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The RN and the NA are caring for four clients, all in need of immediate attention. The NA is a senior nursing student who has been giving medications and performing procedures on clients as a student nurse. The unit charge nurse determines that care is appropriate when the RN working with the NA delegates which actions? Select all that apply.
- A. Give acetaminophen to the client with a high temperature.
- B. Take vital signs on the client newly admitted with heart failure.
- C. Discuss the pacemaker discharge handout so this client can go home.
- D. Change this client’s chest tube dressing; it got wet with drinking water.
- E. Provide a sponge bath for the client with the increased temperature.
Correct Answer: B;E
Rationale: The RN delegates appropriately when having the NA: B) Take vital signs; E) Perform a sponge bath. Administering medication (A), teaching (C), and changing chest tube dressings (D) are outside the NA’s scope of practice.
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The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.
The client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?
- A. Call the HCP immediately; administer diphenhydramine.
- B. Stop the infusion; apply a warm, moist compress to the affected area.
- C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
- D. Discontinue the potassium chloride; document the client’s allergic reaction.
Correct Answer: B
Rationale: The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm, moist compress and restart the IV at another location, giving the infusion at a slower rate. Other options misinterpret the situation as an allergy or fail to address the phlebitis.
The nurse is caring for the client with a suspected DVT. For which diagnostic test should the nurse anticipate the client will need to be prepared?
- A. V/Q Scan
- B. Arteriogram
- C. Venogram
- D. Embolectomy
Correct Answer: C
Rationale: The nurse should anticipate preparing the client for a venogram, which allows visualization of veins and is used to diagnose a DVT. V/Q scans diagnose PE, arteriograms visualize arteries, and embolectomy is a treatment, not a diagnostic test.
The nurse, caring for the client following an anterior MI, obtains the assessment findings illustrated. Based on these findings, the nurse should immediately notify the HCP and plan which intervention?
- A. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure.
- B. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.
- C. Prepare the client for pericardiocentesis; the findings support cardiac tamponade.
- D. Notify radiology for a STAT chest x-ray to rule out pulmonary embolism (PE).
Correct Answer: B
Rationale: Complications of an anterior MI are left ventricular failure, reduced cardiac output, and cardiogenic shock. The client’s MAP is 55, with hypotension, tachycardia, tachypnea, and low urine output, indicating cardiogenic shock. Dopamine is administered to increase cardiac output. Right HF, tamponade, and PE are less likely based on the findings.
Two days ago the client underwent femoral popliteal artery bypass graft surgery. What should be the nurse’s priority at this time?
- A. Monitor intake and output every four hours.
- B. Report any edema that develops in the operative leg.
- C. Place the client in a 60-degree sitting position when in bed.
- D. Check pedal and post tibial pulses bilaterally every 4 hours.
Correct Answer: D
Rationale: The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Checking both sides allows for comparison. I&O, edema, and positioning are secondary.