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The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients?
- A. Perform a 'down and dirty' assessment on each client soon after receiving report.
- B. Determine which client should have a bath and inform the unlicensed assistive personnel.
- C. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste.
- D. Pick up any paper on the floor and get the room ready for morning physician rounds.
Correct Answer: A
Rationale: A quick 'down and dirty' assessment (A) prioritizes client stability post-report. Bathing (B), hygiene (C), and room prep (D) are secondary to safety.
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The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?
- A. Tell the UAP to go take the client's vital signs.
- B. Ask the UAP to have the telemetry nurse read the strip.
- C. Notify the client's health-care provider.
- D. Go to the room and assess the client's chest pain.
Correct Answer: D
Rationale: Chest pain in CAD requires immediate nurse assessment (D) to determine severity and cause. Vital signs (A), telemetry (B), and notifying HCP (C) follow assessment.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.
- A. Encourage a low-fat, low-cholesterol diet.
- B. Instruct the client to walk 30 minutes a day.
- C. Decrease the salt intake to two (2) g a day.
- D. Refer to a counselor for stress reduction techniques.
- E. Teach the client to increase fiber in the diet.
Correct Answer: A,B,D,E
Rationale: Low-fat/cholesterol diet (A), walking (B), stress reduction (D), and high-fiber diet (E) reduce CAD risk. Salt restriction (C) is more specific to CHF or hypertension.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's blood pressure and apical rate every four (4) hours.
- B. Place the client on intake and output every shift.
- C. Require the client to sleep with the head of the bed elevated.
- D. Teach the patient to perform Buerger Allen exercises daily.
- E. Determine if the client is on an antiplatelet or anticoagulant medication.
- F. Assess the client's neurological status every shift and prn.
Correct Answer: A,E,F
Rationale: Monitoring BP/apical rate (A), anticoagulation status (E), and neurological status (F) address AF-related perfusion risks (clots, stroke). I/O (B) is for fluid status, HOB elevation (C) is for CHF, and Buerger Allen (D) is for PAD.
The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.