CASE STUDY
3
Multiple Clients on a Medical-Surgical Unit
You are the leader of a team providing carefor six clients. Your
team includes yourself (an RN), an LPN, and a newly hired
nursing assistant, who is undergoing orientation to the unit.
The clients are asfollows:
• Mr. C, a 68-year-old with unstable angina who needs
teaching for a cardiac catheterization scheduled this
morning
• Ms. .1, a 45-year-old experiencing chest pain scheduled
for a graded exercise test later today
• Mr. R, a 75-year-old who had a left-hemisphere stroke
4 days ago
• Ms. S. an 83-year-old with heart disease, a history of
myocardial infarction, and mild dementia
• Ms. B, a 93-year-old newly admittedfrom a long-term
carefacility, with decreased urine output, altered level of
consciousness, and an elevated temperature of 99.5° F
(37.5° C)
• Mr. L, a 59-year-old with mild shortness of breath and
chronic emphysema
1. For which clients should you assign the LPN to
perform nursing care tasks, under your supervision?
(Select all that apply.)
1. Mr. C
2. Ms. J
3. Mr. R
4. Ms. S
5. Ms. B
6. Mr. L
2. Which client should you assess first?
1. Mr. C
2. Ms. J
3. Ms. B
4. Mr. L
3. Which key point would you be sure to include when
teaching the client about the postprocedure care after
cardiac catheterization?
1. "There are no restrictions after the procedure."
2. "We will get you out of bed within 2 hours after the
procedure."
3. "You will have to stay flat in bed for 4 to 6 hours."
4. "Family visitors will be restricted until the next day"
4. The physician's orders for Ms. J, who is experiencing
chest pain, are as follows. List the orders in the
sequence in which they should be completed. (Answers
may be used more than once.)
1. Obtain a 12-lead electrocardiogram when the client
experiences chest pain.
2. Administer nitroglycerin (Nitrostat) 0.6 mg sublingually every 5 minutes as needed for chest pain.
3. Administer morphine 2 mg intravenous push as
needed for chest pain.
4. Monitor blood pressure and heart rate.
5. Which task should you delegate to the nursing
assistant?
1. Asking Ms. S memory-testing questions
2. Telling Ms. J about treadmill exercise testing
3. Performing pulse oximetry for Mr. L
4. Monitoring urine output for Ms. B
6. The nursing assistant is delegated the task of measuring
morning vital signs for all six clients. What would you
instruct the nursing assistant to report immediately?
1. Temperature higher than 102° F (38.9° C) orally
2. Blood pressure higher than 140/80 mm Hg
3. Heart rate lower than 65 beats/min
4. Respiratory rate lower than 18 breaths/min
7. The nursing assistant asks you why it is important to
notify someone whenever a client with heart disease
complains of chest pain. What is your best response?
1. "It's important to keep track of the chest pain
episodes so we can notify the physician."
2. "The client may need morphine to alleviate the
chest pain."
3. "Chest pain may indicate coronary artery blockage
and heart muscle damage."
4. "Our unit policy includes specific steps to take in
the treatment of clients with chest pain."
Copyright © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
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CASE STUDY 3 Multiple Clients on a Medical-Surgical Unit
8. The physician's orders for Mr. R (the client with a
stroke) include assisting the client with meals. Which
person should be assigned to this task?
1. Physical therapist
2. Nursing assistant
3. LPN
4. Occupational therapist
9. The nursing assistant tells you that Mr. L, the client
with chronic emphysema, says he is feeling short of
breath after walking to the bathroom. What action
should yot take first?
1. Notify the physician
2. Increasle oxygen flow to 4 L/min via nasal cannula
3. Assess oxygen saturation by pulse oximetry
4. Remind the client to cough and deep breathe
10. The oral temperature of Ms. B, the client newly
admitted from a long-term care facility with decreased
urine output and altered level of consciousness, is now
102.6° F (39.2° C). What is your best action?
1. Notify the physician
2. Administer acetaminophen (Tylenol) 2 tablets orally
3. Ask tlat LPN to give an acetaminophen suppository
4. Remove extra blankets from the client's bed
11. Which factor most likely precipitated Ms. B's elevated
temperature?
1. Bladder infection
2. Increased metabolic rate
3. Kidney failure
4. Nosocomial pneumonia
12. You are vVorking on a nursing care plan for Ms. B.
Which nursing intervention is most appropriate to
delegate to the nursing assistant?
1. Check the client's level of consciousness every shift
2. Assist the client with ambulation to the bathroom
to urinate
3. Teach the client the side effects of antibiotic
therapy
4. Administer sulfamethoxazole/trimethoprim (Bactrim) orally every 12 hours
13. The nursing assistant reports that Mr. L's heart rate,
which was 86 beats/min in the morning, is now
98 beats/min. What would be the most appropriate
question for the nurse to ask Mr. L?
1. "Have you just returned from the bathroom?"
2. "Did you recently use your albuterol inhaler?"
3. "Are you feeling short of breath?"
4. "How much do you smoke?"
14. The LPN reports that Ms. S will not leave the chest
leads for her cardiac monitor in place and asks if the
client can be restrained. What is your best response?
1. "Yes, this client had a heart attack and we must
keep her on the cardiac monitor."
2. "Yes, but be sure to use soft restraints so that the
client's circulation is not compromised."
3. "No, we must have a physician's order before we
can apply restraints in any situation."
4. "No, but try covering the lead wires with the sheet
so that the client does not see them."
15. Close to the end of the shift, the LPN reports that
the nursing assistant has not totaled clients' intake
and output for the past 8 hours. What is your best
action?
1. Confront the nursing assistant and instruct her to
complete this assignment at once
2. Delegate this task to the LPN
3. Ask the nursing assistant if she needs assistance
completing the intake and output records
4. Notify the nurse manager to include this on the
nursing assistant's evaluation
16. The "Five Rights" guide delegation of nursing care
tasks. As the team leader, list the Five Rights.
Copyright © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.