A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with acute myocardial infarction. Which of the following actions would breach the client’s confidentiality? A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit. B. The… Read More »
A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilation through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the… Read More »
After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching. B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59-year-old with Parkinson’s… Read More »
The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action (s) to the LPN/LVN? Select all that apply. A. Check the patient’s skin for pressure from the device. B. Assess the patient’s neurologic status for… Read More »
All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? Select all that apply. A. Check for orthostatic changes in pulse and blood pressure. B. Monitor for… Read More »
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care? A. Perform postural drainage and chest physiotherapy every 4 hours. B. Allow the patient to decide whether she needs aerosolized medications. C. Place the patient… Read More »
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female… Read More »
There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room? A. A client with a cough who may have tuberculosis B. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C) C. A… Read More »
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A. Reassure the patient that the ventilator will do the work of breathing for… Read More »
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client? A. Hepatitis A vaccine B. Lyme’s disease vaccine C. Hepatitis B vaccine D. Pneumococcal vaccine Correct Answer: D. Pneumococcal vaccine… Read More »