Leadership/Management

Client VS change suddenly, nurse unsure of resuscitative status, action? CALL CHARGE NURSE TO
CHECK ADVANCED DIRECTIVE WHILE CONTINUSING TO ASSESS THE CLIENT
Several discharges and census is unusually low, best way to use the time? ENCOURAGE STAFF TO
PARTICIPATE IN ONLINE IN-SERVICE EDUCATION
Only RN performing admission assessment on client scheduled for surgery in 2 hours. UAP
reports unresponsive client with continuous feeding tube just vomited. Action to delegate to
UAP? POSITION THE CLIENT ON HIS SIDE AND OBTAIN VITAL SIGNS
Nurse wants to verify steps for specific client procedure, action? CONSULT THE AGENCYS
POLICIES AND PROCEDURES MANUAL AND FOLLOW THE GUIDELINES
Well baby clinic in low income neighborhood, most important to assess? IMMUNIZATION HISTORY

IV Lines
Resistance when flushing Central Venous Cath, action? EXAMINE FOR CLAMP CLOSURE
(thrombus, closed clamp or crystallized medication can cause resistance) diluted solution of
hepairin (10-100 u/ml after checking clamp closure)

Respiratory
Emphysema client difficulty breathing. Position? SITTING UPRIGHT AND FORWARD, ARMS ON
TABLE (allowsincrease of longitudinal and anterior-posterior maxiumum expansion and reduces
dyspnea)
Tracheostommy suctioning on comatose client, interventions? CHECK SUCTION REGULATOR AND
ADJUST SUCTION PRESSURE TO 120-150 MMHG, HYPEROXYGENATE USING MANUAL RESERVOID
EQUIPPED RESUSCITATION BAG, GENTLY INSERT CATHETER WITHOUT SUCTION USING STERILE
TECHNIQUE, APPLY SUCTION INTERMITTENTLY WHILE WITHDRAWING THE CATHETER
Client on mechanical ventilator for several days, what should nurse document for respiration?
VENTILATOR SETTING FOR RESPIRATORY RATE AND CLIENT INITIATED RESPIRATIONS (count both
client and machine)
MusculoSkeletal
Right above knee amputation needs repositioning in bed, action to include? INSTRUCT CLIENT TO
GRASP THE OVERHEAD TRAPEZE BAR (client gains upper body strength and independence)
Preparing surgical stabilization for fractured lumbar vertebrae. Which indication best supports
clients need for insertion of indwelling catheter? HOURLY URINE OUTPUT, BLADDER DISTENTION,
INTRAOPERATIVE BLADDER DECOMPRESSION (continuous bladder drainage using indwelling
catheter is indicated)

Hemiplegia on bed rest turned to supine position, hips externally rotated, intervention? PLACE
TROCHANTER ROLLES ON LATERAL ASPECS OF CLIENTS THIGHS (to prevent external rotation of
hips)

Diabetes
Fasting glucose level most needing immediate intervention? 50 MG/DL (low level needs
intervention to prevent LOC loss)

Endocrine
Levothyroxine (Synthroid) given to hypothyroid client, effective? INCREASE IN t3 AND t4,
DECREASE IN PERIORBITAL EDEMA

Liver/GI
Hepatic failure used Tylenol, resond to patient? ACETAMINOPHEN HEPATOTOXIC AND
CONTRAINDICATED)
Renal
Client has dysuria and urinary frequency, teaching? SAVE NEXT URINE SAMPLE
50 year old complains of pain on ejaculation, action? ASK ABOUT SCROTAL PAIN OR BLOOD IN
SEMEN (Orchitis is an acute testicular inflammation resulting from recurrent UTI, STD, or
indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in semen and
penile discharge)
Pysch/Mental
AIDS client hospitalized after recent discharge, nursing intervention important in reducing stress?
ENCOURAGE AS MUCH INDEPENDENCE IN DECISION MAKING AS POSSIBLE (helps reduce stress
from repeated hospitalization)
Schizophrenia world coming to an end. All the violence in middle east, nurse response?
LISTENING TO THE NEWS SEEMS TO BE FRIGHTENING YOU (best to identify the feeling
associated with the delusion)
Client admitted to mental health unit with crying depressed mood and sleeping difficulties, talks
about death of friend, statement most therapeutic? TELL ME MORE ABOUT HOW YOU ARE
FEELING (therapeutic to ask open-ended question and encourage client to talk)
OB-PEDI
40yrold at 36 weeks gestation complaining of pounding HA, blurry vision, and swollen ankles.
Which intervention? CHECK BP (Preeclampsia multisystem disorder and women older than 35 yrs
w/chronic HTN at risk.) Classic SxS: HA, visual changes, edema, recent rapid weight gain and
elevated BP

Postpartum client, promote PVD? ENCOURAGE TO AMBULATE EVERY 3 HOURS

2yr old osteomyelitis, question to ask about history? CHILD HAD EAR INFECTION (osteomyelitis
caused by internal infections, ex: otitis media)
Child with nephrotic syndrome receiving prednisone (Deltasone), breakfast? TOASTED OAT
CEREAL AND LOW FAT MILK (follow low sodium, low fat and low sugar diet)