After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the registered nurse immediately? A. Heart rate of 98 beats/min B. Respiratory rate of 24 breaths/min C. Blood pressure of 168/90 mm… Read More »
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first? A. A client scheduled for cardiac ultrasound this morning. B. A client with syncope being discharged today. C. A client with chronic bronchitis on nasal oxygen. … Read More »
A 7-year-old girl who has just endured allogeneic stem cell transplantation will need protective environmental stimulation. Which nursing task should the nurse delegate to the nursing assistant? Select all that apply. A. Educating the client to perform careful handwashing after using the bathroom. B. Communicating with the family members about the grounds for isolation.… Read More »
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority? A. Irregular apical pulse B. Ecchymosis in the flank area C. A deviated trachea D. Unequal pupils Correct Answer: C. A deviated trachea A deviated trachea is a… Read More »
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first? A. Determine the level of consciousness B. Push the call button for help C. Turn the client face up to assess D.… Read More »
Several people were killed and injured in a recent industrial explosion. The victims are being interviewed and assessed by the nurses for possible psychiatric crises. Which client has the greatest risk for posttraumatic distress disorder? A. An individual who was injured and trapped for 8 hours before rescue. B. A person who saw the death… Read More »
An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A. Auscultate breath sounds B. Administer medications via metered-dose inhaler (MDI) C. Complete in-depth… Read More »
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB). B. A 68-year old just returned from bronchoscopy and biopsy. … Read More »
The nurse assessed the client and noted shortness of breath and a recent trip to China. The client is strongly suspected of having Severe Acute Respiratory Syndrome (SARS). Which of these prescribed actions will the nurse take first? A. Place the client on airborne and contact precautions B. Introduce normal saline at 75 mL/hr… Read More »