1. Mrs.

Thomas diagnosed with dementia, is an 85-year-old newly admitted resident of a longterm care facility who has started to wake up in the middle of the night and wander the unit. What is the most appropriate action for the nurse to take? a)Accompany the resident during her walks to ensure safety b)Develop a night walking program for the resident c) Escort resident back to bed and raise the side rails to ensure safety d) Ensure residents safety and perform an assessment Correct answer: d) a)Not an adequate intervention as assessment is the priority after ensuring the resident is safe. b)This may be appropriate only after assessing the causes of the residents wandering as nurses need to continually assess changes in the residents behaviour. cThis is not the most appropriate intervention as raising the side rails is a form of a physical restraint. Physical restraints require a doctors order and consultation with the resident and with the residents family or power of attorney (for incompetent residents) and can be used only after assessment of the residents condition has found that the resident is at risk of falling (Sollins, 2009). Restraints should only be used when all other interventions have been unsuccessful. d)Initially, need to ensure resident remains safe and then perform a comprehensive assessment as wandering (a symptom of dementia) may be the residents way of communicating environmental irritants, physical discomforts or psychological distress (Nowicki, Fulbrook, & Burns, 2010; Reed & Tilly, 2008). 2. Anna, 22 years old, was admitted to the unit with pneumonia. She is on 2L of oxygen via nasal prongs. Catherine, Annas mother, came out and stated: Anna is having difficulty breathing. The nurse notes that patient is diaphoretic, short of breath, restless, and disorientated. Her vitals are 36.2C, 103 b/min, 28 breaths/min, 122/88 mmHg, and 83% in a semi-Flowers position. What would be the nurses initial action? a) Reposition the patient and reassess vital signs. b) Administer high flow oxygen via nonrebreather mask. c) Initiate positive pressure ventilation via an endotracheal tube. d) Notify physician and respiratory therapist immediately.

Answer: B a) Vital signs and repositioning the client are important to assess clients current status and promote maximal chest expansion. However, at this time her oxygen saturation takes priority. b) ABCs is a primary initiative for patients that become critical. In this case, breathing was affected which results in hypoxia. Common compensation responses to respiratory distress are tachycardia, tachypnea, and a change in behavioral and mental status due to inadequate oxygen supply. As oxygen demands increase, a nonrebreather mask maintains a higher (up to 100 percent) oxygen concentration supply in the reservoir bag that can be delivered to the patient compared to nasal prongs, which delivers 22%-44% oxygen. Therefore, one major goal for respiratory distress is to maintain adequate oxygenation. c) PPV is another intervention that is usually initiated in collaboration with the respiratory therapist when the patient is unresponsive to high oxygen concentrations. d) Notifying the physician and the respiratory therapist is important, yet the nurse must supply 100 percent oxygen as an initial response to prevent a possible respiratory arrest. 3. Nurse Edith on entering Mr Bs room noticed that Mr. B is feeling congested. On exploring further, Mr B admits that he used to smoke 10 to 20 cigarettes per day. He stated that any time he coughs there is no secretion. What intervention should the nurse implement first in this situation? A. B. C. D. Initiate deep-breathing and coughing exercise Suction the patient gently Auscultate the patients lungs Perform percussion and postural drainage.

Rationale: The correct answer is C A. Deep-breathing and coughing exercise will enhance lung expansion but is not the first intervention for Mr. B. B Assessment of the lungs determines whether suctioning is required C.Assessing the patient first is very important to determine the right intervention. Auscultation of the lungs is appropriate at this time. D.Percussion and postural drainage is not the right intervention at this time 4. Henry, 12 years old, has arrived on the unit following a surgical procedure to correct a left femoral fracture. An hour following the onset of administration of pain medication, the patient indicates increasing levels of pain that are progressively unrelieved and rated 10/10 on the pain

scale. He also indicates loss of sensation to his toes. What should be the nurses primary intervention? A) In recognition that this level of pain is appropriate with a femoral fracture, the nurse should administer additional pain medication according to physicians orders and continue to monitor and re-assess his pain. B)Check vital signs to observe for changes in client condition. C) Perform a neurovascular assessment of the affected limb and immediately contact the physician regarding significant findings. D)Document findings and enhance client comfort by repositioning the affected limb, performing cast care and utilizing distraction techniques. Correct Answer: C A) This level of pain that is progressively unrelieved is not normal. Increasing the pain medication does not seek to explore the etiology responsible for the pain. B) Regular vital assessments will already be scheduled. This is not a priority over performing an initial neurovascular assessment. C) The nurse needs to assess the patients risk for developing compartment syndrome a medical emergency. D) This is not a priority over performing an initial neurovascular assessment 5. Katie is a 9 year-old patient who has cerebral palsy. She recently underwent lower-extremity orthopedic surgery to lengthen muscles and tendons in order to alleviate contractures that have caused movement problems. She was assigned to your care in the post-surgical unit at 1430h. It is now 1900h and she has not yet voided. She has not expressed a need to void and palpation of her bladder reveals no distention. Based on her calculated bladder volume and estimated time to void (4.5 hours), Katie was ordered to have a bladder scan. The scan revealed that her bladder was at 75% of the predicted bladder capacity. As Katies nurse, you are aware of the postoperative risk for urinary retention. Which of the following would not be the best nursing intervention to encourage spontaneous voiding and prevent complications or injury?

A)Calculating her maintenance intravenous fluid when she arrives on the unit. B)Utilize intermittent catheterization to prevent urinary retention.

C)Let Katie know it is time for her to void, altering her position in bed to promote use of a bedpan, and running water. D) Recognize that since Katie needs large amounts of morphine for pain control, frequent nursing assessment of urinary status following the bladder scan is necessary. Correct Answer: B A)Calculating appropriate fluid maintenance will prevent dehydration, and subsequent decreases in urinary output, and ensure that bladder volume is not increased beyond predicted capacity. This could result in increased incidence of bladder stretch injury and urinary retention. B)Catheterization should only be utilized when other less-invasive interventions are performed since the procedure has the potential to introduce infection. Studies have indicated that if bladder scan volumes are less than 120% of the predicted volume, bladder scans are to be repeated every hour until the child voids or until catheterization is required. When the bladder scan result equals the predicted volume, the nurse initiates non-invasive strategies to encourage spontaneous voiding. When the bladder scan indicates approaching or exceeding 120% of predicted volume or the child is uncomfortable, the child is encouraged to void and an order for catheterization becomes necessary. C)These non-invasive strategies are useful to assist in promote spontaneous voiding. D)High doses of pain medication (i.e. morphine) are more likely to cause urinary retention. Also, they are likely to cause increased sedation and decreased awareness of bladder fullness. Since pain control is an essential intervention with this surgery, routine assessments of the childs urinary status are required. 6. Mias next client for the day is Mrs. Brown. She is an 87 year-old lady who has been diagnosed with severe dehydration, occurring as a result of decreased fluid intake. Mrs. Brown receives intravenous (IV) hydration therapy through an IV site located on her left hand, and requires nursing care on a daily basis. Upon arrival, Mia notices that the IV bag is full, the IV fluids are not draining, and Mrs. Browns left hand is swollen, pale and cold. What should the nurse do first? a) Apply warm and moist compresses to the left hand b) Elevate Mrs. Browns hand on a pillow c) Inspect the IV site and discontinue the infusion d) Insert a new cannula on the other extremity and secure it with tape. Correct answer: c)

a) Even though applying warm and moist compresses to the affected hand may be helpful in decreasing the edema associated with infiltration of the IV site, this is not the best answer choice. In this situation, instead of focusing her actions on removing the cause that perpetuated the infiltration, such as IV fluids infusing interstitially, the nurse concentrates on treating the consequences of the intravenous complication. Therefore, although the application of warm and moist compresses may be incorporated in the treatment plan for Mrs. Browns infiltration, it does not indicate the most appropriate first action of the nurse. b) Elevating Mrs. Browns hand on a pillow indicates an effective strategy that would promote the absorption of fluids, facilitate venous return, and decrease the edema related to infiltration, but is not the most appropriate initial nursing action. In addition, by elevating Mrs. Browns hand on a pillow the nurse would not eliminate the root cause of the infiltration, but treat the consequences of it. c) Inspecting the IV site for signs and symptoms of infiltration, including swelling, pallor, coolness and pain, and discontinuing the IV infusion would be the most appropriate initial nursing action and the best answer choice in this case. In this instance, the nurse utilizes her critical thinking abilities and understands that the preliminary action should involve discontinuing the flow of fluids in the interstitial space, and preventing any further progress of the infiltration. Hence, by inspecting the IV site and discontinuing the infusion first, the nurse is treating the direct cause of the infiltration and preventing any further damage to the client. d) Inserting a new cannula and securing it with tape is an important aspect of Mrs. Browns hydration treatment plan, primarily because she is suffering from severe dehydration. However, this is not the best choice because it does not suitably address the question regarding the most appropriate first action of the nurse. Initiating a new cannula and securing it properly would be appropriate only after the infiltrated IV infusion site is discontinued and further damage is prevented. 7. Mrs. Peters has been admitted to long term care with diabetes, dementia, and congestive heart failure. In the morning, the nurse enters the room to check her blood sugar. Upon entering the room, the nurse notes Mrs. Peters looks pale, anxious, sweating and the BS is 3.3. What is nurses first priority? a.Encourage Mrs. Peters to exercise b.Give a cookie c.Give 125 ml orange juice d.Recheck the blood sugar in 15 minutes Correct answer: c Rationale:

a.This is not the first priority for hypoglycemic clients. Exercising will lower the blood sugar level. b. Giving cookie is not the first priority as complex carbohydrates takes too long to absorb and is not useful for quick hypoglycemic treatment. c.Nurses first priority is to give 15g of simple glucose (125 ml orange juice) as this will bring the sugar level up. d.Nurses first priority is to give 15g of simple glucose and then she needs to recheck the blood sugar to make sure BS is at optimal level. 8. Mr. Raymond is a 68 year old obese client with an history of DVT. He had a Gastrectomy due to gastric cancer. It has been 24 hours since his surgery. He has a PCEA (Patient controlled epidural analgesic), appears to be a bit drowsy and is on and off in a normal sleep. What important consideration should the nurse add to Mr. Raymonds plan of care? a) Assess the client for pain b) Encourage deep breathing and coughing every hour c) Encourage ambulation/Get the client up out of bed d) Ensure the client eats all his breakfast for adequate nutritional intake Correct answer c) a) Pain assessment should be an important part of assessment; however, the patient is in a normal sleep and is not showing signs of pain (e.g. guarding, grunting etc) b) Post operative clients are at risk for respiratory complications such as pneumonia, atelectasis etc. This is an important part of patients plan of care. However, for Mr Raymond, ambulation and posture will help decrease respiratory complications. c) Ambulation is encouraged to decrease DVT. Increase stress response after surgery may lead to increase clotting tendencies in the post operative client by increasing platelet production. Clients with an history of DVT has a more increased risk for pulmonary embolism. d) The client had a Gastrectomy; therefore, will be NPO. Bowel sounds are frequently diminished/decreased. IV infusion is usually given to maintain fluid and electrolyte balance. 9. A resident has been given a bath at the shower room when she started to have a seizure attack. The resident has a history of seizure disorder documented on her chart. The personal support worker who was giving the resident a bath called the nurse on the floor. When the nurse arrived, what will she do during the attack?

a.)Call the designated physician immediately. b.)Transport the resident back to her bed. c.)Insert an oral airway instrument. d.)Put the resident in a side-lying position and allow the resident to finish her seizure attack. Correct answer: d.) a.)This is not a priority at the moment because the physician is aware that the resident has a history of seizure disorder. Inform physician after the residents seizure episode. b.)It is not a good idea to move the resident while she is having her seizure because she is unstable and transferring her could cause more harm than good. c.)This had been done in the past to maintain the airway of residents/clients to be clear but was stopped because forcing an airway instrument to the resident who is currently having the seizure could cause injury to the jaw, teeth or to the tongue. Also, if in the process of inserting the oral airway the gag reflex had been stimulated, it could lead for the resident to vomit which could be aspirated and can cause greater risk/harm. d.)This is the correct response because putting the resident in a side-lying position would allow any secretions to drain from the mouth and not be accumulated which could be aspirated by the resident. Also, it will allow better ventilation for the resident to be able to breathe while having the seizure. The surroundings of the resident who is having a seizure should be clear of any tools or furnitures that could cause harm throughout the episode. The nurse should observe the type of the seizure that the resident is having for proper documentation and intervention afterwards.

10. Mr. Gonzales, 58 years old, has returned to a surgical unit following transurethral resection of the prostate. He has an IV NS infusing at 100 mls per hour, a three-way urinary catheter in place and continuous bladder irrigation with sterile NS solution. After a short while, Mr. Gonzales complains of abdominal pain and bladder spasms. As you enter his room, Mr Gonzales anxiously says, Im in pain, could you do something about it? Which nursing action is most appropriate in this situation? a.) Irrigate the bladder manually with 50 cc irrigating solution b.) Assess the catheter patency for kinks or clots c.) Administer antispasmodics (e.g., oxybutynin) as ordered d.) Stop the CBI and notify the physician immediately

Correct Answer: B Rationale: a.) Irrigating the bladder manually is done when tube patency is confirmed (ie, catheter tubing is kinked or blocked with clots). In this case, 50 cc of irrigating solution should be instilled and then withdrawn with a syringe to remove clots that may be in the bladder and catheter. In this case, tube patency is not confirmed yet and there is no identifiable cause for Mr. Gonzales abdominal pain/bladder spasms yet. b.) Catheter patency must be checked first in order to identify the cause of Mr. Gonzales pain and bladder spasms. If present, the clots should be removed by irrigation so that urine can flow freely. This is the most immediate nursing action: to assess and identify the problem first then proceed with your plan. c.) Antispasmodics (e.g., oxybutynin or Ditropan) along with relaxation techniques (e.g., guided imagery) are used to relieve the pain and decrease spasm. In this case, you know that Mr. Gonzales verbally expressed hes in pain and asking if you could do something about it. Considering the phases of the Nursing Process (ie, Assessment, Diagnosis, Planning, Implementation and Evaluation), you must collect both the subjective and objective data in order to analyze and critically think what is going on first BEFORE you implement an intervention. It is totally explicable that Mr. Gonzales is in pain and you would like to help alleviate that pain, but you must first identify the problem in order to solve it. a.) This may be a serious situation but stopping the CBI and notifying the physician immediately is done only if the outflow is blocked and patency of the tubing cannot be re-established by manual irrigation. Therefore, at this time you are not sure yet if this is considered an emergency situation (ie, life threatening) 11. Nurse Jane accompanied by a nursing assistance walked into a patients room at about 1500hrs and observed the patient to be pale and diaphoretic. The patient complained of headache, and then tells Nurse Jane to go away. His hands are very shaky. As the nurse caring for this patient, the most appropriate initial management of this situation is to: A. Instruct the nursing assistance to stay with the patient while you obtain a glass of orange juice and call the doctor B. Instruct the nursing assistance to remain with the patient while you obtain some insulin and report to the team leader C.Stay with the patient and try to obtain a urine specimen while the nursing assistance reports to the team leader D. Remain with the patient and ask the nursing assistance to quickly obtain the glucometer and a glass of juice..

Rationale: The correct answer is D A. The patient is confused at this stage, and it is not right to leave him at that time. B.It is important to check the blood sugar reading first before administering insulin C. Urine specimen is not the right intervention at this time D. These are signs of hypoglycaemia, checking the blood sugar is very important and giving Patrick a glass of juice is the best option at this stage. 12. Mr. Raines is a 62 year old gentleman admitted to the med-surg unit from emergency with confusion, chills and intermittent chest pain. Vital signs on admission are temperature 39.1 degrees C, BP- 167/98, HR- 115, and R-26. Following a CT scan and MRI the client has been diagnosed with septicemia due to an infected artificial mitral valve. He is started on 1gram Ceftriaxone Q8hrs IV and NS to run at 100mls/hour with a heparin drip titrating to PPT levels. Code status: Full Code The call bell rings, its Mr. Raines roommate reporting that Mr. Raines is coughing and gasping for a breath. On arrival the client is not breathing, unconscious, colour appears dusky from the chest up, diaphoretic, pink frothy sputum is coming from the clients mouth and nose, BP- 75/34, HR- 148 and faint, all symptoms indicative of a pulmonary embolism (PE).What is the nurses priority action?

a)Place client in semi to high fowlers and administer oxygen via non-rebreather mask b)Perform a thorough chest assessment and call another nurse for assistance. c)Administer analgesic and monitor vital signs as client is a DNR d)Place the client in trendelenburg, call a code blue, and begin cardio pulmonary resuscitation. Correct Response: D a)This is an appropriate intervention if the client was having a sub-massive or non-massive pulmonary embolus. b)The client is not breathing therefore immediate life saving interventions are required, chest assessment could hinder oxygenation potentially leading to undesirable outcomes such as brain death.

c)Essential to a clients care plan is advanced directives including code status, nurses must be aware of the clients status in order to provide the appropriate care. As stated in the case study, this client is a full code and would require all life saving interventions. d)Trendelenburg position promotes oxygenated blood flow to the brain preserving brain function. Activating a code alters the response team to begin invasive medical interventions. 13. Mr. Hall, 62 years old, has had a left carotid endarterectomy, and upon assessment of cranial nerve function the nurse notes that he has difficulty articulating, slurs when saying the phrase, Mom and Dad bought puppies, and has an asymmetrical droop on the left side of his mouth. What initial action should the nurse take? a) Call the physician and the critical care outreach team (CCOT) STAT to inform them in the change of Mr. Halls condition. b) Document the findings and report to the charge nurse concerning the change in Mr. Halls condition. c) Call the patients wife and ask her to clarify whether or not Mr. Hall has experienced symptoms like this before. d) Apply oxygen at 4L/minute via nasal cannula, start intravenous therapy of 0.9% normal saline, and continue to monitor. Correct Answer: a) a) This indicates cranial nerve damage and must be assessed by the physician and CCOT. b) The nurse would document findings, but must notify the physician. c) This would be inappropriate at the time, the physician must be notified. d) The nurse would apply oxygen only if Mr. Halls oxygen saturation was low, and the nurse would need an order prior to initiating IV therapy. 14. Mr. Paul is a 60 years old client with chronic renal failure who has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the clients status immediately after dialysis? a) Vital signs and BUN b) Weight and potassium level c) BUN and creatinine levels d) Vital signs and weight

Correct Answer: d) Rationale for correct answer: d) After hemodialysis, the clients vital signs are assessed to see if the client is stable hemodynamically. Clients weight is measured and compared with the clients pre-dialysis weight to check how much blood filtration has occurred and the effectiveness of fluid removal. Rationale for incorrect choices: a) BUN level is not an immediate standard intervention at the end of every hemodialysis treatment as it is not viable to do lab tests for every client after each dialysis. b) Doing blood test for potassium is critical to identify acute changes in clients and is done on case by case basis. But it is not a standard post dialysis protocol. c) Laboratory tests like potassium and BUN level are done as per hospital protocol but are not necessarily done after the hemodialysis treatment has ended. 15. You have been working with Mrs. Jones who is a 92 year old post operative patient who underwent a hip replacement. During your initial assessment Mrs. Jones has lower than normal blood pressure, generalized weakness, and pallor. Looking at the results from her blood work you notice that her haemoglobin is 75g/L. You immediately call the doctor to receive an order for blood. Once the blood has arrived and consent obtained the nurse will then? A) Independently verify the patient identification number, blood unit number and then administer the blood. B) Administer the blood after the check has been performed. C) Begins the infusion rate at 100ml/hr. D) Discuss the signs and symptoms of adverse reactions should any occur. Correct Answer: D) A) The nurse must verify with another nurse when reading the codes. B) Before administration of blood a baseline assessment of vital signs must be documented in case of a reaction. C) The infusion rate will be prescribed by the physician for each person and should begin slowly for the first fifteen minutes of administering blood. D) Right, after obtaining consent the nurse should further explain what the adverse reactions would be like as so the patient can pay attention to any changes as they occur during the infusion. 16. Mr Arawinda a 59yr old male walks into your triage station from the waiting room in an emergency department. On assessment you notice your clients skin is pale and he appears SOB. Your Oxygen sat probe is malfunctioning, radial pulse is 58, BP 90/56, T- 36.1, R- 24 Your client explains he has been feeling lousy since morning and had pain in his upper back and neck and a sore left arm. Your client continues to say and that he thinks he may have the flu but came to the unit today, to have his pain addressed as he felt he may have pulled some muscles lifting boxes at work.

Based on this initial story, what would be the nurses next step be to provide the best care for this client in a timely fashion. a)Assess the client for pain so they can receive prompt analgesia appropriate for the level of pain the client describes b)Offer the client Oxygen as they appear SOB and you do not have a functioning O2 probe c)Ensure the client has an ECG and continue the assessment d)Triage the client to the orthopaedic dedicated section of the ER for prompt X-ray Correct Answer: C a)While it is important to conduct a proper pain assessment for a client, pain relief is secondary in priority to recognizing the possible symptoms of an acute MI, also pain relief may also mask some of the symptoms prolonging time to proper re-perfusion treatment in an acute MI. b)The client was able to walk into the triage station and into the unit itself, Oxygen may be offered in the course of treatment but it is not a priority intervention that will route the client to the correct health services promptly. c) Provision of an ECG early in the treatment cycle for this type of client will ensure that they receive appropriate targeted care for the exact condition they may be presenting with today. Also their story describes many of the symptoms of an acute MI or cardiac event including SOB, bradycardia, low BP, pain profile. Ruling out or confirming a cardiac event will help best create a plan of care for this client d) While the client may have actually pulled muscles or a fracture but an ECG would help rule out a cardiac event and a muscle pull or broken bone is unlikely to be as consequential as a possible MI. The client may be routed to the wrong health professionals or an inappropriate plan of care may be created. 17. Mr. Peterson,50, is in the surgical unit since 2 days after his appendectomy surgery. He reported having passed liquid stools 9 times in the past 8 hours. From assessment, nurse finds that he is weak and disoriented. The patients skin is cold and clammy. Nurse takes Vital Signs (VS). BP: 87/43, P-110, SaO2- 86% on 2L oxygen via nasal prongs, Respirations-12/minute His PRN orders are: Imodium (To be given in the case of diarrhea) NaCl bolus (when fluid loss is greater than 600ml) Oxygen 2-4 L Which one of the following interventions would be the most appropriate initial action for the nurse to take? a- Calculate the amount of stool and accordingly plan to administer the NaCl bolus b- Increase oxygen delivery to 4L and ask a secondary nurse to monitor VS. c- Call the physician and inform him about Mr. Petersons deteriorating VS

d- Administer Imodium to treat diarrhea, and assess amount of fluid loss. Correct Answer: (b) Rationale: a- The patient is showing symptoms of hypovolemic shock: low blood pressure, rapid pulse, cold and clammy skin. Although, treating hypotension is important, it should always begin with oxygen therapy to promote oxygenation of hypoperfused organs. Hence, calculating the amount of stool and planning to administer the NaCl bolus should not be the nurses immediate action. b- This is the best response. Mr. Peterson is showing signs of hypovolemic shock. Treating this should always start with oxygen therapy to promote oxygenation of hypoperfused organs (Smith, 2006, p.404). The patient has low oxygen saturation and is disoriented. Disorientation could be a sign that the brain is not receiving adequate oxygen (Smith, 2006). Mr. Peterson is currently receiving 2L oxygen via nasal prongs. His order reads 2-4 L oxygen. Thus, increasing the oxygen delivered to 4L and asking a secondary nurse to monitor VS is the best first action. c- Although calling the physician is important, the priority in this situation is to recall Mr. Petersons PRN medication orders, apply critical thinking and recognize that oxygen can be increased and later NaCl bolus could be given. d- Administering Imodium to treat diarrhea is not a priority while considering immediate action in this situation. It is more important to ensure adequate oxygenation and perfusion of vital organs. 18. Mrs. Lorenza, 45, has a diagnosis of diabetes and is in the surgical unit. She has an ulcer on her right foot and one of her toe is necrotic. She reported having pain of 6/10 on the right foot and her pain medication morphine - was administered. Although, her next dose is due after 3 hours, she reports having unrelieved pain. She has pain of 7/10 in the same area. The nurse got to know that Mrs. Lorenza has been using morphine for 4 months prior to her hospitalization. What is the most appropriate initial response by the nurse? a- Use patient preferred non-drug therapy to relieve pain till next dose is scheduled. b- Advice patient that applying cold compress over her foot is most effective to relieve pain till next scheduled dose. c- Take vital signs and perform an assessment of the foot. d- Consult the pain specialist and inform him about ineffectiveness of the medication Correct Answer: (c) Rationale: a- Mrs. Lorenza is showing signs of tolerance to her pain medication i.e . experiencing end of dose failure (Ersek & Poe, 2006). However, it is important to rule out possible infection or disease progression as the cause of pain before considering the possibility of drug tolerance (Ersek & Poe, 2006). Hence this is not the best response. b- This is not the best response since the priority nursing action should be to rule out drug tolerance (Ersek & Poe, 2006). Also, cold compress should not be applied to areas with poor circulation (Ersek & Poe, 2006) which might be the reason why the patients foot is ulcerous and necrotic (Warren, 2010). c- This is the best initial response since the nurse first suspects drug tolerance and uses critical thinking to evaluate if there were other reasons for an increase in pain (Ersek & Poe, 2006). This is evident as she performs foot assessment and takes vital signs.

d- Although it is important to inform the pain specialist about unrelieved pain (RNAO, 2002), the priority in this situation is to get necessary information through assessment. 19. Mrs. Daley, 54 years old, is admitted to the acute respiratory unit with a diagnosis of pneumonia. She has tracheostomy tube and on 36% FiO2. After three hospitalized weeks, now she is having difficulty expectorating sputum and mucus rattling in the tube is heard. Her respiratory rate is 30 breaths/ min. what is the most appropriate action? a) Increasing oxygen level. b) Maintaining head of bed at 30 to 40 degrees. c) Providing oral care. d) Suctioning the tracheostomy tube. Correct answer: d) a) Hyperoxygenation will ensure that the patients oxygen level does not drop during suctioning. Increasing oxygen level can not help the patient clear musus from tracheostomy tube. Should suction initially. b) The head of bed should be maintained at 30 to 40 degrees to the patient for proper breathing, but is not the most appropriate action. c) Oral care needs to be provided, but it is not the most appropriate action to relieve her problem. d) Should clear the patients airway make sure the airway is patent. Suctioning the tracheostomy tube is needed to clear secretions in the tube. 20. A 63 year old male, presents with atrial fibrillation since he was admitted to CCU, two days ago. His vitals on the monitor show pulse in 55s, BP 150/75 and respirations as 23. 3+ pitting edema present on lower extremities and pedal pulses audible by Doppler. Keeping in mind the presenting problem, which medication would you ensure this patient is administered to prevent the worsening of this patients cardiac status? a) Lasix (diuretic) b) Metoprolol (anti-hypertensive) c) Heparin (anti-coagulant) d) Nitroglycerin IV (vasodilator) Correct Answer c)

a) Diuretics will be needed, since this patient has 3+ pitting edema. However, the arrhythmia this male patient is present since 2 days, is a higher risk factor for the worsening of his cardiac functioning. b) anti-hypertensive will also be prescribed to the patient, most probably from the time he was at home because high blood-pressure is one of the causes that increase the chances of one getting a heart disease. If he was not on anti-hypertensive earlier, then it can be the bodys way of compensating for low cardiac output which is caused by the arrhythmia. c) Since this patient is presenting atrial fibrillation continuously for the last 48 hours, the major manifestation of it is the formation of thrombus in the atrium. This is due to the incomplete contraction of the atrium which causes the blood to accumulate and clot (Watson, Shantsila, & Lip, 2009). Hence, it should always be ensured that the patient is on an anti-coagulant to prevent the formation of a thrombus. Thrombus can lead to further complications by dislodging into a peripheral vein or coronary artery. d) A cardiac patient will have a prn order for nitro spray for chest pain. Nitro IV can be used for some patients to dilate coronary blood vessels for proper oxygenation of the heart. Yet again, this is not the priority right now, since there is no pain, but could be used to lower the BP and helping to reduce the workload on the heart. 21. Mr. Johnson has been on dialysis for the past five years. He just had a kidney transplant two days ago with PCA pump. His medical history includes hypertension, diabetes (NIDM), and ESRF (end stage renal failure). The doctor has ordered Ampicillin 1 g po OD, Metformin 500mg po BID, Dimenhydrinate 50 mg IV TID PRN and packed RBC to be infused over 2 hours. Two hours after leaving Mr. Johnsons room he calls and starts complaining of severe pain at the incision site, he is diaphoretic and restless. What sequence of actions should the nurse take under this circumstance? A). Call the doctor-explain what just happened, give Ampicillin and document. B). Check vital signs, give Ampicillin and document. C). Check vital signs, give Dimenhydrinate and document. D). Check vital signs, check operative site, call doctor and document. a). Calling the doctor without a complete assess of the patient will not enable the doctor to order the right medical interventions for the patient. b). Check vital signs, give Ampicillin and document-the results of vital signs has to be reported to the doctor in order for the doctor to order the right medical interventions. c). Check vital signs, give Dimenhydrinate and document the results of vital signs has to be reported to the doctor in order for the doctor to order the right medical interventions. d). Check vital signs, check operative site, call doctor and document

the correct answer is D- a complete assessment by the nurse will enable the doctor to prescribe the right intervention for the patient. Also patients with kidney transplant are put on antirejection medications which increase their chances of acquiring infection (Lewis, 2006, p.414). 22. Mrs. M a 45 year old woman was admitted to the neurology rehab unit following a brain tumour. She was recently diagnosed with a urinary tract infection. During a visit her physician had advised her to drink more fluids on a regular basis. Mrs. M discusses her physicians advice with the nurse and states that she is worried that an increase in fluids will increase urinary frequency and cause discomfort as a result of the urinary tract infection. In this case what should be the nurses best response? a) Theres nothing to worry about. b)Although fluids will increase frequency, it will also dilute the urine and help flush out bacteria. c)Although drinking fluids is important, alcohol, chocolate, and spicy food should be avoided in order to manage the urinary tract infection. d)You should drink fluids every 4 hours. Correct answer: b) Rationale: a)This response fails to address the patients concerns. b)The nurse is validating the patients concerns of increase frequency while providing health teaching regarding the importance of drinking fluids. c) This nurse provides information that is relevant, although the patients concerns were different from what the nurse wanted her to know. d)Drinking fluids every 4 hours is insufficient and also disregards the patients concerns. 23. Mr. Bones, 72 years old, had undergone hip surgery after he fell at his home. He is receiving a postoperative pain medication which is morphine I.V. through Patient Controlled Analgesia (PCA) infusion pump as physician ordered. Which of the following nursing intervention is appropriate in managing his pain? a. Tell him to wait until he is feeling uncomfortable before pressing the button. b. Teach his wife how to assist him in operating the PCA device. c.Administer another oral analgesic as needed breakthrough pain and assess q1h. d. Monitor and record the clients sedation level as per hospital policy. Correct Answer: c Rationale:

a. Patient should be encouraged to administer the analgesic before pain intensity is greater than the patients desired pain intensity goal b. No one else administers the PCA for the patient, only the patient by himself. c.PCA can not be enough to decrease pain and discomfort level since pt is in post-op pain. Additionally, PRN analgesics will be controlled the severity of the pain effectively. d. Although to monitor and record the clients sedation level is necessary, but it is not the appropriate nursing intervention to manage the patients pain. 24. Mrs. Jones, 30 years old was brought into the emergency department by ambulance with 2nd degree burns to the right side of her face and neck. The clients voice is very shallow and she tells you that she was trying to light a cigarette when her hair caught on fire. As her nurse what is your first priority? A. Establish IV access to increase fluid volume B. Remove clothing to assess burns elsewhere on the body C. Asses airway patency D Provide pain relief Correct answer: C A Establishing IV access is important for fluid replacement however it is not as important as maintaining the airway. B.Removal of the clothing can be done after the ABCs are completed. C Assessing airway patency is essential because the client may have inhaled flames. This would make the airway become edematous and the client can go into respiratory arrest. As the nurse it is our responsibility to assess the airway and determine if the client will need intubation before the airway is too swollen. Using our assessment skills and anticipatory planning the nurse can prevent the client from needing a tracheotomy. D. Providing pain relief is important but not the main priority because the client may not be feeling that much pain depending on the extent of nerve damage. 25. After her patient received an epidural, the nurse noticed a rapid dip in the fetal heart rate (FHR) down to 60 beats per minute for a length of 2 minutes. What would the nurses priority of care be? a) Reassure the mother that this is a normal reaction to the epidural and the FHR will return to a normal range within a few minutes. b) Page the Obstetrician on call and prepare the patient for a cesarean section. c) Reposition the patient, apply oxygen via face mask and perform fetal scalp stimulation. d) Discontinue the epidural infusion and remove the epidural catheter. Correct Answer: C Rationale

a) Is incorrect because any prolonged fetal heart deceleration is considered abnormal and concerning. While you do not want to alarm the patient, it is unethical to reassure her that everything is fine, when actions need to be taken (Canadian Nurses Association, 2008). b) Is incorrect because it is not the role of the RN to determine the need for surgery. Although, he/she would page the obstetrician and update them on the condition of the patient (Evans, Evans, Brown, & Orshan, 2009). c) Is correct because all of these interventions are the standard protocol for reestablishing the fetal heart. Repositioning the mother might help if the baby is pinching the umbilical cord and that is the reason for the deceleration. Giving the mother oxygen ensure increased oxygen to the baby, who may be having difficult recovering from contractions. With fetal scalp stimulation, the hope is that the we will see accelerations of the fetal heart rate (Lee, Sprague, Yee & Ehman, 2009) d) Is incorrect because although the fetal heart deceleration did occur after the epidural was initiated (commonly referred to as a post-epi dip), removing the epidural will not resolve the issue and would only mean that the patient would need to go through the whole procedure again (Lee, Sprague, Yee & Ehman, 2009). 26. When coming onto your shift you do your initial assessments of your patients. After first rounds you see that one of your patients is agitated and calling out. From the report that the night staff gave is that this particular patient is just old and a nuisance. Upon your initial assessment you find out that the patient is gasping for air and is wheezing. He has only been able to settle when he is in an upright sitting position. Upon review of the kardex again you see that there has been very little output into the catheter bag that this patient has. There are no PRN medications ordered. Your next course of action is to: a) You listen to what nights have said to you and ignore what your assessments have told you. Let this patient struggle for air in the Geri-chair. b) Get an order from the physician for a ventolin treatment to deal with the shortness of breath and the wheezing. c) Contact the sending facility to see about a proper history on the patient. See if this calling out is common or if it is a new thing. d)Contact physician to get an order for lasix to help reduce the fluid in the lungs and eliminate the wheezing. Answer: a)Is wrong because you are obligated to treat any patient regardless of how they are or what another nurse has told you. b)Is wrong even though Ventolin is a good option but due to the fact that this patient has little to no input is a good indicator that this is not a problem that ventolin treatment cannot treat.

c) Is wrong because just seeing if this calling out and erratic behaviour is new or not is a good option it will not help in treating congestive heart failure. d) Is correct because the patient is having no output and is only able to breathe in an upright position. The patient is experiencing fluid accumulation in his lungs and needs to reduce the fluid as soon as possible. 27.Mr. Smith is admitted to the hospital for congestive heart failure. His condition has been stable for the past two days, however, today he began to complain of shortness of breath, fatigue, and there is a greater presence of pitting edema in his extremities. What is the most important intervention that the nurse needs to perform? a) Weigh Mr. Smith b) Administer lasix c) Maintain oxygen therapy and obtain oxygen saturation level d) Decrease and manage patients activity level Correct Answer: C a) Although this is very important to monitor how much fluid Mr. Smith is retaining, or dieresis and or weight reduction, however it is not a priority at this moment. b) Administering lasix will help Mr. Smith decrease the amount of fluid in his body, but this is also not the first priority in the situation. c) This is the correct answer. Administering oxygen therapy will decrease the risk of hypoxemia, and it will establish the range of the O2 Saturation. d) This will help with the fatigue and allow Mr. Smith to retain energy, and once the client feels fatigued he will automatically stop or decrease his activity level. 28. Mrs. Scott is a 35 year old woman who is 38 weeks pregnant. This is her fourth pregnancy and she has two children at home. Mrs. Scott was admitted to labour and delivery at 2300 hours. Upon her admission, the nurse does routine vitals and attaches the fetal monitor to Mrs. Scott. Mrs. Scotts labour progresses but the nurse notices decelerations in the babys heart rate on the monitor. What should the nurse do to correct the problem? a)Keep the patient in the same position that she is in because the nurse does not want to make the decelerations worse b) Get the patient up to walk in the hall because this will increase the intensity and strength of the contractions c)Reposition the patient on the left side by placing a pillow or blanket under her right side. d) Administer Oxytocin in order to increase the intensity and frequency of the contractions so the baby can be delivered quickly.

Correct answer: c a)Keeping the patient in the same position is not correct because the blood flow to the vena cave could be compromised due to positioning. In order to correct the decelerations and increase blood flow, repositioning the patient is required. b) Getting the patient to walk in the hall helps to get the babys head in the birth canal but that is not this patients concern. In order to increase the intensity and strength of the contractions, the obstetrician may order a medication called Oxytocin. This medication helps to increase the intensity and frequency of contractions in order to speed up the labour process. Oxytocin is not administered if there are deceleration. c) Repositioning Mrs. Scott on her left side helps to increase blood flow to the vena cava. The vena cava is responsible for carrying blood to the right atrium of the mothers heart. It is important to make sure the mother is getting adequate amounts of blood because in doing so the baby is also getting sufficient amounts of blood. Repositioning the patient on her left side is one of the many ways to help rectify the decelerations that the nurse sees in the babys heart rate. d) Administering Oxytocin to the patient is not an appropriate action because this can cause the deceleration to get worse. For example if the decelerations are caused by the babys head being compressed with each contraction, the babys head will continue to get compressed but at a higher rate. This would cause the babys heart rate to drop more drastically. If the patient was on Oxytocin to help with the progression of labour and the nurse notices decelerations, the priority of the nurse would be to stop Oxytocin. This is one of the many actions of uterine resuscitation. 29. Mrs. Kikelomo, 33 years old, G1P1. She is hepatitis B negative, rubella immune, group B streptococcus (GBS) positive and treated twice. She has a history of asthma and smoked until 20 weeks of pregnancy. She is gestational diabetes mellitus (GDM) on insulin. She has undergone spontaneous vaginal delivery with 2 degree episiotomy. Baby is 8 hours old, weighs 4050, Apgar score 7, 9, at 1 and 5 minutes respectively and has shoulder dystocia. On entering the room, you found baby jittery. You should first: a. Encourage the mother to feed baby b. Facilitate skin to skin contact c.Check babys blood glucose level d Transfer baby to the neonatal intensive care unit(NICU) Correct answer: C Rationales a.Feeding the baby is relevant but not a priority at this time b.Facilitating skin to skin contact is important but not a priority for this baby. c.Jittery is a sign and symptom of hypoglycemia in infants, since the mother is GDM on insulin, it makes sense that the baby is experiencing low blood glucose. In order to effectively treat hypoglycemia, careful blood glucose monitoring is critical. d.There is no need to transfer baby to NICU. 30. You are a nurse on a Schizophrenia Unit in a Mental Health Hospital. It is your weekend to work. John is one of your primary clients and presents at the nursing station complaining of a stiff and sore neck. You begin to inquire as to the source of the discomfort, the client requests the

acetaminophen again, but with more urgency. You approach the client and notice the clients right hand has tremors. John also appears to be thrusting his tongue and speaking as if his tongue is swollen. The client has come to the nursing station requesting a prn Acetaminophen to help with the neck stiffness. Your initial response would be? a) a) Administer 500-1000mg of prn Acetaminophen for pain as requested by client and document as necessary. b) b) Ask your client if they have taken any non-prescription medication or any street drugs and order a Urine Drug Screen to test for illegal drug use as these symptoms could be that of withdrawal. c) c) Call the duty doctor and request that they come to assess the client. d) d) Check prn medication sheet and administer Benztropine po prn for extrapyramidal symptoms. If not ordered, call the psychiatrist and get a stat order for Benztropine. Correct answer: d) a) a) Pain management is important, but not a priority due to the other noticeable symptoms. b) b) Urine Drug Screens are only ordered for the clients who have a history of addiction. A history of addiction was not indicated for John. c) c) The duty doctor will not consider this to be of an urgent nature and the client is requesting immediate attention. d) d) Neck stiffness, tongue thrusting, tremors are all identifiable symptoms of benzodiazepines use, called Extrapyramidal symptoms and are treated with Benztropine. 31. T. P is a 24 year old patient with the history of chronic ulcerative colitis. Patients ulcerative colitis became very severe and physician decided that surgical intervention with possible permanent colostomy will be necessary in this case. Patient is very anxious and upset. Which of the following nursing interventions would provide the best support for T. P? A)Preoperative health teaching on colostomy care B)Provide patient with the assurance that whatever happens, you will be at her side C)Administer Valium as ordered preoperative D)Allow patient to express her feelings Correct answer is D.

A) Patient education on self care of ostomy is very important since it increases patients independence and enhances self-esteem when the patient demonstrated the correct skill before the discharge. However, in this case it is not considered to be as a best support for T. P since she is anxious and upset. Thus, nurse should 1st attend to her psychological well-being. B) Providing assurance to the patient- will create a communication block and will not allow nurse to further explore patients feelings and concerns. C) Yes, the patient is anxious and upset and by giving her Valium will not solve her root causes for concerns. As a competent nurse, he/she should explore patients feelings because permanent stoma at her young age could lead to distorted body image, isolation, depression and change in lifestyle. D) This is the correct answer. Psychological health is very important to this young patient. In this case, the nurse allows patient to express her immediate feelings, concerns and anxieties related to permanent stoma. 32. Mr. Brady, 57 years old is a patient in the Cardiovascular Surgery Unit who was admitted with CHF. On entering the room, it is observed that the patient is in bed and is sleepy. A nurse enters the room to administer digitalis but before she does it she takes the vital signs. The patients VS read as: BP 155/92, RR-18, O2-95, HR-59. Which of the following is the most appropriate action to be taken by the nurse? a) administer medication as per MD order b) withhold the medication c) report to the physician immediately d) retake vital signs Correct answer: b) a) the patients heart ate is lower than 60 beats per minute. This could be a sign of drug toxicity, therefore this is the wrong answer. b) this is the most appropriate action to be taken so as to prevent digoxin toxicity c) this is also the right answer, but this is not the priority d) vital signs can be taken later but the priority is to withhold medication 33. Mrs. Buttercup is 41 years old recently had thyroidectomy. What sign should a nurse check for to identify symptoms of hypocalcaemia? a) Goodells sign

b) Homans' sign c) Tinel's sign d) Chvostek's and Trousseau's signs Correct answer: d) a) Softening of the cervix; a sign of pregnancy. b) Discomfort behind the knee on forced dorsiflexion of the foot, a sign of thrombosis c) A tingling sensation in the distal end of a limb when percussion is made over the site of a divided nerve. Indicates a partial lesion not calcium deficiency. d) Twitching of all facial muscles when tapped and carpal spasm with use of B/P cuff indicates hypocalcaemia. 34. Janie is planning discharge for her patient, George, who has been diagnosed with Acute Renal Failure. Which comment from George would indicate to Janie that he would require additional health teaching?

a. infection. b. c. d.

I should monitor my temperature because this is my best indicator for a possible Mouth care is important due to my increased ammonia levels. My diet should be high in calories. I should use humidified oxygen and deep breathing to prevent pneumonitis.

Correct answer is a. a This response would tell Janie that George requires additional health teaching because often patients with renal failure have a blunted febrile response to infection and therefore an elevated temperature may not be present (Holechek, 2004). b This is true; mouth care is important because it prevents stomatitis, which develops when ammonia (produced by bacterial breakdown of urea) in saliva irritates the mucous membranes (Holechek, 2004). c This is true; good nutrition is necessary in recovery from Acute Renal Failure (Holechek, 2004). d This is true; Humidified oxygen and deep breathing are two techniques which help maintain adequate respiratory ventilation (Ormandy, 2008). 35. A client with end-stage renal disease arrives at the hospital with a blood pressure of 200/100 mm Hg, heart rate of 110 beats/ minute, and a respiratory rate of 36 breaths/ minute. Oxygen saturation on room air is 89%. He complains of shortness of breath, and you note +2 pedal edema.

His last hemodialysis treatment was yesterday. Which of the following interventions should you do first? a) Administer oxygen. b) Elevate the foot of the bed. c) Restrict the client's fluids. d) Prepare the client for hemodialysis Correct answer: a a) Airway and oxygenation always are the first priority. Because the client is complaining of shortness of breath and his oxygen saturation is only 89%, you need to administer oxygen to increase the PaO2. b) After taking care of airway and oxygenation, you also need to ensure that the client is dialyzed to remove the excessive fluid. c) Thirdly, his fluids must be restricted in order to prevent further overload of fluid. d) The foot of the bed may be elevated to reduce edema, but this is not a priority. 35. Mrs. S. is 77 years old, diagnosed with T-Cell Lymphoma. She got a chemotherapy treatment two days ago. Currently complaining of constipation and stomach cramps, her recent unstable lab results are platelet 56 (normal: 140-400 E9/L), and WBC count- .45 (normal: 4.00-11.00 E9/L). Based on her constipation complain, and being in lots of discomfort, crying and trying to push out the feces, what is the best intervention the nurse should do? a) Give her a fleet enema PRN to ease the stool. b)Encourage Mrs. S to push out the feces slowly c)Call the Doctor to get an order for suppository stool softener. d) Give her all her oral PRN laxative medications, and place a warm towel on her lower abdomen Correct answer: d a)As a nurse, you need to first give her all the oral medication then wait to see if it will be effective, and since its just her first complaint of constipation. Also, based on her unstable lab result you should not insert any object into her anus because of the low WBC and platelet count she has. Any injury she sustains will lead to an infection. The reason for her low WBC count and platelet is a side effect of chemotherapy. As a nurse, a preadministration assessment (e.g. laboratory results) needs to be done, in order to give medication appropriately. b) Do not encourage her to push when you have not given her any medication to soften the stool; also pushing might rupture her anus, and that will lead to infection c)You do not have to call the doctor for a new order of laxative (suppository), as you have not given her any of the ordered PRN medication the doctor ordered, also you cannot insert anything into her anus because it might rupture her anus d)Giving her all her oral prescribed laxative including the syrups and the tablets is the most effective way to help her at that moment. According to CNO (2008), nurses have to be able to competently assess clients for the appropriate PRN medication to administer. Also placing a warm towel on her lower abdomen will relieve the cramps. Then whatever result you get after doing all this, if it

is not effective, then call the doctor and document appropriately. If it is effective, you should document appropriately as well. 36. Mr. C. is 78 years old. Diagnosed with bilateral hip pain, has a history of prostate cancer. At 12am he complained of nausea, and he was gagging as well. Originally he has a 12am PO (by mouth) medication. What should the nurse do? a) Give Gravol PRN (PO), and wait 30min-1hour before giving him the 12am PO medication b) Give Zofran/ Ondansteron PRN (IV), and his 12am PO medication c) Give Gravol PRN (PO), and his 12am PO medication d) Give Zofran PRN (IV), and wait 30min-1hour before giving him the 12 am PO medication. Correct answer: d a) Since, he feels nauseated and he is gagging, giving him any PO med. Is not a good idea because he might vomit all the medication back, and that will make the matter worst, and he might not even be able to take is scheduled 12am med. an hour or half an hour later. b) Giving him the antiemetic (Zofran) via IV is a good idea, but giving him his 12am PO medication is not a good because he might vomit the medication. c) Giving him any PO medication at the time that he is nauseated is not a good idea because he might vomit all the medication. d) The best option for him is to take the antiemetic (Zofran) via IV, and then wait for the medication to get to its peak before you give him the PO medication. The client can also be asked if he is still nauseated or not. Since medication can be administer an hour early, and an hour after, it is Ok to give him his scheduled PO med late, that is, he can take the PO med. at 1am. 37. Lucy, two and half years old, is very lethargic, convulsing, and has a temperature of 39.5 degree centigrade. The physician ordered Diazepam (Valium) to be administered to her rectal. The parents are very worry and ask why their daughter is receiving this medication. What should the nurse do? a. b. c. d. Inform them that she is receiving a medication rectally to lower her temperature. Reassure the parents that everything possible is being done for their daughter. Explain to them that she is receiving a medication for her convulsion. Wait for her condition to stabilize and ask the physician to talk to the parents.

Correct Answer: (c) Rationales Diazepam does not lower temperature. This does not answer the parents questions.

Parents need and have a right to receive the information. This does not address the parents immediate concern and it is a nurses responsibility to teach about medication administration. 38. Anita is a nurse in an acute care psychiatric unit caring for Mr. Lin a patient diagnosed with bipolar mania. Anita recognizes that Mr. Lin has gotten into an altercation with another patient and is putting the patient down stating I am better than you because you are worthless. What is the nurses initial response to dissolving the issue? a. Provide the patient with a quiet room to decrease stimuli b. Carefully indicate that aggressive behaviour is unacceptable c. Respond to Mr Lins remarks stating that he is worthless instead d. Reinforce the benefits of good behaviour Correct answer: b a. Providing the patient with a quiet room to decrease stimuli is likely to help the situation with continuing de-escalation however it is better to first let the patient know in a calm matter of fact tone that his actions are unacceptable on the unit. b. Carefully confronting unacceptable behaviour is beneficial for patients with bipolar mania because it helps redirect them to engage in healthier interpersonal interactions while providing noticeable cognitive behaviour therapy c. Responding to Mr. Lins remark in anger would further exacerbate and prolong the altercation. d. Patients with bipolar mania need to be reminded of good behaviour however; unacceptable behaviour should not be overlooked or ignored. 39. Sally is a newly graduated RN working in labour and delivery. Today she is caring for Jennifer, a multiparous woman who gave birth vaginally to a 4200 gram baby boy 35 minutes ago following a very rapid labour. Sally is alone with Jennifer in the room completing her newborn assessments when Jennifer states I keep feeling gushes of blood coming out of me. Sally puts the sides up on the baby cot and pulls back the sheets to see what is on the pads below Jennifer. The pads are completely saturated as are the sheets around the pad, in bright rubra discharge. What should be Sallys next action? A) Press the call bell for assistance and massage the fundus. B) Press the call bell for assistance and take vital signs. C) Initiate a large bore catheter into her vein for blood administration and take vital signs.

D) Massage the fundus and empty the bladder. This question relates to a maternal/infant area of focus. It is testing the nursing intervention related to a postpartum hemorrhage. It is connected to competency #3 of recognizing limitations of practice and seeking necessary assistance (College of Nurses of Ontario, 2008). The correct answer is A. In the first 2 hours after birth, the discharge should not exceed that of a heavy menstrual cycle (Wong, Perry & Hockenberry, 2006). Sally would recognize the situation as a postpartum hemorrhage which can occur when the uterus is not firm and contracting (Wong et al., 2006). A is correct because massaging the fundus is the best way to get the uterus contracting and firm (Wong et al., 2006). When it is contracting, it stops the bleeding from the vessels within the uterus (Wong et al., 2006). According to the Salus Global Corporation in their MOREOB Postpartum Hemorrhage document (2011), the mortality rate associated with a postpartum hemorrhage is greatly decreased when a team approach is taken. By calling for assistance, Sally will have extra help to contact the OB and initiate whatever step is needed depending on the effect the massage has on the amount of bleeding. Sally would also recognize that Jennifer has some risk factors for a postpartum hemorrhage in that she had a macrosomic baby, had a rapid labour and has a high parity (Salus Global Corporation, 2011). Choice B is not the most correct although it would be in other areas of practice if a hemorrhage was suspected. Vital signs are not the best indicator of going into shock as the postpartum woman has many physiologic adaptations (Wong et al., 2006). Also, the blood pressure and pulse would be getting measured every 15 minutes as is standard protocol after a normal vaginal birth (Wong et al., 2006). Choice C is not the next logical step. Although a large bore catheter may be required if blood is needed, it is not as important as stopping the bleeding and getting the uterus to contract. Choice D is not as correct as A in that it does not get the assistance for help. A full bladder may prevent a uterus from contracting efficiently and may need to be emptied but when the bleeding is greater than normal, getting assistance is the priority (Wong et al., 2006). 40. Mrs. Smith, 78 year old client was admitted for shortness of breath. You the nurse enter her room to provide AM care and you noticed she is experiencing respiratory distress. What is the FIRST nursing intervention you would perform? a) Give her 4L of oxygen b) Take a set of vital signs c) Call the doctor d) Raise the head of the bed Correct Answer: A a) Providing oxygen right away helps correct the situation and provide relief to the client. b) Taking a set of vital signs take time to do and during that time, the clients health status could decrease even more because no treatment or relief is being offered. Also the nurse has a general idea what the vitals would be due to the signs and symptoms the client is displaying. c) Calling the doctor and waiting for orders takes several minutes which in the end could affect the clients overall health status d) Raising the head of the bed is the second intervention that would be performed to help the clients health status.