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1 · Management of Care
The nurse receives handoff report on four clients on a surgical unit. Which client should the nurse assess first?
Answer and option-by-option rationales
C
A. A client with chronic obstructive pulmonary disease whose oxygen saturation is 90% on oxygen at 2 L/min by nasal cannula
A saturation of 90% can be within the stated COPD oxygen target and is not the newly threatened airway.
B. A client who had an open colectomy 2 days ago, rates incisional pain 6 on a 0-to-10 scale, and is due for an oral analgesic in 30 minutes
Postoperative pain needs care but does not outrank the evolving airway threat.
C. A client who had a total thyroidectomy 6 hours ago and reports that the neck dressing feels tight and that swallowing is getting harder
Neck tightness and worsening swallowing after thyroidectomy suggest a compressive hematoma.
D. A client with type 2 diabetes whose fasting capillary blood glucose is 188 mg/dL
Moderate hyperglycemia does not outrank the acute airway concern.
A client is 3 days postoperative after an open bowel resection and is in stable condition. Which tasks can the registered nurse (RN) delegate to assistive personnel (AP)? Select all that apply.
Answer and option-by-option rationales
A, C, E
A. Measuring and recording the client's oral intake and urine output
Routine measured intake and output can be assigned to trained personnel for a stable client.
B. Teaching the client how to splint the incision when coughing
Initial teaching requires nursing judgment.
C. Assisting the client to walk in the hallway
Routine assisted ambulation can be assigned after assessment and competence verification.
D. Evaluating the client's pain relief 30 minutes after an IV opioid dose
Evaluating an opioid response requires nursing judgment.
E. Obtaining and recording the client's vital signs
Routine vital sign collection can be assigned with reporting parameters.
The nurse is about to witness a client's signature on the consent form for a laparoscopic cholecystectomy. The client says, "The surgeon said something about maybe needing a bigger cut, but I don't really understand why." Which action should the nurse take?
Answer and option-by-option rationales
A
A. Notify the surgeon that the client needs more information before signing.
The surgeon should clarify the unresolved procedure-specific question before consent.
B. Explain to the client why a surgeon may need to convert to an open incision.
The nurse should not replace the surgeon's required disclosure.
C. Witness the signature, because the client has already agreed to have the surgery.
An unresolved material question prevents assuming informed signing.
D. Reassure the client that conversion to an open incision is rarely needed.
Reassurance about frequency does not answer the client's question.
A client with advanced amyotrophic lateral sclerosis has decision-making capacity and has named an adult son as health care agent in a durable power of attorney for health care. The client declines placement of a gastrostomy tube. The son tells the nurse, "I'm the health care agent, so the tube is going in." Which response by the nurse is most appropriate?
Answer and option-by-option rationales
D
A. "As the health care agent, you have the legal authority to make this decision for your parent."
An agent does not override a client who currently has decision-making capacity.
B. "Your parent's refusal needs to be written in an advance directive before it can be honored."
A capable client's informed verbal refusal is valid; it does not need to be written in an advance directive to be honored.
C. "Because you and your parent disagree, the ethics committee will make the final decision."
An ethics consultation supports deliberation but does not automatically replace the client's decision.
D. "Your parent can still make this decision, so the refusal will be respected."
While the client retains capacity, the client's own informed refusal guides care; the agent's authority applies only when capacity is lost.
A client is admitted with diarrhea, and stool testing confirms Clostridioides difficile infection. Which actions should the nurse include in the client's care? Select all that apply.
Answer and option-by-option rationales
A, C, D, F
A. Put on a gown and gloves before entering the client's room.
Gown and gloves support Contact Precautions.
B. Wear a fit-tested N95 respirator during care.
An N95 is not required solely for C. difficile contact transmission.
C. Wash hands with soap and water after caring for the client.
Soap-and-water handwashing is included in the case's C. difficile precautions.
D. Use a dedicated stethoscope and blood pressure cuff for this client.
Dedicated equipment reduces cross-transmission.
E. Place the client in a negative-pressure airborne infection isolation room.
Negative pressure is for airborne isolation rather than C. difficile alone.
F. Clean room surfaces with an EPA-registered sporicidal disinfectant.
An appropriate sporicidal product addresses spores on surfaces.
A client with suspected pulmonary tuberculosis is in an airborne infection isolation room and must be taken to the radiology department. Which action should the nurse take?
Answer and option-by-option rationales
B
A. Have the client wear a fit-tested N95 respirator during transport.
A fitted respirator is not the routine source-control mask required for this transport.
B. Have the client wear a surgical (procedure) mask during transport.
A surgical mask provides source control during necessary transport.
C. Postpone the imaging until the client has received 2 weeks of anti-tuberculosis therapy.
Essential imaging need not always wait two weeks when precautions are arranged.
D. Have the transport staff wear a gown and gloves without respiratory protection.
Gown and gloves do not replace indicated respiratory protection for staff.
A client with delirium who is receiving mechanical ventilation keeps reaching for the endotracheal tube despite less restrictive measures. Soft wrist restraints have been prescribed. Which actions by the nurse are appropriate? Select all that apply.
Answer and option-by-option rationales
A, C, E, F
A. Verify that the prescription specifies the type of restraint and a time limit.
The order must meet restraint type and duration requirements.
B. Tie the restraint straps to the bed's side rails.
Side rails can move and create unsafe restraint tension.
C. Secure the straps to a part of the bed frame that moves with the client, using quick-release ties.
An appropriate bed-frame attachment and quick release support safe application.
D. Ask the provider to write the restraint prescription as needed (PRN) for future agitation.
PRN restraint orders are not an appropriate substitute for current assessment and orders.
E. Check circulation, skin, and comfort of the restrained wrists at regular intervals.
Neurovascular, skin, and comfort checks detect harm.
F. Reassess the client regularly so the restraints can be removed at the earliest possible time.
Frequent reassessment supports the earliest safe removal.
At the start of a shift, a nurse notices that a colleague has slurred speech, an unsteady gait, and the odor of alcohol on the breath while preparing client medications. Which action should the nurse take first?
Answer and option-by-option rationales
A
A. Notify the nursing supervisor immediately about the observed signs.
The supervisor can remove the impaired colleague from client care at once, which is the first priority for client safety.
B. Ask a second nurse to observe the colleague and confirm the findings before reporting.
Seeking confirmation delays removing a possibly impaired nurse from client care; the observed signs are enough to report to the supervisor now.
C. Report the colleague to the board of nursing before taking any other action.
Immediate removal from unsafe care precedes longer reporting processes.
D. Suggest that the colleague go home sick, and offer to cover the assignment.
An informal departure without appropriate handoff and reporting does not ensure safety.
The nurse is teaching the parents of a healthy 2-week-old infant how to reduce the risk of sleep-related infant death. Which instructions should the nurse include? Select all that apply.
Answer and option-by-option rationales
A, C, E
A. Place the infant on the back for every sleep, including naps.
Supine positioning is recommended for routine infant sleep.
B. Place the infant on the side after feedings to prevent choking.
Side sleep is unstable and not the recommended routine position.
C. Use a firm, flat sleep surface that is not inclined.
A firm flat noninclined surface supports safer sleep.
D. Use soft crib bumper pads to protect the infant's head.
Soft bumpers introduce suffocation and entrapment hazards.
E. Keep the infant's crib or bassinet in the parents' room.
Room sharing on a separate infant surface supports safer sleep.
F. Use a weighted sleep sack to help the infant sleep longer.
Weighted sleep products can create hazards and are not recommended.
Eight hours after a vaginal birth, the nurse palpates the client's uterine fundus 2 cm above the umbilicus and displaced to the right. The fundus is firm, and the lochia is moderate rubra. Which action should the nurse take first?
Answer and option-by-option rationales
B
A. Massage the fundus and reassess the amount of lochia.
The fundus is already firm; its elevation and lateral displacement point to a distended bladder, so massage is unnecessary, painful, and does not correct the cause.
B. Assist the client to the bathroom to void, then reassess the fundus.
Helping the client void can correct displacement; reassessment verifies response.
C. Notify the provider that the client may be having a postpartum hemorrhage.
The stated findings do not establish hemorrhage as the immediate explanation.
D. Increase the rate of the prescribed oxytocin infusion to firm the uterus.
Increasing oxytocin does not address the likely full bladder and requires an authorized plan.
The nurse is providing anticipatory guidance to the parent of a 7-month-old infant who has no eczema or food allergies and has started eating solid foods. Which statement by the parent indicates a NEED FOR FURTHER TEACHING?
Answer and option-by-option rationales
C
A. "I will wait until after the first birthday to give cow's milk as a drink."
Cow's milk as the main drink is delayed until after infancy.
B. "I will offer peanut-containing foods in a safe form, such as peanut butter thinned with water."
Peanut can be introduced in a developmentally safe form according to the feeding plan.
C. "I can mix a little honey into the cereal to help my baby accept it."
Honey before twelve months carries infant botulism risk and needs correction.
D. "I will not give whole grapes or whole nuts."
Avoiding whole grapes and nuts reduces choking risk.
The nurse is caring for a client who is hospitalized for major depressive disorder. Which findings should the nurse recognize as warning signs that require an immediate suicide risk assessment? Select all that apply.
Answer and option-by-option rationales
A, C, D, F
A. The client gives a favorite watch to a roommate.
Giving away a valued possession can be a warning sign.
B. The client asks to attend the unit's morning exercise group.
Interest in exercise alone is not a recognized suicide warning sign.
C. The client, who had been withdrawn and tearful, suddenly appears calm and cheerful.
Sudden calm after severe distress can warrant renewed risk assessment.
D. The client says, "Soon none of this will matter anymore."
A statement of finality can suggest suicidal thinking.
E. The client asks what time visiting hours start so a sister can visit.
Planning a supportive visit alone is not a recognized warning sign.
F. Several of the client's tablets are found hidden in a sock in the bedside drawer.
A client who had surgical repair of a hip fracture 2 days ago drinks about 10 alcoholic drinks a day; the last drink was 52 hours ago. The client is now disoriented to place and time, is picking at the air, and says insects are crawling on the walls. Vital signs: T 38.4°C (101.1°F), HR 126/min, BP 176/102 mm Hg, RR 24/min, SpO2 96% on room air; capillary blood glucose is 112 mg/dL. The client is diaphoretic and tremulous. Which prescription should the nurse implement first?
Answer and option-by-option rationales
A
A. Lorazepam 2 mg IV
The prescribed benzodiazepine addresses severe alcohol withdrawal and seizure risk.
B. Haloperidol 5 mg IM
Haloperidol alone does not treat the underlying withdrawal physiology or protect against seizures.
C. Acetaminophen 650 mg orally for fever
An antipyretic does not address the dangerous withdrawal process.
D. Urine drug screen
Testing should not delay treatment of severe withdrawal.
A client who has just learned of a diagnosis of pancreatic cancer tells the nurse, "I did everything right. Why is this happening to me?" Which response by the nurse is most therapeutic?
Answer and option-by-option rationales
C
A. "Many people with this diagnosis do very well, so try to stay positive."
Positivity can bypass the client's distress.
B. "Why do you think that you did everything right to stay healthy?"
A challenging why-question can sound blaming.
C. "This feels very unfair to you. Tell me more about what you're feeling."
Acknowledging unfairness and inviting feelings supports therapeutic exploration.
D. "It is better to focus on your treatment plan than on why this happened."
Redirecting immediately can dismiss the emotional concern.
During a skin assessment of a client who is immobile, the nurse finds an open area over the sacrum with full-thickness skin loss. Subcutaneous fat is visible, and yellow slough covers part of the wound bed, but the depth of the wound can be seen. No bone, tendon, or muscle is visible or palpable. How should the nurse document this wound?
Answer and option-by-option rationales
B
A. Stage 2 pressure injury
Visible adipose indicates deeper loss than Stage 2.
B. Stage 3 pressure injury
Full-thickness skin loss with visible adipose and no exposed deeper structures fits Stage 3.
C. Stage 4 pressure injury
Stage 4 requires exposed or directly palpable deeper structures such as muscle or bone.
D. Unstageable pressure injury
The described base is visible rather than obscured by slough or eschar.
The nurse is caring for an adult client receiving a continuous feeding through a nasogastric tube; tube placement was confirmed by radiograph when the tube was inserted. Which actions are appropriate? Select all that apply.
Answer and option-by-option rationales
A, C, D
A. Keep the head of the bed elevated at least 30 degrees during the feeding.
Head elevation reduces aspiration risk during feeding.
B. Confirm that the tube is still in place by injecting air and listening over the stomach.
Air-bolus auscultation alone does not reliably verify placement.
C. Check the external length marking of the tube at regular intervals and before giving medications.
External length checks can identify migration and support the prescribed verification process.
D. Flush the tube with water before and after each medication.
Appropriate flushing helps maintain patency and separate medications.
E. Crush the client's medications and add them to the formula bag.
Mixing drugs into formula creates compatibility and dosing problems.
F. Mix all of the client's crushed medications together and give them as one dose.
Combining all drugs can cause incompatibility and tube blockage.
A client with advanced dementia who cannot reliably report pain had surgical repair of a hip fracture yesterday. Which approach should the nurse use to assess the client's pain?
Answer and option-by-option rationales
D
A. Ask the client to rate the pain on a 0-to-10 numeric rating scale.
The described client cannot reliably use the numeric self-report scale.
B. Use changes in heart rate and blood pressure as the main indicator of pain.
Vital signs are nonspecific and often unchanged with persistent pain, so they cannot serve as the main pain indicator.
C. Wait for the client to ask for the as-needed analgesic before giving it.
A client with advanced dementia may be unable to request analgesia, so waiting for a verbal request leads to undertreated pain.
D. Observe for pain behaviors using a validated behavioral pain scale.
A validated behavioral tool supports assessment when self-report is unavailable.
A client with a serum potassium level of 3.0 mEq/L has a prescription for potassium chloride 10 mEq in 100 mL to infuse intravenously over 1 hour through a peripheral IV. Which actions should the nurse take? Select all that apply.
Answer and option-by-option rationales
A, C, E
A. Confirm that the client has adequate urine output before starting the infusion.
Renal elimination and adequate urine output are relevant before potassium replacement.
B. Run the infusion by gravity if an infusion pump is not available.
IV potassium requires a controlled rate; a gravity drip can free-flow and cause dangerous hyperkalemia and dysrhythmias.
C. Administer the infusion using an electronic infusion pump.
A pump supports controlled prescribed delivery.
D. Inject the potassium into the client's currently infusing 1-liter bag of IV fluid.
Adding concentrated potassium to a hanging bag risks uneven mixing and error.
E. Monitor the IV site for pain, redness, and swelling during the infusion.
The site needs monitoring for irritation and infiltration.
F. Infuse the potassium through the same IV line as a unit of packed red blood cells that is running.
Blood products should not share an unverified potassium-containing infusion line.
At 0730, the nurse is preparing to give a client with type 1 diabetes the prescribed insulin lispro 6 units subcutaneously with breakfast. The client's capillary blood glucose is 146 mg/dL. The dietary department reports that the breakfast tray will be delayed until 0830. Which action should the nurse take?
Answer and option-by-option rationales
B
A. Give the insulin lispro now so that the dose is given at the scheduled time.
Mealtime rapid-acting insulin without available food increases hypoglycemia risk.
B. Hold the insulin until the tray arrives and the client can eat.
Rapid-acting lispro is timed to the meal, so the dose should be given when food is actually available.
C. Give the insulin now and provide a carbohydrate snack until the tray arrives.
A snack does not match the meal the lispro dose is meant to cover, so hypoglycemia can still occur before or after the delayed meal; the dose should be timed to the meal.
D. Omit this dose and document that the client's meal was delayed.
Automatic omission does not establish an appropriate revised treatment plan.
The nurse is teaching a client who has just been prescribed warfarin for atrial fibrillation. Which statements by the client indicate understanding of the teaching? Select all that apply.
Answer and option-by-option rationales
A, B, D, F
A. "I will keep the amount of green leafy vegetables I eat about the same from week to week."
Consistent vitamin K intake supports stable warfarin effect.
B. "I will use an electric razor and a soft toothbrush."
A soft brush and electric razor reduce avoidable trauma.
C. "I can take ibuprofen when my knees ache."
Ibuprofen can increase bleeding risk and needs clinician review.
D. "I will tell my dentist and other health care providers that I take warfarin."
Other clinicians need to know about anticoagulation before procedures.
E. "If I miss a dose, I will take two doses the next day."
Doubling a missed dose without the prescribed guidance can cause excess anticoagulation.
F. "I will report black, tarry stools or pink or red urine."
Melena and hematuria can indicate bleeding and should be reported.
A client receiving IV hydromorphone after surgery was found difficult to arouse with a respiratory rate of 7/min. After naloxone 0.04 mg IV was given and repeated twice as prescribed, the client is arousable and the respiratory rate is 14/min. Which action is most important for the nurse to take next?
Answer and option-by-option rationales
C
A. Resume the previous hydromorphone dose, because the respiratory rate is now normal.
Restarting the prior opioid without reassessment can reproduce respiratory depression.
B. Give an additional 0.4 mg dose of naloxone to prevent the sedation from returning.
Automatic prophylactic redosing is not a substitute for assessed protocol-based treatment.
C. Monitor sedation level and respiratory rate closely for recurrence.
Naloxone's duration can be shorter than hydromorphone's, so sedation and respiratory depression can recur and must be monitored.
D. Assess the client's pain and request a non-opioid analgesic.
Pain needs reassessment after reversal, but the priority is close monitoring because naloxone can wear off before hydromorphone and respiratory depression can recur.
During a colonoscopy with moderate sedation using IV midazolam and fentanyl, the client's oxygen saturation drops from 97% to 86%. The client is snoring loudly, does not respond to voice, and has a respiratory rate of 8/min. Which action should the nurse take first?
Answer and option-by-option rationales
B
A. Give flumazenil IV as prescribed.
Reversal may be indicated after immediate airway positioning and ventilation assessment.
B. Open the airway with a jaw thrust and stimulate the client.
Opening the airway and stimulating the client address the immediate obstruction or hypoventilation.
C. Apply a nonrebreather mask at 15 L/min and monitor the SpO2 closely.
Higher-concentration oxygen alone does not correct an obstructed airway or inadequate ventilation.
D. Give naloxone IV as prescribed.
Opioid reversal may be needed, but airway positioning and stimulation act immediately and come first.
A client with type 1 diabetes is admitted with diabetic ketoacidosis. Initial results: blood glucose 486 mg/dL, arterial pH 7.15, serum bicarbonate 10 mEq/L, and serum potassium 3.1 mEq/L. A 0.9% sodium chloride IV bolus is infusing. Which prescription should the nurse clarify with the provider before implementing it?
Answer and option-by-option rationales
B
A. Infuse potassium chloride 10 mEq/h IV through an infusion pump.
Potassium replacement is appropriate for the described low potassium under the treatment plan.
B. Start a continuous regular insulin infusion at 0.1 units/kg/h now.
Starting insulin before correcting marked hypokalemia can worsen the potassium deficit.
C. Check the capillary blood glucose level every hour during treatment.
[Case Study 1, Screen 1: 0800 nurses' notes, vital signs, and 0815 laboratory results.] The nurse reviews the client's information. Select the findings that require follow-up. Select all that apply.
Client chart
CLIENT
63-year-old woman. Weight 70 kg.
History: type 2 diabetes (takes metformin), hypertension (takes lisinopril).
Lives with spouse; independent in all activities; baseline fully oriented.
Home blood pressure readings usually about 132/78 mm Hg.
NURSES' NOTES - 0800
Spouse reports the client has been "sleepy and confused" since last night.
Client reports burning on urination for 3 days and has been eating and
drinking very little for 2 days. Oriented to person only. Skin warm and
flushed; mucous membranes dry. Reports right flank pain, 5/10. Lungs clear
bilaterally. Capillary refill 3 seconds. Last voided a small amount of dark
urine early this morning.
VITAL SIGNS - 0800
Temperature 39.0°C (102.2°F)
Heart rate 116/min
Respiratory rate 24/min
Blood pressure 88/50 mm Hg (MAP 63 mm Hg)
SpO2 95% on room air
LABORATORY RESULTS - 0815 Result Reference range
WBC 18,600/mm³ 5,000-10,000/mm³
Bands 14% 0-5%
Lactate 4.1 mmol/L 0.5-2.0 mmol/L
Creatinine 1.9 mg/dL 0.5-1.1 mg/dL
(baseline 1 month ago: 0.9 mg/dL)
BUN 40 mg/dL 7-20 mg/dL
Glucose (random) 238 mg/dL 70-140 mg/dL
Sodium 137 mEq/L 135-145 mEq/L
Potassium 4.6 mEq/L 3.5-5.0 mEq/L
Platelets 172,000/mm³ 150,000-400,000/mm³
Urinalysis: cloudy; nitrite positive; leukocyte esterase positive;
WBC more than 50/hpf
Answer and option-by-option rationales
A, C, D, F
A. Oriented to person only
New disorientation can indicate acute organ dysfunction.
B. Lungs clear bilaterally
Clear lungs do not establish sepsis-related organ dysfunction.
C. Respiratory rate 24/min
Tachypnea is a concerning systemic response in this case.
D. Blood pressure 88/50 mm Hg
Hypotension indicates impaired perfusion.
E. Potassium 4.6 mEq/L
The potassium is within the supplied interval.
F. Lactate 4.1 mmol/L
Elevated lactate supports impaired perfusion or severe illness.
