CS 3 Multiple Clients on a Medical- Surgical Unit Flashcards
The RN is the leader of a team providing care for six clients. The team includes the RN,
an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP)
who is in his fourth week of orientation to the acute care unit. The clients are as
follows:
• Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching
for a cardiac catheterization scheduled this morning
• Ms. J, a 45-year-old woman who had chest pain during the night and is now
experiencing chest pain. She is scheduled for a graded exercise test later today
• Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago
• Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction,
and mild dementia
• Mr. B, a 93-year-old newly admitted man from a long-term care facility, with
decreased urine output, altered level of consciousness, and an elevated temperature of
99.5°F (37.5°C)
• Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema
During shift change report, the night RN informs the team that Ms. S is to be
transferred back to her long-term care facility after lunch. What action should
be taken for this client?
1. Instruct the UAP to awaken her for vital signs and breakfast.
2. Allow her to sleep for an hour or two while the other clients are assessed.
3. Assign the LPN/LVN to immediately pack up the client’s belongings.
4. Call the nursing home to find out if the transfer can wait until tomorrow.
Ans: 2 Because Ms. S is not scheduled to be transferred until after lunch, it is
not urgent to get her ready at this time. Allowing her to rest while the staff
takes care of other clients whose needs are more urgent is acceptable. The RN
could instruct the UAP to keep the client’s breakfast tray and warm it up
when she is ready to eat. Focus: Prioritization, Supervision.
The RN is the leader of a team providing care for six clients. The team includes the RN,
an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP)
who is in his fourth week of orientation to the acute care unit. The clients are as
follows:
• Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching
for a cardiac catheterization scheduled this morning
• Ms. J, a 45-year-old woman who had chest pain during the night and is now
experiencing chest pain. She is scheduled for a graded exercise test later today
• Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago
• Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction,
and mild dementia
• Mr. B, a 93-year-old newly admitted man from a long-term care facility, with
decreased urine output, altered level of consciousness, and an elevated temperature of
99.5°F (37.5°C)
• Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema
Which clients should the team leader assign to the LPN/LVN for nursing care, under the RN's supervision? Select all that apply. 1. Mr. C 2. Ms. J 3. Mr. R 4. Ms. S 5. Mr. B 6. Mr. L
Ans: 1, 3, 4, 6 It is important to recognize that the RN continues to be
accountable for the care of all clients by this team. Appropriate client
assignments for the LPN/LVN include clients whose conditions are stable
and not complex. Ms. J is currently experiencing chest pain, and Mr. B is a
complex new admission. Focus: Assignment, Supervision.
The RN is the leader of a team providing care for six clients. The team includes the RN,
an experienced LPN/LVN, and a newly educated unlicensed assistive personnel (UAP)
who is in his fourth week of orientation to the acute care unit. The clients are as
follows:
• Mr. C, a 68-year-old man with unstable angina who needs reinforcement of teaching
for a cardiac catheterization scheduled this morning
• Ms. J, a 45-year-old woman who had chest pain during the night and is now
experiencing chest pain. She is scheduled for a graded exercise test later today
• Mr. R, a 75-year-old man who had a left-hemisphere stroke 4 days ago
• Ms. S, an 83-year-old woman with heart disease, a history of myocardial infarction,
and mild dementia
• Mr. B, a 93-year-old newly admitted man from a long-term care facility, with
decreased urine output, altered level of consciousness, and an elevated temperature of
99.5°F (37.5°C)
• Mr. L, a 59-year-old man with mild shortness of breath and chronic emphysema
Which client should the RN assess first?
- Mr. C
- Ms. J
- Mr. B
- Mr. L
Ans: 2 Although it is important that the nurse see all of these clients, Ms. J’s
assessment takes priority. Her chest pain may indicate coronary artery
blockage and acute heart attack. None of the other clients’ needs is life
threatening. Focus: Prioritization; Test Taking Tip: A question like this asks
the nurse to prioritize in order to make a decision about which client most
urgently needs to be evaluated. The client is having chest pain, and the risk is
life threatening for coronary artery blockage and heart attack.
The RN is assessing Ms. J’s chest pain. Which questions would the RN be sure
to ask the client? Select all that apply.
1. “When did you first notice the chest pain?”
2. “Did your pain start suddenly or gradually?”
3. “How long has the chest pain lasted?”
4. “Have you experienced confusion or loss of memory with the pain?”
5. “Can you grade your pain on a scale of 1 to 10, with 10 being the worst pain
ever?”
6. “What were you doing when the chest pain started?”
Ans: 1, 2, 3, 5, 6 The RN should thoroughly evaluate the nature of the client’s
pain. Asking the client when the pain started focuses on the onset. Asking if
the pain was sudden or slow in onset deals with the manner of onset. Asking
how long the pain has lasted speaks to duration of symptoms. Having the
client grade the pain on a scale of 1 to 10 evaluates the intensity. Asking what
the client what he or she was doing when the pain started helps delineate
factors that can lead to pain onset. Clients do not usually experience
confusion or memory loss with cardiac pain. Focus: Prioritization.
The health care provider’s (HCP’s) prescribed actions for Ms. J, who is
currently experiencing chest pain, are as follows. Which intervention should
be completed first?
1. Administer nitroglycerin 0.6 mg sublingually as needed for chest pain.
2. Administer morphine 2 mg IV push as needed for chest pain.
3. Check blood pressure and heart rate.
4. Lab tests to include cardiac markers and daily electrocardiogram.
Ans: 3 When the client experiences chest pain, vital signs should be checked
immediately to establish a baseline. Nitroglycerin is usually tried every 5
minutes for three doses before morphine to relieve the chest pain.
Hypotension is a side effect of nitroglycerin. Blood pressure and heart rate
are monitored after each dose of nitroglycerin is administered. When
nitroglycerin fails to relieve chest pain, IV morphine is the next action, and
the HCP should be notified. Focus: Prioritization; Test Taking Tip: This
question asks the nurse to apply knowledge about common side effects of
medications. Checking blood pressure and heart rate is essential when
evaluating a client for the common side effect of nitroglycerin, which is
hypotension.
Which tasks should the nurse delegate to the newly hired UAP? Select all
that apply.
1. Asking Ms. S memory-testing questions
2. Teaching Ms. J about treadmill exercise testing
3. Checking vital signs on all six clients
4. Recording oral intake and urine output for Mr. B
5. Assisting Mr. L to walk to the bathroom
6. Helping Mr. R with morning care
Ans: 3, 4, 5, 6 Assessment and teaching are more appropriate to the
educational preparation of licensed nursing staff. Checking vital signs,
monitoring and recording intake and output, assisting clients to the
bathroom, and helping clients with morning care are all within the educational scope of the UAP. Focus: Delegation, Supervision.
Which key point would the nurse be sure to include when teaching Mr. C
about the postprocedure care for cardiac catheterization?
1. “There are no restrictions after the procedure.”
2. “You will be able to get out of bed within 2 hours after the procedure.”
3. “You will have to stay almost flat in bed with limited position changes for 4
to 6 hours.”
4. “Family visitors will be restricted until the next day.”
Ans: 3 Cardiac catheterization is usually accomplished by inserting a large-
bore needle into the femoral vein or artery (or both). Clients are routinely
restricted to bed rest, with the affected extremity kept straight, for 4 to 6
hours after the procedure to prevent hemorrhage. Family members are
usually permitted to visit as soon as the client returns to the room. Focus:
Prioritization.
The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT).
What is the nurse’s best action?
1. Instruct the UAP to put the client in a wheelchair and take her to the lab.
2. Call the cardiac lab and ask to delay the test until later in the day.
3. Contact the HCP to ask if the client should still have the GXT.
4. Ask the client if she is continuing to have chest pain.
Ans: 3 The client had chest pain during the night and this morning. She may
be experiencing acute coronary syndrome, a term used to describe clients
who have either unstable angina or an acute myocardial infarction. In this
situation, the best action by the RN is to contact the HCP and ask if the
client’s GXT should be cancelled. Sending her to take the GXT would increase
the risk of cardiac damage and should not be done. Asking if the client is still
having chest pain is important and may reinforce the need to cancel the test.
Focus: Prioritization.
The UAP is delegated the task of measuring morning vital signs for all six
clients. Which finding would the nurse instruct the UAP to report
immediately?
1. Oral temperature higher than 102°F (38.9°C)
2. Blood pressure higher than 140/80 mm Hg
3. Heart rate lower than 65 beats/min
4. Respiratory rate lower than 18 breaths/min
Ans: 1 A temperature elevation to 102°F (38.9°C) is likely an indicator of an
infectious process. The other criterion parameters are near normal, and
assessment or evaluation would instead be based on abnormalities from each
client’s baseline. Focus: Delegation, Supervision.
The UAP asks the RN why it is important to notify someone whenever a
client with heart problems reports chest pain. What is the RN’s best
response?
1. “It’s important to keep track of the chest pain episodes so we can notify the
health care provider.”
2. “The client may need morphine to treat the chest pain.”
3. “Chest pain may indicate coronary artery blockage and heart muscle
damage that will need treatment.”
4. “Our unit policy includes specific steps to take in the treatment of clients
with chest pain.”
Ans: 3 Acute chest pain can indicate myocardial ischemia, coronary artery
blockage, or myocardial damage. The UAP’s question should be answered
with the most accurate response. Although the unit may have protocols that
the UAP should be familiar with, option 4 is not the most accurate response.
Focus: Prioritization, Supervision.
The HCP’s prescribed interventions for Mr. R, who had a stroke 4 days ago,
include assisting the client with meals. Which staff member would be best to
assign this task?
1. Physical therapist
2. UAP
3. LPN/LVN
4. Occupational therapist
Ans: 2 Assisting clients with activities of daily living such as feeding is most
appropriate to the scope of practice of the UAP. The RN would be sure to
instruct the UAP to avoid rushing the client and to report any difficulty with
swallowing. Focus: Delegation, Supervision.
The LPN/LVN reports to the RN that Mr. R was unable to take his oral
medications because of difficulty swallowing. The RN assesses Mr. R and
finds that he is having dysphagia. What is the RN’s best instruction for the
LPN/LVN?
1. “Keep Mr. R NPO, and I will contact his health care provider.”
2. “Try giving his medications with applesauce or pudding.”
3. “Check with the pharmacy to find out if they have liquid forms of Mr. R’s
medications.”
4. “Assess Mr. R’s ability to speak and move his tongue.”
Ans: 1 The client who has difficulty chewing or swallowing foods and
liquids (dysphagia) is at risk for aspiration pneumonia. At this time, the best
action is to keep the client NPO and contact the HCP. Attempting to give him
oral foods, drugs, or fluids increases his risk for aspiration. Assessing his
speech and tongue movement is important but not as urgent as keeping him
NPO. The client likely will require screening or use of an evidence-based
bedside swallowing screening tool to determine if dysphagia is present. A
referral to a speech-language pathologist for a swallowing evaluation per
stroke protocol is needed. If dysphagia is present, develop a collaborative
plan of care to prevent aspiration and support nutrition and prevent
constipation or dehydration. Focus: Prioritization.
The UAP reports to the RN that Mr. L, the client with chronic emphysema,
says he is feeling short of breath after walking to the bathroom. What action
should the RN take first?
1. Notify the HCP.
2. Increase oxygen flow to 6 L/min via nasal cannula.
3. Assess oxygen saturation by pulse oximetry.
4. Remind the client to cough and deep-breathe.
Ans: 3 The nurse should gather more information before notifying the HCP.
Pulse oximetry assessment provides information about the client’s gas
exchange and oxygenation status. Clients with chronic obstructive
pulmonary disease (COPD) usually receive low-dose oxygen (1–3 L) because
466their stimulus for breathing is a low oxygen level. Coughing and deep
breathing help mobilize secretions and can be helpful, but these are not the
first priority. Focus: Prioritization.
The oral temperature of Mr. B, the client newly admitted from a long-term
care facility with decreased urine output and altered level of consciousness, is
now 102.6°F (39.2°C). What is the nurse’s best action?
1. Notify the HCP.
2. Administer acetaminophen 2 tablets orally.
3. Ask the LPN/LVN to give an acetaminophen suppository.
4. Remove extra blankets from the client’s bed.
Ans: 1 This client’s temperature elevation is most likely caused by an
infection. The HCP must be notified to modify the client’s plan of care.
Administering acetaminophen and removing extra blankets may decrease the
client’s temperature, but they will not treat the infection. Focus: Prioritization.
Which factor does the nurse suspect most likely precipitated Mr. B's elevated temperature? 1. Bladder infection 2. Increased metabolic rate 3. Kidney failure 4. Nosocomial pneumonia
Ans: 1 The client’s temperature elevation indicates an infectious process. For
older adult clients, changes in level of consciousness are frequently an early
sign of bladder or urinary tract infections. Focus: Prioritization.
