Title: ASN 210 EXAM #3 (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 6

This exam will cover the following lessons from Week 5 & 6:

Pain
Genetics, Genomic Concepts & RNs
Using Evidence-Based Practice
Emergency & Trauma Nursing
Emergency, Disasters & Preparedness
Managing Shock

This examination is TIMED and you are allotted 2 hours to complete it.
Be sure you are taking this exam on a reliable computer with reliable internet source, if you lose connection you will NOT be allowed to log into the exam again.
Once you start the exam you will need to complete the exam in one setting.
The exam will shut off automatically after the allotted time has elapsed.
This is NOT an open book exam.  This exam contains 75 NCLEX-RN Style Questions and is worth 150 POINTS (15% of your ASN 210 Grade)
No collaboration allowed during this exam or it will be noted as a breach of academic integrity.
You must send a message to the instructor immediately (within 10 minutes) with any technical issues or irregularities related to the exam.

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Q: A medical-surgical nurse asks the nurse researcher, “What is the difference between qualitative and quantitative questions?” How should the nurse researcher respond?
- “Quantitative questions analyze the content of what a person says or does.”
- “Qualitative questions utilize a strict statistical analysis of information.”
- “Quantitative questions identify relationships between measurable concepts.”
- “Qualitative questions ask about associations among defined phenomena.”
A: “Quantitative questions identify relationships between measurable concepts.”
If right: Quantitative questions ask about the relationship between or among defined, measurable phenomena and include statistical analysis of information that is collected to answer a question. Qualitative questions focus on the meanings and interpretations of human phenomena or experiences of people and usually analyze the content of what a person says during an interview or what a researcher observes.
If wrong: Quantitative questions ask about the relationship between or among defined, measurable phenomena and include statistical analysis of information that is collected to answer a question. Qualitative questions focus on the meanings and interpretations of human phenomena or experiences of people and usually analyze the content of what a person says during an interview or what a researcher observes.

Q: A nurse assesses this PICOT question: “In the adult hospitalized client, does a COX-2 inhibitor decrease the risk of gastrointestinal bleeding compared with other NSAIDs?” What is the outcome component in this question?
- Adult hospitalized client
- Cyclooxygenase-2 (COX-2) inhibitor
- Decreased risk of gastrointestinal bleeding
- Other nonsteroidal anti-inflammatory drugs (NSAIDs)
A: Decreased risk of gastrointestinal bleeding
If right: The outcome component of the clinical question specifies the measureable and desired outcomes of the practice innovation. In this question, the decreased risk of gastrointestinal bleeding is the outcome. The population is adult hospitalized clients, the comparison component is NSAIDs, and innovative practice is COX-2 inhibitors.
If wrong: The outcome component of the clinical question specifies the measureable and desired outcomes of the practice innovation. In this question, the decreased risk of gastrointestinal bleeding is the outcome. The population is adult hospitalized clients, the comparison component is NSAIDs, and innovative practice is COX-2 inhibitors.

Q: A nurse identifies clinical practice problems on a cardiac unit. Which question is a background question?
- “How should a client experiencing chest pain be prioritized?”
- “What is the experience of a cardiac catheterization like for middle-aged men?”
- “How are a client’s vital signs affected by anxiety?”
- “What is the best treatment for a myocardial infarction?”
A: “How are a client’s vital signs affected by anxiety?”
If right: A background question asks for a fact. The response of anxiety on vital signs is a background question. A foreground question asks a question of relationship and may be controversial (best treatment). Questions related to a client’s experience and best treatment are foreground questions.
If wrong: A background question asks for a fact. The response of anxiety on vital signs is a background question. A foreground question asks a question of relationship and may be controversial (best treatment). Questions related to a client’s experience and best treatment are foreground questions.

Q: A nurse is developing a clinical question in a PICOT format. What components are included in the question? <b>(Select all that apply.)</b>
- Patient
- Comparison
- Outcome
- Implementation
- Time
A: Comparison; Outcome; Time
If right: The major components of a PICOT question are <u>p</u>opulation, <u>i</u>ntervention, <u>c</u>omparison, and <u>o</u>utcome, with an added <u>t</u>ime component when appropriate.
If wrong: The major components of a PICOT question are <u>p</u>opulation, <u>i</u>ntervention, <u>c</u>omparison, and <u>o</u>utcome, with an added <u>t</u>ime component when appropriate.

Q: A health care provider prescribes genetic testing for a client who has a family history of colorectal cancer. Which action should the nurse take before scheduling the client for the procedure?
- Confirm that informed consent was obtained and placed on the client’s chart.
- Provide genetic counseling to the client and the client’s family members.
- Assess if the client is prepared for the risk of psychological side effects.
- Respect the client’s right not to share the results of the genetic test.
A: Confirm that informed consent was obtained and placed on the client’s chart.
If right: Informed consent is required before genetic testing. The person tested is the one who gives consent. An advanced practice provider should explain the procedure and provide genetic counseling. Although the client should be prepared for the risk of psychological side effects and the client’s rights should be respected, the procedure cannot occur without informed consent.
If wrong: Informed consent is required before genetic testing. The person tested is the one who gives consent. An advanced practice provider should explain the procedure and provide genetic counseling. Although the client should be prepared for the risk of psychological side effects and the client’s rights should be respected, the procedure cannot occur without informed consent.

Q: A nurse cares for a client of Asian descent who is prescribed warfarin (Coumadin). What action should the nurse perform first?
- Schedule an international normalized ratio (INR) test to be completed each day.
- Initiate fall precautions and strict activity limitations.
- Teach the client about bleeding precautions, including frequent checks for any bruising.
- Confirm the prescription starts warfarin at a lower-than-normal dose.
A: Confirm the prescription starts warfarin at a lower-than-normal dose.
If right: Most individuals of Asian heritage have a <i>single nucleotide polymorphism</i> in the <i>CYP2C19</i> gene that results in low activity of the enzyme produced. This mutation greatly reduces the metabolism of warfarin, leading to increased bleeding risks and other serious side effects. Any person of Asian heritage who needs anticoagulation therapy should be started on very low dosages of warfarin and should have his or her INR monitored more frequently. The nurse can always teach about the risk of bleeding and can monitor for any bruising. The priority action is for the nurse to check the prescription and confirm the dose prior to administering the medication. It is not necessary to initiate fall precautions and to limit activity based on the administration of warfarin.
If wrong: Most individuals of Asian heritage have a <i>single nucleotide polymorphism</i> in the <i>CYP2C19</i> gene that results in low activity of the enzyme produced. This mutation greatly reduces the metabolism of warfarin, leading to increased bleeding risks and other serious side effects. Any person of Asian heritage who needs anticoagulation therapy should be started on very low dosages of warfarin and should have his or her INR monitored more frequently. The nurse can always teach about the risk of bleeding and can monitor for any bruising. The priority action is for the nurse to check the prescription and confirm the dose prior to administering the medication. It is not necessary to initiate fall precautions and to limit activity based on the administration of warfarin.

Q: A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?
- “It is required by law that you inform your siblings and children about this result so that they also can be tested and monitored for colon cancer.”
- “It is not necessary to tell your siblings because they are adults, but you should tell your children so that they can be tested before they decide to have children of their own.”
- “It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.”
- “It is your decision to determine with whom, if anyone, you discuss this test result. However, you may be held liable if you withhold this information and a family member gets colon cancer.”
A: “It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.”
If right: This situation represents an ethical dilemma. It is the client’s decision whether to disclose the information. However, the information can affect others in the client’s family. The law does not require the client to tell family members about the results, nor can the client be held liable for not telling them. The nurse may consider it ethically correct for the client to tell family members so that they can take action to prevent the development of cancer, but the nurse must respect the client’s decision.
If wrong: This situation represents an ethical dilemma. It is the client’s decision whether to disclose the information. However, the information can affect others in the client’s family. The law does not require the client to tell family members about the results, nor can the client be held liable for not telling them. The nurse may consider it ethically correct for the client to tell family members so that they can take action to prevent the development of cancer, but the nurse must respect the client’s decision.

Q: A nurse cares for a client who has a specific mutation in the <i>a1AT</i> (alpha<sub>1</sub>-antitrypsin) gene. Which action should the nurse take?
- Teach the client to perform monthly breast self-examinations and schedule an annual mammogram.
- Support the client when she shares test results and encourages family members to be screened for cancer.
- Advise the client to limit exposure to secondhand smoke and other respiratory irritants.
- Obtain a complete health history to identify other genetic problems associated with this gene mutation.
A: Advise the client to limit exposure to secondhand smoke and other respiratory irritants.
If right: The <i>a1AT </i>gene mutation increases risk for developing early-onset emphysema. Clients should be advised to limit exposure to smoke and other respiratory irritants as a means of decreasing environmental influences that may aggravate an early onset of emphysema. This gene mutation does not promote cancer, nor does it occur with other identified genetic problems. The <i>BRCA1 </i>gene mutation gives the client a higher risk for developing breast cancer.
If wrong: The <i>a1AT </i>gene mutation increases risk for developing early-onset emphysema. Clients should be advised to limit exposure to smoke and other respiratory irritants as a means of decreasing environmental influences that may aggravate an early onset of emphysema. This gene mutation does not promote cancer, nor does it occur with other identified genetic problems. The <i>BRCA1 </i>gene mutation gives the client a higher risk for developing breast cancer.

Q: A nurse cares for a client who recently completed genetic testing and received a negative result. The client states, “I feel guilty because so many of my family members are carriers of this disease and I am not.” How should the nurse respond?
- “You are not genetically predisposed for this disease but you could still become ill. Let’s discuss a plan for prevention.”
- “Since many of your family members are carriers, you should undergo further testing to verify the results are accurate.”
- “We usually encourage clients to participate in counseling after receiving test results. Can I arrange this for you?”
- “It is normal to feel this way. I think you should share this news with your family so that they can support you.”
A: “We usually encourage clients to participate in counseling after receiving test results. Can I arrange this for you?”
If right: Clients who have negative genetic test results need counseling and support. Some clients may have an unrealistic view of what a negative result means for their general health. Others may feel guilty that they were “spared” when some family members were not. The client will not be symptomatic if he is not a carrier of the disease. A second round of testing is not recommended, because false-negatives are rare with this type of testing. It is the client’s choice to reveal test results to family members; the nurse should not encourage him to do this.
If wrong: Clients who have negative genetic test results need counseling and support. Some clients may have an unrealistic view of what a negative result means for their general health. Others may feel guilty that they were “spared” when some family members were not. The client will not be symptomatic if he is not a carrier of the disease. A second round of testing is not recommended, because false-negatives are rare with this type of testing. It is the client’s choice to reveal test results to family members; the nurse should not encourage him to do this.

Q: A nurse cares for a client who recently completed genetic testing that revealed that she has a <i>BRCA1 </i>gene mutation. Which actions should the nurse take next? <b>(Select all that apply.)</b>
- Discuss potential risks for other members of her family.
- Assist the client to make a plan for prevention and risk reduction.
- Disclose the information to the medical insurance company.
- Recommend the client complete weekly breast self-examinations.
- Assess the client’s response to the test results.
- Encourage support by sharing the results with family members.
A: Discuss potential risks for other members of her family.; Assist the client to make a plan for prevention and risk reduction.; Assess the client’s response to the test results.
If right: The medical-surgical nurse can assess the client’s response to the test results, discuss potential risks for other family members, encourage genetic counseling, and assist the client to make a plan for prevention, risk reduction, and early detection. For some positive genetic test results, such as having a <i>BRCA1 </i>gene mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client should have a plan for prevention and risk reduction. One form of prevention is early detection. Breast self-examinations may be helpful when performed monthly, but those performed every week may not be useful, especially around the time of menses. A client who tests positive for a <i>BRCA1</i> mutation should have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would never reveal any information about a client to an insurance company or family members without the client’s permission.
If wrong: The medical-surgical nurse can assess the client’s response to the test results, discuss potential risks for other family members, encourage genetic counseling, and assist the client to make a plan for prevention, risk reduction, and early detection. For some positive genetic test results, such as having a <i>BRCA1 </i>gene mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client should have a plan for prevention and risk reduction. One form of prevention is early detection. Breast self-examinations may be helpful when performed monthly, but those performed every week may not be useful, especially around the time of menses. A client who tests positive for a <i>BRCA1</i> mutation should have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would never reveal any information about a client to an insurance company or family members without the client’s permission.

Q: A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is unsure if she wants to participate in genetic testing. What action should the nurse take?
- Provide information about the risks and benefits of genetic testing.
- Empathize with the client and share a personal story about a hereditary disorder.
- Teach the client that early detection can minimize transmission to the fetus.
- Advocate for the client and her baby by encouraging genetic testing.
A: Provide information about the risks and benefits of genetic testing.
If right: Genetic counseling is to be nondirective. The nurse should provide as much information as possible about the risks and benefits but should not influence the client’s decision to test or not test. Once the client has made a decision, the nurse should support the client in that decision. Carrier testing will determine if a client without symptoms has an allele for a recessive disorder that could be transmitted to his or her child. Genetic testing will not minimize transmission of the disorder.
If wrong: Genetic counseling is to be nondirective. The nurse should provide as much information as possible about the risks and benefits but should not influence the client’s decision to test or not test. Once the client has made a decision, the nurse should support the client in that decision. Carrier testing will determine if a client without symptoms has an allele for a recessive disorder that could be transmitted to his or her child. Genetic testing will not minimize transmission of the disorder.

Q: A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client’s health history would lead the nurse to consult with the provider over the choice of medication?
- 25–pack-year smoking history
- Drinking 3 to 5 beers a day
- Previous peptic ulcer
- Taking warfarin (Coumadin)
A: Drinking 3 to 5 beers a day
If right: The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
If wrong: The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

Q: A client is to receive 4 mg morphine sulfate IV push. The pharmacy delivers 5 mg in a 2-mL vial. How much should the nurse administer for one dose? (<i>Record your answer using a decimal rounded to the nearest tenth.</i>) ____ mL
Feedback: 1.6 mL 5x = 8 mL x = 1.6 mL

Q: A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? <b>(Select all that apply.)</b>
- Consult with the prescriber and voice objections.
- Delegate administration of the placebo to another nurse.
- Give the placebo and reassess the client’s pain.
- Notify the nurse manager of the physician’s request.
- Tell the client what the prescriber ordered.
A: Consult with the prescriber and voice objections.; Notify the nurse manager of the physician’s request.
If right: Nurses should never give placebos to treat a client’s pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse should not delegate giving the placebo to someone else, nor should the nurse give it. The nurse should not tell the client unless absolutely necessary (the client asks) as this will undermine the prescriber-client relationship.
If wrong: Nurses should never give placebos to treat a client’s pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse should not delegate giving the placebo to someone else, nor should the nurse give it. The nurse should not tell the client unless absolutely necessary (the client asks) as this will undermine the prescriber-client relationship.

Q: A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the client’s care plan?
- As-needed pain medication after therapy
- Client-controlled analgesia with a basal rate
- Pain medications prior to therapy only
- Round-the-clock analgesia with PRN analgesics
A: Round-the-clock analgesia with PRN analgesics
If right: Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy.
If wrong: Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy.

Q: A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? <b>(Select all that apply.)</b>
- Ask for a physical therapy consult.
- Educate the client on cold therapy.
- Offer to provide a heating pad.
- Repeat the ice application.
- Teach the client relaxation techniques.
A: Educate the client on cold therapy.; Repeat the ice application.; Teach the client relaxation techniques.
If right: Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury.
If wrong: Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury.

Q: A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? <b>(Select all that apply.)</b>
- Addiction is a chronic physiologic disease process.
- Physical dependence and addiction are the same thing.
- Pseudoaddiction can result in withdrawal symptoms.
- Tolerance is a normal response to regular opioid use.
- Tolerance is said to occur when opioid effects decrease.
A: Addiction is a chronic physiologic disease process.; Tolerance is a normal response to regular opioid use.; Tolerance is said to occur when opioid effects decrease.
If right: Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.
If wrong: Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

Q: A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? <b>(Select all that apply.)</b>
- Induction
- Modulation
- Sensory perception
- Transduction
- Transmission
A: Modulation; Sensory perception; Transduction; Transmission
If right: The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.
If wrong: The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

Q: A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?
- Hydrocodone and acetaminophen (Lorcet)
- Hydromorphone (Dilaudid)
- Meperidine (Demerol)
- Tramadol (Ultram)
A: Hydromorphone (Dilaudid)
If right: Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the client’s sertraline. Meperidine is rarely used and is often restricted.
If wrong: Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the client’s sertraline. Meperidine is rarely used and is often restricted.

Q: A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?
- Assess and record the client’s pain every 4 hours.
- Ensure the client is eating a high-fiber diet.
- Monitor the client’s bowel function every shift.
- Remove the old patch when applying the new one.
A: Remove the old patch when applying the new one.
If right: The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.
If wrong: The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.

Q: A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
- “Being able to sleep doesn’t mean pain doesn’t exist.”
- “Have you ever experienced any type of pain?”
- “The client should be assessed for drug addiction.”
- “You’re right; I would put the medication back.”
A: “Being able to sleep doesn’t mean pain doesn’t exist.”
If right: A client’s description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose.
If wrong: A client’s description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the client’s descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client’s report of pain serves no useful purpose.

Q: A nurse is assessing pain in an older adult. What action by the nurse is best?
- Ask only “yes-or-no” questions so the client doesn’t get too tired.
- Give the client a picture of the pain scale and come back later.
- Question the client about new pain only, not normal pain from aging.
- Sit down, ask one question at a time, and allow the client to answer.
A: Sit down, ask one question at a time, and allow the client to answer.
If right: Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.
If wrong: Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.

Q: A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?
- Numeric rating scale
- Verbal Descriptor Scale
- FACES Pain Scale-Revised
- Wong-Baker FACES Pain Scale
A: FACES Pain Scale-Revised
If right: All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.
If wrong: All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.

Q: A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?
- Assess and record vital signs every 2 hours.
- Have another nurse double-check the pump settings.
- Instruct the client to report any unrelieved pain.
- Monitor for numbness and tingling in the legs.
A: Have another nurse double-check the pump settings.
If right: PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.
If wrong: PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.

Q: A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first?
- Client who is crying and agitated
- Client with a heart rate of 104 beats/min
- Client with a Pasero Scale score of 4
- Client with a verbal pain report of 9
A: Client with a Pasero Scale score of 4
If right: The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.
If wrong: The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

Q: A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?
- Bilateral lung crackles
- Hypoactive bowel sounds
- Self-reported pain of 3/10
- Urine output of 20 mL/2 hr
A: Urine output of 20 mL/2 hr
If right: Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the-clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.
If wrong: Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the-clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.

Q: A nurse is preparing to give an infusion of acetaminophen (Ofirmev). The pharmacy delivers a bag containing 50 mL of normal saline and the Ofirmev. At what rate does the nurse set the IV pump to deliver this dose? (<i>Record your answer using a whole number.</i>) ____ mL/hr
Feedback: 200 mL/hr Intravenous acetaminophen (Ofirmev) is approved for treatment of pain and fever in adults and children ages 2 years and older and is given by a 15-minute infusion. To deliver 50 mL in 15 minutes, set the IV pump for 200 mL/hr. To run 50 mL in 60 minutes, the pump would be set for 50 mL/hr. To run this volume in one quarter of the time, divide by 4: 200 ÷ 4 = 50.

Q: A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?
- Client being discharged later on a complicated analgesia regimen
- Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
- Postoperative client who received oral opioid analgesia 45 minutes ago
- Client who has returned from physical therapy and is resting in the recliner
A: Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
If right: Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.
If wrong: Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

Q: A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?
- Client who appears to be sleeping soundly
- Client with no bolus request in 6 hours
- Client who is pressing the button every 10 minutes
- Client with a respiratory rate of 8 breaths/min
A: Client with a respiratory rate of 8 breaths/min
If right: Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client’s pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.
If wrong: Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client’s pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

Q: A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? <b>(Select all that apply.)</b>
- Avoid using other medications that cause sedation.
- Delay giving medication if the client is sleeping.
- Give the lowest dose that produces good control.
- Identify clients at high risk for unwanted sedation.
- Use an oximeter to monitor clients receiving analgesia.
A: Avoid using other medications that cause sedation.; Give the lowest dose that produces good control.; Identify clients at high risk for unwanted sedation.; Use an oximeter to monitor clients receiving analgesia.
If right: Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client’s oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.
If wrong: Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client’s oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

Q: A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
- Assess physiologic indicators and vital signs.
- Do not give pain medication as no pain is indicated.
- Document the findings and continue to monitor.
- Try a small dose of analgesic medication for pain.
A: Assess physiologic indicators and vital signs.
If right: Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.
If wrong: Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.

Q: A nursing student is studying pain sources. Which statements accurately describe different types of pain? <b>(Select all that apply.)</b>
- Neuropathic pain sometimes accompanies amputation.
- Nociceptive pain originates from abnormal pain processing.
- Deep somatic pain is pain arising from bone and connective tissues.
- Somatic pain originates from skin and subcutaneous tissues.
- Visceral pain is often diffuse and poorly localized.
A: Neuropathic pain sometimes accompanies amputation.; Deep somatic pain is pain arising from bone and connective tissues.; Somatic pain originates from skin and subcutaneous tissues.; Visceral pain is often diffuse and poorly localized.
If right: Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.
If wrong: Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

Q: A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? <b>(Select all that apply.)</b>
- Ask the client to point out any areas of numbness or tingling.
- Determine how many people are needed to ambulate the client.
- Perform a bladder scan if the client is unable to void after 4 hours.
- Remind the client to use the incentive spirometer every hour.
- Take and record the client’s vital signs per agency protocol.
A: Perform a bladder scan if the client is unable to void after 4 hours.; Remind the client to use the incentive spirometer every hour.; Take and record the client’s vital signs per agency protocol.
If right: The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.
If wrong: The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

Q: A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?
- Ask the client about pain goals and if they are being met.
- Ask the client why he or she is being uncooperative with therapy.
- Increase the dose of analgesia given prior to therapy sessions.
- Tell the client that physical therapy is required to regain function.
A: Ask the client about pain goals and if they are being met.
If right: A comprehensive pain management plan includes the client’s goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the client’s pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the client’s behavior. Asking the client why he or she is being uncooperative is not the best response for two reasons. First, “why” questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the client that physical therapy is required does not address the issue.
If wrong: A comprehensive pain management plan includes the client’s goals for pain control. Adequate pain control is necessary to allow full participation in therapy. The first thing the nurse should do is to ask about the client’s pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the client’s behavior. Asking the client why he or she is being uncooperative is not the best response for two reasons. First, “why” questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the client that physical therapy is required does not address the issue.

Q: A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?
- Assesses the client’s pain level per agency policy
- Monitors the client’s respiratory rate and sedation
- Presses the button when the client cannot reach it
- Reinforces client teaching about using the PCA pump
A: Presses the button when the client cannot reach it
If right: The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate.
If wrong: The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate.

Q: A student asks the nurse what is the best way to assess a client’s pain. Which response by the nurse is best?
- Numeric pain scale
- Behavioral assessment
- Objective observation
- Client’s self-report
A: Client’s self-report
If right: Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
If wrong: Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

Q: A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?
- “A multimodal approach is the preferred method of control.”
- “Doctors are much more liberal with pain medications now.”
- “Pain is so complex it takes different approaches to control it.”
- “Clients are consumers and they demand lots of pain medicine.”
A: “Pain is so complex it takes different approaches to control it.”
If right: Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences.
If wrong: Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences.

Q: A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? <b>(Select all that apply.)</b>
- Decreased immune response
- Development of chronic pain
- Increased gastrointestinal (GI) motility
- Possible immobility
- Slower healing
A: Decreased immune response; Development of chronic pain; Possible immobility; Slower healing
If right: There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.
If wrong: There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.

Q: A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?
- A 22-year-old with a painful and swollen right wrist
- A 45-year-old reporting chest pain and diaphoresis
- A 60-year-old reporting difficulty swallowing and nausea
- An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
A: A 45-year-old reporting chest pain and diaphoresis
If right: A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
If wrong: A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

Q: A nurse is triaging clients in the emergency department. Which client should be considered “urgent”?
- A 20-year-old female with a chest stab wound and tachycardia
- A 45-year-old homeless man with a skin rash and sore throat
- A 75-year-old female with a cough and a temperature of 102° F
- A 50-year-old male with new-onset confusion and slurred speech
A: A 75-year-old female with a cough and a temperature of 102° F
If right: A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
If wrong: A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

Q: A nurse is triaging clients in the emergency department. Which client should the nurse classify as “nonurgent?”
- A 44-year-old with chest pain and diaphoresis
- A 50-year-old with chest trauma and absent breath sounds
- A 62-year-old with a simple fracture of the left arm
- A 79-year-old with a temperature of 104° F
A: A 62-year-old with a simple fracture of the left arm
If right: A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.
If wrong: A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

Q: A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? <b>(Select all that apply.)</b>
- Provide medical supplies to the family.
- Consult a home health agency.
- Encourage participation in community activities.
- Screen for depression and suicide.
- Complete a functional assessment.
A: Screen for depression and suicide.; Complete a functional assessment.
If right: Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.
If wrong: Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

Q: A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?
- Contact the on-call orthopedic surgeon.
- Don personal protective equipment.
- Notify the Rapid Response Team.
- Obtain a complete history from the paramedic.
A: Don personal protective equipment.
If right: Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in <i>all</i> resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
If wrong: Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in <i>all</i> resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

Q: An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?
- Communicate client needs and restrictions to support staff.
- Prescribe low-cost antibiotics to treat community-acquired infection.
- Provide referrals to subsidized community-based health clinics.
- Offer counseling for substance abuse and mental health disorders.
A: Provide referrals to subsidized community-based health clinics.
If right: Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.
If wrong: Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

Q: An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report?<i> </i><b>(Select all that apply.)</b>
- Mechanism of injury
- Diagnostic test results
- Immunizations
- List of home medications
- Isolation precautions
A: Mechanism of injury; Diagnostic test results; Isolation precautions
If right: Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.
If wrong: Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

Q: An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?
- Remove all tubes and wires in preparation for the medical examiner.
- Limit the number of visitors to minimize the family’s trauma.
- Consult the bereavement committee to follow up with the grieving family.
- Communicate the client’s death to the family in a simple and concrete manner.
A: Communicate the client’s death to the family in a simple and concrete manner.
If right: When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.
If wrong: When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

Q: An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client’s trust?
- Speak in a quiet and monotone voice.
- Avoid eye contact with the client.
- Listen to the client’s concerns and needs.
- Ask security to store the client’s belongings.
A: Listen to the client’s concerns and needs.
If right: To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client’s belongings and personal space.
If wrong: To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client’s belongings and personal space.

Q: An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care?
- Emergency medicine physician
- Case manager
- Forensic nurse examiner
- Psychiatric crisis nurse
A: Forensic nurse examiner
If right: All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
If wrong: All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

Q: A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?
- Provide a calm location for the family to cope and discuss needs.
- Call the hospital chaplain to stay with the family and pray for the deceased.
- Do not allow visiting of the victims until the bodies are prepared.
- Provide privacy for law enforcement to interview the family.
A: Provide a calm location for the family to cope and discuss needs.
If right: The nurse should first provide emotional support by encouraging relaxation, listening to the family’s needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family’s needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family’s needs.
If wrong: The nurse should first provide emotional support by encouraging relaxation, listening to the family’s needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family’s needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family’s needs.

Q: A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? <b>(Select all that apply.)</b>
- Paramedic – Decides the number, acuity, and resource needs of clients
- Hospital incident commander – Assumes overall leadership for implementing the emergency plan
- Public information officer – Provides advanced life support during transportation to the hospital
- Triage officer – Rapidly evaluates each client to determine priorities for treatment
- Medical command physician – Serves as a liaison between the health care facility and the media
A: Hospital incident commander – Assumes overall leadership for implementing the emergency plan; Triage officer – Rapidly evaluates each client to determine priorities for treatment
If right: The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.
If wrong: The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

Q: A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? <b>(Select all that apply.)</b>
- Older adult in the medical decision unit for evaluation of chest pain
- Client who had open reduction and internal fixation of a femur fracture 3 days ago
- Client admitted last night with community-acquired pneumonia
- Infant who has a fever of unknown origin
- Client on the medical unit for wound care
A: Client who had open reduction and internal fixation of a femur fracture 3 days ago; Client on the medical unit for wound care
If right: The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.
If wrong: The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

Q: A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?
- Provide water and healthy snacks for energy throughout the event.
- Schedule 16-hour shifts to allow for greater rest between shifts.
- Encourage counseling upon deactivation of the emergency response plan.
- Assign staff to different roles and units within the medical facility.
A: Provide water and healthy snacks for energy throughout the event.
If right: To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each other’s stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.
If wrong: To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each other’s stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

Q: A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite?
- Ask the client about pruritus at the bite site.
- Inspect the bite site for a bluish purple vesicle.
- Assess the extremity for redness and swelling.
- Monitor the client’s temperature every 4 hours.
A: Monitor the client’s temperature every 4 hours.
If right: Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse’s priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.
If wrong: Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse’s priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

Q: A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first?
- Unilateral peripheral swelling
- Clotting times
- Cardiopulmonary status
- Electrocardiogram rhythm
A: Cardiopulmonary status
If right: Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.
If wrong: Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

Q: A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, “Why are the individuals with black tags not receiving any care?” How should the nurse respond?
- “To do the greatest good for the greatest number of people, it is necessary to sacrifice some.”
- “Not everyone will survive a disaster, so it is best to identify those people early and move on.”
- “In a disaster, extensive resources are not used for one person at the expense of many others.”
- “With black tags, volunteers can identify those who are dying and can give them comfort care.”
A: “In a disaster, extensive resources are not used for one person at the expense of many others.”
If right: In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not “sacrificed.” Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.
If wrong: In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not “sacrificed.” Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

Q: A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, “I can’t believe that my wife is gone and I am left to raise my children all by myself.” How should the nurse respond?
- “Please accept my sympathies for your loss.”
- “I can call the hospital chaplain if you wish.”
- “You sound anxious about being a single parent.”
- “At least your children still have you in their lives.”
A: “You sound anxious about being a single parent.”
If right: Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client’s distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client’s feelings and situation.
If wrong: Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client’s distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client’s feelings and situation.

Q: A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?
- Dislocated right hip and an open fracture of the right lower leg
- Large contusion to the forehead and a bloody nose
- Closed fracture of the right clavicle and arm numbness
- Multiple fractured ribs and shortness of breath
A: Multiple fractured ribs and shortness of breath
If right: Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the “walking wounded” and classified as nonurgent.
If wrong: Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the “walking wounded” and classified as nonurgent.

Q: A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm?<i> </i><b>(Select all that apply.)</b>
- Seek shelter inside a building or vehicle.
- Hide under a tall tree.
- Do not take a bath or shower.
- Turn off the television.
- Remove all body piercings.
- Put down golf clubs or gardening tools.
A: Seek shelter inside a building or vehicle.; Do not take a bath or shower.; Turn off the television.; Put down golf clubs or gardening tools.
If right: When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person’s chances of being struck by lightning.
If wrong: When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person’s chances of being struck by lightning.

Q: A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? <b>(Select all that apply.)</b>
- “Wear synthetic clothing instead of cotton to keep your skin dry.”
- “Drink plenty of fluids. Brandy can be used to keep your body warm.”
- “Remove your hat when exercising to prevent the loss of heat.”
- “Wear sunglasses to protect skin and eyes from harmful rays.”
- “Know your physical limits. Come in out of the cold when limits are reached.”
A: “Wear synthetic clothing instead of cotton to keep your skin dry.”; “Wear sunglasses to protect skin and eyes from harmful rays.”; “Know your physical limits. Come in out of the cold when limits are reached.”
If right: To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.
If wrong: To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.

Q: A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?
- The facility’s neurologist
- The poison control center
- The physical therapy department
- A herpetologist (snake specialist)
A: The poison control center
If right: For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.
If wrong: For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.

Q: A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client’s teaching? <b>(Select all that apply.)</b>
- “Consult an exterminator to control bugs in and around your home.”
- “Do not swat at insects or wasps.”
- “Wear sandals whenever you go outside.”
- “Keep your prescribed epinephrine auto-injector in a bedside drawer.”
- “Use screens in your windows and doors to prevent flying insects from entering.”
A: “Consult an exterminator to control bugs in and around your home.”; “Do not swat at insects or wasps.”; “Use screens in your windows and doors to prevent flying insects from entering.”
If right: To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.
If wrong: To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

Q: A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
- “I can go swimming all by myself because I am a certified lifeguard.”
- “I cannot leave my toddler alone in the bathtub for even a minute.”
- “I will appoint one adult to supervise the pool at all times during a party.”
- “I will make sure that there is a phone near my pool in case of an emergency.”
A: “I can go swimming all by myself because I am a certified lifeguard.”
If right: People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.
If wrong: People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

Q: A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? <b>(Select all that apply.)</b>
- A 35-year-old female with severe chest pain: red tag
- A 42-year-old male with full-thickness body burns: green tag
- A 55-year-old female with a scalp laceration: black tag
- A 60-year-old male with an open fracture with distal pulses: yellow tag
- An 88-year-old male with shortness of breath and chest bruises: green tag
A: A 35-year-old female with severe chest pain: red tag; A 60-year-old male with an open fracture with distal pulses: yellow tag
If right: Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.
If wrong: Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.

Q: A nurse caring for a client notes the following assessments: white blood cell count 3800/mm<sup>3</sup>, blood glucose level 198 mg/dL, and temperature 96.2° F (35.6° C). What action by the nurse takes priority?
- Document the findings in the client’s chart.
- Give the client warmed blankets for comfort.
- Notify the health care provider immediately.
- Prepare to administer insulin per sliding scale.
A: Notify the health care provider immediately.
If right: This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.
If wrong: This client has several indicators of sepsis with systemic inflammatory response. The nurse should notify the health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may or may not need insulin.

Q: A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately?
- Blood pressure of 98/68 mm Hg
- Pedal pulses 1+/4+ bilaterally
- Report of chest heaviness
- Urine output of 32 mL/hr
A: Report of chest heaviness
If right: Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client’s previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.
If wrong: Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client’s previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

Q: A client in shock is apprehensive and slightly confused. What action by the nurse is best?
- Offer to remain with the client for awhile.
- Prepare to administer antianxiety medication.
- Raise all four siderails on the client’s bed.
- Tell the client everything possible is being done.
A: Offer to remain with the client for awhile.
If right: The nurse’s presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client’s blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client’s safety. Telling a confused client that everything is being done is not the most helpful response.
If wrong: The nurse’s presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client’s blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client’s safety. Telling a confused client that everything is being done is not the most helpful response.

Q: A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client’s sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?
- “All my friends and neighbors are planning a party for me.”
- “I hope I can get my water turned back on when I get home.”
- “I am going to have my daughter scoop the cat litter box.”
- “My grandkids are so excited to have me coming home!”
A: “I hope I can get my water turned back on when I get home.”
If right: All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.
If wrong: All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

Q: A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
- “High glucose is common in shock and needs to be treated.”
- “Some of the medications we are giving are to raise blood sugar.”
- “The IV solution has lots of glucose, which raises blood sugar.”
- “The stress of this illness has made your spouse a diabetic.”
A: “High glucose is common in shock and needs to be treated.”
If right: High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not “made” the client diabetic.
If wrong: High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not “made” the client diabetic.

Q: A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? <b>(Select all that apply.)</b>
- Bringing the client warm blankets
- Giving the client hot tea to drink
- Massaging the client’s painful legs
- Reorienting the client as needed
- Sitting with the client for reassurance
A: Bringing the client warm blankets; Reorienting the client as needed; Sitting with the client for reassurance
If right: The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.
If wrong: The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

Q: A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
- Alert and oriented, answering questions
- Client denial of chest pain or chest pressure
- IV site without redness or swelling
- Urine output of 30 mL/hr for 2 hours
A: Alert and oriented, answering questions
If right: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.
If wrong: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

Q: A client with severe sepsis has a serum lactate level of 6.2 mmol/L. The client weighs 250 pounds. To infuse the amount of fluid this client requires in 24 hours, at what rate does the nurse set the IV pump? (<i>Record your answer using a whole number.</i>)<i> </i>____ mL/hr
Feedback: 142 mL/hr The client weighs 250 pounds = 113.63636 kg. The fluid requirement for this client is 30 mL/kg = 3409 mL. To infuse this amount over 24 hours, set the pump at 142 mL/hr (3409/24 = 142).

Q: A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
- Assess the client for pain or discomfort.
- Measure urine output from the catheter.
- Reposition the client to the unaffected side.
- Stay with the client and reassure him or her.
A: Measure urine output from the catheter.
If right: Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.
If wrong: Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

Q: A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
- Ask if the client needs pain medication.
- Assess the client’s tissue perfusion further.
- Document the findings in the client’s chart.
- Increase the rate of the client’s IV infusion.
A: Assess the client’s tissue perfusion further.
If right: Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.
If wrong: Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.

Q: A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
- Creatinine: 0.9 mg/dL
- Lactate: 6 mmol/L
- Sodium: 150 mEq/L
- White blood cell count: 11,000/mm<sup>3</sup>
A: Lactate: 6 mmol/L
If right: A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm<sup>3</sup> is slightly high but is not as critical as the lactate level.
If wrong: A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm<sup>3</sup> is slightly high but is not as critical as the lactate level.

Q: A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
- Do not get dehydrated in warm weather.
- Drink fluids on a regular schedule.
- Seek attention for any lacerations.
- Take medications as prescribed.
A: Drink fluids on a regular schedule.
If right: Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.
If wrong: Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.