Basic Physical Care PrepU

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?

Assess the patient for the medications' effects. The nurse should immediately assess the client who received the wrong medications. This assessment should include potential allergies to the medications and the side effects of the medications. The nurse should then notify the practitioner and the charge nurse. An incident report should be completed and submitted as directed by the facility's policy. The nurse should complete a set of vital signs with the assessment of the client.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

At the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

A scrub nurse in the operating room has which responsibility?

Handing surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:

Improved circulation to the area. Heat applications cause vasodilation, which promotes circulation to the area, and increase tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of cold are used to prevent swelling by causing vasoconstriction. Moist heat applications do not reduce bruising or scaling on the skin.

When providing oral hygiene for an unconscious client, the nurse must perform which action?

Place the client in a side-lying position. An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.

The nurse is observing a client who is recovering from back strain lift a box as shown in the accompanying image. What should the nurse do?

Praise the client for using correct body mechanics. The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which of the following actions should the nurse take before starting the NG feeding on the child? Select all that apply.

- Verify the physician's order. - Check placement of the NG tube. - Assess for bowel sounds. Verifying the order, checking the placement of the NG tube, and assessing bowel sounds are necessary before initiating an NG feeding. Formula should not be heated in the microwave, and no more than a 4-hour supply should be hung to prevent the growth of microorganisms.

A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when the vital signs suddenly change. The nurse checks the recovery room record (see chart). In addition to notifying the health care provider (HCP), what other action should the nurse take immediately?

Administer dantrolene The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetabolism occur. The client's body temperature can rise as high as 109° F (42.8° C) as body muscles contract. Dantrolene, an IV skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia.

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

Asking the physician to write an order for home skilled nursing assessments and interventions Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home health care. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home health care. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse?

Complete an incident report. Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps are kept in the client's hospital room for:

Handling of the dislodged radiation source. Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

Moist sterile saline gauze Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

During the entry phase of a home visit, the nurse is likely to perform which of the following tasks?

The nurse establishes nursing diagnoses for the client. During the entry phase of a home visit, the nurse develops rapport with the client and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. The pre-entry phase includes making initial contact, scheduling a visit, gathering supplies needed for the first visit, and obtaining directions to the client's home.

A priority for nursing care for an older adult who has pruritus, is continuously scratching the affected areas, and demonstrates agitation and anxiety regarding the itching is:

Preventing infection. The client is at risk for infection because of the pruritus, and the nurse should institute measures to help the client control the scratching such as cutting fingernails, using protective gloves or mitts, and, if necessary, using antianxiety medications. More information is required regarding the knowledge level of the client, but learning cannot take place when an individual's attention is distracted with pruritus. Increasing fluid intake is not a priority at this time. There are no data to indicate the client is experiencing social isolation.

The nurse is assigning care to the unlicensed assistive personnel (UAP) for a client with a nasogastric tube with intermittent suction after gastric surgery. Which tasks cannot be delegated to the UAP?

Repositioning the tube Repositioning the tube in a client who has undergone gastric surgery should be performed (per prescription of the surgeon) by the registered nurse. Recording output, securing the nasal tape, cleansing the nares, and documenting the color of the drainage could safely be delegated to the UAP.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6° F (37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)?

Temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min his client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 100.4° F (38° C) (or less than 96.8° F [36°C]), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min. The fourth indicator is an abnormal white blood cell count (greater than 12,000 [12 × 109/L], less than 4000 [4 × 109/L] or greater than 10% [0.1 × 109/L] bands). At least two of these variables are required to define SIRS.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions. The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.