Prioritization, Delegation, & Management of Care for the NCLEX-RN® Exam 2024-2025 all, Exams of Nursing

Download Prioritization, Delegation, & Management of Care for the NCLEX-RN&#174; Exam 2024-2025 all and more Exams Nursing in PDF only on Docsity! Prioritization, Delegation, & Management of Care for the NCLEX-RN&#174; Exam 2024-2025 all what you need to know NCLEX [Type the author name] [Pick the date] PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM ALL WHAT YOU NEED TO KNOW v 1 Introduction to Prioritization, Assignment, Delegation, and Management 1 NCSBN BLUEPRINT FOR QUESTIONS 1 GUIDELINES FOR MAKING A DECISION 2 TYPES OF QUESTIONS 4 PUTTING THE PIECES TOGETHER 5 2 Cardiovascular Management 7 QUESTIONS 7 CARDIAC CLINICAL SCENARIO 20 ANSWERS AND RATIONALES 22 CLINICAL SCENARIO ANSWERS AND RATIONALES 40 3 Peripheral Vascular Management 43 QUESTIONS 43 PERIPHERAL VASCULAR DISEASES CLINICAL SCENARIO 54 ANSWERS AND RATIONALES 56 CLINICAL SCENARIO ANSWERS AND RATIONALES 74 4 Respiratory Management 77 QUESTIONS 77 RESPIRATORY CLINICAL SCENARIO 88 ANSWERS AND RATIONALES 90 CLINICAL SCENARIO ANSWERS AND RATIONALES 107 5 Gastrointestinal Management 109 QUESTIONS 109 GASTROINTESTINAL CLINICAL SCENARIO 120 ANSWERS AND RATIONALES 122 CLINICAL SCENARIO ANSWERS AND RATIONALES 139 6 Renal and Genitourinary Management 141 QUESTIONS 141 RENAL AND GENITOURINARY CLINICAL SCENARIO 152 ANSWERS AND RATIONALES 154 CLINICAL SCENARIO ANSWERS AND RATIONALES 171 ix Table of Contents x TABLE OF CONTENTS 7 Neurological Management 173 QUESTIONS 173 NEUROLOGICAL CLINICAL SCENARIO 185 ANSWERS AND RATIONALES 187 CLINICAL SCENARIO ANSWERS AND RATIONALES 204 8 Endocrine Management 207 QUESTIONS 207 ENDOCRINE CLINICAL SCENARIO 220 ANSWERS AND RATIONALES 221 CLINICAL SCENARIO ANSWERS AND RATIONALES 238 9 Integumentary Management 239 QUESTIONS 239 INTEGUMENTARY CLINICAL SCENARIO 250 ANSWERS AND RATIONALES 252 CLINICAL SCENARIO ANSWERS AND RATIONALES 269 10 Hematological and Immunological Management 271 QUESTIONS 271 HEMATOLOGICAL AND IMMUNOLOGICAL CLINICAL SCENARIO 282 ANSWERS AND RATIONALES 284 CLINICAL SCENARIO ANSWERS AND RATIONALES 299 11 Women’s Health Management 301 QUESTIONS 301 MATERNAL-CHILD CLINICAL SCENARIO 312 ANSWERS AND RATIONALES 314 CLINICAL SCENARIO ANSWERS AND RATIONALES 330 12 Pediatric Health Management 333 QUESTIONS 333 PEDIATRIC CLINICAL SCENARIO 345 ANSWERS AND RATIONALES 347 CLINICAL SCENARIO ANSWERS AND RATIONALES 361 13 Mental Health Management 363 QUESTIONS 363 MENTAL HEALTH CLINICAL SCENARIO 376 ANSWERS AND RATIONALES 378 CLINICAL SCENARIO ANSWERS AND RATIONALES 394 TABLE OF CONTENTS xi 14 Case Studies: Care of Clients in Various Settings 397 MEDICAL NURSING CASE STUDY 397 CRITICAL CARE NURSING CASE STUDY 400 OUTPATIENT NURSING CASE STUDY 403 HOME HEALTH CASE STUDY 406 MENTAL HEALTH NURSING CASE STUDY 409 MATERNAL-CHILD CASE STUDY 412 ANSWERS TO CASE STUDIES 414 15 Comprehensive Exam 429 QUESTIONS 429 ANSWERS AND RATIONALES 446 Appendix A: Normal Laboratory Values 469 Glossary of English Words Commonly Encountered on Nursing Examinations 471 Index 475 The nurse is caring for a client diagnosed with congestive heart failure who is currently com- plaining of dyspnea. Which intervention should the nurse implement first? 1. Administer furosemide (Lasix), a loop diuretic, IVP. 2. Check the client for adventitious lung sounds. 3. Ask the respiratory therapist to administer a treatment. 4. Notify the healthcare provider. Answer: 2 Checking for adventitious lung sounds is assessing the client to determine the extent of the client’s breathing difficulties causing the dyspnea. 2 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM practice, informed consent, information technology, and performance improvement. Other topics also include legal rights and responsibilities, referrals, resource management, staff education, supervision, confidentiality/information security, and continuity of care. The questions in this book follow this blueprint. GUIDELINES FOR MAKING A DECISION Nurses* base their decisions on many different bodies of information in order to arrive at a course of action. Among the basic guidelines to apply in nursing practice—and in answering test questions—are the nursing process and Maslow’s Hierarchy of Needs. The Nursing Process One of the basic guidelines to apply in nursing practice is the nursing process, which consists of five steps—assessment, nursing diagnosis, planning, intervention, and evaluation—usually completed in a systematic order. Many questions can be answered based on “assessment.” If a priority-setting question asks the test taker which step to implement first, the test taker should look for an answer that would assess for the problem discussed in the stem of the question. EXAMPLE There are numerous words, such as “check,” that can be used to indicate assessment. The test taker should not discard an option because the word “assess” or “assessment” is not used. Alternatively, the test taker shouldn’t assume that an option is correct merely because the word “assess” is used. The test taker must also be aware that the assessment data must match the problem stated in the stem, regardless of terminology. The nurse must assess for the correct information. If option 2 in the above example said, “Assess uri- nary output,” it would not be a correct option even though it includes the word “assess,” since urinary output is not related to heart failure or breathing difficulties. In addition, the test taker should be aware that assessment is not always the correct answer when the question asks which should be done first. Suppose, for example, that the above question had listed option 3 as “Apply oxygen via nasal cannula at 2 LPM.” In that case, assessment does not come first. The nurse would first attempt to relieve the client’s distress and then assess. When a question asks what a nurse should do next, the test taker should determine from the information given in the question which steps in the nursing process have been completed and then choose an option that matches the next step in the nursing process. In this book, the term “nurse,” unless otherwise specified, refers to a licensed registered nurse (RN). An RN can assign tasks to an LPN or delegate to unlicensed assistive personnel (UAP), which may be known under other terms such as medical assistant or nurse’s aide. An LPN can delegate tasks to UAP. Each state will have specific regulations that govern what duties/tasks can be delegated/assigned to each of these types of personnel. The term “healthcare provider,” as used in this book, refers to a client’s primary provider of medical care. It includes physicians (including osteopathic physicians), nurse practitioners (NPs), and physician assistants (PAs). Depending on state regulations, many NPs and some PAs have prescriptive authority at least for some categories of prescribed drugs. The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis “altered tissue perfusion related to decreased circulatory volume.” Which intervention should the nurse implement first? 1. Notify the laboratory to draw a type & crossmatch. 2. Assess the client’s abdomen for tenderness. 3. Insert an 18-gauge catheter and infuse lactated Ringer’s. 4. Check the client’s pulse oximeter reading. Answer: 3 1. Notifying the laboratory for a type & crossmatch would be an appropriate intervention since the client is showing signs of hypovolemia, but it is not the first intervention because it would not directly support the client’s circulatory volume. 2. The stem of the question has provided enough assessment data to indicate the client’s problem of hypovolemia. Further assessment data are not needed. 3. The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client’s circulatory volume. The nurse can do this by infusing lactated Ringer’s. 4. A pulse oximeter reading would not support the client’s circulatory volume. CHAPTER 1 INTRODUCTION TO PRIORITIZATION, ASSIGNMENT, DELEGATION, AND MANAGEMENT 3 EXAMPLE The nurse has assessed the client and formulated a nursing diagnosis. The next step in the nursing process is implementation. The nurse should proceed to a nursing intervention appropriate to the situation. These types of questions are designed to determine if the test taker can set priorities in client care. Maslow’s Hierarchy of Needs If the test taker has looked at the question and the nursing process can’t help in determining the correct option, then using a tool such as Maslow’s Hierarchy of Needs (Fig. 1-1) can assist in choosing the correct answer. Remember that the bottom of the pyramid—physiological needs—represents the top priority in instituting nursing interventions. If a question asks the test taker to determine which is the priority intervention and a physiological need is listed among the options, then that is the priority. If a physiological need is not listed, safety and security take priority, and so on up the pyramid. Figure 1–1. Maslow’s Hierarchy of Needs. Self- Actualization Esteem and Self Respect Belongingness and Affection Safety and Security Physiological Needs IN T R O D U C T IO N The nurse is assigning tasks to the UAP. Which is an appropriate delegation to the UAP? Select all that apply. 1. Check the area around an incisional wound for redness. 2. Help a client with an upper limb cast to eat. 3. Assist a patient recovering from a hysterectomy to walk to the bathroom. 4. Explain to a client being discharged how to empty and clean the colostomy. 5. Transport a client with a suspected fractured tibia to the x-ray department. 4 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM TYPES OF QUESTIONS Most of the questions on the NCLEX-RN® are multiple choice. The questions involve prioritizing client care, delegating staff tasks, and managing issues dealing with clients and staff. These questions may include interpreting medication administration records (MARs), knowing when notifying the primary healthcare provider (HCP) is priority, and knowing which tasks can be assigned to a licensed practical nurse (LPN) or unlicensed assistive per- sonnel (UAP) and which must be performed by a registered nurse (RN). Some questions on the NCLEX-RN® are termed alternate-format questions and includ- ing choosing more than one option that correctly answers a question, ranking procedures or actions in correct order, drop-and-drag questions, and fill-in-the-blank questions. EXAMPLE Prioritizing Questions/Setting Priorities In test questions that ask the nurse which action to take first, two or more of the options will be appropriate nursing interventions for the situation described. When choosing the correct answer, the test taker must decide which intervention should occur first in a sequence of events, or which intervention directly impacts the situation. With a question that asks which client should the nurse assess first, the test taker should first look at each option and determine if the signs/symptoms the client is exhibiting are nor- mal or expected for the disease process; if so, the nurse does not need to assess that particular client first. Second, if two or more of the options state signs/symptoms that are not normal or expected for the disease process, then the test taker should select the option that has the greatest potential for a poor outcome. Each option should be examined carefully to determine the priority by asking these questions: • Is the situation life threatening or life altering? If yes, this client is the highest priority. • Is the situation unexpected for the disease process? If yes, then this client may be priority. • Is the data presented abnormal? If yes, then this client may be priority. • Is the situation expected for the disease process and not life threatening? If yes, then this client may be—but probably is not—priority. • Is the situation/data normal? If yes, this client can be seen last. The test taker should try to make a decision pertaining to each option. On pencil-and- paper examinations, it may be helpful to note the decision near the option. On a computerized test, the test taker should make the decision and move on to the next question. Delegating and Assigning Care Although each state and province has its own Nursing Practice Acts, there are some general guidelines that apply to all professional nurses. • When delegating to an unlicensed assistive personnel (UAP), the nurse may not delegate any activity that requires nursing judgment. These include assessing, teaching, evaluat- ing, or administering medications to any client and the care of any unstable client. • When assigning care to an LPN, the RN can assign the administration of some medica- tions but cannot assign assessing, teaching, or evaluating any client and cannot delegate the care of an unstable client. When you do the common things in life in an uncommon way, you will command the attention of the world. —George Washington Carver 1. The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected. 2. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The cardiac glycoside to the client who has an apical pulse of 58. 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L. 3. The antidysrhythmic to the client in ventricular fibrillation. 4. The calcium-channel blocker who has a blood pressure of 110/68. 3. Which client should the telemetry nurse assess first after receiving the a.m. shift report? 1. The client diagnosed with deep vein thrombosis who has an edematous right calf. 2. The client diagnosed with mitral valve stenosis who has heart palpitations. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with congestive heart failure who has pink frothy sputum. 4. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain. 7 Cardiovascular Management 2 QUESTIONS 8 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 5. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? 1. Assign an RN to perform all sterile procedures. 2. Assign an LPN to give all IV medications. 3. Assign an UAP to complete the a.m. care. 4. Assign an LPN to write the care plans. 6. The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? 1. Discuss personal information the client shared with the nurse in confidence. 2. Provide the case manager with any information that is required for continuity of care. 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the case manager to get the client’s permission before sharing information. 7. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client’s telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor. 8. The charge nurse on the cardiac unit has to float a nurse to the emergency depart- ment for the shift. Which nurse should be floated to the emergency department? 1. The nurse who has 4 years of experience on the cardiac unit. 2. The nurse who just transferred from critical care to the cardiac unit. 3. The nurse with 1 year of experience on the cardiac unit who has been on a week’s sick leave. 4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years. 9. The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtts/min the first 15 minutes. 2. Check the unit of blood and the client’s blood band with another nurse. 3. Initiate Y-tubing with normal saline via an 18-gauge angiocatheter. 4. Assess the client’s vital signs and lung sounds, and assess for a rash. 5. Obtain informed consent for the unit of blood from the client. 10. The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first? 1. The client with coronary artery disease who is complaining that the nurses are being rude and won’t answer the call lights. 2. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level. 3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 4. The client 2 days’ postoperative coronary artery bypass who is being transferred to the cardiac unit. 11. The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe con- gestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client’s identification band. 5. Clamp the primary tubing distal to the port. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 9 12. The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse imple- ment first? 1. Discontinue the client’s vasoconstrictor, dopamine. 2. Notify the client’s healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client’s neurological status. 13. The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH, 7.35; PaO2, 88; PaCO2, 44; HCO3, 22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization. 14. The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic. 15. The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 16. The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy? 1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit. 2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift. 3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated. 4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team. 17. Which client warrants immediate intervention by the nurse? 1. The client diagnosed with pericarditis who has chest pain with inspiration. 2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. 3. The client diagnosed with Marfan syndrome who has pectus excavatum. 4. The client diagnosed with atherosclerosis who has slurred speech and drooling. Q U E S T IO N S 12 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 30. The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first? 1. Tell the UAP to change it immediately. 2. Ask the UAP why the sharps container has not been changed. 3. Change the sharps container as per clinic policy. 4. Document the situation and place a copy of the documentation in the employee file. 31. The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won’t go to the hospital. Which action should the nurse implement first? 1. Instruct the wife to call 911 immediately. 2. Tell the wife to have the client chew an aspirin. 3. Ask the wife what the client had to eat recently. 4. Request the husband talk to the clinic nurse. 32. The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first? 1. The client diagnosed with hypertension who is reporting a BP of 148/92. 2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93%. 3. The client diagnosed with congestive heart failure who has edematous feet. 4. The client diagnosed with chronic atrial fibrillation who is having chest pain. 33. The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first? 1. Assist the client to a sitting position. 2. Assess the client’s vital signs. 3. Call 911 for the paramedics. 4. Auscultate the client’s lung sounds. 34. The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client’s family is at the bedside. Which intervention should the HH nurse implement first? 1. Contact the agency’s chaplain. 2. Pronounce the client’s death. 3. Ask the family to leave the bedside. 4. Call the client’s funeral home. 35. The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse? 1. The client who has an INR of 2.8. 2. The client who has a serum potassium level of 3.8 mEq/L. 3. The client who has a serum digoxin level of 2.6 mg/dL. 4. The client who has a glycosylated hemoglobin of 6%. 36. The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement? 1. Encourage the client to walk 30 minutes a day. 2. Request an HH-registered dietician to talk to the client. 3. Refer the client to a cardiac rehabilitation unit. 4. Discuss the client’s need to lose 1 to 2 pounds a week. 37. The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first? 1. Prepare all the needed equipment for the visit. 2. Call the client to arrange a time for the visit. 3. Review the client’s referral form/pertinent data. 4. Make the necessary referrals for the client. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 13 38. Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing? 1. If the client or family is hostile or obnoxious, call the police. 2. Carry the HH care agency identification in a purse or wallet. 3. Visits can be scheduled at night with permission from the agency. 4. Inform the agency of the times of the client’s scheduled visits. 39. The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse’s best response? 1. “I am so excited for you; he seems like a very nice young man.” 2. “You should not go out with him as long as she is a client of our agency.” 3. “I think you should tell the director of the HH care agency about this date.” 4. “You should never date someone you meet while taking care of a client.” 40. The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply. 1. Notify the healthcare provider (HCP) if the client gains more than 2 lb in one day. 2. Keep the head of the bed elevated when sleeping. 3. Take the loop diuretic once a day before going to sleep. 4. Teach the client which foods are high in sodium and should be avoided. 5. Perform isotonic exercises at least once a day. 41. The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time (PT) of 14 and an International Normalized Ratio (INR) of 1.6 mg/dL. 2. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L. 3. Atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotrans- ferase (AST) of 18 U/L. 4. Lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL. 42. The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement? 1. Assess the client’s spiritual needs. 2. Assess the client’s financial situation. 3. Assess the client’s support system. 4. Assess the client’s medical diagnosis. 43. The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, “My wife is not breathing.” Which intervention should the nurse implement first? 1. Contact the client’s healthcare provider (HCP). 2. Notify the Rapid Response Team. 3. Stay with the client and her husband. 4. Instruct the UAP to perform post-mortem care. 44. The hospice nurse is triaging phone calls from clients. Which client should the nurse call first? 1. The client whose family reports the client is not eating. 2. The client who wants to rescind the out-of-hospital DNR. 3. The client whose pain is not being controlled with the current medications. 4. The client whose urinary incontinence has caused a Stage 1 pressure ulcer. 45. The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer? 1. Sit with the client while he or she reminisces about life experiences. 2. Give the client a sponge bath and rub lotion on the bony prominences. 3. Provide spiritual support for the client and family members. 4. Check the home to see that all necessary medical equipment is available. Q U E S T IO N S 14 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 46. The nurse delegates post-mortem care to the unlicensed assistive personnel (UAP). The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP? 1. “It can be uncomfortable. I will go with you and show you what to do.” 2. “The client is already dead. You cannot hurt him now.” 3. “There is nothing to it; it is just a bed bath and change of clothes.” 4. “Don’t worry. You can skip it this time but you need to learn what to do.” 47. The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP? 1. Call the healthcare provider (HCP) and report the client’s chest pain. 2. Give a client some acetaminophen (Tylenol) while the nurse checks the client. 3. Get the client’s medical records and bring them to the client’s room. 4. Notify the client’s family of the onset of chest pain. 48. The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? 1. Feed the client who has an IV in both forearms. 2. Assess the client diagnosed with stage IV heart failure. 3. Discharge the client who had a cardiac catheterization. 4. Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin). 49. The hospice nurse is discussing the clients’ care with the unlicensed assistive personnel (UAP). Which statement contains the best information about caring for a client with end-stage heart failure who is dying? 1. “Perform as much care for the client as possible to conserve his or her strength.” 2. “Do not get too attached to the client because it will hurt when he or she dies.” 3. “Be careful not to promise to withhold healthcare information from the team.” 4. “The client may want to talk about his or her life, but you should discourage that.” 50. The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)? 1. Have the UAP call the operator and announce the code. 2. Tell the UAP to answer the other call lights on the unit. 3. Send the UAP to the room to start rescue breaths. 4. Ask the family to step out of the room during the code. 51. The female family member of the client experiencing a cardiac arrest refuses to leave the client’s room. Which intervention should the administrative supervisor implement? 1. Stay with the family member and explain what the team is doing. 2. Call hospital security to escort the family member out of the room. 3. Ask the healthcare provider (HCP) whether the family member can stay. 4. Ignore the family member unless she becomes hysterical. 52. The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first? 1. Place the client on a telemetry monitor and assess the client. 2. Call an ambulance to transfer the client to a charity hospital. 3. Have the client sign a form agreeing to pay the bill. 4. Ask the client why he chose to come to this hospital. 53. The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first? 1. The client diagnosed with angina who is reporting chest pain. 2. The client diagnosed with CHF who has bilateral 4+ peripheral edema. 3. The client diagnosed with endocarditis who has a temperature of 100°F. 4. The client diagnosed with aortic valve stenosis who has syncope. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 17 66. The nurse is caring for Mr. A.B., a client on a telemetry unit. At 0830 the client complains of chest pain. Which medication should the nurse administer? Client Name: Mr. A.B. Account Number: 1122337 Allergies: Meperidine Height: 72 inches Weight in pounds: 202 Weight in kg: 91.82 Date of Birth: 01/05/1945 Date: Today Medication 2301–0700 0701–1500 1501–2300 Morphine Sulfate 2 mg IVP every 1 hour PRN chest pain Oxycodone 7.5/ 0030 NN acetaminophen 325 mg PO every 0545 NN 4 hours PRN pain Maalox 30 mL PO PRN indigestion Nitroglycerin 0.4 mg SL every 5 minutes up to 3 tablets PRN Chest pain Nitroglycerin transdermal cream 1/2 inch 0900 Apply 2100 Remove Signature/ Initials Night Nurse RN/NN Day Nurse RN/DN 1. Administer 1/2 inch of nitroglycerin transdermally now. 2. Morphine sulfate 2 mg IVP STAT. 3. Oxycodone 7.5 mg/acetaminophen 325 mg PO now. 4. Nitroglycerin 0.4 mg sublingual STAT. Q U E S T IO N S 18 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 67. The charge nurse on a cardiac unit has received laboratory reports to assess. Which lab report is priority for the charge nurse to assess? 1. Ms. C.T., who is on a heparin drip. Client Name: C.T. Account Number: 2233669 Allergies: NKDA Diagnosis: Deep Vein Thrombosis Height: 66 inches Weight in pounds: 132 Weight in kg: 60 Laboratory Report Lab Test Client Value Normal Value aPT 15 10–13 seconds INR 1.4 2.0–3.0 (therapeutic value) aPTT 56 25–35 seconds 2. Mr. R.S., who is scheduled for a coronary artery bypass graft (CABG) this morning. Client Name: R.S. Account Number: 8855992 Allergies: Sulfa Diagnosis: Coronary Artery Disease Height: 73inches Weight in pounds: 248 Weight in kg: 112.73 Laboratory Report Lab Test Client Value Normal Value aPT 11 10–13 seconds INR 1.0 2.0–3.0 (therapeutic value) aPTT 34 25–35 seconds WBC 5.9 4.5–11.0 (103 mm) RBC 4.9 Male: 4.7–5.1 (106 cells/mm) Female: 4.2–4.8 (106 cells/mm) Hemoglobin 13.5 Male: 13.2–17.3 g/dL Female: 11.7–15.5 g/dL Hematocrit 44.2 Male: 43%–49% Female: 38%–44% Platelets 292 150–450 (103 mm) 3. Ms. T.R., who had a cardiac cauterization 18 hours ago. Client Name: T.R. Account Number: 6655774 Allergies: Penicillin Diagnosis: Chest pain Height: 62 inches Weight in pounds: 200 Weight in kg: 90.9 Laboratory Report Lab Test Client Value Normal Value aPT 12 10–13 seconds INR 1.0 2.0–3.0 (therapeutic value) aPTT 29 25–35 seconds CHAPTER 2 CARDIOVASCULAR MANAGEMENT 19 4. Mr. J.E., who was admitted to rule out gallbladder disease. Client Name: J.E. Account Number: 6251489 Allergies: NKDA Diagnosis: R/O Gall- bladder Disease Height: 68 inches Weight in pounds: 198 Weight in kg: 90 Laboratory Report Lab Test Client Value Normal Value aPT 9.8 10–13 seconds INR 1.3 2.0–3.0 (therapeutic value) aPTT 26 25–35 seconds Platelet 392 150–450 (103 mm) 68. The nurse on a medical unit is making rounds after receiving the shift report. Which client should the nurse see first? Rank in order of priority. 1. The 45-year-old client who complained of having chest pain at midnight last night and received NTG sublingually. 2. The 62-year-old client who is complaining that no one answered the call light for 2 hours yesterday. 3. The 29-year-client diagnosed with septicemia who called to request more blankets because of being cold. 4. The 78-year-old client diagnosed with dementia whose daughter is concerned because the client is more confused today. 5. The 37-year-old client who has a Stage 4 pressure sore and the dressing needs to be changed this morning. 69. While ambulating in the hallway with the nurse, the client diagnosed with myocardial infarction complains of chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer nitroglycerin 0.4 mg sublingual STAT. 2. Have the client walk back to the room. 3. Take the client’s vital signs. 4. Place the client on supplemental oxygen. 5. Ask the ward secretary to call the healthcare provider for orders. 70. The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client’s drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should the nurse set the pump? Q U E S T IO N S 22 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM ANSWERS AND RATIONALES The correct answer number and rationale for why it is the correct answer are given in boldface type. Rationales for why the other possible answer options are incorrect also are given, but they are not in boldface type. 1. 1. This client may or may not be stable. The client may have “no complaints” at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first. 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated and the pain was a 3. The nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure and a bilateral pedal pulse indicates the client is stable; therefore, this client does need to be seen first. 4. Psychological issues are important, but not more so than a physiological issue, and the client admitted from the ED may have a physiological problem. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker should use some tool as a reference to guide in the decision-making process. In this situation, Maslow’s Hierarchy of Needs should be ap- plied. Physiological needs have priority over psychosocial ones. 2. 1. The cardiac glycoside, such as digoxin, should not be administered unless the apical pulse is 60 or above. 2. Because the client’s serum K+ level is already low, the nurse should question administering a loop diuretic. 3. The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first. 4. The client’s blood pressure is above 90/60, so the calcium-channel blocker can be adminis- tered but it is not priority over a client who is in a life-threatening situation. Content – Medical/Surgical: Category of Health Alteration– Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker should know which medications are priority, such as life-threatening medications, insulin, and mucolytics (Carafate). These medications should be administered first by the nurse. 3. 1. The nurse would expect the client with a deep vein thrombosis to have an edematous right calf, so the nurse would not need to assess this client first. 2. The nurse would expect the client with mitral valve stenosis to have heart palpitations (sensa- tions of rapid, fluttering heartbeat). 3. The nurse would expect the client with arterial occlusive disease to have intermittent claudica- tion (leg pain), so the nurse would not need to assess this client first. 4. The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker must determine which sign/symptom is not expected for the disease process. If the sign/ symptom is not expected, then the nurse should assess the client first. This type of question is determining if the nurse is knowl- edgeable of signs/symptoms of a variety of disease processes. 4. 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 3. A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 23 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Nursing Process – Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: When the test taker is deciding which client should be assigned to a new graduate, the most stable client should be assigned to the least experienced nurse. 5. 1. An LPN can perform sterile procedures such as inserting indwelling catheters and IV catheters. An RN should perform the functions that require nursing judgment, such as planning and evaluating the care of the clients. 2. Although an LPN could administer most in- travenous piggyback (IVPB) medications, only qualified RNs may administer intravenous push (IVP) medications and chemotherapy. 3. A UAP is capable of performing the morn- ing care. This is an appropriate nursing task to delegate. 4. Writing a care plan for a client requires nurs- ing judgment; therefore, an RN should be assigned this function. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: An RN cannot del- egate assessment, teaching, evaluation, medica- tions, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions that require nursing judgment. Remember that in most instances, options with the word “all” (op- tions 1 and 2) can be eliminated because if the test taker can think of one time when some other level of licensure could safely perform the task, then the option automatically becomes wrong. 6. 1. Unless the information shared is directly con- nected to healthcare issues, the nurse should not share confidential information with any- one else. The nurse should inform clients that information directly affecting the client’s healthcare will be shared on a need-to-know basis only. 2. The case manager’s job is to ensure conti- nuity and adequacy of care for the client. This individual has a “need to know.” 3. The case manager is part of the healthcare team; therefore, information should be shared. 4. The client gave permission when being admit- ted to the hospital for information to be shared among those providing care. The case manager does not need to obtain further consent. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Knowledge MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. 7. 1. The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested. 2. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable. 3. The UAP can take care of this problem; there is no need for the primary nurse to check the client. 4. The strip indicates an artifact, but there is no indication that the client should be removed from telemetry. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment, Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, med- ications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interven- tions requiring nursing judgment. 8. 1. The nurse who just has surgical nursing expe- rience would not be the choice to float to the emergency department. 2. The nurse with critical care experience would be the best choice to float to the emergency department. 3. The nurse just returning from sick leave would not be a good choice to send to the emergency department, which may be very busy at times. 4. This nurse has not had experience in critical care; therefore, this nurse would not be the best choice to float to the emergency department. A N S W E R S 24 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing: Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The nurse needs to know management issues for the RN-NCLEX®. The nurse with experience in certain areas of nursing would be most appropriate to float to the areas with related types of clients, such as critical care and the emergency department. 9. Correct Answer: 5, 4, 3, 2, 1 5. The nurse must first obtain informed consent prior to administering the blood product. 4. The nurse needs to complete the pre-transfusion assessment including assessing for any signs of allergic reac- tion prior to administering the unit of blood. 3. The blood must be hung with Y-tubing and normal saline, and an 18-gauge an- giocatheter is preferred. 2. The nurse must check the unit of blood from the laboratory with another nurse and with the client’s blood band. 1. During the first 15 minutes, the blood transfusion must be administered slowly to determine if the client is going to have an allergic reaction. Content – Adult Health, Cardiac: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physio- logical Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN® blueprint. The nurse must be able to perform skills in the correct order. Obtaining informed consent and assessment should always be the first interventions. 10. 1. The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening. 2. An elevated CPK-MB, cardiac isoenzyme, level is expected in a client with an acute myocardial infarction; therefore, the charge nurse would not see this client first. 3. The INR is within the normal limits of 2 to 3; therefore, this client does not need to be assessed first. 4. This client is being transferred to the cardiac unit; therefore, the client is stable and does not require the charge nurse to see this client first. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Psychosocial Integrity: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must determine if any of the assessment data is normal or abnormal for the client’s diagnosis. If the data is abnormal, then this client should be seen first. If the data is normal then a client with a psychosocial problem is the client the nurse should assess first. 11. Correct Answer: 3, 2, 4, 5, 1 3. Because this is less than 1 mL, the nurse should draw this medication up in a 1-mL tuberculin syringe to ensure accuracy of dosage. 2. The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administra- tion and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer’s recommended adminis- tration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes. 4. The nurse must check two identifiers according to the Joint Commission safety guidelines. 5. The nurse should clamp the tubing between the port and the primary IV line so that the medication will enter the vein, not ascend up the IV tubing. 1. Cardiovascular and narcotic medications are administered over 5 minutes. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Application MAKING NURSING DECISIONS: This is an alter- nate type of question that is included in the NCLEX-RN® blueprint. The nurse must be able to perform skills in the correct order. 12. 1. The nurse should first discontinue the medication that is causing the increase in the client’s blood pressure prior to doing anything else. 2. The nurse should notify the HCP but not prior to taking care of the client’s elevated blood pressure. 20. 1. The client’s International Normalized Ratio (INR) is 3.4. The therapeutic CHAPTER 2 CARDIOVASCULAR MANAGEMENT 27 should send the UAP for help and the crash cart. range is 2 to 3 for a client diagnosed with atrial fibrillation. This client is at risk for bleeding. The nurse should hold the medication and discuss the warfarin with the HCP. 2. Metoclopramide is used to stimulate gastric emptying. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication. 3. Docusate is a stool softener. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication. 4. Atorvastatin is a lipid-lowering medication. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Process: Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alter- nate type question included in the NCLEX-RN® blueprint. The test taker must be able to read a medication administration record (MAR), be knowledgeable of medications, and be able to make an appropriate decisions as to the nurse’s most appropriate intervention. 21. 1. The first step in cardiopulmonary resuscita- tion according to the AHA guidelines is to establish unresponsiveness by “shaking and shouting.” If the client does not respond to being shaken, then the nurse can proceed to the next step, which is to “look, listen, and feel” for breaths. This is assessment and, according to AHA guidelines, the UAP could perform this function if alone. How- ever, the nurse should assess the client before a UAP. 2. Administering chest compressions is per- formed after establishing unresponsiveness and lack of respiration. 3. The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is deter- mined, the nurse should not delegate any client care. 4. The nurse should place the client in the recumbent position before attempting to perform chest compressions; the nurse Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: This is an “ex- cept” question. The test taker could ask which task is appropriate to delegate to the UAP; three options would be appropriate to delegate and one would not be. Remember the RN cannot delegate assessment, teaching, evaluation, med- ications, or an unstable client to the UAP. 22. 1. The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client’s heart stops beating. 2. The information about the DNR status is already inside the chart. It may need to be placed on the outside of the chart and a special armband or other notification made to other healthcare personnel. 3. The client has a DNR order, but this does not imply that there may be 6 months or less life expectancy for the client. (Hospice care may be requested for clients with less than a 6-month life expectancy.) An order for hospice must be written by the attending healthcare provider before making this referral. 4. The client should be allowed as many visitors as the hospital policy allows. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Physiological Integrity: Basic Care and Comfort: Cognitive Level – Knowledge MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements. The nurse must be knowl- edgeable of these issues. 23. 1. The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client’s age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the question that should be asked because many clients may be embarrassed to bring up the subject. A N S W E R S 28 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 2. The client should not drive a motor vehicle until released to do so by the healthcare provider (HCP). This is not an appropriate question at this time. 3. The client should be discharged with a prescription for oral pain medications to be taken as directed by the surgeon. The nurse should not encourage the client to use old medications the client may have at home. This is not an appropriate question. 4. The nurse is providing discharge instructions and should tell the client when to call the healthcare provider (HCP). This is not an appropriate question. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Analysis 24. 1. The LPN can contact the HCP and give pertinent information. The INR is high (therapeutic is 2 to 3), and the HCP should be informed. 2. The RN cannot assign assessment to an LPN. 3. The INR is elevated, but this will not affect the client’s atrial fibrillation. The client is at risk for abnormal bleeding, not a life- threatening dysrhythmia. 4. The normal INR is 2 to 3; therefore, some action should be implemented. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse cannot assign assessment, teaching, evaluation, or an unstable client to an LPN. The LPN can tran- scribe HCP orders and can call them on the phone to obtain orders for a client. 25. 1. In a disaster, the nurse should utilize as many individuals as possible to help control the situation; therefore, this is an inappropriate intervention. 2. The unlicensed assistive personnel (UAP) cannot assess clients; therefore, this is not an appropriate action. 3. Unlicensed assistive personnel (UAP) have the ability to keep the victims calm; therefore, this is an appropriate action. This action is not critical to the safety of the victims. 4. The paramedics do not need civilians assisting them as they stabilize and transport the victims. This is not an appropriate action. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. 26. 1. The clinic nurse should not correct the UAP in front of the client. This is embar- rassing to the UAP and makes the client uncomfortable. 2. The clinic nurse must correct the UAP’s be- havior. The client’s weight gain should not be announced in the office area so that all staff, clients, and visitors can hear. This is a violation of confidentiality. 3. The clinic nurse should correct the UAP’s behavior, but it should be done in private and with an explanation as to why the action is inappropriate. This is a violation of confidentiality because the scale is located in the office area and any client or visitor passing by, as well as other staff members, can hear the comment. 4. The clinic nurse should handle this situation. If the UAP’s behavior shows a pattern of behavior, then it should be reported to the director of nurses. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: In any business, including a healthcare facility, arguments or discussions of confidential information should not occur among staff of any level where the customers—in this case, the clinic clients—can hear it or see it. 27. 1, 2, 3, and 5 are correct. 1. Case managers help coordinate health- care between multiple sources of healthcare attempting to contain healthcare cost. 2. The case manager is a client advocate and helps with communication between the client and healthcare providers, which, it is hoped, enhances the client’s quality of life. 3. The case manager coordinates out- patient care and in-patient care, and helps with referrals for the client. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 29 4. Case management is not a form of health insurance. 5. The case manager is involved in assess- ing, planning, facilitating, and advocating for health services for a client, which, it is hoped, provide quality care. Trying to coordinate this is often exhausting and frustrating for the client and family. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each member of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. This is an alternate type question wherein the test taker must select more than one option as correct and must select all appropriate options to receive credit for a correct answer. 28. 1. If the client takes the loop diuretic in the morning, then going to the bathroom fre- quently in the morning would not warrant intervention. 2. Rising from a sitting position slowly helps prevent orthostatic hypotension, which is a potential side effect of all the medica- tions. This statement would not warrant intervention. 3. This statement indicates the client is adher- ing to a low-sodium diet, as he should be. No intervention is warranted. 4. Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants interven- tion by the nurse. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process:Assessment: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must be knowledgeable of medications. In most scenarios, there is no test-taking hint to help the test taker when answering medication questions except common nursing interventions, such as do not administer cardiac medications if client has AP <60 or B/P <90/60, do not administer medications with grapefruit juice or antacids, or most medications are administered with food to prevent GI distress. 29. 1. This is a win-win strategy that focuses on goals (to have adequate staff) and attempts to meet the needs of both parties. The director of nurses keeps an experienced nurse, and the UAP keeps her position. Both parties win. 2. This is a possible win-win strategy in which both parties win. The UAP keeps her job, and the director of nurses can hire a UAP who will be able to work the assigned hours. 3. This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses. 4. This is a negotiation in which the conflicting parties give and take on the issues. The UAP gets one more chance, and the director of nurse’s authority is still intact. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy; the nurse must be knowledgeable of management issues. 30. 1. A full sharps container is a violation of Occupational Health and Safety Administra- tion (OSHA) regulations, and because the UAP has not done it after being asked twice, a third request is not necessary. 2. The nurse should discuss why the sharps container has not been changed, but it is not the first intervention. 3. A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behaviour. 4. The situation should be documented because the UAP was told twice, but documentation is not the first intervention. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Process: Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements. The nurse must be knowl- edgeable of these issues. The nurse may have to A N S W E R S 32 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM MAKING NURSING DECISIONS: The test taker must be knowledgeable of all the various areas of nursing and the role of each member of the mul- tidisciplinary healthcare team, as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. 39. 1. This is professional boundary crossing. Even though the grandson is not the client, he is related to the client. The HH aide should not go out with him. 2. This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service. 3. The nurse’s best response is to tell the HH aide the facts about dating relatives of clients. The director would tell the HH aide the same information. 4. The HH aide could date the grandson when the client is no longer on service. So this statement is not the nurse’s best response. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy; the nurse must be knowledgeable of management issues. Boundary crossings is a very important area every nurse must be aware. 40. 1, 2, 4, and 5 are correct. 1. A 2-lb weight gain indicates the client is retaining fluid and should contact the HCP. This is an appropriate teaching intervention. 2. Keeping the head of the bed elevated will help the client breathe easier; therefore, this is an appropriate teach- ing intervention. 3. The loop diuretic should be taken in the morning to prevent nocturia. This is not an appropriate teaching intervention. 4. Sodium retains water. Telling the client to avoid eating foods high in sodium is an appropriate teaching intervention. 5. Isotonic exercise, such as walking or swimming, helps tone the muscles, and discussing this with the client is an appropriate teaching intervention. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Synthesis MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN®. The nurse must be able to select all the options that answer the question correctly. There are no partially correct answers. 41. 1. The INR is not at a therapeutic level yet; the nurse should administer this medication. 2. This potassium level is very low. Hy- pokalemia potentiates dysrhythmias in clients receiving digoxin. This nurse should discuss potassium replacement with the HCP before administering this medication. 3. An aspartate aminotransferase (AST) test measures the amount of this enzyme in the blood. The enzyme is part of the liver function panel. The normal is 14–20 U/L for males and 10–36 U/L for females. 4. Creatinine level is reflective of renal status. Normal is 0.6–1.2 mg d/L. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must know normal laboratory data. 42. 1. Assessment of the client’s spiritual needs in end-of-life issues is a key consideration but is the chaplain’s responsibility, when he/she is a member of the hospice team. 2. The client’s financial situation can be as- sessed, but it is not priority over the client’s spiritual needs when death is near. 3. The client’s support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client. 4. The client’s medical diagnosis is important when addressing the grieving process but there is nothing the nurse can do about the medical diagnosis, which is why assessing, supporting, and addressing the client’s spiritual needs will be carried out prior to the medical diagnosis. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiologi- cal Integrity: Physiological Adaptation: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker CHAPTER 2 CARDIOVASCULAR MANAGEMENT 33 come to a closure of his or her life. This must be knowledgeable of all the various areas of nursing and the role of each member of the mul- tidisciplinary healthcare team, as well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. 43. 1. The client’s HCP will need to determine time of death but it is not the nurse’s first intervention. 2. The Rapid Response Team would not be notified because the client has a DNR. 3. The nurse should stay with the client and her husband and not make any life- rescuing interventions while the client is dying. The husband should not be left alone. 4. The UAP can perform post-mortem care but it is not the first intervention when the client’s husband tells the nurse his wife has quit breathing. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: A do not resus- citate (DNR) is a written physician’s order instructing healthcare providers not to attempt CPR. A new term recently introduced is “allow natural death” (AND). The nurse cannot legally perform CPR on a client who has a DNR. 44. 1. This client should be seen, but a client who is terminally ill and is refusing to eat is not an emergency situation. 2. The client has a right to rescind the out-of- hospital DNR but paperwork is not priority over a client who is in pain. 3. One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately. 4. A Stage 1 pressure ulcer must be assessed and treatment started but this is not priority over pain control. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The nurse can use Maslow’s Hierarchy of Needs to determine which client to assess first. Pain is a physiological need. 45. 1. Encouraging the client to review his or her life experiences assists the client to is an important intervention the volun- teer can perform. 2. This is the job of the UAP, not the volunteer. 3. This is the job of the chaplain, not the volunteer. 4. This is the job of the nurse or occupational therapist, not the volunteer. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appropriate task to delegate/assign, the test taker should choose the task that allows each staff member to function within his or her full scope of practice. Do not assign a task to a staff member that falls outside the staff member’s or volunteer’s expertise. 46. 1. The nurse should provide instruction and support to the UAP. This is the best re- sponse. 2. This is a callous statement and does not help the UAP learn to provide post-mortem care. 3. This is not hearing the UAP’s concern. 4. The nurse should assist the UAP to learn to perform the duties of a UAP, not circumvent the workload. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis 47. 1. If the HCP is called, the nurse should per- form this task, not the UAP. A UAP cannot take a telephone order; only a licensed nurse can take telephone orders. 2. The UAP cannot administer a medication, not even Tylenol. 3. The nurse should immediately go to the client’s room and assess the client. Sometimes the nurse may need the client’s chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room. 4. The UAP should not be asked to relay such information. This is the nurse’s or HCP’s responsibility. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis A N S W E R S 34 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appro- priate task to delegate/assign, the test taker should choose the task that allows each staff member to function within his or her full scope of practice. Do not assign a task to a staff mem- ber that requires a higher level of expertise than that staff member has. Conversely, do not assign a task to a staff member when that task could be performed by a staff member with a lower level of expertise. 48. 1. The LPN can feed a client who is stable but unable to feed him or herself because of medical equipment. This is an appropriate task to assign. 2. The nurse cannot assign assessment. This is the inappropriate task to assign to the LPN. 3. The LPN can discharge a client who had a procedure and who does not require extensive teaching. 4. The LPN can administer a routine IVPB medication. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The nurse cannot assign assessment, teaching, evaluation, or an unstable client to an LPN. The LPN can tran- scribe HCP orders and can call HCPs on the phone to obtain orders for a client. 49. 1. The UAP should encourage the client to remain independent as long as possible. If the client is unable to perform activities of daily living (ADLs), then the UAP should perform the tasks. 2. This may be true, but the UAP cannot and should not distance himself or herself from the clients. The UAP should maintain a professional relationship with the clients. 3. This is an important statement for the UAP to understand. If information re- vealed to the UAP is necessary to provide appropriate care to the client, then the information must be shared on a need- to-know basis with the healthcare team. 4. Clients should be encouraged to discuss their life because life review may help clients accept their death. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Diagnosis: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each mem- ber of the multidisciplinary healthcare team as well as HIPAA rules and regulations. These top- ics will be tested on the NCLEX-RN® exam. 50. 1. The nurse in the client’s room notifies the hospital operator of a code situation. 2. Answering the call lights of the other clients on the unit can be delegated to the UAP. 3. In a hospital, the respiratory therapist as- sumes the responsibility for ventilations. 4. The nursing supervisor is responsible for requesting the family to leave the room. The UAP does not have the authority to make this request. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appropriate task to delegate/assign, the test taker should choose the task that allows each member of the staff to function within his or her full scope of practice. Do not assign a task to a staff member that requires a higher level of expertise or that a staff member with a lower level of expertise could perform. 51. 1. If the family is not causing a disruption in the code, the family member should be allowed to stay in the room with the super- visor remaining near the family member and explaining why the interventions are being implemented will help the client to survive. The supervisor should be ready to escort the family member out of the code if the family member becomes disruptive. 2. This will cause ill will on the part of the family and could result in the filing of a needless lawsuit. 3. The HCP is busy with the care of the client. This is not the time to ask an HCP a ques- tion the supervisor can handle. 4. Ignoring the family member could cause a problem; the supervisor should be proactive in managing the situation. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse should always try and support the client or the family’s Content – Medical/Surgical; Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Safe and CHAPTER 2 CARDIOVASCULAR MANAGEMENT 37 MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appro- priate task to delegate/assign, the test taker Effective Care Environment: Safety and Infection Control: Cognitive Level – Synthesis MAKING NURSING DECISIONS: When the stem asks the nurse to determine which healthcare provider’s order to question, the test taker needs to realize this is an “except” question. Three of the options are appropriate for the HCP to prescribe and one is not appropriate for the client’s disease process or procedure. 61. 1. The nurse should not document that the client fell unless the nurse observed the client fall. The nurse should never write “incident report” in a chart. This becomes a red flag to a lawyer. 2. The nurse should document exactly what was observed. This statement is the correct documentation. 3. This statement is not substantiated and should not be placed in the chart. 4. This statement is documenting something the nurse did not observe, a fall. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment, Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse must be able to document nursing care safely; it includes accurate, timely documentation; it meets profes- sional, legislative, and agency standards; it facili- tates communication between nurses and other healthcare providers; and it is comprehensive. 62. 1. Cooking and cleaning are jobs that can be arranged through some home health agencies, but these jobs would be done by a housekeeper, not by the UAP. 2. The home health aide is responsible for assisting the client with activities of daily living and transferring from the bed to the chair. Sitting outside is good for the client and is a task that can be delegated to the home health aide. 3. This is boundary crossing by the UAP and could create legal difficulties if the UAP had an accident. 4. This is assessment and cannot be delegated to a UAP. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis should choose the task that allows each staff member to function within his or her full scope of practice. Do not assign a task to a staff mem- ber that falls outside the staff member’s or volunteer’s expertise. Remember the RN cannot delegate assessment, teaching, evaluation, med- ications, or an unstable client to the UAP. 63. 1. If the client is in distress, assessment is not the first intervention if there is an action the nurse can take to relieve the distress. The nurse should administer the nitroglycerin first. 2. Calling for an electrocardiogram and tro- ponin level should be implemented but not before administering the nitroglycerin. 3. Placing nitroglycerin under the client’s tongue may relieve the client’s chest pain and provide oxygen to the heart muscle. This is the nurse’s first intervention. 4. Notification of the HCP can be done after the nurse has stabilized the client. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse should remember that if a client is in distress and the nurse can do something to relieve the distress, that action should be done first, before assess- ment. The test taker should select an option that directly helps the client’s condition. 64. 1. The supervisor can take notes documenting the code until relieved, but the supervisor needs to be free to supervise the code and coordinate room assignments and staffing. 2. The first intervention for the supervisor is to ensure that all the jobs in the code are being filled. 3. This is the responsibility of the supervisor, but it is not the first intervention. 4. The supervisor can administer medications, but the supervisor needs to be flexible to complete the duties of the supervisor. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker must be knowledgeable of the role of each mem- ber of the multidisciplinary healthcare team as A N S W E R S 38 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM well as HIPAA rules and regulations. These topics will be tested on the NCLEX-RN® exam. The administrative manager is responsible for the other members of the healthcare team. 65. 1. This client is being treated, and if the blood is almost finished, then it can be assumed that the client is tolerating the blood without incident. 2. The client has been given devastating news. When all the information in the options is expected and not life threaten- ing, then psychological issues have prior- ity. This client should be seen first. 3. The client has eaten. The nurse could arrange for the dietician to consult with the client about food preferences, but this client does not need to be assessed first. 4. Dyspnea on exertion is not priority if the client is exerting himself or herself. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Psychosocial Integrity: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must determine if the assessment data is normal or abnormal for the client’s diagnosis or situa- tion. If the data is abnormal then this client should be seen first. If the data is normal then a client with a psychosocial problem is the client the nurse should assess first. 66. 1. This medication could be administered but it will not have as rapid an impact as the SL dose. 2. Nitroglycerin is administered first because it will dilate the vessels and resolve the cause of the chest pain. If the chest pain still is pres- ent after three (3) NTG then the morphine should be administered. 3. Oxycodone and acetaminophen will not address the chest pain specifically. 4. The nurse should administer the med- ication that will have the most rapid onset and directly resolve the problem. Nitroglycerin is a potent vasodilator and will dissolve rapidly under the tongue (sublingually). Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alter- nate type question included in the NCLEX-RN® blueprint. The test taker must be able to read a medication administration record (MAR), be knowledgeable of medications, and be able to make an appropriate decision as to the nurse’s most appropriate intervention. 67. 1. A client with a DVT on a heparin drip should have an aPTT in this range. The charge nurse should make sure that the drip is maintaining the client in the therapeutic range, but the safety of the client going to surgery is first priority. 2. This client is scheduled for surgery this morning; therefore, the charge nurse must make sure that he is stable for the procedure and notify the surgeon if there is any reason to question the safety of the client having the procedure this morning. 3. This client is postprocedure and unless there is a situation that arises from the nurse’s assessment then this client is not priority. 4. Gall bladder disease is not life threatening, although it can be very uncomfortable. This client is not priority. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN® blueprint. The test taker must be able to read a chart, be knowledgeable of laboratory data, and be able to make appropriate decisions as to the nurse’s most appropriate action. 68. Correct Answer: 3, 1, 4, 2, 5 3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and the temper- ature to see if interventions should be initiated based on a progression of the septicemia. 1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift. 4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring. 2. This client has a psychosocial need but it must be addressed and steps imple- mented to resolve the problem. 5. A dressing change can take some time to complete. This is a physiological situa- tion but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change. CHAPTER 2 CARDIOVASCULAR MANAGEMENT 39 Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: This is an alter- nate type of question which requires the nurse to assess clients in order of priority. This requires the nurse to evaluate each client’s situation and determine which situations are life threatening, which situations are expected for the client’s situation, or which client has a psychosocial problem. 69. 1, 3, and 4 are correct. 1. Nitroglycerin tablets are vasodilators that are administered to dilate the coronary vessels and provide oxygen to the heart muscle. 2. The client should be made to sit down im- mediately. Exercise is the probable cause of the chest pain; therefore, the activity should immediately stop. 3. The nurse should assess the client’s vital signs as part of the assessment of the client’s current situation. 4. Supplemental oxygen will assist in getting higher concentrations of oxygen to the heart muscle. 5. A ward secretary cannot take orders; only a nurse should discuss the client with the healthcare provider. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN®. The nurse must be able to select all the options that answer the question cor- rectly. There are no partially correct answers. 70. Answer: 24 mL per hour 25,000 divided by 500 mL = 50 units of heparin per mL. 26 (current rate) X 50 = 1300 units of heparin currently infusing. 1300 — 100 = 1200 units of heparin needed as new infusion rate. 1200 divided by 50 = 24 mL per hour to infuse Content – Medical/Surgical: Category of Health Alteration – Drug Administration: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Application MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN®. The nurse must know how to solve math questions. A N S W E R S Not everything that can be counted counts, and not everything that counts can be counted. —Albert Einstein 1. The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with arterial occlusive disease who has intermittent claudication. 2. The client on strict bed rest who is complaining of calf pain and has a reddened calf. 3. The client who complains of low back pain when lying supine in the bed. 4. The client who is upset because the food doesn’t taste good and is cold all the time. 2. The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse? 1. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT). 2. The hemoglobin 11.4 for a client diagnosed with Raynaud’s phenomenon. 3. The white blood cell (WBC) count of 11,000 for a client with a stasis venous ulcer. 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN). 3. The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first? 1. Notify the healthcare provider immediately. 2. Have the UAP recheck the client’s vital signs manually. 3. Place the client in Trendelenburg position. 4. Assess the client’s cardiovascular status. 4. The charge nurse on a vascular unit is working with a new unit secretary. Which statement concerning laboratory data is most important for the charge nurse to tell the unit secretary? 1. “Be sure to show me any lab information that is called in to the unit.” 2. “Make sure to file the reports on the correct client’s chart.” 3. “Do not take any laboratory reports over the telephone.” 4. “Verify all telephone reports by calling back to the lab.” 5. The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering? 1. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8. 2. Propranolol (Inderal), a beta-adrenergic, to a client with arterial hypertension. 3. Nifedipine (Procardia), a calcium channel blocker, to a client with Raynaud’s disease. 4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with a sodium level of 138 mEq/L. 43 Peripheral Vascular Management 3 QUESTIONS 44 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 6. The nurse has received the shift report. Which client should the nurse assess first? 1. The client with a deep vein thrombosis who is complaining of dyspnea and coughing. 2. The client diagnosed with Buerger’s disease who has intermittent claudication. 3. The client diagnosed with an aortic aneurysm who has an audible bruit. 4. The client with acute arterial ischemia who has bilateral palpable pedal pulses. 7. The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first? 1. Assess the client for abnormal bleeding. 2. Instruct the client to stop taking the aspirin. 3. Recommend the client take an enteric-coated aspirin. 4. Instruct the client to notify the HCP. 8. The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching? 1. “The UAP will be practicing on my brand-new nursing license.” 2. “I will still retain accountability for what I delegate to the UAP.” 3. “I must make sure the UAP to whom I delegate is competent to perform the task.” 4. “When I delegate, I must follow up with the UAP and evaluate the task.” 9. The nurse is reviewing the literature to identify evidence-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse’s proposal for a change in the procedure? 1. The article in which the study was conducted by the manufacturer of the product used. 2. The research article that included 10 subjects participating in the study. 3. The review-of-literature article that cited ambiguous statistics about the product. 4. The review-of-literature article that cited numerous studies supporting the product. 10. The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate? 1. Provide indwelling catheter care to a client on bed rest. 2. Evaluate the client’s 8-hour intake and output. 3. Give a bath to the client who is third-spacing. 4. Administer a cation-exchange resin enema to a client. 11. The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take? 1. Tell another UAP to put the SCDs on the client. 2. Demonstrate the procedure for applying the SCDs. 3. Perform the task and apply the SCDs to the client. 4. Request the UAP watch the video demonstrating this task. 12. The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN? 1. Assess the client who will be transferred to the medical unit in the morning. 2. Administer a unit of blood to the client who is 1 day postoperative. 3. Hang the bag of heparin for a client diagnosed with a pulmonary embolus. 4. Assist the HCP with the insertion of a client’s Swan-Ganz line. 13. The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the client becomes restless and complains of itch- ing on the trunk and arms. Which intervention should the nurse implement first? 1. Assess the client’s vital signs. 2. Notify the HCP. 3. Maintain a patent IV line. 4. Stop the transfusion at the hub. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 47 30. The home health (HH) nurse is caring for a client with arterial hypertension who has had a cerebrovascular accident. Which priority intervention should the nurse discuss with the client when teaching about arterial hypertension? 1. Discuss the importance of the client adhering to a low-salt diet. 2. Explain the need for the client to take antihypertensive medications as prescribed. 3. Tell the client to check and record their blood pressure readings daily. 4. Encourage the client to walk at least 30 minutes three times a week. 31. Which action by the unlicensed assistive personnel (UAP) indicates to the nurse the UAP understands the correct procedure for applying compression stockings to the client recovering from a pulmonary embolus? 1. The UAP instructs the client to sit in the chair when applying the stockings. 2. The UAP cannot insert one finger under the proximal end of the stocking. 3. The UAP ensures the toe opening is placed on the top side of the feet. 4. The UAP checked to make sure the client’s toes were warm after putting the stockings on. 32. The home health (HH) nurse enters the yard of a client and is bitten on the leg by the client’s dog. Which intervention should the nurse implement first? 1. Clean the dog bite with soap and water and apply antibiotic ointment. 2. Obtain the phone number and contact the client’s veterinarian. 3. Contact the HH care agency and complete an occurrence report. 4. Ask the client whether the dog has had all the required vaccinations. 33. The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants immediate intervention by the nurse? 1. “My legs start to hurt when I walk to check my mail.” 2. “My legs were so cold I had to put a heating pad on them.” 3. “I hang my legs off the side of my bed when I sleep.” 4. “I noticed that the hair on my feet and up my leg is gone.” 34. The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home. The client tells the nurse they just cannot afford them. Which action should the nurse implement first? 1. Purchase at least one smoke detector for the client’s home. 2. Notify the HH care agency social worker to discuss the situation. 3. Ask the client whether a family member could buy a smoke detector. 4. Contact the local fire department to see if they can provide smoke detectors for the client. 35. The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arms. The client states she fell on an ashtray and doesn’t want to talk about it. Which nursing intervention is priority? 1. Document the objective findings in the client’s chart. 2. Tell the client she must talk about the situation with the nurse. 3. Report the situation to the Adult Protective Services. 4. Take photographs of the bruises and cigarette burns. 36. The nurse is admitting a client diagnosed with deep vein thrombosis (DVT) in the right leg. Which statement by the client warrants immediate intervention by the nurse? 1. “I take a baby aspirin every day at breakfast.” 2. “I have ordered myself a medical alert bracelet.” 3. “I eat spinach and greens at least twice a week.” 4. “I got a new recliner so I can elevate my legs.” Q U E S T IO N S 48 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 37. The male client with peripheral vascular disease tells the nurse, “I know my foot is really bad. My doctor told me I don’t have any choice and I must have an amputation, but I don’t want one.” Which action supports the nurse being a client advocate? 1. Support the medical treatment, and recommend the client have the amputation. 2. Recommend the client talk to his wife and children about his decision. 3. Explain to the client that he has a right to a second opinion if he doesn’t want an amputation. 4. Tell the client she will go with him to discuss his decision with the doctor. 38. The charge nurse observes the unlicensed assistive personnel (UAP) crying after the death of a client. Which is the charge nurse’s best response to the UAP? 1. “If you cry every time a client dies, you won’t last long on the unit.” 2. “It can be difficult when a client dies. Would you like to take a break?” 3. “You need to stop crying and go on about your responsibilities.” 4. “Did you not realize that clients die in a healthcare facility?” 39. The nursing staff confronts the hospice nurse overseeing the care of a client in a long- term care facility. The nursing staff wants to send the client who is diagnosed with gangrene of the left leg secondary to peripheral occlusive disease to the hospital for treatment. Which intervention should the nurse implement first? 1. Check with the client to see whether or not the client wants to go to a hospital. 2. Explain that the client can be kept comfortable at the long-term care facility. 3. Discuss the hospice concept of comfort measures only with the staff. 4. Call a client care conference immediately to discuss the conflict. 40. The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse must notify the significant other. Which statement made by the nurse is the best over the telephone? 1. “I am sorry to tell you, but your loved one has died.” 2. “Could you come to the hospital? The client is not doing well.” 3. “The HCP has asked me to tell you of your family member’s death.” 4. “Do you know whether the client wished to be an organ donor?” 41. The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse? 1. The client with the femoral-popliteal bypass who has paraesthesia of the foot. 2. The client with an abdominal aortic aneurysm who is complaining of low back pain. 3. The client newly diagnosed with chronic venous insufficiency who needs teaching. 4. The client with varicose veins who is complaining of deep, aching pain of the legs. 42. The charge nurse in the vascular intensive care unit assigns three clients to the staff nurse. The staff nurse thinks this is an unsafe assignment. Which action should the staff nurse implement first? 1. Refuse to take the assignment and leave the hospital immediately. 2. Tell the supervisor that he or she is concerned about the unsafe assignment. 3. Document his or her concerns in writing and give it to the supervisor. 4. Take the assignment for the shift but turn in his or her resignation. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 49 43. At 2230, the nurse is preparing to administer pain medication to a male client who rates his pain as a 4 on the numeric pain scale. Which medication should the nurse administer? Client: Mr. C Admit Number: 432165 Allergies: Ibuprofen Date: Today Height: 65 inches Weight: 64.2 kg 141.2 pounds Diagnosis: Chronic vein insufficiency Medication 0701–1500 1501–2300 2301–0700 Morphine sulfate mg IVP q 2 hours PRN 0930 DN2 Promethazine (Phenergan) 12.5 mg IVP q 4 hours PRN 1845 EN Prochlorperazine (Compazine) 5 mg PO tid PRN Hydrocodone (Vicodin) 5 mg PO q 4–6 hours PRN 1730 EN Ibuprofen (Motrin) 600 mg PO q 3–4 hours PRN Nurse’s Name/Initials Day Nurse RN/DN Evening Nurse RN/EN Night Nurse RN/NN 1. Administer morphine 2 mg IVP. 2. Administer promethazine 12.5 mg IVP. 3. Administer hydrocodone 5 mg PO. 4. Administer ibuprofen 600 mg PO. 44. The matriarch of a family has died on the vascular unit. The family tells the nurse the daughter is coming to the hospital from a nearby city to see the body. Which intervention should the nurse implement? 1. Plan to allow the daughter to see the client in the room. 2. Take the client to the morgue for the daughter to view. 3. Request the family call the daughter and tell her not to come. 4. Explain to the daughter that the unit is too busy for family visitation. 45. The unit manager on the vascular unit is planning a change in the way post-mortem care is provided. Which is the first step in the change process? 1. Collect data. 2. Identify the problem. 3. Select an alternative. 4. Implement a plan. 46. The nurse is preparing to administer the third unit of packed red blood cells (PRBCs) to a client with a ruptured aortic aneurysm. Which interventions should the nurse implement? Select all that apply. 1. Hang a bag of D5NS to keep open (TKO). 2. Change the blood administration set. 3. Check the client’s current vital signs. 4. Assess for allergies to blood products. 5. Obtain a blood warmer for the blood. Q U E S T IO N S 52 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 62. The nurse is caring for clients on a vascular surgical floor. Which client should be assessed first? 1. The client who is 2 days postoperative right below-the-knee amputation who has phantom pain in the right foot. 2. The client who is 1 day postoperative abdominal aortic aneurysm who is complain- ing of numbness and tingling of both feet. 3. The client with superficial thrombophlebitis of the left arm who is complaining of tenderness to the touch. 4. The client with arterial occlusive disease who is complaining of calf pain when ambulating down the hall. 63. The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hour if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 20 mL per hour. At what rate should the nurse set the pump? 64. The unlicensed assistive personnel (UAP) is caring for a client diagnosed with chronic ve- nous insufficiency. Which action would warrant immediate intervention from the nurse? 1. The UAP assists the client to apply compression stockings. 2. The UAP elevates the client’s leg while sitting in the recliner. 3. The UAP assists the client to the bathroom for a.m. care. 4. The UAP is cutting the client’s toenails after soaking the client’s feet in tepid water. 65. The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is refusing to eat the high protein meal. 2. The client with varicose veins who is refusing to wear thromboembolic hose. 3. The client with arterial occlusive disease who is refusing to elevate their legs. 4. The client with deep vein thrombosis who is refusing to stay in the bed. 66. At 1000 a client who has had femoral popliteal surgery on the right leg is complaining of severe right upper quadrant pain of 10 out of 10 on the pain scale. Based on the information in the chart below, what should the nurse do for the client? Client Name: Mr. B.A. Account Number: 0101223 Allergies: Codeine Height: 72 inches Weight in pounds: 220 Weight in kg: 100 Date of Birth: 02/05/1982 Date: Today Medication 2301–0700 0701–1500 1501–2300 Morphine Sulfate 0445 NN 0845DN 2 mg IVP every 4 hour PRN pain Oxycodone 7.5/ 0030 NN acetaminophen 325 mg PO every 0545 NN 3 hours PRN pain Maalox 30 mL PO PRN indigestion Nitroglycerin 0.4 mg SL every 5 minutes up to 3 tablets PRN Chest pain Signature/Initials Night Nurse RN/NN Day Nurse RN/DN 1. Administer the oxycodone and acetaminophen PO. 2. Help the client to practice guided imagery for the pain. 3. Call the surgeon for an increase in pain medication. 4. Administer a dose of morphine to the client. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 53 67. The client on a surgical unit is scheduled to receive an antibiotic piggyback over 1 hour. The piggyback is prepared in 150 mL of solution. At what rate should the nurse set the piggyback if the administration set delivers 20 drops per mL? 68. The client in the day surgical unit is scheduled to have vein ligation on the right leg. The client states, “I am having surgery on my left leg.” Which intervention should the nurse implement first? 1. Have the client sign the surgical operative permit. 2. Assess the client’s neurological status. 3. Ask when the client last took a drink of water or ate anything. 4. Call a time out until clarifying which leg is having the vein ligation. 69. The 63-year-old client is diagnosed with an abdominal aortic aneurysm. Which area on the figure should the nurse place a stethoscope to assess for a bruit? C A D 1. A 2. B 3. C 4. D 70. The male post-op femoral popliteal client notifies the desk via the intercom system he has fallen and is now bleeding. Which interventions should the nurse implement? Rank in order of performance. 1. Apply pressure directly to the bleeding site. 2. Notify the surgeon of the fall and the bleeding. 3. Redress the site with a sterile dressing. 4. Assist the client to a recumbent position in the bed. 5. Make out an occurrence report and document the fall. B Q U E S T IO N S 54 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM DH is the charge nurse on a medical unit. She has three primary nurses, JC, who has been a nurse on the unit for 12 years; BN, who has been on the unit for 1 year; and PN, who is a new graduate. There are 3 UAPs, BA, BE, and AM. 1. JC just received the a.m. shift report. Which client should JC assess first? 1. The client diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with deep vein thrombosis who is complaining of calf pain. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with aortic abdominal aneurysm who has low back pain. 2. Which assessment data would warrant immediate intervention by DH, charge nurse for the client diagnosed with arterial occlusive disease? 1. The client has decreased hair on his or her calf. 2. The client has no palpable dorsal pedal pulse. 3. The client has paralysis and parasthesia. 4. The client hangs his or her legs off the side of bed. 3. The nurse and the unlicensed assistive personnel (UAP) are caring for a client who is 4 hours postoperative right femoral–popliteal bypass surgery. Which nursing task should JC delegate to the UAP? 1. Check the client’s pedal pulse with the Doppler. 2. Assist the client to ambulate down the hall. 3. Review the client’s neurovascular assessment. 4. Elevate the client’s leg on two pillows. 4. Which interventions should DH discuss with the client diagnosed with atherosclerosis? Select all that apply. 1. Take a baby aspirin daily. 2. Eat a low-fat, low-cholesterol diet. 3. Maintain a sedentary lifestyle as much as possible. 4. Decrease all foods high in fiber. 5. Walk 30 minutes a day at least 3 days a week. 5. The client is 2 days postoperative abdominal aortic aneurysm. Which intervention should BN implement first when making initial rounds? 1. Auscultate the client’s bowel sounds. 2. Assess the client’s surgical dressing. 3. Encourage the client to splint the incision. 4. Monitor the client’s intravenous therapy. 6. The client is diagnosed with a small abdominal aortic aneurysm. Which statement by the client indicates to BN the client needs more discharge teaching? 1. “I should not lift more than 5 pounds for at least 4 to 6 weeks.” 2. “I attend a support group to help me quit smoking.” 3. “I will need to wear a truss at all times after the surgery.” 4. “If I get a temperature of 101 or higher I will call my doctor.” PERIPHERAL VASCULAR DISEASE CLINICAL SCENARIO CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 57 welfare. The secretary must know how to process the information. 4. The unit secretary should verify the informa- tion by repeating back the information at the time of the call, not by making a second tele- phone call to the lab. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker must be knowledgeable of the roles of all mem- bers of the multidisciplinary healthcare team, as well as HIPAA rules and regulations. The nurse must ensure the healthcare team member knows appropriate actions to take in specific situations. These will be tested on the NCLEX-RN®. 5. 1. Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a client when his or her INR level is above the therapeutic 2–3; therefore, the nurse should question administering this medication. 2. Inderal is administered to clients diagnosed with hypertension; therefore, the nurse would not question administering this medication. 3. Procardia reduces the number of vasospastic attacks in clients with Raynaud’s disease; therefore, the nurse should question adminis- tering this medication to a client with hypotension. 4. Vasotec, an ACE inhibitor, is administered to clients with diabetes to help prevent diabetic nephropathy. The nurse would not question administering this medication. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Analysis MAKING NURSING DECISIONS: The nurse must be aware of interventions that must be imple- mented prior to administering medications. The nurse must know what to monitor prior to ad- ministering medications because untoward reac- tions and possibly death can occur. 6. 1. This client is exhibiting signs/symptoms of a potentially fatal complication of DVT— pulmonary embolism. The nurse should assess this client first. 2. Intermittent claudication of the feet, hands, and arms is a symptom of Buerger’s disease; there- fore, this client should not be assessed first. 3. The client with an aortic aneurysm is expected to have an audible bruit and does not indicate any life-threatening condition; therefore, this client does not need to be assessed first. 4. The client with acute arterial ischemia should have unpalpable pedal pulses to be considered a medical emergency; therefore, this client does not need to be assessed first. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must determine which sign/symptom is not expected for the disease process. If the sign/ symptom is not expected, then the nurse should assess the client first. This type of question is determining if the nurse is knowledgeable of the signs/symptoms of a variety of disease processes. 7. 1. Because the client has been on the daily aspirin for more than a year, the nurse should assess for bleeding by asking ques- tions such as, “Do your gums bleed after brushing teeth?” or “Do you notice blood when you blow your nose?” 2. Because aspirin can cause gastric distress, the nurse could instruct the client to stop taking it; however, because this is a daily medication being used as an antiplatelet agent, the nurse should provide information that would allow the client to continue the medication. 3. The nurse should realize the stomach discom- fort is probably secondary to daily aspirin, and enteric-coated aspirin would be helpful to de- crease the stomach discomfort and allow the client to stay on the medication, but the nurse should first assess the client for bleeding. 4. Because aspirin is not a prescription medica- tion, the nurse can recommend a different form of aspirin, such as one that is enteric coated. However, if the enteric-coated aspirin does not relieve the pain, the HCP should then be notified. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: Assessment is the first step of the nursing process, and the test taker should use the nursing process or some other systematic process to assist in determining priorities. A N S W E R S 58 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 8. 1. This statement indicates the new graduate needs more teaching because the nurse is responsible for delegating the right task to the right individual. Absolutely no one works on the nurse’s license but the nurse holding the license. 2. The nurse does retain accountability for the task delegated; therefore, the new graduate does not need more teaching. 3. The nurse must make sure the unlicensed as- sistive personnel (UAP) is able to perform the task safely and competently; therefore, the new graduate does not need more teaching. 4. The nurse must make sure the delegated task was completed correctly; therefore, the new graduate does not need more teaching. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions requiring nursing judgment. The nurse must be aware of delegation rules and regulations. 9. 1. The manufacturer of a product would provide biased information and would not provide the best data to support a change proposal. 2. Research studies with a limited number of participants indicate the need for further re- search and would not be the best research to support a change proposal. 3. Research should provide clear statistical data that support the research problem or hypothesis. 4. The more research articles there are that support a change proposal, the more valid is the information, which increases the possibility for change to be considered by the healthcare facility. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Knowledge MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care based on evidence-based practice. The nurse must be knowledgeable of nursing research. 10. 1. The unlicensed assistive personnel (UAP) can clean the perineal area of a client who is on bed rest and who has an indwelling catheter. Because the client is stable, this nursing task could be delegated to the UAP. 2. The UAP can obtain the client’s intake and output, but the nurse must evaluate the data to determine whether interventions are needed or whether interventions are effective. 3. A client who is third-spacing is unstable and in a life-threatening situation; therefore, the nurse cannot delegate the UAP to give this client a bath. 4. This is a medication enema, and the UAP cannot administer medications. In addition, if a cation-exchange resin enema is ordered, the client is unstable and has excessively high serum potassium (K+) level. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interventions requiring nursing judgment. 11. 1. Although the nurse could request another unlicensed assistive personnel (UAP) to per- form the task, this is not the best action be- cause the nurse should demonstrate applying SCDs so that the UAP can learn how to complete the task. 2. This is the priority action because the nurse will ensure the UAP knows how to apply SCDs correctly, thereby enabling the nurse to delegate the task to the UAP successfully in the future. 3. The nurse could do the task, but if the UAP is not shown how to do it, then the UAP will not be able to perform the task the next time it is delegated. 4. The UAP could watch a video demonstrating this task, but the priority action is that the nurse should demonstrate SCD application to the UAP. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse cannot delegate any task in which the UAP admits to not being able to perform. It is the nurse’s re- sponsibility to know what can be delegated and CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 59 when. The nurse may have to complete the task if the UAP is not competent to do so. 12. 1. The nurse should not assign assessment of a client to an LPN even if the client is stable. 2. The LPN cannot initiate administration of blood; therefore, this task must be completed by the nurse. 3. The LPN can administer medications; therefore, the LPN could hang a bag of heparin on an IV pump to this client. 4. The nurse must assess for dysrhythmias dur- ing the insertion, and the nurse assisting the HCP should be experienced in inserting the line. An LPN pulled from another unit should not be assigned this task. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The nurse cannot assign assessment, teaching, evaluation, or an unstable client to a LPN. The LPN can tran- scribe HCP orders and can call HCPs on the phone to obtain orders for a client. 13. 1. The client is having signs/symptoms of a blood transfusion reaction. The nurse must stop the transfusion immediately and then assess the client’s vital signs. 2. The HCP needs to be notified, but not be- fore the nurse stops the blood transfusion. 3. The nurse should maintain a patent IV so that medications can be administered, but this is not the first intervention. 4. Any time the nurse suspects the client is having a reaction to blood or blood prod- ucts, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client’s body. This is the nurse’s first intervention. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse should remember: If a client is in distress and the nurse can do something to relieve the distress, it should be done first, before assessment. The test taker should select an option that directly helps the client’s condition. 14. 1. A research article should answer the question “why”: Why was the research done? This statement indicates the charge nurse under- stands how to read a research article. 2. The cost of the research is not pertinent when reading a research article and de- termining whether the research supports evidence-based practice. This statement indicates the charge nurse does not un- derstand how to read a research article. 3. A research article should answer the question “what”: What research method was used? This statement indicates the charge nurse understands how to read a research article. 4. A research article should answer the question “where”: In what setting was the research conducted? This statement indi- cates the charge nurse understands how to read a research article. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care based on evidence-based practice. The nurse must be knowledgeable of nursing research. 15. 1. The nurse should write the order on the HCP’s order and write “per telephone order (TO),” but this is not the nurse’s first intervention. 2. The nurse does not need to have another nurse verify the HCP’s telephone order. 3. The Joint Commission has implemented this requirement for all telephone orders. The nurse should document on the HCP’s order “repeat order verified.” 4. The nurse should transcribe the order to the MAR, but it is not the first intervention. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Knowledge MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care that is ruled by legal requirements as well as rules and regulations of the Joint Commission, Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention, and the Occupational Safety and Health Administration. The nurse must be knowledgeable of these standards. 16. 1. The therapeutic level for a client on warfarin (Coumadin) is an INR of 2 to 3; therefore, this client does not warrant intervention. A N S W E R S 62 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM MAKING NURSING DECISIONS: The nurse should address client needs first, including answering the client’s questions, verifying the client’s vital signs, or assessing the client if the client is not in distress. 24. 1. Intravenous push medications cannot be as- signed to an LPN. It is the most dangerous route for administering medication, and only an RN (or HCP) can perform this task. 2. The client who is diagnosed with a pul- monary embolus is not stable; therefore, this medication is not the best medication to be assigned to the LPN. 3. Trental is a PO medication prescribed specifically to treat intermittent claudica- tion. It increases erythrocyte flexibility and reduces blood viscosity. 4. The client may be having a myocardial in- farction; therefore, this client is unstable and should not be assigned to an LPN. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The test taker must determine which option absolutely is in- cluded within the LPN’s scope of practice. LPNs are not routinely taught how to administer intra- venous push medications. The test taker must also determine which client is the most stable, which makes this an “except” question. Three clients are either unstable or have potentially life-threatening conditions and should not be assigned to an LPN. 25. 1. The nurse should realize the client prob- ably has deep vein thrombosis, which is a medical emergency. The HCP should be notified immediately so the client can be started on IV heparin and admitted to the hospital. 2. This information may be needed, but the nurse should notify the HCP based on the signs/symptoms alone. 3. A neurovascular assessment should be com- pleted, but not before notifying the HCP. The signs/symptoms alone indicate a poten- tially life-threatening condition. 4. The client’s leg should be elevated, but this is a potentially life threatening emergency and the nurse should first call the HCP. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker needs to read all of the options carefully before choosing the option that says, “Notify the HCP.” If any of the options will provide information the HCP needs to know in order to make a decision, the test taker should choose that option. If, how- ever, the HCP does not need any additional in- formation to make a decision and the nurse suspects the condition is serious or life threaten- ing, the priority intervention is to call the HCP. 26. 1. The nurse should first determine whether there is a fire or whether some- one accidentally or purposefully pulled the fire alarm. Because this is a clinic, not a hospital, the nurse should keep calm and determine the situation before taking action. 2. The nurse should not evacuate clients, visitors, and staff unless there is a real fire. 3. The nurse should assess the situation before contacting the fire department. 4. This is an appropriate intervention, but this is not the first intervention. The nurse should first assess to determine whether there is a fire. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Knowledge MAKING NURSING DECISIONS: The nurse must be knowledgeable of emergency preparedness. Employees receive this information in employee orientation and are responsible for implement- ing procedures correctly. The NCLEX-RN® blueprint includes questions on safe and effective care environment. 27. 1. The clinic nurse should allow the director to address sexual harassment allegations. This is a matter that should be handled legally. 2. This is an appropriate question to ask when investigating sexual harassment allegations, but the clinic nurse should allow the director of nurses to pursue this situation. 3. The clinic nurse is responsible for taking the appropriate action when sexual allegations are reported. This statement shows that the clinic nurse is not taking the allegations seri- ously and could result in disciplinary action against the nurse. 4. This is the most appropriate response be- cause sexual harassment allegations are a legal matter. The clinic nurse imple- mented the correct action by making sure the unlicensed assistive personnel (UAP) CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 63 reported the allegation to the director of nurses. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy for these questions. The nurse must be knowl- edgeable of which management issues must com- ply with local, state, and federal requirements. 28. 1. The clinic nurse should not discuss the staff nurses’ statement with the pharmaceutical representative because the staff member’s be- havior is unethical and could have repercus- sions. The clinic nurse should notify the director of nurses. 2. This behavior is unethical and is making promises that the staff nurse may or may not be able to keep. Because this situa- tion includes the HCP, an outside repre- sentative, and the staff nurse, this situation should be reported to the direc- tor of nurses for further action. 3. This behavior must be reported. This is bribing the pharmaceutical representative and using a meeting with the HCP as the reward. 4. The clinic nurse should maintain the chain of command and report this to the nursing supervisor, not to the HCP. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy for these questions. The nurse must be knowl- edgeable of management issues. 29. 1. The nurse should document the results in the client’s chart, but this is not the nurse’s first intervention. 2. The therapeutic value for INR is 2 to 3; levels higher than that increase the risk of bleeding. The nurse should first contact the client and determine whether she has any abnormal bleeding and then instruct the client to not take any more Coumadin. 3. The nurse should notify the client’s HCP, but the nurse should first determine whether the client has any abnormal bleeding so that can be reported to the HCP. 4. The client will need to have another INR drawn, but it is not the nurse’s first intervention. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Analysis MAKING NURSING DECISIONS: Any time the nurse receives information from another source about a client who may be experiencing a com- plication, the nurse must assess the client. In this scenario, the nurse assesses the client by talking to him or her on the phone. The nurse should not make decisions about client needs unless the nurse talks to the client. 30. 1. A low-salt diet is used to treat arterial hypertension, but it is not the priority intervention. 2. The priority intervention for the client with arterial hypertension is to take anti- hypertensive medications. 3. Taking and documenting blood pressure readings is important, but it does not treat the arterial hypertension; therefore, it is not the priority intervention. 4. Walking will help decrease the client’s high blood pressure in some situations, but it is not priority. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Synthesis MAKING NURSING DECISIONS: All options are plausible in questions that ask the test taker to identify a priority intervention. The test taker must identify the most important intervention. 31. 1. Stockings should be applied after the legs have been elevated for a period of time— when the amount of blood in the leg vein is at its lowest. Applying the stockings when the client is sitting in a chair indicates the home health (HH) aide does not understand the correct procedure for applying compres- sion stockings. 2. If a finger cannot be inserted under the prox- imal end of the stocking, the compression hose is too tight, and the HH worker does not understand the correct procedure for applying the stockings. 3. The toe opening should be placed on the plan- tar side of the foot. Placing the toe opening on A N S W E R S 64 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM the top side of the foot indicates the HH aide does not understand the correct procedure for applying compression stockings. 4. Warm toes mean the stockings are not too tight and there is good circulation. Checking that the toes are warm indicates the HH aide understands the correct pro- cedure for applying the compression stockings. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: The nurse must ensure the UAP can perform any tasks that are delegated. It is the nurse’s responsibility to eval- uate the task, demonstrate, and/or teach the UAP how to perform the task. 32. 1. The nurse should first take care of the bite and then determine whether the dog is up to date on the required vaccinations. The nurse should be concerned about the possibility of rabies. 2. If the dog is not up to date on the required vaccinations, then the veterinarian should be notified to quarantine the dog to check for rabies. 3. The nurse should complete an occurrence report and document the dog bite. If the nurse must pay for anything concerning the dog bite, it should be covered by workers’ compensation. 4. Besides an infection of the dog bite, the worst complication would be the nurse con- tracting rabies. If the dog is up to date on the required vaccinations, then this should not be a concern. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The test taker should apply the nursing process when the ques- tion asks, “Which intervention should be imple- mented first?” If the client is in distress, do not assess; if the client is in distress, take action. 33. 1. This would not warrant immediate interven- tion because intermittent claudication, pain when walking, is the hallmark sign of arterial occlusive disease. 2. This comment warrants immediate inter- vention because the client’s legs have de- creased sensation secondary to the arterial occlusive disease, and a heating pad could burn the client’s legs without the client’s realizing it. The client should not use a heating pad to keep the legs warm. 3. Hanging his or her legs off the bed helps in- crease the arterial blood supply to the legs, which, in turn, helps decrease the leg pain. This comment would not warrant immediate intervention by the nurse. 4. Hair growth requires oxygen, and the client has decreased oxygen to the legs; therefore, decreased hair growth would be expected and not require immediate intervention. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Physiological Integrity: Physiological Adaptation: Cognitive Level – Analysis MAKING NURISNG DECISIONS: When the ques- tion asks, “Which warrants immediate interven- tion?” it is an “except” question. Three of the comments indicate the client understands the teaching and one indicates the client does not understand the teaching. 34. 1. The nurse cannot purchase supplies for the client. This is crossing a professional boundary. 2. The social worker does assist with financial concerns and referrals for the client, but pur- chasing smoke detectors is not within the social worker’s scope of practice. 3. The nurse should not encourage the client to be dependent on family members for pur- chasing supplies for the client’s home. This may be a possibility when all other avenues have been pursued. 4. The nurse should contact the fire depart- ment. Many fire departments will supply and install smoke detectors for people who cannot afford them. The nurse should investigate this option first be- cause it is the most immediate response to the safety need. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment; Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse must be knowledgeable of emergency preparedness in the hospital as well as in the community. Em- ployees receive this information in employee ori- entation and are responsible for implementing procedures correctly. The NCLEX-RN® blue- print includes questions on safe and effective care environment. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 67 many instances, there is no test-taking strategy for these questions; the nurse must be knowl- edgeable of management issues. If the nurse thinks the assignment is a violation of the state’s Nursing Practice Act, then the nurse must notify the supervisor immediately. 43. 1. Morphine is a potent narcotic analgesic. A 4 on the 1-to-10 pain scale is considered mod- erate pain and should be treated with a less potent pain medication. 2. Promethazine is administered for nausea. 3. Hydrocodone is a narcotic analgesic that is less potent than morphine. It has been 5 hours since the hydrocodone was last administered, and no other pain medica- tion has been required by the client. This is the best medication for moderate pain. 4. Ibuprofen may be effective for moderate pain, but the client is allergic to ibuprofen. The nurse should tag the medical adminis- tration record (MAR) and chart to notify the HCP to discontinue this medication. Content – Medical/Surgical: Category of Health Alteration – Drug Administration: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alter- nate type question included in the NCLEX-RN® blueprint. The test taker must be able to read a medication administration record (MAR), must be knowledgeable of medications, and be able to make an appropriate decision as to the nurse’s most appropriate intervention. 44. 1. The daughter lives in a “nearby” city. The client should not be moved any- where until the daughter arrives. 2. A morgue is a difficult place to view a body. This could be appropriate if the daughter was going to take hours to days to get to the hospital. 3. Many people feel it is necessary to view the body. Not allowing the daughter time to view the body before transfer to a funeral home or the morgue could cause hurt feel- ings and impede the grieving process. 4. Many people feel it is necessary to view the body. Not allowing the daughter time to view the body before transfer to a funeral home or the morgue could cause hurt feel- ings and impede the grieving process. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Psychosocial Integrity: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse should always try and support the client’s or family’s re- quest, if it does not violate any local, state, or fed- eral rules and regulations. This is the test taker’s best decision if unsure of the correct answer. 45. 1. The change process can be compared to the nursing process. The first step of each process is to assess the problem. As- sessment involves collecting the pertinent data that support the need for a change. 2. The second step is to identify the problem or, in the nursing process, identify possible nursing diagnoses. 3. The third step is to select an alternative to implement to fix the problem. This is similar to choosing a specific nursing diagnosis. 4. The fourth step is to implement a plan of action. This is similar to implementing the nursing care plan. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Analysis MAKING NURSING DECISIONS: Assessment is the first step of the nursing process, and the test taker should use the nursing process or some other systematic process to assist in determining priorities. 46. 2 and 3 are correct. 1. The only solution compatible with blood is normal saline. Dextrose causes the blood to coagulate. 2. The blood administration set is changed after every two units. 3. The nurse must assess the client’s vital signs before every unit of blood is administered. 4. The nurse should assess for allergies prior to administering medications. Before adminis- tering blood products, the nurse should assess to determine compatibility with the client’s blood type. The client may have an incom- patible blood type, but this is not an allergy. 5. A blood warmer is used when the client has identified cold agglutinins. This is not in the stem of the question. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN®. The nurse must be able to select all the options A N S W E R S 68 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM that answer the question correctly. There are no partially correct answers. 47. 1. The client with a deep vein thrombosis is placed on strict bed rest and should not have any type of pressure on his or her calf, which may cause the clot to dislodge and cause a pulmonary embolus. This task should not be delegated to an unlicensed assistive personnel (UAP). 2. The number one intervention for a client with thromboangiitis obliterans is to stop smoking; therefore, this task should not be elevated. The UAP should be on the unit caring for clients, not outside to allow a client to smoke. 3. The leg should be elevated to prevent postoperative edema; therefore, this task could be delegated to the UAP. 4. The UAP cannot perform Doppler studies; a trained technician must perform this test. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: An RN cannot delegate assessment, teaching, evaluation, med- ications, or an unstable client to a UAP. Tasks that cannot be delegated are nursing interven- tions requiring nursing judgment. 48. 1. Only the client should activate the PCA pump. Allowing family or significant others to push the button places the client at risk for an overdose. 2. The nurse is acting appropriately; there is no reason to discuss the instructions further. 3. The nurse is acting appropriately; there is no reason to discuss the instructions further. 4. The nurse is acting appropriately, and there is no reason to discuss the instruc- tions further. The charge nurse should continue with other duties. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Application MAKING NURSING DECISIONS: There will be management questions on the NCLEX-RN®. In many instances, there is no test-taking strategy for these questions; the nurse must be knowl- edgeable of management issues concerning per- sonnel. The nurse is responsible for evaluating the behaviour of subordinates when caring for clients. 49. 1. This client may be having phantom pain, but it must be assessed and the client must be medicated. The nurse should assess this client first. 2. The client’s blood pressure must be taken to determine if the headache is due to hyper- tensive crisis, but it is not priority for postop- erative surgical pain. 3. The client with lymphedema would be ex- pected to have edema of the lower leg; therefore, the nurse would not assess this client first. 4. The client with gangrene would be expected to have a foul-smelling discharge; therefore, this client would not be assessed first. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: When deciding which client to assess first, the test taker should determine whether the signs/symptoms the client is exhibiting are normal or expected for the client situation. After eliminating the ex- pected option, the test taker should determine which situation is more life threatening. 50. 1. The LPN should not administer the medica- tion if the client’s BP is less than 90/50, but this is not the first action the nurse should take. 2. This medication cannot be crushed and the nurse needs to intervene and correct the LPN’s behaviour. 3. The LPN should be shown where to find pudding or applesauce to mix in crushed medications, but this medication should not be crushed. 4. The XL in the name of the medication indicates that this medication is a sustained-released formulation and should not be crushed. The nurse should speak directly with the LPN to correct the behaviour. Content – Medical/Surgical: Category of Health Alteration – Drug Administration: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment, Manage- ment of Care: Cognitive Level – Application MAKING NURSING DECISIONS: The nurse must be aware of interventions that must be imple- mented prior to administering medications. The nurse must know which medications cannot be crushed. The nurse is responsible for evaluating the behavior and actions of their subordinates. 51. 1. This is an example of paternalism or beneficence. 2. This is an example of beneficence. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 69 expected for the disease process. If the sign/ symptom is not expected, then the nurse should assess the client first. This type of question is 3. This is an example of nonmalfeasance or beneficence. 4. This is an example of autonomy. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Basic Care and Comfort: Cognitive Level – Application MAKING NURSING DECISIONS: The NCLEX- RN® blueprint includes nursing care that ad- dresses ethical principles, including autonomy, beneficence, justice, and veracity, to name a few. 52. 1. This would be culturally sensitive to a client who is a Jehovah’s Witness. 2. Mormons do not wear amulets. 3. The devout Mormon client wears a reli- gious undershirt that should not be re- moved; this action indicates cultural sensitivity on the part of the nurse. 4. Mormons do not consult curanderos. Some Hispanic cultures consult curanderos. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Basic Care and Comfort: Cognitive Level – Application MAKING NURSING DECISIONS: The NCLEX- RN® blueprint includes nursing care that ad- dresses cultural diversity. The nurse needs to be aware of cultural differences. 53. 1. These ABGs show respiratory acidosis, which needs immediate intervention; therefore, this client should be assessed first. 2. The client with Reynaud’s phenomenon would be expected to have bluish, cold upper extremities; therefore, the nurse would not need to assess the client first. 3. The client with chronic venous insufficiency has ulceration on the feet; therefore, this nurse would not need to assess the client first. 4. The PTT is 1.5 to 2 times the normal; there- fore, the nurse would not need to assess this client first. Normal PTT is 39 seconds; therefore, therapeutic PTT is 58 to 78. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: The test taker must determine which sign/symptom is not determining if the nurse is knowledgeable of signs/symptoms of a variety of disease processes. 54. 1. The client with arterial occlusive disease dangles the feet off the side of the bed to in- crease the blood supply to the legs; therefore, a less experienced unlicensed assistive per- sonnel (UAP) could care for this client. 2. The nurse should be assigned to care for this client, who is angry about the family’s not visiting, because the client requires assess- ment, nursing judgment, and therapeutic communication and intervention, which are not within the UAP’s scope of practice. 3. This client requires an experienced UAP who is skilled in client lifts, so the client is lifted safely and the UAP is not injured in the process. The most experienced UAP should be assigned this client. 4. The experienced UAP could care for this client, but then other UAPs would not learn to care for the client. This client should be rotated through the UAPs so that all the UAPs can learn to care for the client who is particular about the way things are done. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Planning: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Synthesis MAKING NURSING DECISIONS: When the test taker is deciding which option is the most appro- priate task to delegate/assign, the test taker should choose the task that allows each staff member to function within his or her full scope of practice. Remember: The RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. 55. 1. Chest pain on deep inspiration is a symp- tom of pulmonary embolism. The nurse should first place the client on oxygen. 2. The first intervention is to provide the client with oxygen. The test taker should not assess when the client is in distress. 3. The respiratory therapist can be notified, but it is not the nurse’s first intervention. The nurse should first address the client’s needs. 4. The nurse should not select equipment over addressing the client’s needs. Content – Medical/Surgical: Category of Health Alteration – Cardiovascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Synthesis A N S W E R S 72 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 2. The client’s legs should be elevated; there- fore, this action would not warrant immedi- ate intervention. 3. The client can ambulate with assistance; therefore, this action does not warrant intervention. 4. The client should have a podiatrist cut his or her toenails. The unlicensed assistive personnel (UAP) should not do this be- cause if the UAP accidently cuts the skin, it could cause a sore that may not heal, and then result in amputation of the extremity. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Evaluation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Analysis MAKING NURSING DECISIONS: The nurse cannot delegate any task in which the UAP admits to not being able to perform. Delegation means the nurse is responsible for the UAP’s actions; therefore, the nurse must intervene if the UAP is performing unsafely. 65. 1. The client with a venous stasis ulcer should eat a diet high in protein (meat, beans, cheese, tofu), vitamin A (green, leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood). The nurse needs to talk to this client, but it is not a life-threatening con- dition or a complication; therefore, the client is not assessed first. 2. The client should wear thromboembolic hose, but this is not a life-threatening condi- tion or a complication; therefore, the client does not have to be assessed first. 3. The client with arterial occlusive disease should not elevate the feet because it further decreases oxygen to the extremity; therefore, this action is not required to be assessed by the nurse. 4. The nurse should assess this client first because if the client does not stay in the bed, the clot in the calf muscle may dislodge and result in a pulmonary embo- lus. The client with a DVT must be on bed rest. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Reduction of Risk Potential: Cognitive Level – Analysis MAKING NURSING DECISIONS: The nurse must determine if the client’s behavior is potentially unsafe for the client’s disease process. If the client is putting him- or herself at risk, then the nurse must assess this client first. 66. 1. Oral pain medications provide relief for mild to moderate pain. A 10 is considered to be severe pain. 2. Guided imagery will not alleviate severe pain. 3. If the current pain regimen is not work- ing for this client, the nurse should notify the surgeon for an adjustment in the pain medication. 4. It has only been 1 hour and 15 minutes since the pain medication was administered. It is too soon for the nurse to administer the morphine. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Basic Care and Comfort: Cognitive Level – Application MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN® blueprint. The test taker must be able to read a medication administration record (MAR), must be knowledgeable of medications, and must be able to make an appropriate decisions as to the nurse’s most appropriate intervention. 67. Answer: 50 drops per minute 150 mL divided by 60 = 2.5 mL per minute to infuse 2.5 times 20 = 50 Content – Medical/Surgical: Category of Health Alteration – Drug Administration: Integrated Processes – Nursing Process: Implementation: Client Needs – Physiological Integrity: Pharmacological and Parenteral Therapies: Cognitive Level – Application MAKING NURSING DECISIONS: This is an alter- nate type question included in the NCLEX-RN®. The nurse must be knowledgeable on how to perform math questions. 68. 1. The nurse needs to have the surgical opera- tive permit signed by the client, but not until the discrepancy between what operative per- mit says and what the client said is resolved. 2. The nurse can assess the client’s neurological status, but not prior to calling a time out. Calling a time out is the priority intervention. 3. Determining if the client had anything by mouth is an appropriate intervention, but not priority to clarifying which leg will the surgi- cal procedure be performed. 4. The nurse must stop everything and clar- ify which leg will have the surgical proce- dure. This is the first and priority intervention the nurse must implement. CHAPTER 3 PERIPHERAL VASCULAR MANAGEMENT 73 Content – Medical/Surgical: Category of Health 70. Correct Answer: 1, 4, 3, 2, 5 Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Safety and Infection Control: Cognitive Level – Application MAKING NURSING DECISIONS: The NCLEX-RN® blueprint includes nursing care administered by the current National Patient Safety Goals. The nurse must be knowledgeable of these goals. 69. 1. The abdominal bruit is located at the mid- abdominal area above the umbilicus. 2. The mid-scapula area is not an appropriate area to auscultate an abdominal aortic aneurysm. 3. An abdominal aortic aneurysm is diag- nosed when the client has an abdominal bruit. An abdominal bruit is a murmur that corresponds to the cardiac cycle. It is heard best with the diaphragm of the stetho- scope, usually over the abdominal aorta. 4. The nurse cannot auscultate a bruit on the feet. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Assessment: Client Needs – Physiological Integrity: Basic Care and Comfort: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alter- nate type question included in the NCLEX-RN®. It is a picture and the nurse must be able to point the curser at the appropriate area. It is called a hot spot. 1. The bleeding must be stopped. The nurse should don unsterile gloves and apply pressure to the bleeding site for a minimum of 5 minutes. 4. When the bleeding has stopped, the client can be assisted back to bed so a thorough assessment of the injuries can be performed. 3. The site should be redressed when possi- ble to protect the wound from infectious organisms. 2. Once the nurse has been able to assess the client and has the client in a safe envi- ronment, then the nurse should notify the surgeon. 5. The occurrence should be noted on a re- port form and the appropriate hospital personnel notified, but this can be done after caring for the client. Content – Medical/Surgical: Category of Health Alteration – Peripheral Vascular: Integrated Processes – Nursing Process: Implementation: Client Needs – Safe and Effective Care Environment: Management of Care: Cognitive Level – Analysis MAKING NURSING DECISIONS: This is an alternate type of question included in the NCLEX-RN®. The nurse must be able to place the interven- tions in order of priority. The nurse can use Maslow’s Hierarchy of Needs to prioritize the interventions. Written documentation is the last action taken in an emergency or life-threatening situation. A N S W E R S 74 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM CLINICAL SCENARIO ANSWERS AND RATIONALES The correct answer number and rationale for why it is the correct answer are given in boldface type. Rationales for why the other possible answer options are incorrect also are given, but they are not in bold- face type. 1. 1. The client has an elevated blood pressure, but it is not life threatening; therefore, the client does not need to be seen first. 2. The client with a DVT would be expected to be complaining of calf pain; therefore, this client would not be seen first. 3. The client with peripheral vascular disease would be expected to have intermittent clau- dication; therefore, this client would not be seen first. 4. The client with a triple AAA who has a low back pain could have a leak, which could be life threatening; therefore, this client should be assessed first. 2. 1. Increased hair loss occurs due to decreased oxygen to the lower extremities, but this is not life threatening; therefore, this information would not warrant immediate intervention. 2. The client with arterial occlusive disease would be expected to have an absent dorsal pedal pulse; therefore, this would not warrant immediate intervention. 3. Numbness, tingling, and inability to move his or her toes would warrant intervention by the nurse. This indicates no arterial blood flow to the extremities. 4. The client hangs his or her legs off the bed to help increase arterial oxygen blood flow to the lower extremities. This would not warrant immediate intervention. 3. 1. JC cannot delegate assessment, teaching, evalu- ation, medications, or an unstable client to the UAP. Checking the pedal pulse is assessment. 2. The client who is 4 hours postoperative leg surgery would not be able to ambulate down the hall. The client will be on bed rest for at least 24 hours. 3. JC cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. 4. The leg should be elevated to help de- crease edema secondary to surgery and this can be delegated to a UAP. 4. 3 and 4 are correct. 1. A daily aspirin is recommended as an antico- agulant to clients with atherosclerosis. 2. A low-fat, low-cholesterol diet is recom- mended to help decrease plaque formation in the vessels. 3. Sedentary life style is a “couch potato” lifestyle, which is not recommended for clients with atherosclerosis. 4. The client should eat foods high in fiber to help decrease his or her cholesterol level. 5. Walking is an excellent isotonic exercise, which is recommended to help lose weight, de- velop collateral circulation, and decrease stress. 5. 1. BN should auscultate the bowel sounds, but BN should first assess the client’s surgical in- cision, since the client is 2 days postoperative. 2. BN should first assess the surgical dress- ing to assess for bleeding or any type of drainage, then continue with the rest of the assessment, including bowel sounds, vital signs, and IV therapy. 3. The nurse should assess first, since it is the first part of the nursing process when the client is not in distress. 4. Monitoring the intravenous therapy should be done by BN, but assessment is the first intervention. 6. 1. The client should not lift more than 5 pounds; doing so might cause the surgical incision to have dishensence. This statement indicates the client understands the teaching. 2. The number one factor for developing ath- erosclerosis and increased blood pressure is smoking cigarettes; therefore, the client must quit. This statement indicates the client un- derstands the teaching. 3. A truss is a kind of surgical appliance used for clients with a hernia. It provides sup- port for the herniated area using a pad and belt arrangement to hold it in the cor- rect position. This client would not be prescribed a truss; therefore, the client needs more discharge teaching. 4. The client should notify the healthcare provider if there is an elevated temperature because this indicates that the client has a postoperative infection. This statement indi- cates the client understands the teaching. 7. 1. PN would expect the client to have pain in the surgical area and, though this client’s pain needs to be assessed, it would not be prior to a client in renal failure. If a man does his best, what else is there? —General George S. Patton 1. The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first? 1. The healthcare provider. 2. The unit manager. 3. The respiratory therapist. 4. The case manager. 2. The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients. 2. The bed baths and oral care. 3. Evaluating the client’s progress. 4. Transporting a client to dialysis. 3. Which client should the charge nurse assign to the new graduate on the respiratory unit? 1. The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10. 2. The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. 3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 91% and has a CRT >3 seconds. 4. Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Perform mouth care on the client with pneumonia. 2. Apply oxygen via nasal cannula to the client. 3. Empty the trashcans in the clients’ rooms. 4. Take the empty blood bag back to the laboratory. 5. Show the client how to ambulate on the walker. 77 Respiratory Management 4 QUESTIONS 78 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 5. Which client should the medical unit nurse assess first after receiving the shift report? 1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. 2. The 25-year-old client diagnosed with influenza who is febrile and has a headache. 3. The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. 4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose. 6. The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? 1. Notify the healthcare provider (HCP) immediately. 2. Assess the client’s incisional wound. 3. Prepare to administer dopamine, a vasopressor. 4. Increase the client’s intravenous (IV) rate. 7. The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client’s pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client’s surgical dressing. 8. The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client’s oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation. 9. The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form? 1. The 16-year-old married client who is diagnosed with an ectopic pregnancy. 2. The 39-year-old client diagnosed with paranoid schizophrenia. 3. The 50-year-old client who admits to being a recovering alcoholic. 4. The 84-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). 10. The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Check the ventilator to resolve the problem. 4. Auscultate the client’s lung sounds. 11. The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25. CHAPTER 4 RESPIRATORY MANAGEMENT 79 12. The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse’s priority? 1. Assist the HCP with a sterile dressing change for a client with a left pneumonectomy. 2. Obtain a tracheostomy tray for a client who is exhibiting air hunger. 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED. 4. Assess the client diagnosed with mesothelioma who is upset, angry, and crying. 13. The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client’s posterior breath sounds. 3. Prepare to remove the client’s chest tubes. 4. Notify the HCP that the lungs have re-expanded. 14. The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the client’s lung sounds. 2. Check for any kinks in the tubing. 3. Ask the client to take deep breaths. 4. Turn the client from side to side. 15. Which client requires the immediate attention of the intensive care unit nurse? 1. The client with histoplasmosis who is having excessive diaphoresis and neck stiffness. 2. The client with acute respiratory distress syndrome (ARDS) who has difficulty breathing. 3. The client with pulmonary sarcoidosis who has a dry cough and mild chest pain. 4. The client with asbestosis who has a productive cough and chest tightness. 16. The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Ensure there is a manual resuscitation bag at the bedside. 2. Monitor the client’s pulse oximeter reading every shift. 3. Assess the client’s respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist. 17. The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Explain that the client on a ventilator should not be bathed. 4. Give the UAP praise for performing the bath safely. 18. The female charge nurse on the respiratory unit tells the male nurse, “You are really cute and have a great body. Do you work out?” Which action should be taken by the male nurse if he thinks he is being sexually harassed? 1. Document the comment in writing and tell another staff nurse. 2. Ask the charge nurse to stop making comments like this. 3. Notify the clinical manager of the sexual harassment. 4. Report this to the corporate headquarters office. Q U E S T IO N S 82 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 33. The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take? 1. Ask the husband to allow his wife to answer the questions. 2. Request the husband to leave the examination room. 3. Continue to allow the husband to answer the wife’s questions. 4. Do not ask any further questions until the client starts answering. 34. The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5). 1. Open the client’s airway. 2. Check the client’s carotid pulse. 3. Assess the client for unresponsiveness. 4. Perform compressions at a 30:2 rate. 5. Pinch the nose and give two breaths. 35. The home health nurse is visiting the client diagnosed with end-stage chronic obstruc- tive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client’s oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner. 36. Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? 1. Changing the client’s subclavian dressing. 2. Reinserting the client’s Foley catheter. 3. Demonstrating ambulation with a walker. 4. Getting the client up in a chair three times a day. 37. In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse? 1. Do not approach the staff member in the restaurant. 2. Ask the staff member not to discuss anything about the client. 3. Contact the staff member’s clinical manager and report the behavior. 4. Tell the client that the staff member was discussing confidential information. 38. The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse? 1. “I do not give her a lot of fluids so she won’t wet the bed.” 2. “I perform passive range-of-motion exercises every morning.” 3. “I put her on her side so that there will be no pressure on her butt.” 4. “I do not pull her across the sheets when I am moving her in bed.” 39. The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client’s oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths. CHAPTER 4 RESPIRATORY MANAGEMENT 83 40. The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the home health nurse’s best response? 1. “I will start an IV if your husband continues to refuse to eat or drink.” 2. “You should discuss placing a PEG feeding tube in your husband with the HCP.” 3. “This is normal at the end of life; the dehydration produces a type of euphoria.” 4. “You are right to be concerned. Would you like to talk about your worry?” 41. The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time? 1. A home health nurse. 2. The client’s pastor. 3. A hospice agency. 4. The social worker. 42. The hospice client asks the nurse, “What should I do about my house? My son and daughter are fighting over it.” Which statement is the nurse’s best response? 1. “I think you should tell your children that you will leave the house to a charity.” 2. “I would sell the house and go on an extended vacation and spend the money.” 3. “What do you want to happen to your house? It is your decision.” 4. “Wait and let your children fight over the house after you are gone.” 43. The female nurse manager is discussing the yearly performance evaluation with a male nurse. Which information regarding communication styles should the nurse manager employ when talking with the employee? 1. Men tend to see the work from a global perspective centering on feelings. 2. Men often see the work environment from a logical, focused perspective. 3. Men ask many more questions than women and require specific answers. 4. Men and women communicate similarly in a nursing environment. 44. The newly hired nurse manager has identified that whenever a specific staff member is unhappy with an assignment, the entire unit has a bad day. Which action should the unit manager take to correct this problem? 1. Determine why the staff member is unhappy. 2. Discuss the staff member’s attitude and the way it affects the unit. 3. Place the staff member on a counseling record for the behavior. 4. Suspend the staff member until the behavior improves. 45. The healthcare facility where the nurse works uses e-mail to notify the staff of in-services and mandatory requirements. Which is important information for the nurse manager to remember when using e-mail to disseminate information? 1. Give as much information as possible in each e-mail. 2. Use e-mail for all communications with the staff. 3. Use capital letters to get a point across with emphasis. 4. Make the e-mail notices quick and easy to read. 46. At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client’s chart. Which is the most appropriate response by the charge nurse? 1. Call the lab and have the lab supervisor talk with the HCP. 2. Discuss the HCP’s complaints with the nursing supervisor. 3. Form a committee of lab and nursing personnel to fix the problem. 4. Tell the HCP to stop yelling and calm down. Q U E S T IO N S 84 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 47. The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5). 1. Assess the client’s lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside. 48. The nurse is assessing clients on a respiratory unit. Which client should be the nurse’s first priority? 1. The client diagnosed with bronchiectasis who has clubbing of the fingernails. 2. The client diagnosed with byssinosis who reports chest tightness. 3. The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%. 4. The client diagnosed with pneumoconiosis who has shortness of breath. 49. The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client’s priority nursing diagnosis? 1. Activity intolerance. 2. Altered coping. 3. Impaired gas exchange. 4. Self-care deficit. 50. The nurse assists with the insertion of a chest tube in a client diagnosed with a sponta- neous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site. 51. The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be admin- istered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client’s output is greater than the intake. 52. The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, “What happened to my child?” The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmalfeasance? 1. “I will find out for you and let you know after surgery.” 2. “I am sorry but your child died at the scene of the accident.” 3. “You should concentrate on your surgery right now.” 4. “You are concerned about your child. Would you like to talk?” 53. The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization? 1. The Commission reviews facilities for compliance with standards of care. 2. Accreditation by the Commission guarantees the facility will be reimbursed for care provided. 3. Accreditation by the Commission reduces liability in a legal action against the facility. 4. The Commission eliminates the need for Medicare to survey a hospital. CHAPTER 4 RESPIRATORY MANAGEMENT 87 68. The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first? 1. The patient diagnosed with end-stage COPD complaining of shortness of breath after ambulating to the bathroom. 2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication. 3. The patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the laboratory. 4. The patient diagnosed with an empyema who has a temperature of 100.8°F, pulse of 118, respiration rate of 26, and BP of 148/64. 69. The respiratory unit nurse is calculating the shift intake and output for a client diag- nosed with right-sided chest tube. The client has received 1,500 mL of D5W, IVPB of 100 mL of 0.9% NS, 12 ounces of water, 6 ounces of milk, and 4 ounces of chicken broth. The client has had a urinary output of 800 mL and chest drainage of 125 mL. What is the total intake and output for this client? 70. Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation? 1. The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing. 2. The client diagnosed with pneumonia who has dull percussion and vocal fremitus. 3. The client diagnosed with a flail chest who has paradoxical movement of the chest wall. 4. The client diagnosed with reactive airway disease who has bilateral wheezing. Q U E S T IO N S 88 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM Ms. Gail is the charge nurse for the 7a-7p shift. The staff includes three RNs, one LPN, and two UAPs for a 16-bed unit. 1. Ms. Gail is making shift assignments. Which client should be assigned to the most experienced RN? 1. The client diagnosed with pneumonia who has bilateral crackles and a pulse oximeter reading of 96%. 2. The client whose pulse oximeter reading keeps decreasing after receiving high levels oxygen via nasal cannula. 3. The client who had a Caldwell Luc procedure 1 day ago and has purulent drainage on the drip pad. 4. The client who had a tonsillectomy this morning who is complaining of throat pain rated 8 on a pain scale of 1 to 10. 2. The client diagnosed with a community-acquired pneumonia is being admitted to the unit. Which healthcare provider’s order should be implemented first? 1. Administer Rocephin 50 mg IVPB every 24 hours. 2. Apply oxygen 2 L via nasal cannula. 3. Obtain a sputum specimen for culture and sensitivity. 4. Place client in respiratory isolation. 3. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Place the client in the orthopnic position. 2. Administer 6 L oxygen via nasal cannula. 3. Assess the client’s pulse oximeter reading. 4. Notify the respiratory therapist. 4. Which client should Ms. Gail assign to the licensed practical nurse (LPN)? 1. The client who had a laryngectomy 2 days ago and has crepitus. 2. The client with respiratory difficulty who is confused and keeps climbing out of bed. 3. The client newly diagnosed with active tuberculosis who needs medication teaching. 4. The client diagnosed with asthma who has a pulse oximetry reading of 90%. 5. Ms. Gail and the UAP are caring for the following clients. Which information provided by the UAP requires immediate intervention by Ms. Gail? 1. The client diagnosed with active tuberculosis who is in respiratory isolation and has orange urine in the urinary catheter. 2. The client who has a right upper lobectomy on the patient controlled analgesia (PCA) pump has level 4 pain on a scale of 1 to 10. 3. The client with a left-sided pneumothorax has 200 mL of blood in the collection chamber of the Pleuravac. 4. The client diagnosed with bacterial pneumonia who has an elevated temperature and chills. 6. One of Ms. Gail’s staff nurses is preparing to administer a.m. medications to clients. Which medication should the nurse question administering to the client? 1. Carafate for the client who has not had breakfast. 2. Digoxin to the client with a digoxin level of 1.9 mg/dL. 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/78. 4. The aminoglycoside antibiotic to the client with an elevated trough level. RESPIRATORY CLINICAL SCENARIO CHAPTER 4 RESPIRATORY MANAGEMENT 89 7. The client is getting out of bed, becomes very anxious, and has a feeling of impending doom. The nurse reports these findings to Ms. Gail. Which intervention should Ms. Gail tell the nurse to implement first after placing the client in the high-Fowler’s position? 1. Administer oxygen via nasal cannula. 2. Prepare the client for a ventilation/perfusion scan. 3. Notify the client’s healthcare provider. 4. Auscultate the client’s lung sounds. 8. The client with a right-sided chest tube is complaining of pain rated 6 on a pain scale of 1 to 10. Which intervention should the nurse implement first? 1. Document the client’s pain complaint in the nurse’s notes. 2. Instruct the client to take slow, deep breaths and exhale slowly. 3. Assess the client’s respiratory status and chest tube insertion site. 4. Check the client’s MAR to determine when the last pain medication was administered. 9. Ms. Gail is discussing the care of a client with a right-sided chest tube secondary to a pneumothorax with a graduate nurse. Which interventions should Ms. Gail discuss with the graduate nurse? Select all that apply. 1. Place the client in the high-Fowler’s position. 2. Assess the chest tube drainage system every shift. 3. Maintain strict bed rest for the client. 4. Ensure the tubing has no dependent loops. 5. Mark the collection chamber for drainage every shift. 10. Ms. Gail is making client assignments. Which client should Ms. Gail assign to the LPN? 1. The client who is suspected of having acute respiratory distress syndrome. 2. The client with a hemothorax who needs two units of blood. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is scheduled for a bronchoscopy to R/O lung cancer. C L IN IC A L S C E N A R IO