A group of passengers enters the ED with complaints of cough, tightness in the throat, and extreme periorbital swelling. There is a strong odor exuding from their clothes. They report exposure to a “gas bomb” that was placed in the bus terminal. What is the priority action? A. Readily transfer clients and visitors from the area… Read More »
A 25-year-old client comes to the outpatient unit with complaints of diarrhea, abdominal pain, shortness of breath, and epistaxis. Which action should the nurse take first? A. Learn whether the client has had recommended immunizations. B. Ask the client about any recent travel to Asia or the Middle East. C. Have the client… Read More »
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing. B. Plan a nursing care regimen that gradually increases activity intolerance. C. Assist the patient with basic activities of… Read More »
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant? A. Teaching the patient about the importance of adequate fluid intake and hydration. B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed.… Read More »
A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis? A. Risk for Nutritional Deficit… Read More »
A mother of a 14-year-old client receiving chemotherapy for leukemia calls out to the unit concerning her other child having chickenpox. Which of these actions will the nurse anticipate taking next? A. Plan to admit the client to a private room in the hospital. B. Teach the mother about contact and airborne precautions. … Read More »
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase… Read More »
You are making a home visit to a 50-year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician? A. The patient says that her right leg aches… Read More »
During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area? A. Supply oxygen via nasal cannula B. Place intravenous (IV) access C. Notify the ED physician D. Set the client on continuous electrocardiographic monitoring … Read More »
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately? A. Decrease in pain level from 6 to 2 (on a scale of 10) B. Heart rate of 90 to 100 beats/min… Read More »