BA 108 (BA108)/ BA 108 Delegation Questions and Answers

Exam (elaborations) BA 108 (BA108)/ BA 108 Delegation Questions and Answers 1. 1.ID: 0 A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all that apply. A. A client who had a mastectomy 2 days ago Correct B. A client with type 1 diabetes mellitus who has a foot ulcer Correct C. A client with left-side weakness who will need assistance with personal care Correct D. A newly admitted client with chronic obstructive pulmonary disease (COPD) E. A client being transferred in from the intensive care unit with a deep vein thrombosis and a heparin drip Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN. Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the LPN. Recalling that an LPN may not administer high-risk intravenous medications will assist you in eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp. 305, 308). St. Louis: Elsevier Awarded 3.0 points out of 3.0 possible points. 2. 2.ID: 1 A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first: A. Weigh the client Incorrect B. Assess the client’s intake and output Correct C. Encourage the client to verbalize her feelings about the diagnosis D. Review the results of the hemoglobin and hematocrit determinations Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid-base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client’s intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client’s weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention during physical assessment. Test-Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that physiological needs are the priority. To select from the remaining options, recall the description of HEG; this will direct you to the correct option. Review the priority physical assessment techniques in this disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Nutrition HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. 3. 3.ID: 5 A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply. A. A client who undergoing a 24-hour urine collection Incorrect B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct C. A client with urinary frequency who needs assistance in getting to the bathroom D. A client scheduled for renal dialysis in the morning who needs assistance with hygiene E. A client who has been fitted with skeletal traction of the right leg after an open reduction measures Correct Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant. Test-Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures. Also note that the remaining options involve routine care of the postoperative client and activities that are within the scope of practice for the LPN. Review the principles of delegation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 262, 281-283). St. Louis: Mosby. Awarded 1.0 points out of 2.0 possible points. 4. 4.ID: 3 A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client’s respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first: A. Takes the client’s vital signs health care provider B. Contacts the health care provider Incorrect C. Discontinues the magnesium sulfate Correct D. Checks the most recent serum magnesium sulfate level Rationale: A respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity.Other signs include the absence of deep tendon reflexes, altered sensorium, hypotension, and a serum magnesium level above the therapeutic range of 5 to 8 mg/dL (2.05 to 3.29 mmol/L). In this situation, the nurse would first discontinue the magnesium sulfate. The nurse would then take the client’s vital signs and contact the health care provider health care providerThe most recent serum magnesium level may be checked; however, a current serum level would provide more useful data. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling that a respiratory rate slower than 12 breaths/min is a sign of magnesium toxicity will direct you to the correct option. Review these signs and the appropriate nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 595). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. 5. 5.ID: 8 A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split open.” The nurse checks the abdominal incision and finds wound evisceration. The nurse immediately: A. Documents the findings B. Notifies the operating room C. Takes the client’s vital signs D. Contacts the health care provider Correct Rationale: Wound evisceration is the total separation of a surgical incision or wound with extrusion of the internal organs or viscera through the open wound. When evisceration occurs, the nurse immediately calls for help and has the health care provider notified. The nurse stays with the client and positions the client with the hips and knees bent. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline solution. The nurse would then take the client’s vital signs and document the occurrence. Since this is a surgical emergency, the operating room would be notified but this would not be done until directed to do so by the surgeon. Test-Taking Strategy: Use the process of elimination and your prioritizing skills. Note the strategic word “immediately.” Recalling that wound evisceration is a surgical emergency will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound evisceration occurs if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 1 A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125 mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of dependent edema and puffiness around the client’s eyes. The nurse suspects circulatory overload and immediately: A. Slows the IV rate Correct B. Administers a diuretic C. Contacts the health care provider D. Places the client in a supine position Rationale: Signs of circulatory overload include shortness of breath, cough, increased blood pressure, puffiness around the eyes, and edema in dependent areas. The client’s neck veins may be engorged, and the nurse may hear moist breath sounds on auscultation of the lungs. If circulatory overload occurs, the nurse must immediately slow the IV rate and then notify the health care provider. The client would be placed in an upright position. The nurse would monitor the client’s vital signs and administer oxygen and diuretics as prescribed. Test-Taking Strategy: Focus on the data in the question and note the strategic word “immediately.” Eliminate the option in which the client is place in a supine position, because this position will exacerbate the existing shortness of breath. Recalling that administration of a diuretic requires a health care provider’s prescription will assist you in eliminating this option. To select from the remaining options, focus on the strategic word and note that circulatory overload is suspected; this will direct you to the correct option. Review the interventions to be taken immediately when circulatory overload is suspected if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Intravenous therapyGiddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 230). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 6 A nurse is performing closed suctioning through a tracheostomy for a ventilator-dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately: A. Contacts the respiratory therapist B. Rechecks all ventilator connections C. Oxygenates the client manually with 100% oxygen Correct D. Increases the degree of PEEP the client is receiving Rationale: Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client’s problem in this situation. An increase in PEEP is not indicated at this time. Test-Taking Strategy: Focus on the data in the question and note that the client is exhibiting severe bradycardia. Use your knowledge of the ABCs — airway, breathing, and circulation. This will direct you to the correct option. Review the complications associated with suctioning and the immediate nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1623). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 8 Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle crash. During an assessment, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client exhibits signs of hypoxia. The nurse immediately: A. Cuts the mouth wires Correct B. Administers an antiemetic C. Contacts the anesthesiologist D. Places the client is a supine position Rationale: IMF is a common means of securing a mandibular fracture. The bones are realigned and then wired in place with the bite closed. After surgery, the client is at risk for aspiration if he or she vomits because of the impossibility of opening the jaws to allow ejection of the emesis. If vomiting occurs, the nurse would attempt to suction the client. If suctioning is unsuccessful, the wires are cut. Wire cutters are kept with the client at all times in readiness for this emergency. Antiemetics may be prescribed to prevent nausea and subsequent vomiting; however, this is not the immediate action if the client is vomiting. Placing the client in a supine position increases the risk of aspiration. The client is placed in an upright position and turned to the side. There is no helpful reason to contact the anesthesiologist. Test-Taking Strategy: Use the process of elimination and visualize this surgical procedure. Noting that the client is vomiting and recalling that aspiration is a risk in this situation will direct you to the correct option. Review care of the client after IMF if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. ). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 2 A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first: A. Call a code B. Start an intravenous (IV) line C. Initiate cardiopulmonary resuscitation (CPR) D. Place a tourniquet proximal to the site of the insect sting Correct Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated, and start an IV line. Test-Taking Strategy: Note the strategic word “first” and use the skills of prioritizing to answer the question. Recognizing that there is no information in the question that indicates that CPR is necessary will assist you in eliminating the options that are comparable or alike (calling a code and initiating cardiopulmonary resuscitation). To select from the remaining options, visualize the situation and note the relationship between the situation and the correct option. Review the interventions to be taken immediately in the event of anaphylaxis resulting from a bee sting if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange References: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 351). St. Louis: Elsevier. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 627, 629-630). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 0 A nurse is preparing to care for a child being admitted to the hospital with infectious gastroenteritis. The priority nursing intervention is: A. Obtaining a stool sample for culture Incorrect B. Administering prescribed antimicrobials C. Starting an intravenous (IV) line as prescribed Correct D. Instructing the parents in home care measures to prevent infection Rationale: Infectious gastroenteritis is caused by a variety of communicable viruses, bacteria, and parasites capable of causing serious diarrhea, massive fluid and electrolyte loss, sepsis, and death. The priority therapy in a child with infectious gastroenteritis is the replacement of water and correction of acid-base or fluid and electrolyte disturbances with the use of IV fluids or oral electrolyte-replacement preparations. A stool culture and antimicrobial drugs may be prescribed, but these are not the priority interventions. Instructions to the parents may be necessary but are not the priority on admission of the child to the hospital. Test-Taking Strategy: Note the strategic words “priority nursing intervention.” Use Maslow’s Hierarchy of Needs theory and your knowledge of the ABCs (airway, breathing, and circulation). The correct option addresses a physiological need and the child’s circulatory status. Review care of the child with infectious gastroenteritis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Cargiving, Fluid and Electrolytes HESI Concepts: Caregiving, Fluids and Electrolytes Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 955). St Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 11. 11.ID: 8 A nurse is caring for a client after tonsillectomy and adenoidectomy. The nurse notes that the client has become restless and is swallowing frequently. List in order of priority the actions that the nurse should take in this situation, with number 1 as the first action. Incorrect 1. Notifying the surgeon 2. Inspecting the client’s throat 3. Checking the client’s vital signs 4. Maintaining NPO status The correct order is: 5. Inspecting the client’s throat 6. Checking the client’s vital signs 7. Notifying the surgeon 8. Maintaining NPO status Rationale: Bleeding is a potential complication after tonsillectomy and adenoidectomy. If the client becomes restless and is swallowing frequently, the nurse should suspect bleeding. The nurse would first inspect the throat for the presence of bleeding and then check the client’s vital signs for indications of hypovolemia. The surgeon would be notified. Because recauterization is the treatment of choice when bleeding is uncontrolled, the client would be maintained on nothing-by-mouth (NPO) status in anticipation of a return to surgery. Test-Taking Strategy: Focus on the data in the question and use your prioritizing skills. Noting the strategic words “swallowing frequently” will direct you to assessment of the client for bleeding as the first action. The next step is checking the vital signs next to detect signs of shock and to have the data that the health care provider will need. Although food or fluids would not be given to the client during this episode anyway, keeping the client on NPO status would be the fourth priority. Review the nursing actions to be taken immediately when bleeding occurs after tonsillectomy and adenoidectomy if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Perfusion HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 12. 12.ID: 3 A nurse is caring for a client with a diagnosis of endocarditis when the client suddenly begins to experience chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism. List in order of priority the actions that the nurse would take in this situation, with number 1 as the first action. Incorrect 0. Notifying the health care provider 1. Placing a nasal oxygen cannula on the client 2. Ensuring that the intravenous (IV) line is patent 3. Preparing an IV heparin sodium infusion 4. Preparing the client for a computerized tomography (CT) scan The correct order is: 5. Placing a nasal oxygen cannula on the client 6. Notifying the health care provider 7. Ensuring that the intravenous (IV) line is patent 8. Preparing an IV heparin sodium infusion 9. Preparing the client for a computerized tomography (CT) scan Rationale: Pulmonary embolism is a life-threatening emergency. Stabilizing the cardiopulmonary system is the first priority. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. The health care provider is notified. Because IV infusion lines are needed to administer fluids to treat the hypotension and to administer medications, the nurse ensures that the client has patent IV lines. Anticipating that IV anticoagulant therapy will be started, the nurse next prepares an administration set. Finally, because a CT scan or other diagnostic test may be performed to confirm the diagnosis, client preparations for testing are begun. Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Recalling that stabilizing the cardiopulmonary system is the priority will direct you to the administration of oxygen. Recognizing the immediacy of the situation will then direct you to notification of the health care provider. Next, visualize the situation to determine the order of the remaining options. Review the nursing actions to be taken immediately in the event of pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Perfusion HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 13. 13.ID: 8 A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately: . Obtain a chest x-ray A. Notify the health care provider B. Place the client in a semi-Fowler position Correct C. Prepare a thoracentesis tray and chest drainage equipment Incorrect Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed chest injury is suspected, the nurse must immediately place the client in a semi-Fowler position. Because this is a medical emergency, the nurse then notifies the health care provider. A chest x-ray, computed tomography, or ultrasonography would be used to confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and placement of a chest drainage system, the nurse then prepares a thoracentesis tray and chest drainage equipment. Test-Taking Strategy: Analyze the information in the question to determine that the client has a closed pneumothorax. From this point use your knowledge of the ABCs (airway, breathing, and circulation) to identify the correct initial option. An upright position will help the client breathe. Review the nursing actions to be taken immediately in the event of a closed pneumothorax if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Collaboration/Managing Care – Care Coordination, Oxygenation/Gas Exchange Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 415). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. 14. 14.ID: 3 A registered nurse (RN) is planning assignments for six clients on a nursing unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) on the nursing team. Which clients should the nurse assign to the RN? Select all that apply . A client who requires tap water enemas until clear A. A client with newly diagnosed type 1 diabetes mellitus Correct B. A client requiring complete assistance with personal care C. A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L) Correct D. A client who was admitted during the night after an acute asthma attack Correct E. A client who has undergone amputation of the right leg amputation and a dressing change Incorrect Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The client with newly diagnosed type 1 diabetes mellitus will require significant education, which should be provided by the RN. The client with gastrointestinal bleeding and a low hemoglobin level will likely require a blood transfusion, which must be performed by the RN. The client who was admitted to the hospital during the night after an acute asthma attack would most appropriately be assigned to the RN, because frequent respiratory assessments will be required. The UAP can most appropriately assist with personal care. The LPN can perform dressing changes and administer enemas. Test-Taking Strategy: Recall that education and job position, as set forth in the state’s nurse practice act, and employee guidelines must be considered when activities are being delegated and assignments made. Recall that the RN has the knowledge and experience to perform client education, nursing assessments, and blood transfusions. If you had difficulty with this question, review the principles of delegation and assignment-making. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp. 305, 308). St. Louis: Elsevier Awarded 1.0 points out of 3.0 possible points. 15. 15.ID: 5 A registered nurse (RN) is planning the client assignments for the day. To which nurse does the RN appropriately assign care of a woman undergoing brachytherapy with a sealed radiation source for cervical cancer? . A pregnant nurse who has special expertise in oncology A. A nurse who has worked with clients undergoing brachytherapy in the past Correct B. A male nurse who has never worked with a client undergoing brachytherapy C. A nurse who is also assigned to provide care to another client undergoing brachytherapy Rationale: Brachytherapy involves the use of radioactive isotopes in solid form or within body fluids. Because the radiation source is within the client, the client emits radiation for some time and may pose a hazard to others. A pregnant nurse should not care for a client undergoing brachytherapy. The time any nurse is exposed to such radiation sources should be limited to 30 minutes of direct care per 8-hour shift, so a nurse should not be assigned to care for more than one client undergoing brachytherapy. It is most appropriate to assign a nurse who is familiar with the care of a client with brachytherapy rather than to assign a nurse who is not. Test-Taking Strategy: Use the process of elimination. Recalling the radiation safety standards involved in the care of a client undergoing brachytherapy will assist you in eliminating the pregnant nurse and the nurse caring for another client undergoing brachytherapy. From the remaining options, note the strategic word “appropriately.” It is appropriate to assign a nurse who is familiar with the care of a client with brachytherapy instead of one who is not. Review radiation safety standards for the care of a client undergoing brachytherapy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 413). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 6 A client is complaining of chest pain, and the nurse notes that the client’s skin is cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the pulse oximetry reading is 84%. Which action should the nurse take first? . Administering nitroglycerin Incorrect A. Taking the client’s vital signs B. Increasing the oxygen to 3 L/min Correct C. Obtaining an arterial blood gas (ABG) specimen Rationale: Pulse oximetry identifies hemoglobin saturation. A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur. Ideal pulse oximetry values range from 90% to 100%. A range of 85% to 89% is acceptable in certain chronic disease conditions. When the value is below 85%, the body’s tissues have a difficult time becoming oxygenated. Therefore the nurse would increase the oxygen to 3 L/min. Although the client is complaining of chest pain, there is no information to indicate that the client is experiencing chest pain that is cardiac in origin, so administering nitroglycerin as the first action is incorrect. Taking the client’s vital signs and obtaining an ABG specimen will provide additional data, but in this situation an intervention is needed first. Test-Taking Strategy: Note the strategic word “first.” Use the process of elimination and your knowledge of the ABCs (airway, breathing, and circulation). This will direct you to the correct option. Review pulse oximetry values and appropriate interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Collaboration/Managing Care – Care Coordination, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 589, 750). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 17. 17.ID: 2 A nurse is assigned to care for a client with a closed chest drainage system that was inserted 1 day ago after the client sustained a stab wound to the chest. List in order of priority the actions that the nurse would take in caring for the client, with number 1 the first action. Incorrect 0. Assessing the client’s level of discomfort 1. Assessing patency and function of the chest tube 2. Checking the client’s vital signs 3. Asking the client to cough and deep-breathe The correct order is: 4. Assessing patency and function of the chest tube 5. Checking the client’s vital signs 6. Assessing the client’s level of discomfort 7. Asking the client to cough and deep-breathe Rationale: The first action the nurse needs to perform is to assess the chest tube’s patency and function, because a properly functioning chest drainage system promotes adequate drainage of blood and air. After this assessment, the nurse would check the client’s vital signs, including pulse oximetry. The nurse would determine the client’s level of discomfort, then provide appropriate pain relief measures, because improving the client’s level of comfort will facilitate more effective coughing and deep-breathing efforts. Finally, the nurse would encourage the client to cough and deep-breathe. Test-Taking Strategy: Focus on the client’s problem. Use your knowledge of the ABCs (airway, breathing, and circulation) to select assessment of chest tube patency and function, then a check of the client’s vital signs. To select from the remaining options, focus on effective means of facilitating coughing and deep breathing. Review care of the client with a chest drainage system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Collaboration/Managing Care – Care Coordination, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 18. 18.ID: 1 An emergency department (ED) nurse receives a telephone call and is informed that several victims from a train accident will be brought to the ED. The nurse who received the telephone call must first: . Activate the agency disaster plan Correct A. Empty all available rooms in the ED B. Ensure that the triage rooms are stocked with additional dressing supplies C. Call the intensive care unit (ICU) and asks for nurses to assist with the victims Rationale: In an external disaster, many people may be brought to an ED for treatment. Calling the ICU and asking the nurses to assist with the victims, making room for the arriving victims, and ensuring that making sure the triage rooms are supplied may all be components of preparing for the casualties, but activation of the disaster plan must be the initial action. Ideally the nurse would notify the nursing supervisor, who would then ensure that the ED is adequately staffed. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action and also note that the correct option is the umbrella option. Once you activate the disaster plan, the activities in the other options will be carried out. Review procedures for management in a disaster if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Giddens Concepts: Care Coordination, Health Policy HESI Concepts: Collaboration/Managing Care – Care Coordination, Health Policy/Systems – Health Care Organization Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 160-161). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 2 A home health nurse is assigned to three client visits today. One client requires twice-daily irrigation of an abdominal wound. Another client was discharged from the hospital yesterday after cardiac catheterization and will require an admission assessment and assistance with the scheduling of medications. The last client has diabetes mellitus and requires a blood specimen for serum glucose testing to be drawn. The nurse will schedule the assignment by visiting: . The client with diabetes mellitus first, the client with the wound irrigation second, and the client requiring admission last Correct A. The client needing wound irrigation first, the client with diabetes mellitus second, and the client requiring admission last B. The client requiring admission first, the client with diabetes mellitus second, and the client needing wound irrigation last C. The client with diabetes mellitus first, the client requiring admission second, and the client needing wound irrigation last Rationale: The client with diabetes mellitus must remain on nothing-by-mouth (NPO) status until the blood specimen is drawn and so should be seen first. Because the client requiring wound irrigations will need to be visited twice, that client should be seen next. The client requiring admission would be visited third, after which the nurse would make the second visit to the client requiring wound irrigation. Test-Taking Strategy: Think about the needs of each client in determining the correct option. The client who must remain NPO until visited by the nurse is the priority. Because the wound irrigation must be performed twice, the two visits should be separated by as much time as possible, so this client would be the next and then visited last. The admission assessment may take some time to complete, so this client would be visited third. If you had difficulty with this question, review time management and prioritization of client needs. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination References: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 20, 237). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9 A registered nurse is planning client assignments for the day. Which clients should the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply. . A client scheduled for colonoscopy A. A client who underwent mastectomy 2 days ago B. A client scheduled for discharge after cardiac catheterization C. A client with diarrhea who requires assistance with hygiene care Correct D. A client on strict bed rest who requires range-of-motion exercises every 2 hours Correct Rationale: The registered nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the nurse practice act and the job description of the employing agency. A client scheduled for colonoscopy has physiological needs and requires nursing assessments, as well as psychosocial support. A client who underwent mastectomy 2 days earlier will require both physiological and psychosocial care. A client scheduled for discharge after cardiac catheterization will require reinforcement of medication information and home care management. The nursing assistant may care for the client requiring hygiene care for diarrhea. The UAP has been trained to care for a client on bed rest and in the procedure for performing range-of-motion exercises. The nurse would provide instructions to the UAP regarding these tasks, but the tasks required for this client are within the role description of a UAP. Test-Taking Strategy: Note that the question asks for the assignment to be delegated to the UAP. When asked questions related to delegation, think about the role description of the employee and the needs of the client. Remember that tasks that are noninvasive and basic may safely be assigned to the UAP. In using the process of elimination, you will easily identify the correct options. Review the responsibilities of delegation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Health Care Policy HESI Concepts: Collaboration/Managing Care – Care Coordination, Health Policy/Systems – Health Care Organization Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., p. 305). St. Louis: Elsevier Awarded 2.0 points out of 2.0 possible points. 21. 21.ID: 6 A registered nurse (RN) must determine how best to assign an RN and a licensed practical nurse (LPN) to provide care to a group of clients. Which is the appropriate assignment? . Assigning the RN to care for a woman with newly diagnosed metastatic carcinoma who has two school-aged children Correct A. Assigning the RN to care for a woman, hospitalized for chest pain, who is being discharged home today with no medications B. Assigning the LPN to care for a client who has undergone craniotomy and was transferred from the intensive care unit (ICU) this morning C. Assigning the LPN to provide initial discharge teaching about cardiac medications to a client who has undergone a coronary artery bypass graft Rationale: For an accurate determination of what may or may not be delegated to a co-worker, several factors must be considered. The nurse must carefully consider the level of care each client requires, immediately and potentially in the future; the competencies possessed by the co-workers; and the legal limitations on the practice of those co-workers. The woman with newly diagnosed metastatic carcinoma who has two school-aged children is likely to be in need of the skills of an RN, in terms of both physiological needs and psychosocial needs, making this the correct option and an appropriate assignment. The client who was transferred from the ICU this morning has undergone a neurosurgical procedure (craniotomy) in which the risk of increased intracranial pressure is present and therefore requires frequent neurological assessments. This, in addition to the fact that the client was transferred from the ICU this morning, makes this an inappropriate assignment for an LPN. The LPN should not provide initial discharge teaching on medications to a client. Teaching is a professional responsibility that the RN may not delegate to anyone but another RN, making this option incorrect. Although under some circumstances the RN might care for a client being discharged after chest pain, the question tells you that an LPN is available. The RN would be best used to care for the clients with more critical or complicated needs. Therefore this option is incorrect. Test-Taking Strategy: Use the process of elimination. Focus on the clients in the options and think about their actual and potential needs, then consider the roles of the RN and LPN. Remember that the RN should care for clients who have critical or complex needs, require assessments, or require teaching. Review the guidelines for delegation and assignment-making if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Huber, D. (2014). Leadership and nursing care management (5th ed., pp. 147-148). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 2 A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour is 20 mL. On the basis of this finding, the nurse should first: . Call the health care provider A. Increase the rate of the IV infusion Incorrect B. Check the client’s overall intake and output record Correct C. Administer a 250-mL bolus of normal saline solution (0.9%) Rationale: Clients are at risk for hypovolemia after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Increasing the rate of the IV infusion and administering a 250-mL bolus of normal saline (0.9%) would not be implemented without a prescription from the health care provider. The health care provider is called once the nurse has gathered all necessary assessment data, including the overall fluid status, and vital signs. Test-Taking Strategy: Note the strategic word “first.” Visualize the situation, then use the steps of the nursing process to answer the question. Checking the client’s overall intake and output record addresses the process of assessment. Eliminate an increase the rate of the IV infusion and administration of a 250-mL bolus of normal saline, because each requires a health care provider’s prescription; also, recall that in this situation the nurse needs to gather additional information before contacting the health care provider. Review unexpected outcomes after surgery and the priority nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Elimination HESI Concepts: Collaboration/Managing Care – Care Coordination, Elimination Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 290). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 23. 23.ID: 6 A nurse is delegating tasks to the nursing staff. Which tasks are appropriate for the unlicensed assistive personnel (UAP? Select all that apply. . Feeding a newly admitted client with dysphagia after a stroke A. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion Correct B. Accompanying a man being discharged home to his transportation at the hospital entrance Correct C. Obtaining a 24-hour dietary recall from a client admitted to the hospital with anorexia nervosa D. Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency Correct Rationale: The nurse must determine the most appropriate assignments on the basis of the skills of the staff member and the needs of the client. Although assisting clients with feeding is often within the scope of practice of a UAP, a newly admitted client who has had a stroke and is experiencing dysphagia should be cared for by the RN so that an assessment of the client’s risk for aspiration may be completed and appropriate recommendations for safe feeding made. Neither would it be appropriate to assign a UAP to obtain a 24-hour dietary recall from a client with anorexia nervosa. This assessment is most appropriately conducted by a registered nurse, who would assess the quantity of food consumed by the client. The tasks identified in the remaining three options include no data to indicate that they carry any major risks. Test-Taking Strategy: Note the strategic word “appropriate.” Remember that work that is delegated to another must be consistent with the individual's level of expertise and licensure or lack thereof. Noting the subject, appropriate tasks for a nursing assistant, will direct you to the correct options. Remember that noninvasive and basic tasks may be assigned to the UAP. Review the principles of assignment-making and delegation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 15-16). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 24. 24.ID: 6 A nurse on the day shift (7 a.m.–3 p.m.) is assigned to care for four clients. In planning care, which client does the nurse assess first? . A client scheduled for a barium enema at 9 a.m. A. A client requiring a daily dressing change on an amputation stump B. A client with emphysema who is receiving oxygen at a rate of 2 L/min Correct C. A client who has undergone angioplasty and is preparing to be discharged at 10 a.m. Rationale: Airway is always the priority, so the nurse would first attend to the client who has emphysema and is receiving oxygen. The client scheduled for a barium enema today, the client requiring the daily dressing change on an amputation stump, and a client who has undergone angioplasty and is preparing for discharge are all intermediate priorities. Test-Taking Strategy: Use your knowledge of the ABCs — airway, breathing, and circulation — to answer the question. Remember that airway is always the first priority. Review the guidelines for prioritizing if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 238, 279-280). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 2 A nurse is planning client assignments for the shift. Which clients would the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply. . A client receiving blood transfusions A. A client who needs to be ambulated with a walker twice a day Correct B. A client with incontinence who requires a bladder scan after each void Correct C. A client with diabetes mellitus who requires blood glucose testing every 2 hours D. A client on a bowel management program who requires a daily rectal suppository Incorrect Rationale: Assignment of tasks must be implemented on the basis of the job description of the UAP, the UAPs level of clinical competence, and state law. A client who is receiving blood transfusions, one in a bowel-management program who requires a rectal suppository daily, and one with diabetes mellitus who requires blood glucose monitoring all require the skill of a licensed nurse, because these are invasive procedures. A client receiving blood must be monitored closely for transfusion reactions. A rectal suppository must be administered by a licensed nurse. Blood glucose monitoring needs to be performed by a licensed nurse. A client with incontinence requiring a bladder scan after each void and a client who needs to be ambulated with a walker twice a day are the most appropriate assignments for the UAP. Test-Taking Strategy: Use the process of elimination and your knowledge regarding tasks that may be safely delegated to a nursing assistant. A UAP is trained to perform a bladder scan and ambulate a client with a walker, and these are both noncritical, noninvasive tasks. Review the principles of delegation and assignment-making if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Huber, D. (2014). Leadership and nursing care management (5th ed., pp. 147-148). St. Louis: Saunders. Awarded 1.0 points out of 2.0 possible points. 26. 26.ID: 5 A registered nurse is in charge of the emergency department on the night shift when a client is brought for treatment after being sexually assaulted. The nurse has never cared for anyone after a sexual assault. To determine the interventions that the client requires, the nurse would first: . Call the police department A. Call the nursing supervisor B. Call the nurse in charge of the day shift C. Check unit policy regarding the protocol for care to clients who have been sexually assaulted Correct Rationale: A policy is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online in the institution’s computer network. Specific unit policies are sometimes referred to as protocols. The policy or protocol for dealing with a client who has been sexually assaulted will identify which authorities (e.g., the police) should be notified and the interventions required in the care of the client. It is inappropriate to call the nurse in charge of the day shift. If additional information was needed after a review of the policy or protocol, the nurse would contact the nursing supervisor for the night shift. Test-Taking Strategy: Use the process of elimination and note the strategic word “first.” Recalling the purpose of organizational policies will direct you to the correct option. Also, note that the correct option is the umbrella option. Review the purpose of organizational policies if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Interpersonal Violence HESI Concepts: Collaboration/Managing Care – Care Coordination, Violence Reference: Huber, D. (2014). Leadership and nursing care management (5th ed., pp. 260-262). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 5 A client with a spinal cord injury suddenly experiences a severe headache and nasal stuffiness. The client is also diaphoretic, hypertensive, and bradycardic. The nurse determines that the client is experiencing autonomic dysreflexia and immediately: . Notifies the health care provider A. Checks the bladder and catheterizes the client B. Raises the head of the bed to a high Fowler position Correct C. Performs a rectal examination to check for a fecal impaction Rationale: Autonomic dysreflexia is an emergency that occurs in people who have sustained spinal injuries as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distension or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a high Fowler position to lower the blood pressure. The health care provider is then notified of the emergency. Finally the nurse performs a rapid assessment to identify and alleviate the cause. The client’s bladder is emptied immediately with the use of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or other compromise. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and note that the client is hypertensive. This will direct you to the correct option. Placing the client in a high Fowler position will help lower the blood pressure. Review care of the client experiencing autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Intracranial Regulation HESI Concepts: Collaboration/Managing Care – Care Coordination, Intracranial Regulation Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1479). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 1 A client calls the nurse at the emergency department (ED), says that he thinks that he came in contact with poison ivy while working in his yard, and asks the nurse for advice. The nurse tells the client immediately to: . Take a shower Correct A. Come to the ED B. Soak in a warm oatmeal bath C. Apply hydrocortisone cream to the areas that may have been in contact with the poison ivy Rationale: If contact with poison ivy is suspected, symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before it can penetrate the skin. It is not necessary for the client to be seen immediately in the ED. Oatmeal baths are useful in soothing dry or itchy skin. The nurse would not advise the client to apply hydrocortisone cream. Medications should be recommended by the health care provider, and this intervention would probably not be recommended unless a pruritic poison ivy rash actually developed. Test-Taking Strategy: Use the process of elimination and focus on the information in the question. Recalling that the resin from the plant penetrates the skin and causes the dermatitis will direct you to the correct option. Review immediate treatment measures after poison ivy exposure if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Tissue Integrity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 444). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 1 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is red and inflamed and feels hard on palpation. On the basis of this assessment, the nurse should first: . Remove the IV catheter Correct A. Slow the rate of infusion B. Notify the health care provider C. Place warm compresses on the IV site Rationale: Phlebitis at an IV site may be signaled by client discomfort at the site, as well as by redness, warmth, hardness, and swelling proximal to the catheter. The IV catheter should be removed and a new IV catheter inserted at a different site. Recognizing that slowing the infusion will not resolve the client’s symptoms will help you eliminate this option. The health care provider would be notified if phlebitis occurred, but this is not the first action for the nurse. Warm compresses are applied to the site to relieve pain and discomfort, but the IV catheter would be removed first. Test-Taking Strategy: Use the process of elimination and your prioritization skills, focusing on the data in the question. Eliminate the option that calls for continuation of the IV therapy. Although the other options are appropriate interventions, the strategic word “first” should direct you to the correct option. Review the signs of phlebitis and the initial nursing actions when phlebitis occurs if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination, Inflammation HESI Concepts: Collaboration/Managing Care – Care Coordination, Inflammation Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 707). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 8 A nurse assesses a client at the beginning of the shift and notes an intravenous (IV) infusion is running at 100 mL/hr and that 800 mL of fluid remains in the IV bag. Thirty minutes later, the client calls the nurse and complains of shortness of breath. The nurse sees that 400 mL of IV solution remains in the IV bag. The nurse immediately: . Administers oxygen A. Elevates the head of the bed B. Notifies the health care provider C. Stops the rate of the IV infusion Correct Rationale: The client is most likely experiencing circulatory overload. The nurse may identify the condition by noting that 400 mL has infused over the course of 30 minutes. The first action on the part of the nurse is to stop the rate of the IV infusion but ensure that IV patency is maintained so that any prescribed medications can be administered. Other actions may follow in rapid sequence: The nurse raises the client to an upright position to aid the client’s breathing, notifies the health care provider, monitors the client’s vital signs, and administers oxygen as prescribed. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting the strategic word “immediately” and noting that 400 mL of IV solution has infused in 30 minutes will direct you to the correct option. Review the immediate nursing actions in regard to this complication if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Proces