The correct answer number and rationale for why it is the correct answer are given in boldface type.
Rationales for why the other possible answer op-tions are incorrect also are given, but they are not in boldface type.
1. 1. Praxada is a medication specifically prescribed to prevent clotting in clients who have atrial fibrillation. Any nurse could administer the first dose of the medication; it would not have to be the most experienced nurse.
2. Pink, frothy sputum indicates pulmonary edema, which is a serious complication of CHF; therefore, the most experienced nurse should be assigned this client.
3. Occasional premature ventricular contrac-tions are experienced by most individuals and this client would not require the most experienced nurse.
4. Clients with mitral valve prolapse exhibit signs of congestive heart failure; therefore, SOB is expected and the most experienced nurse should not be assigned to this client.
2. 1. The crash cart would need to be brought to the room if the client was coding, but first the nurse should determine if the client’s leads are on the chest.
2. The Rapid Response Team is called if the client is in a potentially life-threatening situation and the nurse must first determine if the leads are on the client.
3. The nurse should assess the client’s vital signs but because the telemetry technician reports the client is flat-lined the nurse should first check if the leads are in place on the chest.
4. The nurse should first determine if the client’s telemetry leads are in place on the chest. If the leads are off then it will show as a flat line at the telemetry station.
The telemetry technician cannot leave the station.
3. 1. This warrants intervention because the telemetry technician needs to know if the client’s telemetry is being removed so the technician won’t think the client is in asystole.
2. The electrodes attached to the client’s chest do not have to be removed when the client showers, so this would not warrant interven-tion. The telemetry must be removed, not the electrodes.
3. Placing a bath chair in the shower is an ap-propriate intervention so the client won’t get
tired during the shower; this would not warrant intervention.
4. The UAP should stay near the client in the shower in case the client needs assistance; this would not warrant intervention.
4. 1. The therapeutic digoxin level is 0.8 to 2.0 mg/dL; therefore, Ms. Teresa should notify the client’s HCP because this is above the therapeutic level.
2. The therapeutic INR level is 2 to 3; there-fore, Ms. Teresa would not notify the HCP.
3. The normal potassium level is 3.5 to 5.5 mEq/L, so Ms. Teresa would not notify the HCP.
4. Normal cholesterol level is below 200, but 205 is not life threatening and would not warrant notifying the HCP.
5. 1. This client must have an admission assess-ment completed and Ms. Teresa cannot assign assessment to an LPN.
2. The client with SVT will need intravenous adenosine; therefore, this client should not be assessed to an LPN.
3. The LPN could care for a client who has had a diagnostic test; this would be an appropriate client assignment.
4. Ms. Teresa cannot assign teaching to the LPN.
6. 1. The client would need to have cardiac isoen-zymes to determine if a myocardial infarction has occurred; therefore, this HCP would not be questioned.
2. The client probably has coronary artery disease and a low-fat, low-cholesterol diet would be expected.
3. Intravenous morphine is the drug of choice for chest pain; therefore, this order would not be questioned.
4. An endoscopy is not an usual diagnostic test for a client diagnosed with R/O myo -cardial infarction; therefore, Ms. Teresa should question this order.
7. 1. The UAP can obtain the client’s weight.
The nurse cannot delegate assessment, teaching, evaluation, medications, or an unstable client.
2. The custodial or housekeeping department is responsible for cleaning the room, not the UAP.
3. The nurse cannot delegate assessment, teach-ing, evaluation, medications, or an unstable
client. A client who is hypovolemic is not stable; therefore, this task cannot be delegated.
4. The nurse cannot delegate assessment, teach-ing, evaluation, medications, or an unstable client. Discussing the diet is teaching, which cannot be delegated to a UAP.
8. 1. The nurse can check the MAR but it is not the first intervention when the client is having acute chest pain. Remember, the nurse does not treat paperwork.
2. When the client is in distress the nurse should not assess. The nurse should treat the client’s pain immediately; therefore, this is not the first intervention.
3. The nurse should treat the pain, so ad-ministering sublingual nitroglycerin, a coronary vasodilator, is the nurse’s first intervention.
4. The nurse should administer oxygen but not prior to addressing the client’s chest pain first.
9. 1. The nurse must first determine if the client has a pulse. If the client does not have a pulse then the nurse must defibrillate the client. If the client has a pulse then the nurse should not defibrillate the client.
2. The nurse must determine if the client has a pulse or not prior to taking any further action; therefore, this is the nurse’s first intervention.
3. This is the first medication administered during a code but the nurse first determines if the client has a pulse.
4. This is appropriate intervention if the client has no pulse but the nurse first determines if the client has a pulse.
10. 1. Nitroglycerin tablets lose efficacy when exposed to sunlight; therefore, keeping the tablets in a dark bottle indicates the client understands the teaching.
2. A sedentary lifestyle is a modifiable risk factor for atherosclerosis, which causes angina, so walking three times a week is an appropriate intervention.
3. This is a modifiable risk factor; the client must stop smoking altogether. Decreasing the number of cigarettes a day indicates the client needs more teaching.
4. A daily aspirin will help prevent platelet aggregation; therefore, this indicates the client understands the discharge teaching.
SCENARIO ANSWERS
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