PLACE IN ORDER1. A lethargic one-hour-old infant is brought to the nursery for further assessment. In what order should the nurse assess the infant? 1. Heart rate. 2. Respirations. HRTH 3. Temperature. 4. Heel stick. 2. The nurse is preparing a client for a scheduled cesarean section. In what order should the nurse perform these actions? 1. Verifying the consent form is signed. VIPP 2. Inserting an indwelling catheter. 3. Prepping the site with iodophor (Betadine). 4. Performing a time-out procedure. 3. During change of shift, the oncoming nurse learns that soft restraints were applied to a combative client at 0600 after multiple alternatives were attempted and the client’s healthcare provider was notified. The nurse and unlicensed assistive personnel (UAP) initially enter the client’s room at 0800. In what order should the nurse implement these interventions? 1. Assess the client’s skin and circulation for impairment related to the restraints. AEAC 2. Evaluate the client’s mentation to determine need to continue the restraints. 3. Assign the UAP to follow restraint protocol until a new prescription is obtained. 4. Contact the client’s healthcare provider to confirm continued use of restraints. 4. During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get out of bed, soft restraints were applied at 0400. In what order should the nurse who is receiving report implement these interventions? 1. Assess the client’s skin and circulation for impairment related to the restraints. 2. Evaluate the client’s mentation to determine need to continue the restraints. AEAC 3. Assign unlicensed assistive personnel to remove restrains and remain with client. 4. Contact the client’s surgeon and primary healthcare provider. 5. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells AMSV 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia 6 A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? 1. Call the rapid response team to assist. 2. Move the crash cart to the client room. CMNI 3. Notify the client’s healthcare provider. 4. Inform the family of the critical situation. 7 . The staff nurse is assigned the care of four clients on the day shift. After receiving report, in what order should the nurse assess the assigned clients? 1. An adolescent whose left foot was amputated last night after a tree fell on it. 2. An adult receiving patient controlled analgesia (PCA) whose spinal tumor causes pain and paresthesia. 3. An adult with a leg infection who is scheduled to receive insulin before breakfast. 4. An older adult who had knee replacement and is scheduled for transfer to rehabilitation later today. 8. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. 1. Open the sterile catheter kit close to the client’s perineum. ODCP 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus 9. The nurse is collecting a sterile urine specimen using a straight catheter tray for culture…. The nurse implement these actions? 1. Drape the client in a recumbent position for privacy DODU 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus 10. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? 1. Note date and time of the behavior. NDPE 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. 11. A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? 1. Stop the infusion. 2. Assess vital signs. SACDI 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate an adverse event report. 12. The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? 1. Obtain blood glucose level. OVDC 2. Verify the insulin prescription. 3. Draw insulin into insulin syringe. 4. Cleanse the selected site. 13. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? 1. Start chest compressions with assisted manual ventilations. SAAR 2. Administer epinephrine 0.01 mg/kg intraosseous (IO). 3. Apply pads and prepare for transthoracic pacing. 4. Review the possible underlying causes for bradycardia. 14. Which actions should the nurse implement with auscultating anterior breath sounds? 1. Place stethoscope in suprasternal area to auscultate from bronchial sounds PADD 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds 15. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? 1. Verify the drug and dose with the label on the vial VIAA 2. Inject the volume of air to be aspirated from each vial 3. Aspirate the desired volume from vial A 4. Aspirate the desired volume from vial B 16. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? 1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. TDSCF 3. Submit a written report to the director of nursing. 4. Contact the hospital’s chief of medical services. 5. File a formal complaint with the state medical board. 17. A client is complaining of intermittent, left, lower abdominal pain that began two days ago…implement the following interventions? 1. Determine when the client had last bowel movement 2. Position client supine with knees bent DPIA 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants