kaplan management of care quiz 1: setting priorities, making nursing judgements

25 flashcards

The nurse plans care for assigned patients. In which order will the nurse prioritize the care for these patients? (Please arrange in order. All options must be used.) 1. Adolescent diagnosed with sickle cell disease reporting a 30-minute penile erection. 2. Infant who is vomiting and has frothy oral secretions. 3. Child whose temperature has increased to 103.8°F (39.9°C). 4. Child requiring observation following an acute asthma attack.

Correct order: 2, 4, 3, 1. In order: 2. Infant who is vomiting and has frothy oral secretions. 4. Child requiring observation following an acute asthma attack. 3. Child whose temperature has increased to 103.8°F (39.9°C). 1. Adolescent diagnosed with sickle cell disease reporting a 30-minute penile erection. First, the nurse will care for the patient with vomiting and frothy oral secretions since this could indicate a tracheoesophageal fistula and potentially cause aspiration. The patient's airway must be maintained as a priority. Second, the nurse will care for the patient requiring observation after an acute asthma attack. The airway may still be compromised. Third, the nurse will care for the patient with a temperature increase. Fourth, the nurse will care for the patient diagnosed with sickle cell disease and who has had a penile erection for 30 minutes. This patient may need intervention if the erection persist. However, this patient's problem is not as acute as the other patients' health problems.

The nurse manager overhears a staff nurse working with a student nurse. Which statement, if made by the staff nurse, indicates that the staff nurse is unfamiliar with the role of the student nurse? 1. "After you complete a full assessment on your patient, I will double-check it before you document." 2. "Before we go into the patient's room, review with me how you will insert this indwelling urinary catheter." 3. "Before we go into the patient's room, do you have any questions about how we are going to transfer this patient from the bed to the chair?" 4. "When you call the health care provider with the patient's lab results, make sure you write down any prescriptions you receive."

Correct answer: 4. "When you call the health care provider with the patient's lab results, make sure you write down any prescriptions you receive." 1) INCORRECT – This statement is appropriate in that the nurse provides an opportunity for the student to learn yet maintains responsibility for ensuring accurate information is documented. 2) INCORRECT – This statement is appropriate in that the nurse provides an opportunity for the student to describe the procedure and ask questions while ensuring the client will receive safe care. Discussing the procedure in the hallway, rather than in the patient's room, is preferred so the patient does not question the student's capabilities. 3) INCORRECT – This statement is appropriate in that the nurse provides an opportunity for the student to describe the planned transfer and ask questions while ensuring the patient will receive safe care. Discussing the procedure in the hallway, rather than in the patient's room, is preferred so the patient does not question the student's capabilities. 4) CORRECT – The student nurse is not licensed to take prescriptions from the health care provider. Therefore, the nurse should place these calls.

After the nurse assesses the assigned patients, which activity does the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Complete tracheostomy care. 2. Provide oral suctioning using a Yankauer suction tube. 3. Change the appliance of a new colostomy. 4. Obtain a wound culture from a leg ulceration.

Correct answer: 2. Provide oral suctioning using a Yankauer suction tube. 1. Completing tracheostomy care requires knowledge of sterile technique and potential problem-solving skills. As such, this skill is not within the scope of practice of the UAP and must be performed by the nurse or respiratory therapist. 2. Providing oral suctioning using a Yankauer suction tube can be delegated to the UAP, for this is not a sterile procedure and is within their scope of practice. 3. Due to the need to assess the stoma and surrounding skin, the care associated with a new colostomy should not be delegated to the UAP. This is not within the UAP's scope of practice. 4. Obtaining a wound culture requires application of sterile technique and knowledge of wound healing. Therefore, the task should not be delegated to the UAP as it is not within the scope of practice. Think Like a Nurse: The scope of practice for the UAP includes standard and unchanging procedures for a stable client. Procedures that require assessment or nursing judgment cannot be delegated. Tracheostomy care is a sterile procedure that requires assessment and evaluation of the airway, so this should not be delegated to the UAP. Care of an established colostomy could be delegated to the UAP, but this is a new colostomy and requires assessment and evaluation. Obtaining a wound culture requires assessment of the wound bed and requires the use of sterile technique. Oral suctioning is a safe procedure that does not require sterile technique, so this could be delegated to the UAP. Content Refresher: Delegation is the process of transferring authority for a specific nursing care task to a competent person in a stable patient situation with a predictable outcome. You can delegate a task to a UAP with clear communication about the task, its purpose, the desired timeline for performance, and expected outcomes. To maintain patient safety, it is essential that you are knowledgeable of the UAP's scope of practice. UAPs may perform standard, unchanging procedures for stable patients

The nurse notices a patient's family gathering outside of the client's room to take a group picture. The patient seems to be in agreement with the picture. Which action by the nurse is appropriate? (Select all that apply.) 1. Take the picture for the family to be sure the privacy of all patients in the unit is protected. 2. Politely instruct the family to take the picture inside the patient's room. 3. Call security to ask the family to leave because they have broken confidentiality and privacy regulations. 4. Tell the family there is a private area outside of the unit where a picture could be taken. 5. Take no action if other patients are not outside of their room when the picture is taken.

Correct answers: 2, 4. 2. Politely instruct the family to take the picture inside the patient's room. 4. Tell the family there is a private area outside of the unit where a picture could be taken. 1) INCORRECT – This nursing action is inappropriate. Seeing the nurse take a picture outside of the patient's room may make other clients feel as though their privacy and confidentiality are not protected. It also gives a mixed message to the patient's family, as well as other patients and families, about the correct location to take the picture. 2) CORRECT – It is appropriate for the nurse to ask the family to take the picture inside the patient's room to protect the privacy of the other patients in the hospital. 3) INCORRECT – It is not necessary for the nurse to call security. The nurse should first approach the family politely and inform them about the confidentiality and privacy regulations as well as tell them the correct location to take the picture. 4) CORRECT – It is appropriate for the nurse to escort the family to a more common and appropriate area outside of the unit to take the picture where the trust and privacy of the patients would not be compromised. It is important for the nurse to explain the reason for taking the picture in this area. 5) INCORRECT – It is inappropriate for the nurse to avoid dealing with the situation just because there are no other patients outside of the room. Medical information, patient initials, and/or room numbers could be visible in the picture, and that would compromise patient confidentiality and privacy regulations.

The nurse provides care for patients in the emergency department. Four patients come in at the same time. Which patient does the nurse see first? 1. A 6-month-old patient with vomiting and diarrhea. 2. A 2-year-old patient with a temperature of 101°F (38°C). 3. A 20-year-old patient at 8 weeks gestation and reporting vaginal spotting. 4. A 32-year-old reporting nausea and vomiting for several hours.

Correct answer: 1. A 6-month-old patient with vomiting and diarrhea. 1. This patient is at significant risk for dehydration and electrolyte imbalances due to the small body mass, inability to compensate effectively, and loss from both upper and lower GI sources. This patient is the priority. 2. Obtain a prescription for an antipyretic and monitor until the health care provider (HCP) can evaluate the patient. 3. Spotting can be caused by a drop in the progesterone level, and there is a potential for a spontaneous abortion. Encourage the patient to rest and offer reassurance until the health care provider can evaluate the patient. 4. The average healthy young adult's body can adequately compensate for dehydration over the short term. The patient may require an injection of an antiemetic to stop the vomiting; however, the infant is the priority. Think Like a Nurse: Dehydration occurs more readily in infants and young children than it does in adults. The risk is increased in infants and young children because they have an increase in extracellular fluid percentage and a relative increase in body water compared to that in adults. You should first assess a 6-month-old with vomiting and diarrhea. Nursing goals for this client are restoring fluid volume and preventing hypovolemic shock. Provide oral rehydration to children with mild to moderate dehydration and IV fluids for children with moderate to severe dehydration. The pregnant patient and the adult client with nausea and vomiting will require further assessment: however, the infant is the priority. The toddler could be given an antipyretic while the source of the fever is determined, but the infant is still the priority. Content Refresher: Dehydration results from a loss of body fluids, mainly water, with resultant changes in serum electrolytes. Assist w collaborative interventions for dehydration, s/a admin of oral or parenteral fluids and treatment for the underlying cause of dehydration. Monitor pt tolerance of fluids. assess intake and output, urine specific gravity, VS, and daily weights. auscultate breath sounds before and during fluid resuscitation to assess tolerance. monitor for s/s fluid overload. NCLEX Tip: changes in VS and weights are late indicators of fluid V status. You be proactive in monitoring I/O and lung sounds to detect early signs of fluid V overload

The nurse reviews prescriptions for a newly admitted patient. Which prescription does the nurse clarify with the health care provider? (Select all that apply.) 1. Famotidine 20 mg PO qd. 2. Docusate 100 mg PO twice daily. 3. Captopril 25.0 mg PO every 8 hours. 4. MS ER 30 mg PO twice daily. 5. Tetracycline 250 mg PO four times daily.

Correct answers: 1, 3, 4. 1. Famotidine 20 mg PO qd. 3. Captopril 25.0 mg PO every 8 hours. 4. MS ER 30 mg PO twice daily. 1. The abbreviation for daily, "qd," is on the "Do Not Use" abbreviation list from The Joint Commission. Abbreviations qd (daily) and qod (every other day) are often mistaken for each other. 2. The docusate prescription is correctly written; therefore, it does not need clarification. 3. The use of a trailing zero is on the "Do Not Use" abbreviation list from The Joint Commission. If the period is missed, the client receives 10 times the prescribed dosage. 4. The abbreviation for morphine sulfate, "MS," is on the "Do Not Use" abbreviation list from The Joint Commission because it could also indicate magnesium sulfate. The abbreviation "ER" is not common and should not be used. 5. The number of times a medication is prescribed daily should be written out; therefore, it does not need clarification. Think Like a Nurse: Medication safety is a priority in health care. The Joint Commission has published a list of "Do Not Use" abbreviations, which includes Q.D., QD, q.d., qd (daily), Q.O.D., QOD, q.o.d., and qod (every other day). Lack of leading zero (.X mg) or the use of a trailing zero (X.0 mg) is also prohibited due to the risk of overdosing a client. Typically, this list is posted in the medication room or in high traffic areas for nurses and health care providers. The official "Do Not Use' list applies to all prescriptions and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms. Do Not Use Abbreviations u "unit" -- use IU "International Unit" Q.D., QD, q.d., qd -- use "daily" Q.O.D., QOD, q.o.d., qod -- use "every other day" MS -- use "morphine sulfate" or "magnesium sulfate"

The nurse receives telephone messages from patients receiving care in the outpatient clinic. Which message will the nurse return first? 1. patient with cold symptoms and an oral temperature of 103°F (39.4°C). 2. patient with a stage 2 pressure injury and reporting that the dressing has come off. 3. patient with nausea and who has vomited 6 times in the previous 24 hours. 4. patient reporting leg pain after walking half a mile.

Correct answer: 3. patient with nausea and who has vomited 6 times in the previous 24 hours. 1. An elevated temperature indicates an infection. The nurse needs to determine the underlying cause and encourage fluids. However, there is another patient who requires priority assessment. 2. The patient with a stage 2 pressure injury and whose dressing has fallen off is considered stable. 3. The patient who is nauseated and has vomited 6 times in the previous 24 hours is at risk for a fluid volume deficit. The amount and character of the emesis need to be assessed. Fluid volume deficit can impact circulation. Therefore, when using the ABCs (airway, breathing, circulation) for prioritization, the nurse returns this message first. 4. Leg pain after walking is a manifestation of intermittent claudication. This patient is stable. The patient needs to be told to rest and then resume walking. Think Like a Nurse: The patient with a 24-hour history of nausea and vomiting is at risk for a fluid and electrolyte imbalance, specifically hypovolemia and hypokalemia and should be contacted first for further assessment. The patient with an elevated temperature and cold symptoms most likely has an infection or the flu and should be contacted soon. However, this patient is in no acute distress. The patient who needs a dressing replaced can be contacted later. The patient experiencing leg pain or intermittent claudication is in no acute distress and can be contacted later. Intermittent claudication is defined as muscle pain caused by exercise that resolves within 10 minutes or less with rest and is reproducible.

The nurse receives a call in which the caller self-identifies as the daughter of a patient in the nurse's care. Which action is appropriate for the nurse to take? 1. Ask the caller for the patient's Health Insurance Portability and Accountability Act (HIPAA) password. 2. Ask the caller to provide the patient's date of birth. 3. Tell the caller you are unable to provide any patient data over the phone. 4. Tell the caller to call back and talk to the charge nurse.

Correct answer: 1. Ask the caller for the patient's Health Insurance Portability and Accountability Act (HIPAA) password. 1) CORRECT – patients provide a password to health care providers to ensure that only those persons the patient identifies are able to receive protected health care information. 2) INCORRECT – Knowing the patient's date of birth does not indicate that the caller has been identified as someone who should be given the patient's protected health care information. 3) INCORRECT – This action is premature. If the caller is able to provide the patient's HIPAA password, the nurse can share health care information via phone. 4) INCORRECT – The nurse caring for the patient should speak with the caller and, if the caller knows the HIPAA password, provide information regarding the client's condition.

A student reports chest pain to the school nurse. The nurse notes the child has a history of asthma. Which is the priority nursing action? 1. Call the student's parent. 2. Have the student lie down. 3. Obtain a peak flow reading. 4. Administer a bronchodilator, as prescribed.

Correct answer: 3. Obtain a peak flow reading. 1) INCORRECT – While appropriate, the student should be assessed prior to the parent being notified. 2) INCORRECT – Additional assessment data is needed first. 3) CORRECT – Checking the peak flow reading will determine the status of the student's asthma. 4) INCORRECT – The student should first be assessed to determine the necessity for the medication.

A client has refused all pain medications. The nurse plans care to provide non-pharmacological pain relief and comfort to the client. Which action is appropriate to delegate to the LPN/LVN? 1. Teaching the client meditation techniques. 2. Administering transcutaneous electrical nerve stimulation (TENS). 3. Reinforcing teaching about the use of heat and cold applications. 4. Assessing the effectiveness of non-pharmacological methodologies to alleviate pain.

Correct answer: 3. Reinforcing teaching about the use of heat and cold applications. 1) INCORRECT – Initial teaching about treatment modalities is beyond the scope of practice of the LPN/LVN. 2) INCORRECT – Administering TENS is performed by the primary care provider or a therapist who received special training to do so. 3) CORRECT – Reinforcing teaching is within the scope of practice of the LPN/LVN. 4) INCORRECT – Assessment of clients and the use of nursing judgment is beyond the scope of practice of an LPN/LVN.

The nurse provides care for a confused patient who underwent a cardiac catheterization through the right femoral artery. The patient refuses to follow directions and keep the affected leg flat and straight postoperatively. The nurse assesses the right groin catheterization site and notes a large hematoma is beginning to form. Which nursing intervention is priority? 1. Use restraints to keep the leg straight. 2. Apply direct pressure to the hematoma. 3. Notify the health care provider of the hematoma. 4. Check pedal pulses with Doppler ultrasound.

Correct answer: 2. Apply direct pressure to the hematoma. 1) INCORRECT – The focus needs to be directed to the hematoma that is already forming. 2) CORRECT – It is important to apply pressure to the site to reduce further bleeding from the femoral artery into the tissue, which may occlude blood flow to distal extremities. The nurse should apply firm pressure to the site and then call for assistance. 3) INCORRECT – The nurse should first apply pressure to the site to manage and reduce bleeding from the right femoral artery catheter site. 4) INCORRECT – Checking the pedal pulses with Doppler ultrasound should be done after the bleeding/hematoma is controlled to assess damage to distal extremities.

A 21-year-old patient diagnosed with asthma falls on the college running track while preparing for a track meet. Use of the inhaler restores breathing and equilibrium. The patient is conscious, alert, and oriented. Blood pressure is 120/82 mm Hg, pulse is 84 beats/min, and respirations are 14 breaths/min. The university health center nurse asks the patient to go to the emergency department to obtain a medical evaluation. The patient refuses to seek medical evaluation. Which action is best for the nurse to take? 1. Contact the patient's parents to obtain consent for hospital evaluation and any needed treatment. 2. Call an ambulance and ask the patient for an emergency contact name. 3. Tell the patient that the patient has the right to refuse medical evaluation. 4. Suggest the coach remove the patient from the training roster unless the client consents to be medically evaluated.

Correct answer: 3. Tell the patient that the patient has the right to refuse medical evaluation. 1. The patient has the right to refuse treatment. The patient is of legal age and is conscious and oriented. 2. The patient has the right to refuse treatment. 3. The patient is of legal age to refuse treatment. A competent adult can refuse emergency treatment, and that refusal must be respected by all. 4. This may be an appropriate response to the coach, but the nurse should direct comments to the patient, who has the right to refuse treatment. Think Like a Nurse: It is important for you, as the nurse, to remember that patients have rights and responsibilities associated with care that is received by health care professionals. One of the rights is to be able to refuse medical treatment. The patient in this scenario has the right to refuse treatment due to legal age. You have an obligation to inform patients about their rights; however, you should also share possible consequences of not seeking medical attention.

The nurse receives hand-off communication from the nurse who provided care to a group of patients during the previous shift. Which patient does the nurse see first? 1. A patient diagnosed with dementia and who is at risk for falling. 2. A patient who is one day postoperative and receiving maintenance IV fluids at a rate of 50 mL/hr. 3. A patient diagnosed with pneumonia and reporting shortness of breath. 4. A patient with a hip fracture reporting 9/10 on a pain scale.

Correct answer: 3. A patient diagnosed with pneumonia and reporting shortness of breath. 1. After seeing the patients with physiological needs, the nurse sees the patients with safety and security needs, such as the patient diagnosed with dementia and who is at risk for falling. 2. After attending to the patients with greater physiological needs, the nurse assesses the patient who has IV fluids infusing to evaluate the patient's fluid volume status. 3. The nurse sees the patient with physiological needs first. Of the patients with physiological needs, the nurse first addresses the patient diagnosed with pneumonia and who reports shortness of breath because airway, breathing, and circulation take priority. 4. After seeing the patient diagnosed with pneumonia who reports shortness of breath, the nurse provides care to the patient who reports 9/10 pain on a pain scale. Think Like a Nurse: When prioritizing patient care, you will need to determine who the most unstable patient is. Determine whether the patient is stable or unstable, then evaluate whether the patient findings are expected are not. Stable patients, or those with findings expected for their health condition, should be seen after you assess the least stable patient. Use the airway, breathing, and circulation (ABC) mnemonic as a guide. Based on this scenario, the patient with a diagnosis of pneumonia and who is experiencing shortness of breath has a breathing issue necessitating immediate action. This patient requires further assessment, and you may need to notify the health care provider for further evaluation and treatment. Once this patient is stabilized, the patient experiencing severe pain can be addressed.

The nurse makes client care assignments for the day. Which activities can the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Ambulate a client who has a lower limb prosthesis. 2. Discontinue a painful peripheral intravenous line. 3. Verify placement of a nasogastric tube. 4. Obtain a telephone prescription from the health care provider. 5. Reconstitute a powdered medication with normal saline. 6. Pad the side rails for a client who had a seizure.

Correct answers: 1, 6. 1. Ambulate a client who has a lower limb prosthesis. 6. Pad the side rails for a client who had a seizure. 1. The UAP can assist a client with ambulation. 2. This is not an appropriate task to delegate to the UAP. This task requires assessment by the nurse to determine whether infiltration or phlebitis is present. 3. This is not an appropriate task for the nurse to delegate to the UAP. This task requires verification of correct nasogastric tube placement, which requires assessment. 4. This is not an appropriate task to delegate to the UAP. The nurse must take all telephone prescriptions. 5. This is not an appropriate task to delegate to the UAP. The nurse cannot delegate medication administration or preparation to the UAP. 6. The UAP can pad the side rails for client safety. Think Like a Nurse: When considering delegation, you must be aware of the state's Nurse Practice Act and the agency's policies. The scope of practice for unlicensed assistive personnel (UAP) includes completing standard, unchanging tasks and providing basic care for stable clients. When deciding whether or not to delegate a nursing task, you need to assess the following factors: The client's present health status. The safety of the situation. The intended client outcome. Of the tasks needing to be completed, you can safely delegate ambulating a client with a prosthesis and padding the side rails of a client's bed. You are responsible for discontinuing an IV infusion, verifying the placement of a nasogastric tube, obtaining a telephone prescription, and preparing medication.

The nurse admits a client diagnosed with type 1 diabetes who reports numbness and tingling in the lower extremities. Which intervention is the most important component to include in the client's plan of care? 1. Place foot cradle on the bed. 2. Wash feet with mild soap. 3. Daily examination of feet. 4. Change socks or stockings daily.

Correct answer: 3. Daily examination of feet. 1) INCORRECT – Use of a foot cradle may be needed to prevent pressure on sensitive points. Other measures that may be needed include heel protectors or pressure-relief mattresses. 2) INCORRECT – Following daily inspection, cleansing the feet is also a part of the client's care plan. Feet should be cleansed using mild soap, dried well, and a gentle moisturizer applied. It is important to check water temperature before bathing, as decreased sensation increases the risk for burns. 3) CORRECT – Numbness and tingling are signs of diabetic neuropathy, which is a risk factor for the development of foot ulcers. The most important nursing intervention to prevent the formation of foot ulcers is examination of the feet on a daily basis. During the examination, the nurse will assess skin integrity and note any signs of erythema or trauma. 4) INCORRECT – Socks or stockings should be changed daily to prevent infection. However, daily examination is the priority nursing intervention. Encourage the client to wear white cotton socks with no elastic. With white fabric, any blood or exudates are easily seen.

Case study: The nurse provides care for an adult client in the oncology clinic. The client was diagnosed with AML three months ago. Nurse's notes: 1325: The client's treatment plan includes chemotherapy every two weeks for six months. The client has received three treatments. Chemotherapy was last administered 12 days ago. The client appears pale, tired, and short of breath. Client reports a dry cough which began approximately 3 days ago. For the last day, the cough has become productive with thick, yellow sputum. Coarse crackles auscultated in bilateral lower lobes. Other symptoms include chills, anorexia, generalized body aches, and fatigue. The client states, "I just want to lay in bed all day; I'm so tired, and my chest hurts from coughing." The client reports, "I attended a family gathering for a relative's birthday party 4 days ago and felt pretty good then. I haven't been out of the house since." Blood specimens collected for laboratory testing and chest x-ray results are pending. Vital signs: BP 154/86 mm Hg HR 106/min RR 20/min SpO2 90% RA T (oral) 101.9F (38.8C) Pain 4/10 The nurse documents the assessment. > Complete the sentence with three findings: The nurse is most concerned about the client's ___, _, and ___ Choices: oxygenation level chills temperature fatigue anorexia body aches lung sounds

Correct findings: oxygenation level lung sounds temperature. The client findings of an elevated temperature, decreased oxygen saturation, and lung sounds with crackles present are all concerning findings. This client has a diagnosis of leukemia and has been receiving chemotherapy treatments. This client is at high risk for infection. Chills, fatigue, anorexia, and body aches are symptoms associated with an acute infection. Although uncomfortable for the client, they are not the most concerning symptoms.

Case study: The nurse provides care for an adult client in the oncology clinic. The client was diagnosed with AML three months ago. Nurse's notes:1325: The client's treatment plan includes chemotherapy every two weeks for six months. The client has received three treatments. Chemotherapy was last administered 12 days ago. The client appears pale, tired, and short of breath. Client reports a dry cough which began approximately 3 days ago. For the last day, the cough has become productive with thick, yellow sputum. Coarse crackles auscultated in bilateral lower lobes. Other symptoms include chills, anorexia, generalized body aches, and fatigue. The client states, "I just want to lay in bed all day; I'm so tired, and my chest hurts from coughing." The client reports, "I attended a family gathering for a relative's birthday party 4 days ago and felt pretty good then. I haven't been out of the house since." Blood specimens collected for laboratory testing and chest x-ray results are pending. Vital signs:BP 154/86 mm HgHR 106/minRR 20/minSpO2 90% RAT (oral) 101.9F (38.8C)Pain 4/10 > Complete the following sentence: The nurse is concerned that the client may have developed __ d/t __ first blank: pneumonia depression bleeding second blank: decreased platelets impaired immunity a diagnosis of cancer

Correct completion: pneumonia due to impaired immunity. The nurse recognizes the risk of infection for this client is especially high due to the leukemia diagnosis and current chemotherapy treatments. The respiratory symptoms indicate the client has developed pneumonia. Clients undergoing chemotherapy have a weakened immune system and a decrease in the number of healthy white blood cells. A client with cancer may develop depression due to the change in lifestyle, numerous medical treatments, and change in health status. The client's acute symptoms suggest fatigue and anorexia are due to infection. Fatigue may suggest bleeding, but the client's vital signs do not indicate active bleeding, and the respiratory symptoms and decreased oxygenation indicate the client has developed a respiratory infection.

Case study: The nurse provides care for an adult client in the oncology clinic. The client was diagnosed with AML three months ago. Nurse's notes:1325: The client's treatment plan includes chemotherapy every two weeks for six months. The client has received three treatments. Chemotherapy was last administered 12 days ago. The client appears pale, tired, and short of breath. Client reports a dry cough which began approximately 3 days ago. For the last day, the cough has become productive with thick, yellow sputum. Coarse crackles auscultated in bilateral lower lobes. Other symptoms include chills, anorexia, generalized body aches, and fatigue. The client states, "I just want to lay in bed all day; I'm so tired, and my chest hurts from coughing." The client reports, "I attended a family gathering for a relative's birthday party 4 days ago and felt pretty good then. I haven't been out of the house since." Blood specimens collected for laboratory testing and chest x-ray results are pending. Vital signs:BP 154/86 mm HgHR 106/minRR 20/minSpO2 90% RAT (oral) 101.9F (38.8C)Pain 4/10 Which potential complication is of greatest concern to the nurse? 1. Weight loss. 2. Stomatitis. 3. Sepsis. 4. Anemia.

Correct answer: 3. Sepsis. The nurse understands the priority concern for the client is the development of sepsis. For an immunocompromised client, a respiratory infection can quickly progress to sepsis and become life threatening. The client may lose weight due to anorexia; however, the greatest concern is the development of an infection which the body cannot fight. Stomatitis can also develop in a client undergoing chemotherapy, but the greatest danger to the client is the development of sepsis.

Case study: The nurse provides care for an adult client in the oncology clinic. The client was diagnosed with AML three months ago. Nurse's notes:1325: The client's treatment plan includes chemotherapy every two weeks for six months. The client has received three treatments. Chemotherapy was last administered 12 days ago. The client appears pale, tired, and short of breath. Client reports a dry cough which began approximately 3 days ago. For the last day, the cough has become productive with thick, yellow sputum. Coarse crackles auscultated in bilateral lower lobes. Other symptoms include chills, anorexia, generalized body aches, and fatigue. The client states, "I just want to lay in bed all day; I'm so tired, and my chest hurts from coughing." The client reports, "I attended a family gathering for a relative's birthday party 4 days ago and felt pretty good then. I haven't been out of the house since." Blood specimens collected for laboratory testing and chest x-ray results are pending. Vital signs:BP 154/86 mm HgHR 106/minRR 20/minSpO2 90% RAT (oral) 101.9F (38.8C)Pain 4/10 Diagnostic results: WBC 2,500/mm³ (2.5 × 10⁹/L) - low ANC 900/mm³ (0.9 × 10⁹/L) - low RBC 5.1 million/mm³ (5.1 × 10¹²/L) - normal platelets 152,000/mm³ (152 × 10⁹/L) - normal The client's diagnostic results are reviewed by the physician. The client is diagnosed with pneumonia and neutropenia. The nurse prepares the client's plan of care. > For each potential nursing intervention, specify if the intervention is indicated or not indicated. 1. Prepare the client for hospital admission. 2. Administer oxygen via nasal cannula. 3. Provide information about neutropenic precautions. 4. Prepare the client for a blood transfusion.

Correct classifications: 1. Indicated. 2. Indicated. 3. Indicated. 4. Not indicated. The management of pneumonia and neutropenia includes hospitalization for the client to receive intravenous antibiotic treatment, as well as placing the client in a private room and limiting visitors to decrease the exposure to pathogens. Oxygen should be administered to increase the client's low oxygen level. The client's RBC count is normal, therefore it will not be necessary for the client to receive a blood transfusion at this time.

Case study: same as the cancer stuff from before When providing information regarding management of an acute infection and neutropenia to the client, which statement does the nurse include? (Select all that apply.) 1. "Your white blood cell count is low, which prevents your body from fighting off infections." 2. "You will likely be hospitalized for several weeks." 3. "Visitors should be limited to avoid potential infectious pathogens." 4. "You should not have any live plants in your hospital room or at home." 5. "It is important to begin intravenous antibiotics as soon as possible."

Correct answers: 1, 3, 4, 5. 1. "Your white blood cell count is low, which prevents your body from fighting off infections." 3. "Visitors should be limited to avoid potential infectious pathogens." 4. "You should not have any live plants in your hospital room or at home." 5. "It is important to begin intravenous antibiotics as soon as possible." The nurse should address the effects of leukemia and chemotherapy, which could increase the risk of developing neutropenia. Neutropenia places the client at an increased risk of infections and illnesses. The client should be taught to limit the number of people they interact with, as well as pets, small children, and those with known illnesses. This is a safety measure to minimize the risk of illness for the client. Live plants breed bacteria and mold and place the client at an increased risk of illness. Intravenous antibiotics are important to treating the active infection. The use of antibiotics and other medications intravenously usually take effect quickly and the client improves within several days. Safety measures and neutropenic precautions should be taught and implemented at home as well.

Case study: same as the cancer stuff from before Which 3 client statements indicate further teaching is needed regarding the management of neutropenia and decreasing the risk for infections? 1. "I am really looking forward to seeing my grandbabies when I get out of the hospital." 2. "I will take the antibiotics until the cough is no longer productive." 3. "If I have to leave my house, I will wear a mask." 4. "I will be sure to wash all fresh fruits and vegetables well before eating them." 5. "If I start to feel sick, I will use some essential oils in my humidifier." 6. "I need to wash my hands frequently and encourage my family members to do so."

Correct answers: 1, 2, 5. 1. "I am really looking forward to seeing my grandbabies when I get out of the hospital." 2. "I will take the antibiotics until the cough is no longer productive." 5. "If I start to feel sick, I will use some essential oils in my humidifier." The client should be taught the importance of minimizing contact with others and being in large crowds, as well as avoiding interactions with small children as this could increase the client's risk of acquiring infections or illnesses. It is important for the client to complete the full course of antibiotics as prescribed by the physician, even if feeling better or symptoms improve. Stopping the antibiotic prematurely can lead to the infection returning stronger and the bacteria developing resistance to the antibiotic, making it less effective in the future. A humidifier, diffuser, or any appliance with standing water breeds mold and bacteria and can pose a threat of infection to the client. If the client must leave the home, a mask should be worn for protection from acquiring an illness or infection. All fresh fruits and vegetables should be washed thoroughly to ensure any infectious material is removed from the food before ingestion. Frequent and meticulous handwashing by the client and family members can decrease the risk of spreading infection among family members.

The nurse provides care for clients in the emergency department. Which client does the nurse assess first? 1. A client with a burn to the palm of the hand. 2. A client reporting a bee sting, causing diffuse redness. 3. A client reporting blood and blood clots in the urine. 4. A client reporting right lower leg pain, edema, and warmth.

Correct answer: 2. A client reporting a bee sting, causing diffuse redness. 1. Burns to the palm of the hand may result in loss of function if scar tissue forms as the burn heals. This often requires evaluation by a plastic surgeon. The client likely requires pain medication as well, but this client is not the priority. 2. A sting should cause a local reaction. What is described is the start of a systemic reaction, which may lead to anaphylaxis and airway loss if not treated promptly. 3. This client requires evaluation for the cause of the bleeding, such as bladder cancer, but is likely not losing enough blood in the urine to experience cardiac output decrease and is not the priority. 4. This client may have a deep vein thrombosis and requires prompt treatment. The nurse instructs the client to avoid walking around, to report shortness of breath, and to wait for the health care provider to evaluate further. Think Like a Nurse: Bee stings can potentially cause a life-threatening anaphylactic reaction. You should examine this client first and assess the client for airway patency and adequate oxygenation. You should also anticipate providing epinephrine, diphenhydramine and/or a corticosteroid, and supplemental oxygen as needed. NCLEX Tip: Be sure to read the question stem carefully. The word "diffuse" indicates a systemic rather than local reaction.

A term client in active labor suddenly grabs her chest and states, "My chest hurts bad and I can't breathe!" The client's skin begins to turn a gray color. The nurse calls for assistance and performs which action next? 1. Administer prescribed IV fibrinogen. 2. Begin cardiopulmonary resuscitation. 3. Initiate intravenous normal saline infusion. 4. Provide 100% oxygen via non-rebreather mask.

Correct answer: 4. Provide 100% oxygen via non-rebreather mask. 1) INCORRECT – Though disseminated intravascular coagulation likely will develop following amniotic fluid embolism, the medication is not yet required. 2) INCORRECT – Cardiopulmonary resuscitation is not yet indicated. 3) INCORRECT – Hemodynamic support is required with amniotic fluid embolism, but oxygen should be administered first. 4) CORRECT – The symptoms indicate amniotic fluid embolism and oxygen should be provided first to ensure adequate oxygenation of both the client and fetus.

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first? 1. A client reports a headache unrelieved by extra-strength acetaminophen doses every 4 hours for 2 days. 2. A client reports ankle pain, swelling, and warmth. The client states there is no injury to the ankle. 3. The parent of a toddler client calls to report that the client has a rash and sore throat. 4. The parent of a toddler client calls to report that the client swallowed a nickel.

Correct answer: 4. The parent of a toddler client calls to report that the client swallowed a nickel. 1. Extra-strength acetaminophen is 500 to 1000 mg. This medication is 90 to 95% metabolized by the liver. The limit is 4000 mg per day. The client is at risk for damage to the liver as a result of overdose. The nurse needs to clarify the doses taken and have the client evaluated for the headache cause and liver function. This client is unstable; however, the toddler who swallowed the nickel is priority due to airway. 2. The possibility of an infectious process requiring evaluation and treatment exists. The toddler that swallowed the coin is the priority. 3. The rash and sore throat probably describe a Streptococcus A infection or virus. There is no indication in the question stem that the client is having respiratory difficulty so the toddler that swallowed the coin is the priority. 4. The nurse should immediately evaluate to determine if the toddler is having respiratory difficulty due to airway obstruction. Think Like a Nurse: A child client who swallowed a nickel requires further evaluation for possible airway or gastrointestinal obstruction. Foreign body aspiration is common in infants and toddlers and can be life-threatening. You should anticipate sending the child for an x-ray. Once the child is stabilized, provide parental teaching including methods for avoiding aspiration or swallowing of foreign bodies. The remaining clients need further assessment but do not take priority over the choking/airway issue for the toddler who swallowed the coin.

A client underwent a total abdominal hysterectomy for cervical cancer 1 day ago. Which nursing assessment finding is most concerning? 1. Amber urine (30 mL/hr) in the collection bag. 2. Fine crackles auscultated in bilateral lung bases. 3. Left calf swelling with mild tenderness. 4. Patient-controlled analgesia (PCA) use every 30 minutes.

Correct answer: 3. Left calf swelling with mild tenderness. 1) INCORRECT – Urinary output is minimally adequate, though the client should be encouraged to increase fluid intake. 2) INCORRECT – This is somewhat of an expected finding in the postoperative period, though the client should be encouraged to cough and deep breathe, as well as use the incentive spirometer. The care of this client should be prioritized second. 3) CORRECT – Signs of a possible deep vein thrombosis (DVT) are most concerning as this condition will impact the plan of care. A pulmonary embolism is the most serious complication of a DVT and occurs when a part of the clot breaks off and travels through the bloodstream to the lungs. 4) INCORRECT – One day postoperative, it is expected that the client would use the PCA at this frequency. The nurse should assess the client's pain.