UoN Unlicensed Assistive Personnel Taking Vital Signs on Mechanical Ventilation MCQs

Question Description

After a accident the nurse to the injured , Basic upon the triage protocol, which individual should be seen first?
The nurse admitted a client to the surgical unit who had an open reduction internal fixation (ORI of severely fractured right ursing care would be appropriate for the licensed assistive personnel (UAP)? Select all that apply

25 year – old with an abrasion to left eye and swollen an who to bear – old client chest pains b. 80- years old client with chest pains and shortness of breath

C 66 year old with no , visible injures, but who experiencing tachycardia and seems confused with who draining the right

D 16 years old client with fixed, dilated pupils who is unresponsive and has clear fluid draining from the right ear

-A Measure & intake and output in the client’s electronic health record (EHR )

B Teach the client about opioid analgesic ordered by intravenous

C Measure and document signs every 4 hours

-D Elevate the casted arm above the level of the heart with one or two pillows

– E Assess neurovascular status of the tasted extremity hourly

A client has been referred for dietary teaching regarding the management of hepatitis . The nurse would base development of nutritional goals on which data. The need to institute tube feedings to allow the liver to rest and regenerate

The diet should be high carbs and moderate proteins

The diet should be balanced except for limiting dietary fats

The type of hepatitis that the client has affects dietary needs

A client with lymphoma is receiving chemotherapy with nitrogen mustard and has swelling at the intravenous (IV ) site. Which initial action would the nurse take
The nurse is assessing a client who has acute pancreatitis . Assessment findings include the client lying the fetal position , abdominal tenderness & rigidity and guarding . What priority assessment findings needs to be communicated to the health care team ?
The nurse assessing a client who has pain in the right upper quadrant which radiates to the right shoulder. The client states this is their gall bladder attack but states that this is worse than usual . The nurse assesses that the client has tachycardia, pallor and diaphoresis What about this situation requires immediate attention ?
The nurse is planning care for a client diagnosed with increased intracranial pressure ( ICP ) after a head injury . Which of the following interventions can be used to reduce ICP ?
The nurse is participating in community health fair for traumatic brain injury preventionwhat should the nurse instruct the older adult client about prevention injuries.
The end of client is exhibiting the Cheyne -Stokes breathing pattern. The family contacts the nurse with concerns of distress about the client struggling to breathe. What intervention should the nurse provide to help with that breathing pattern?
The nurse is instructing a new graduate nurse about a client who sustained a traumatic brain injury (TB and assessing for Cushing’s triad .which symptoms will nurse find if a ptient is displaying crushings triad.
The nurse is admitting a client who had a liver biopsy . What problem is most important to assess ? A Pain B bleeding, C itching D infection
The nurse is assessing a client who had surgery for a hip fracture . What is the priority intervention by the nurse ?
13. The nurse is preparing to teach a client with cirrhosis about dietary restrictions . Which instructions are most important for the nurse to give the client?
14.What is an indication of a neurovascular problem found during an assessment of a client with a fracture ?
Hematologic laboratory test results indicate a client with cancer is in the nadir period following the last round of chemotherapy . Which medication should the nurse avoid administering to the client at this time ?
A home care nurse is following up with the client who was diagnosed with liver cancer 3 months ago Which assessment information should the nurse communicate immediately to the provider

A Obtain a new site for medication adiminister

B continue with the infusion after trying to aspirate for blood return

C stop administration and temp to aspirate for blood return

D flush the intravenous line with saline

A The clients blood sugar levels are slightly above normal

B the client has negative Chvostek and trousseau signs

C hypotension, tachycardia, dyspnea, elevated temperature

D the client has electrolytes within normal ranges

A Place the client in a busy part of the unit to allow more stimulation.

B. Cluster all nursing activities and cares at one time to keep from stimulatingclient

C Raise the head of the bed to 90 degrees to allow the client to set up

D Closely assess vital signs and oxygen saturations to prevent secondary

Atell the client that they need to sign up for meals on wheels

B make sure that the older client can preform ADLS every

C prevents falls by the managing safety risks and working on balance

D ensure that the client understand how to drive

A call the health care provider to intubate

B have the family members ambulate the client

C place the client in the prone position

D administer the order opioid to minimize distress

A Severe hypotension , widened pulse pressure, bradycardia

B Severe hypertension , widened pulse pressure bradycardia

C Severe hypotension narrow pulse pressure tachycardia

D Severe hypertension narrow pulse pressure , tachycardia

A Plan the help the client ambulate around the nursing unit

B Tell the client that they will need to order their next two meals right away

C Assist the client to the bathroom while wearing the abductor pillow

D Have the nursing assistant apply the sequential compression devices now

A The client needs to limit sodium intake in the diet to 4-6 grams /day

B The client needs to limit sodium Intake the diet to 1 – 2grams / day

C The client can eat hard dry foods, such as taco chips and beef Jerky

D The client can safely consume 2-3 alcoholic drinks each day

A Increased redness and heat below the injury

B Decreased sensation distal to the fracture site

C Exaggeration of strength with movement

D Purulent drainage at the site of an open fracture

A The client is weak and pale: remained in bed during the visit

B The client’s pain level averages to 10 scale with scheduled opiods

C The cent’s is unchanged sinceb the previous visir

D the clients itching is less with diphenthydramine

29. The nurse received each of these orders for the client with a pelvic fracture . Which order should the nurse implement first?

-Get the client’s pelvic CT completed

-Draw a blood alcohol level and toxicology screen

-Get a urinalysis and urine culture

-Draw a type & cross match for blood administration

30. While assessing the client with an arm fracture , the nurse notes that the client has finger swelling but no other abnormal findings . Which is the nurse’s priority action ?

-Document the degree of finger swelling

-Elevate the casted arm on pillows Split the cast open to relieve pressure

-Notify the provider immediately.

31. The nurse is assessing a client who has ascites from liver disease. Which assessment is most reliable when determining fluid retention in this client?

Measuring the client’s daily weight output of

The family’s report of dietary intake

The client’s report of intake

32. The rhythm on the monitor triggers an alarm and the nurse needs to respond to the alarm. Seeing this rhythm, the nurse needs to: m Ask the client if they want to ambulate with the nursing assistant Check the client determine pulselessness , call a code start CPR Call the provider and request an order for a beta blocker to slow the HR Silence the cardiac alarm give handoff report and go to lunch

33. An end- of-life client receiving home hospice care states he no longer wants to eat . The nurse should perform which action ?

-Ask the client’s family to bring the client’s favorite foods

-Accept the client’s decision & work to keep the client comfortable

-Encourage the client to eat small nutritious meals

-Speak with the health care provider about inserting a feeding tube

34. The nurse is assessing a client with a right lower leg cast for a fracture . The chent reports having a pins-and-needles sensation in the toes . What assessment finding should the nurse prioritize?

– Moving toes without discomfort

-Capillary refill time of 3-5 seconds

-Severe pain after medication

-Persistent itching under the cast to this answer

35. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain?

-Approximate time of symptom onset

– Loss of bladder control

-Progression of symptoms

-Other medical conditions

36. The nurse is assigned to a client diagnosed with head and neck cancer who is receiving enteral feedings vía gastrostomy tube (G -tube ). When the nurse is called away to care for another client which task could most appropriately be delegated to the unlicensed assistive person (UAP )?

– Exploring how the client is currently coping with the diagnosis

-Administering a bath and changing bed lineas

-Determining the amount of residual for the tube feeding

-Giving mouth care and assessing the oral cavity changes to this answer

37. A presents to the emergency department (ED) with a stab wound to the right upper abdominal quadrant The client’s vital signs are : blood pressure (BP ) 85/60 (HR) minute (bpm ). The nurse should immediately suspect damage to which organ ?

– Kidney

-Spleen

-Stomach

-Liver

38. A nurse cares for a client with a fractured fibula . Which assessment would alert the nurse to take immediate action ?

-Pain of 4 on a scale of to 10

-Feeling cold while lying in bed

-Swollen extremity at the Injury

-Numbness in the extremity

65. The nurse is planning care for a client who sustained an ankle sprain and has prescribed hydrocodone/acetaminophen (Norco) for the pain. What statement by the client causes the nurse to question the routine plan of care?

-I know that this is an opioid and I need to be careful when taking it

-I can still drink my end of day beer with this medication ”

-“I should rest , ice , and apply compression to the ankle

-“When run out of this medication I do not get a refill , right ?

67 A client with bone cancer receiving chemotherapy has developed bone marrow suppression. Which laboratory results are highest priority for the nurse to assess at this time?

-Calcium level

-Phosphorus level

– White blood cell count

-Prostate -specific antigen

68. The nurse is admitting a client with thermal burns to both arms and anterior trunk . The client asks for a drink of water What is the most appropriate response for the nurse to make ?

– ” Would you like me to order you a meal tray ? I can help you with setting it up ” -” Ill get you a drink as soon as I’m finished . What would you prefer ? ” “

– I can only give you juice to drink , not water Is that ok with you ? ”

-” I’m sorry you cannot drink anything right now , let me moisten your mouth instead “

69 .The experienced nurse observes the new graduate nurse caring for the client in traction to stabilize a femur fracture before surgery Which action by the new graduate nurse indicates a need for more -=Performs pin site cares every 8 hours with chlorhexidine solution according to orders

– Positions the client to keep the client’s feet away from the bottom panel of the bed

-Removes the weights from the ropes to inspect the apparatus for any tears fraying 100 Question

-Checks weight ropes so that they are positioned in the wheel grooves of the pulleys res this answer

70. What is the earliest finding in a client which can indicate increased in intracranial pressure ?

-Change in pupil size and drooling

-Change in blood pressure and heart rate

-Change in hemoglobin and white blood cells

-Change in Level of Consciousness ( LOC ) A Moving to the next question

During the time when a client diagnosed with a terminal illness became comatose health care proxy made decisions about the clients When the client regained consciousness a few days , the nurse whom regarding the client’s ongoing care decisions ?
The nurse is assessing a client who has a hematoma from a motor vehicle crash. Assessment findings include lucid intervals when the client is alert and talking . What priority safely concern should the nurse communicate to the health care team?
Which of the following should be avoided when caring for a client diagnosed with increased intracranial pressure (lCP)
The nurse is caring for a burned client during the resuscitation phase. Which change noticed during assessment is the highest priority? -=The client has generalized edema and cool extremities
The client returned from surgery to place a new internal arteriovenous fistula in the left arm for hemodialysis. Which interventions should the nurse implement? Select all that apply.
- Allopurinol 300mg is ordered twice daily for the client with tumorlysis syndrome . The medication vial contains 500mg 25 the nearest whole number . Enter only the number do not add unit or rate information
- The nurse receives an order for 1500ml D5W over 12 hours . The drop factor is 15 drips / ml . The IV flow rate should be set at_ unit or rate information 31 Question 80 of 100
- Atrial fibrillation Normal sinus rhythm Sinus tachycardia Supraventricular tachycardia
- A client with a medical diagnosis of cirrhosis has been admitted to the medical unit and the nurse is doing an assessment. Which complaint from the client requires immediate follow-up?
- A client had a cast applied to immobilize a right ulnar fracture. Which of the following nursing interventions is most important? –=Check the capillary refill on the client’s fingers after cast application -Tell the client to remove the cast in five days if the cast is dirty -Teach the client that the arm can be dependent to promote blood flow
- The nurse is caring for a client on the oncology unit . Which nursing activity is appropriate to delegate to the unit’s LPN ? —-=Obtaining vital signs
- The nurse is caring for a client who had a stroke. Which nursing intervention does the nurse implement during the first 72 hours to anticipate complications?
- A client received instructions from the nurse about a low -sodium diet Which statement made by the client indicates a lack of understanding about the diet ? “
- A client is admitted with a suspected osteomyelitis infection secondary to an ankle wound. During assessments, the nurse notes that the client’s ankle is painful, redswollenand warm and the wound is draining. The clients temperature is 102.2 ^ 0 * F . Based on the client’s current status, which provider order should the nurse defer until later?
- The nurse is planning care for a client who presented in the Emergency Department with symptoms of stroke.
- The client is admitted to the Burn Center with burns to the head, neck, chestback and left arm. On assessment the nurse initially auscultates wheezes in the lungs. During reassessment, the nurse notes the wheezes are absent and the breath sounds substantially diminished . What is the most appropriate action for the nurse to take next?

– The client

-The client’s friends

-The health care proxy

-The client’s family

-The client is asking to go home and recover there

-The client just had a loss of consciousness in the last 5 minutes

-The client has no recollection of the injury

-The client is complaining about a headache.

-Starting an intravenous line in the arm

-Administering oxygen by high – flow

-Placing the bed in Trendelenburg position

-Place the client in a noisy room for stimuli

-The client’s blood pressure () and heart rate (HR) are at baseline

-The client has urine output of 1 ml/ kg/ hr

-The client started to drool and has audible exhalations

-Palpate for a thrill over the left forearm fistula

-Instruct patient on range of motion exercises to begin as soon as possible -Aspirate blood from the fistula for laboratory specimens

-Tell the Unlicensed Assistance Personal ( UAP ) to take blood pressure ( BP) readings on the right arm

77 The nurse is preparing to teach a client with cirrhosis about their medication list. Which statement by the client changes the teaching plan?

– “I take lactulose my doctor ordered to have 2-3 bowel movements daily “

-I take the water pills that my doctor ordered to remove extra fluid ”

-” take 4000mg of acetaminophen every day for joint pain ” ”

-take metoprolol as ordered by my doctor every day “

78 The unlicensed assistive personnel (UAP ) is taking vital signs on a client on mechanical ventilation . Which of the following findings should the UAP report to the nurse immediately

-Temperatuce of 102.1 degrees * F

-Blood pressure of 152/86

-Heart rate of 82 beats per minute

-Respiratory rate of 26 breaths per minute

-Pants cannot zip up due to enlarged abdomen

-Bloody expectorant with coughing episodes

-Swelling in the feet and lower legs

-Yellowing of the eyes and mucous membranes

– Check the cast to ensure that it’s tight enough on the arm

– Administration of intravenous (IV) chemotherapy agents –=Administration of blood

-Administration of intravenous () pain medication

– Position with the head of the bed flat to enhance cerebral perfusion -Cluster nursing procedures together to avoid fatiguing the client —–0-Assess neurologic and vital signs closely to identify early changes in status

-Administer prescribed analgesics to promote pain relief

-I’ll still enjoy eating takeout food”

– I will miss eating tomatoes”

-“I’ll avoid potato chips and cheese”

“I will miss eating celery and carrots

-Teach the client about antibiotic administration

– Administer ceftriaxone intravenously (IV ) Q12 hrs

– Apply splint to immobilize the ankle

-Obtain a culture of the ankle wound

What information is essential for the nurse to obtain from the dient or family about the occurrence of the stroke?

If the client is incontinent of urine

-How long ago did the client appear ‘normal ‘ or well

– If the client is taking any antibiotic medications

– If the client ate an evening meal last night

-Anticipate the need for endotracheal intubation & notify the provider -Document the results & continue to assess the patient’s condition —Place the client in high Fowler’s position

-Encourage the client to cough & reassess the lung sounds

The nurse is assessing a client who needs to have an endotracheal (ET) tube placed to protect their airway as a result of an airway burn Which priority safety concern should the nurse communicate to the health care team?

-The client needs a diuretic administered before sedation and intubation

– The client needs an antibiotic administered over minutes before Intubation

– Before intubation, the client needs sedation medication before receiving paralytic medications

-The client is receiving fluids for resuscitation and needs to have output assessed

After a accident the nurse to the injured , Basic upon the triage protocol, which individual should be seen first?
The nurse admitted a client to the surgical unit who had an open reduction internal fixation (ORI of severely fractured right ursing care would be appropriate for the licensed assistive personnel (UAP)? Select all that apply

25 year – old with an abrasion to left eye and swollen an who to bear – old client chest pains b. 80- years old client with chest pains and shortness of breath