationale: iWhen ia inurse idelegates iaspects iof ia iclient’s icare ito ianother istaff
i member, ithe inurse iassigning ithe itask iis iresponsible ifor iensuring ithat ieach itask
is iappropriately iassigned ion ithe ibasis iof ithe ieducational ilevel iand icompetency
i
i of ithe istaff imember. iAn iLPN imay iperform icertain iinvasive iprocedures. iA iclient
i with ia inasogastric itube iwho iunderwent ibowel iresection i2 idays iago iand ia iclient
in iskeletal itraction ito ithe iright ileg iafter iopen ireduction imay isafely ibe iassigned ito
i
the iLPN, ibecause ithe iLPN iis icapable iof iperforming ithe inasogastric itube icare,
i
dressing ichanges, iand imonitoring ifor ipostoperative icomplications ithat itheiclients
i
will irequire. iInterventions isuch ias iassisting iclients iwith iambulation iand ihygiene
i
measures iand iperforming inoninvasive iprocedures i— ithe itypes iof itasks
i
identified iin ithe iother ioptions i— imay ibe iassigned ito ia inursing iassistant.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe isubject,
i assignment ito ian iLPN. iEliminate ithe ioptions ithat iare icomparable ior ialike iin ithat
they iare inoninvasive iprocedures. iAlso inote ithat ithe iremaining ioptions iinvolve
i
i routine icare iof ithe ipostoperative iclient iand iactivities ithat iare iwithin ithe iscope iof
practice ifor ithe iLPN. iReview ithe iprinciples iof idelegation iif iyou ihad idifficulty iwith
i
this iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Planning
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iCare iCoordination, iSafety
HESI iConcepts: iCollaboration/Managing iCare i– iCare iCoordination, iSafety
Reference: iPotter, iP., iPerry, iA. iG., iStockert, iP. iA., i& iHall, iA. iM. i(2013).
Fundamentals iof inursing. i(8thed., ipp. i262, i281-283). iSt. iLouis: iMosby.
iAwarded i2.0 ipoints iout iof i2.0 ipossible ipoints.
4.ID: i9476867243
A inurse iis imonitoring ia iclient iwith ipreeclampsia iwho iis ireceiving iintravenous
magnesium isulfate ito iprevent iseizures. iThe inurse inotes ithat ithe iclient’s
i
respiratory irate iis i10 ibreaths/min. iOn ithe ibasis iof ithis ifinding, ithe inurse ifirst:
A. Takes ithe iclient’s ivital isigns ihealth icare iprovider
B. Contacts ithe ihealth icare iprovider
C. Discontinues ithe imagnesium isulfate iCorrect
D. Checks ithe imost irecent iserum imagnesium isulfate ilevel
Rationale: iA irespiratory irate islower ithan i12 ibreaths/min iis ia isign iof imagnesium
toxicity. iOther isigns iinclude ithe iabsence iof ideep itendon ireflexes, ialtered
i
i sensorium, ihypotension, iand ia iserum imagnesium ilevel iabove ithe itherapeutic
i range iof i5 ito i8 img/dL i(2.05 ito i3.29 immol/L). iIn ithis isituation, ithe inurse iwould
i first idiscontinue ithe imagnesium isulfate. iThe inurse iwould ithen itake ithe iclient’s
, vital isigns iand icontact ithe ihealth icare iprovider ihealth icare iproviderThe imost
i recent iserum imagnesium ilevel imay ibe ichecked; ihowever, ia icurrent iserum ilevel
would iprovide imore iuseful idata.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination, ifocusing ion ithe idata iin ithe
question. iRecalling ithat ia irespiratory irate islower ithan i12 ibreaths/min iis ia isign iof
i
magnesium itoxicity iwill idirect iyou ito ithe icorrect ioption. iReview ithese isigns
i
and ithe iappropriate inursing iinterventions iif iyou ihad idifficulty iwith ithis iquestion.
Level iof iCognitive iAbility: iApplying
Client iNeeds: iSafe iand iEffective iCare iEnvironment
iIntegrated iProcess: iNursing iProcess/Implementation
iContent iArea: iDelegating/Prioritizing
Giddens iConcepts: iClinical iJudgment, iSafety
HESI iConcepts: iClinical iDecision-Making/Clinical iJudgment, iSafety
Reference: iMcKinney, iE., iJames, iS., iMurray, iS., iNelson, iK. i& iAshwill, iJ. i(2013).
Maternal-child inursing i(4th ied., ip. i595). iSt. iLouis: iElsevier.
iAwarded i1.0 ipoints iout iof i1.0 ipossible ipoints.
5.ID: i9476864338
A iclient iwho ihas ijust iundergone iabdominal isurgery icalls ithe inurse iand istates, i“I
feel ias iif iI ijust isplit iopen.” iThe inurse ichecks ithe iabdominal iincision iand ifinds
i
wound ievisceration. iThe inurse iimmediately:
A. Documents ithe ifindings
B. Notifies ithe ioperating iroom
C. Takes ithe iclient’s ivital isigns
D. Contacts ithe ihealth icare iprovider iCorrect
Rationale: iWound ievisceration iis ithe itotal iseparation iof ia isurgical iincision ior
i wound iwith iextrusion iof ithe iinternal iorgans ior iviscera ithrough ithe iopen iwound.
When ievisceration ioccurs, ithe inurse iimmediately icalls ifor ihelp iand ihas ithe
i
i health icare iprovider inotified. iThe inurse istays iwith ithe iclient iand ipositions ithe
i client iwith ithe ihips iand iknees ibent. iThe inurse ithen icovers ithe iabdominal iwound
with ia isterile idressing imoistened iwith isterile isaline isolution. iThe inurse iwould
i
then itake ithe iclient’s ivital isigns iand idocument ithe ioccurrence. iSince ithisiis ia
i
surgical iemergency, ithe ioperating iroom iwould ibe inotified ibut ithis iwould inot
i
be idone iuntil idirected ito ido iso iby ithe isurgeon.
Test-Taking iStrategy: iUse ithe iprocess iof ielimination iand iyour iprioritizing iskills.
i Note ithe istrategic iword i“immediately.” iRecalling ithat iwound ievisceration iis ia
i surgical iemergency iwill idirect iyou ito ithe icorrect ioption. iReview ithe inursing
i actions ito ibe itaken iimmediately iin ithe ievent iof iwound ievisceration ioccurs iif iyou
had idifficulty iwith ithis iquestion.
iLevel iof iCognitive iAbility: iApplying
iClient iNeeds: iPhysiological iIntegrity
Integrated iProcess: iNursing iProcess/Implementation
Content iArea: iDelegating/PrioritizingGiddens iConcepts: iClinical iJudgment,
Caregiving
HESI iConcepts: iClinical iDecision-Making/Clinical iJudgment, iCargiving
