Question

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The unlicensed assistive personnel (UAP) working on a general medical unit ask the charge nurse what they should do first. Which instructions should the charge nurse provide to the UAPS?

Answer 1

Correct Answers:

Shut all doors to client rooms on the unit in case a fire erupts.

Rationale :

⚡A complete power failure can leave hospital units with severely limited lighting and increase the risk of falls, collisions, and other injuries.

🛡️The immediate priority is client safety, so keeping ambulatory clients in their rooms reduces unnecessary movement through dark hallways.

👥The UAPs should remain on their assigned unit and first help secure the safety of the clients already under their care before being reassigned elsewhere.

🚨This action follows disaster-management priorities by minimizing preventable harm while the hospital activates its internal emergency response.

📌Core Message:

During an internal power-failure disaster, UAPs should first keep their assigned clients safely in their rooms to minimize falls and other injuries.

Answer 2

Correct Answers:

Validate prescribed intravenous flow rates.

Rationale :

💉A practical nurse can perform routine, predictable nursing activities for stable clients when these activities fall within the applicable nursing scope of practice.

📋Checking and validating a prescribed IV flow rate is a focused implementation task rather than an initial comprehensive assessment or evaluation of the nursing plan.

🧠The registered nurse retains responsibility for activities requiring initial assessment, nursing judgment, care-plan evaluation, and initial client education.

⚖️Actual PN/LPN scope of practice varies by jurisdiction and employer policy, but delegation must match the delegatee's authorized scope and competency.

📌Core Message:

The PN can validate prescribed IV flow rates, while the RN retains responsibility for initial assessment, teaching, and evaluation of the plan of care.

Answer 3

Correct Answers:

Pain scale.

Rationale :

📊An equianalgesic dose is intended to provide approximately equivalent pain relief when an opioid dose, medication, or route is changed.

🩺The client's reported pain intensity is therefore the most direct assessment of whether the new IV regimen is providing comparable analgesia.

💉When opioids are converted between routes, clinicians must reassess analgesic effectiveness because individual response and opioid tolerance vary.

🔍Although respiratory rate and consciousness must also be monitored for opioid toxicity, they assess safety rather than whether equivalent analgesia has been achieved.

📌Core Message:

The client's pain scale rating is the best measure for determining whether oral-to-IV hydromorphone conversion provides equivalent analgesia.

Answer 4

Correct Answers:

31

Rationale :

🧮The total volume to be infused is 250 mL through tubing calibrated at 15 gtt/mL.

⏱️The prescribed infusion time of 2 hr converts to 120 min.

💧The calculation is 250 mL × 15 gtt/mL ÷ 120 min, which produces 31.25 gtt/min.

🔢Rounding to the nearest whole drop results in 31 gtt/min.

📌Core Message:

Using the prescribed volume, tubing drop factor, and 120-minute infusion time, the vancomycin should run at 31 gtt/min.

Answer 5

Correct Answers:

Provide information on the benefits of weight loss.

Rationale :

⚖️A BMI of 26 kg/m² falls within the standard adult overweight category of 25.0 to 29.9 kg/m².

📚Providing education about healthy weight management is appropriate because the client's BMI is above the supplied healthy reference range.

🩺BMI is a screening measure, so weight-management counseling should also consider health status, physical function, comorbidities, nutrition, and body composition.

👵For older adults, intentional weight loss requires individualized planning to minimize loss of muscle and bone, but bariatric treatment or high-calorie supplementation is not indicated solely by a BMI of 26.

📌Core Message:

A BMI of 26 kg/m² indicates overweight, so individualized education about healthy weight management and its potential benefits is appropriate.

Answer 6

Correct Answers:

Set up supplemental oxygen delivery
Gather supplies for extubation

Rationale :

🫁The client has progressed to zero pressure support and has continued spontaneous breathing, indicating successful tolerance of a spontaneous breathing trial if other clinical criteria remain satisfactory.

🩺A spontaneous breathing trial is used to determine whether a mechanically ventilated client can tolerate the work of breathing required after ventilator liberation.

🧰Following successful evaluation by the healthcare provider, the nurse should prepare extubation supplies so the artificial airway can be removed safely.

💨The nurse should also prepare supplemental oxygen because oxygen support is commonly required immediately after extubation while respiratory status is reassessed.

📌Core Message:

Successful tolerance of spontaneous breathing without pressure support indicates readiness for provider-directed extubation preparation, including extubation equipment and supplemental oxygen.

Answer 7

Correct Answers:

Monitor the client's white blood cell count.
Institute contact precautions for staff and visitors.
Send wound drainage for culture and sensitivity.

Rationale :

🦠A draining wound with suspected vancomycin-resistant Enterococcus requires microbiologic testing to identify the organism and determine antimicrobial susceptibility.

🧫Sending wound drainage for culture and sensitivity helps confirm the causative organism and guide effective antimicrobial therapy.

🧤Contact precautions are appropriate for transmissible multidrug-resistant organisms such as VRE, especially when infected wound drainage cannot be reliably contained.

🩸Monitoring the white blood cell count assists in evaluating the client's systemic response to infection and treatment.

📌Core Message:

Suspected VRE wound infection requires contact precautions, culture and sensitivity testing, and continued monitoring for evidence of infection.

Answer 8

Correct Answers:

Give a 5% dextrose solution as prescribed.

Rationale :

🍬Parenteral nutrition contains substantial dextrose, and interruption can cause a rapid decrease in glucose delivery, especially when exogenous insulin is being used.

💉A prescribed dextrose-containing IV solution can temporarily maintain carbohydrate delivery while the replacement PN bag is prepared.

📚Current nutrition literature describes 5% or 10% dextrose solutions as possible continuous dextrose support when hypoglycemia occurs during interruption of PN.

⚠️The key nursing concern is preventing or treating hypoglycemia rather than substituting oral candy or independently modifying the PN formula.

📌Core Message:

When parenteral nutrition is unexpectedly interrupted, a prescribed dextrose-containing IV solution can maintain glucose delivery and reduce hypoglycemia risk until PN resumes.

Answer 9

Correct Answers:

Do not take any over-the-counter medications.

Rationale :

🫀An acetaminophen overdose can cause severe hepatic injury and potentially acute liver failure.

💊Many over-the-counter medications contain acetaminophen, sometimes under different product names or in combination cold and pain preparations.

⚠️A client with existing liver damage should avoid self-medicating with OTC products and should consult the healthcare provider or pharmacist before taking medications.

🛡️Preventing additional exposure to potentially hepatotoxic medications is therefore the most directly relevant discharge instruction among these choices.

📌Core Message:

After acetaminophen-induced liver injury, the client should avoid unsupervised OTC medication use because many products may contain acetaminophen or other potentially hepatotoxic ingredients.

Answer 10

Correct Answers:

Just before an arterial blood gas (ABG) laboratory specimen is obtained

Rationale :

🖐️The Allen test evaluates collateral circulation to the hand through the radial and ulnar arteries before radial artery puncture.

🩸An arterial blood gas specimen is commonly obtained from the radial artery at the wrist.

🔍Before radial arterial puncture, the clinician checks that blood flow to the hand is adequate through both major forearm arteries.

🛡️This assessment helps reduce the risk associated with puncturing an artery when collateral circulation may be inadequate.

📌Core Message:

The Allen test is performed before radial artery puncture for an ABG to assess adequate collateral circulation through the ulnar artery.

2 :
After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

3 :
A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

5 :
The nurse is caring for an older adult client who has a body mass index (BMI) of 26 kg/m². Which action should the nurse take? Reference Range: Body mass index [18.0 to 24.9 kg/m²]

6 :
The nurse notifies the healthcare provider of the client's status.

Answer Options

8 :
A client has been prescribed parenteral nutrition (PN) therapy. Which nursing action is appropriate if the current parenteral nutrition bag runs out before the new parenteral nutrition bag is ready?

9 :
A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

10 :
When should the nurse perform an Allen's test?

2 : After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

3 : A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

5 : The nurse is caring for an older adult client who has a body mass index (BMI) of 26 kg/m². Which action should the nurse take? Reference Range: Body mass index [18.0 to 24.9 kg/m²]

6 : The nurse notifies the healthcare provider of the client's status.

Answer Options

8 : A client has been prescribed parenteral nutrition (PN) therapy. Which nursing action is appropriate if the current parenteral nutrition bag runs out before the new parenteral nutrition bag is ready?

9 : A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

10 : When should the nurse perform an Allen's test?

2 :
After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

3 :
A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

5 :
The nurse is caring for an older adult client who has a body mass index (BMI) of 26 kg/m². Which action should the nurse take? Reference Range: Body mass index [18.0 to 24.9 kg/m²]

6 :
The nurse notifies the healthcare provider of the client's status.

8 :
A client has been prescribed parenteral nutrition (PN) therapy. Which nursing action is appropriate if the current parenteral nutrition bag runs out before the new parenteral nutrition bag is ready?

9 :
A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

10 :
When should the nurse perform an Allen's test?