Question 1: 1
1. The nurse’s first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client’s respiratory distress.
2. The nurse should assess the client’s vital signs, but the first intervention is to help the client breathe.
3. The nurse should contact the paramedics if the client does not improve after being placed in a sitting position, but this is not the nurse’s first intervention.
4. The nurse should auscultate the client’s lungs, but the first intervention is to help the client breathe more easily.
Question 2: 4
1. This blood pressure—148/92—is elevated, but it would not be life threatening for someone diagnosed with hypertension; therefore, the nurse would not contact this client first.
2. A pulse oximeter reading of 93% is low but still within normal limits, and a client with cystic fibrosis, a chronic respiratory condition, would be expected to have a chronically low oxygen level.
This client would not need to be contacted first. 3. The client with CHF would be expected to have edematous feet; this client would not need to be contacted first.
4. The client with chronic atrial fibrillation is at risk for pulmonary emboli, a potentially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first.
Question 3: 1
1. First-dose intravenous antibiotic medications are priority medications and should be administered within 1 to 2 hours of when the order was written. This should be the first medication administered.
2. Antiplatelet medication, aspirin, is not a priority medication.
3. A coronary vasodilator patch, nitroglycerin, is not a priority medication.
4. A statin medication that decreases cholesterol level should be administered in the evening when the enzyme for cholesterol metabolism is at its highest peak.
Question 4: 3
1. If the client is in distress, assessment is not the first intervention if there is an action the nurse can take to relieve the distress. The nurse should administer the nitroglycerin first.
2. Calling for an electrocardiogram and troponin level should be implemented but not before administering the nitroglycerin.
3. Placing nitroglycerin under the client’s tongue may relieve the client’s chest pain and provide oxygen to the heart muscle. This is the nurse’s first intervention.
4. Notification of the HCP can be done after the nurse has stabilized the client.
Question 5: 4
1. The client with pericarditis is expected to have chest pain with inspiration; therefore, this client does not warrant immediate intervention.
2. The client with mitral valve regurgitation is expected to have thready peripheral pulses and cool, clammy extremities. Therefore, this client does not warrant immediate intervention.
3. The client with Marfan syndrome is expected to have a chest that sinks in or sticks out, known as funnel chest or pectus excavatum; therefore, this client does not warrant immediate intervention.
4. Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.
Correct Answer: 3, 1, 4, 2, 5
3. This client may be chilling, indicting a potential rise in temperature. The nurse should assess the client and the temperature to see if interventions should be initiated based on a progression of the septicemia.
1. This client should be assessed to be sure that the client is stable because there was chest pain during the last shift.
4. The nurse should assess the client next because although confusion is expected, the nurse must determine whether any new situation is occurring.
2. This client has a psychosocial need but it must be addressed and steps implemented to resolve the problem.
5. A dressing change can take some time to complete. This is a physiological situation but not a life-threatening one and the nurse should see this client when he/she has time to perform the dressing change.
Question 7: 1
1. The nurse should first determine whether there is a fire or whether someone accidentally or purposefully pulled the fire alarm. Because this is a clinic, not a hospital, the nurse should keep calm and determine the situation before taking action.
2. The nurse should not evacuate clients, visitors, and staff unless there is a real fire.
3. The nurse should assess the situation before contacting the fire department.
4. This is an appropriate intervention, but this is not the first intervention. The nurse should first assess to determine whether there is a fire.
Correct Answer: 1, 4, 3, 2, 5
1. The bleeding must be stopped. The nurse should don unsterile gloves and apply pressure to the bleeding site for a minimum of 5 minutes.
4. When the bleeding has stopped, the client can be assisted back to bed so a thorough assessment of the injuries can be performed.
3. The site should be redressed when possible to protect the wound from infectious organisms.
2. Once the nurse has been able to assess the client and has the client in a safe environment, then the nurse should notify the surgeon.
5. The occurrence should be noted on a report form and the appropriate hospital personnel notified, but this can be done after caring for the client.
Correct Answer: 3, 4, 1, 5, 2
3. The nurse needs to determine if the client is unresponsive prior to taking any action. If the client is unresponsive, then perform compressions.
4. The American Heart Association recommends 30 compressions followed by two breaths.
1. After completing compressions, open the client’s airway to ensure a patent airway.
5. The nurse should then administer two breaths while the client’s nose is pinched.
2. The nurse then must determine whether the client’s heart is pumping by checking the carotid pulse.
Correct Answer: 3, 2, 1, 4, 5
3. The nurse must first assess the drainage in the bag for color, consistency, and amount.
2. After removing the bag, the nurse should assess the site to ensure circulation to the stoma. A pink, moist appearance indicates adequate circulation.
1. The nurse should cleanse the area with a mild soap and water to ensure that the skin is prepared for the adhesive paste.
4. The nurse should then apply adhesive paste to the clean, dry skin.
5. The ostomy drainage bag is attached last.