Macncheese
A nurse is teaching a client recovering from a cerebrovascular accident how to dress. The client has residual hemiplegia, so the nurse instructs the client to do which of the following when putting on a shirt?
"Slide your weaker arm through its sleeve first." This method allows the client optimal use of the strong arm in getting the shirt on over the weaker arm.
A client is about to have a nasogastric tube (NG) inserted. The nurse explains the procedure and is ready to begin the insertion when the client says, "No way! You are not putting that hose down my throat. Get away from me." Which of the following statements is an appropriate nursing response?
"I can see that this is upsetting you." This response addresses the client's feelings. It uses the communication tools of reflecting and restating, which encourage communication by the client.
A nurse is preparing a client with a compression injury of the right leg for surgery. After administering the preoperative benzodiazepine, lorazepam (Ativan) as prescribed, the nurse determines that the medication was effective when the client states,
"I feel very sleepy." Preoperative doses of benzodiazepines, such as lorazepam (Ativan) and midazolam (Versed), relieve anxiety and promote sedation.
A client was admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). After the client's condition is stabilized, the client says to the nurse, "All this equipment is making me nervous. Am I so sick that I need all of this?" Which of the following is an appropriate nursing response?
"All of this equipment can be frightening." This statement is therapeutic because it demonstrates the nurse's empathy. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.
A client taking several medications to treat congestive heart failure and rheumatoid arthritis arrives at the clinic reporting fatigue, anorexia, and nausea. Which assessment question is the nurse's priority?
"Have you been taking your medication as prescribed?" This is the nurse's priority because the client takes several medications and therefore is at increased risk for drug interactions and adverse reactions. Fatigue, anorexia, and nausea are common symptoms of both drug interactions and toxicity. Drug interactions and adverse reactions can have the potential to become life-threatening.
A client is admitted to the hospital after being on bed rest at home. The client has been incontinent and smells strongly of urine. His spouse, who has been caring for him at home, states that she is sorry and embarrassed about the unpleasant smell. Which response by the nurse is therapeutic?
"It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the client (the spouse, in this case) by using the communication tool of showing empathy. It also facilitates therapeutic communication because it is nonjudgmental and encourages the spouse to express her feelings.
A client began having sleeping problems 6 months ago soon after being diagnosed with cancer. Prior to that, the client had good physical health, however, the client's spouse of 50 yr died 1 yr ago this week. The client tells the nurse, "I'd be better off dead because I am totally worthless." Which of the following is an appropriate nursing response?
"You have been feeling very sad and alone for some time now." Clients who are depressed have difficulty expressing their feelings. This response by the nurse uses the therapeutic communication tools of empathy, and reflecting to help the client become more aware and accepting of his feelings.
A nurse is planning care for a client with a nasogastric tube following abdominal surgery. Which of the following should the nurse include in the plan of care? (Select all that apply.)
1. Provide oral hygiene frequently. 2. Measure the amount of drainage from the nasogastric tube every 8 hr shift. 3. Secure the nasogastric tube to the client's gown.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse should be concerned about which of the following findings?
A wound dressing with thick, light green drainage. Thick, light-green drainage indicates infection. This is the finding that should cause concern; the nurse should report this to the surgeon immediately.
A postoperative client's knee dressing becomes completely saturated with blood 1 hr after transfer to the clinical unit. Which of the following is an appropriate nursing action?
Apply direct pressure to the operative site. Most bleeding can be stopped with direct pressure, unless a major artery has been severed. The surgeon must be notified because, in some cases, the client must return to the surgical suite for ligation of the bleeding vessels.
A nurse is caring for a 16-year-old client who has multiple injuries including a brain contusion as a result of a motor-vehicle crash. He has been combative and impulsive and has pushed the nurse away and climbed over the side rails. His parents tell the nurse, "This is not like our son at all." Which nursing intervention will best ensure the safety of this client?
Assign a staff member to sit with the client around the clock. Restraints may only be used when all other methods to control a client's unsafe behavior are exhausted. In this situation, these methods include moving the client to a safer location, reorienting the client, and arranging for a staff member to sit with the client at all times. The nurse realizes that the action most likely to ensure the client's safety is to enlist a sitter. A sitter can provide the continuity of care this client needs, including frequent reorientation of the client's behavior for unsafe actions.
A client who has type 1 diabetes is scheduled for an appendectomy. The client has been NPO since midnight. There are no preoperative orders for a daily insulin dose. Which intervention is appropriate?
Call the provider to request an insulin prescription. Surgery is stressful, and adjustments in the diabetes regimen can be planned to ensure glycemic control. Typically, the client is given IV fluids and insulin immediately before, during, and after surgery when there is no oral intake. In this situation, the nurse must contact the provider to clarify how to proceed.
A nursing is caring for a client who is 1 day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that a client's wound has eviscerated?
Cover the incision with a moist sterile dressing. A wound open to air could easily become contaminated, leading to peritonitis, and any exposed organ tissue could dry out. Covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.
A nurse enters a client's room and finds the client is in respiratory arrest. What is the first action the nurse should take?
Establish an open airway. Remember the ABCs of a client found in arrest: Airway, Breathing, and Circulation. The first action the nurse should take is to establish an open airway using the head-tilt, chin-lift method. When cervical injury is suspected, the nurse should open the airway using the jaw-thrust method.
A nurse has just finished teaching a client with diverticulosis about appropriate dietary choices. Which selection by a client on the following day's menu indicates to the nurse that the client understands the teaching?
Fresh green beans instead of canned for lunch A high-fiber diet can help relieve the symptoms. A diet high in fiber produces a large, bulky fecal mass that requires a shorter transit time in the bowel and helps maintain intracolonic pressure within a normal range. The diet should include raw fruits and vegetables instead of canned or cooked ones.
A client is ambulating in the hallway in bare feet. What is the priority nursing action at this time?
Get the client's slippers and have him put them on. Making sure that the client wears slippers or shoes is the priority action since it addresses the client's immediate risk of slipping on the floor.
A nurse is caring for a client admitted to the hospital with a high fever, chills, and dehydration. The nurse knows that which laboratory test will not help the provider confirm infection?
Glucose Blood glucose would not be part of the screening procedure for infection. This test is primarily used for clients who have diabetes mellitus. TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer has to be an INCORRECT laboratory test.
Which nursing action demonstrates safe principles of administering a routine immunization to an infant?
Inject the vaccine into the vastus lateralis muscle. The vastus lateralis muscle is the preferred site for administering routine immunizations to infants because it is large enough to accommodate the volume of the medication.
A nurse is assessing a client who is postoperative following thoracic surgery. Which of the following manifestations should alert the nurse to the possibility of early hypovolemic shock?
Irritability Hypovolemic shock results from a loss of circulatory volume, usually due to hemorrhage. Early in hypovolemic shock, hyperactivity of the sympathetic nervous system with increased secretion of epinephrine makes the client feel anxious, nervous, and irritable.
A client had a hiatal hernia repair 3 days ago. During this morning's assessment, the client tells the nurse, "My abdomen feels swollen, I'm nauseated, and I have even more abdominal discomfort." What should be the nurse's initial action?
Listen for bowel sounds. Paralytic ileus is a complication of after intestinal or abdominal surgery. It's characterized by the absence of bowel sounds, abdominal discomfort, and distention. The nurse should complete an abdominal assessment before taking any other action. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.
A client is transported to a post-anesthesia care unit (PACU) following a splenectomy. The abdominal dressing is dry and intact and IV fluids are infusing at 125 mL/hr. Which of the following is a priority nursing goal at this time?
Maintaining a patent airway Following the ABC (airway, breathing, circulation) guideline, the highest priority goal is maintaining a patent airway.
A right handed client is admitted with a fractured right arm and contusions of the left wrist following a motor vehicle crash. Which intervention should the nurse use when assisting the client with feeding?
Offer small bites of food. Offering small bites of food helps keep the client from choking because of too much food in the mouth.
While eating, a client suddenly coughs a few times then attempts to cough and makes a whistling sound on inhalation. The nurse recognizes that the client is choking. When performing the Heimlich maneuver on a conscious client, which nursing action is effective?
Place both arms around the client, and position a fist in between the bottom of the sternum and the navel. This is the required emergency intervention. The client needs immediate assistance to dislodge the object that is obstructing her airway, as demonstrated by her inability to cough and the whistling sound on inspiration. This is the correct placement for the fist in the Heimlich maneuver: above the navel and below the end of the sternum.
The provider orders a cleansing enema for a client having bowel surgery. Which nursing intervention is appropriate during this procedure?
Position the client on his side. Positioning is an important aspects of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.
A client is transferred to the postanesthesia care unit after a colon resection for adenocarcinoma. Which manifestation would the nurse expect to see if the client were to develop internal abdominal bleeding postoperatively?
Tachycardia Because of the decreased circulating blood volume due to internal bleeding, oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output along with increasing the respiratory rate.
A client is being discharged to home with oxygen therapy via a nasal cannula. Which instruction should the nurse give to the client and family?
Wear clothing to avoid static electricity. The use of cotton clothing will limit static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.
A nurse is planning range-of-motion exercises for a client. The nurse understands that active range of motion is performed before passive range of motion (PROM) because
active range of motion is used to determine limitation of movement. Active range of motion is performed before passive range of motion to determine limitation of movement. This helps ensure that no injury will develop during passive range of motion. Active range of motion requires muscle power and therefore, must be done first. Passive range of motion is then used to assist with circulation, decrease pain, maintain joint and soft tissue flexibility, and keep the client aware of the area of treatment.
Following an accidental fall while playing volleyball, a client is sent home in a lower leg cast due to a hairline fracture of the tibia and must use crutches. When teaching the client the four-point gait, the nurse explains that the client should
be able to bear weight on both legs. With the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. Thus, both legs must be able to bear some weight. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times.
A client is 2 days postoperative following an appendectomy. While changing the linens on the client's bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to
carefully place the soiled sheet in a moisture-resistant plastic laundry bag. Placing the sheet in a moisture-resistant plastic bag protects the laundry employees and others that may come in contact with the bag from exposure to organisms that may be present in the soiled linen.
While preparing a client for discharge, the nurse teaches the proper position for postural drainage. The nurse knows that to achieve success in this teaching program, the information about the client that is most important is the
client's goal concerning his ability to be self-sufficient. The client's motivation and goals are essential for success, and they are a primary concern in any teaching program. Teaching/learning theory states that if the client is not motivated or goal-directed, the discharge teaching program is unlikely to be effective.
Following an emergency splenectomy, a 17-year-old client is admitted to the nursing unit from the postanesthesia care unit (PACU). The client reports severe abdominal pain, and the client's parents are asking to see their child. The nurse's first action should be to
complete a physical assessment including postoperative vital signs. Any client recovering from surgery may have altered vital signs, and the nurse's first priority is a full physical assessment. In addition, a client who has had an emergency splenectomy is at risk for abdominal hemorrhage and has an increased risk for hypovolemia. Therefore, vital signs are a priority. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.
Before giving preoperative medication to a client being prepared for surgery, the nurse must make sure that the
consent form has been signed. For legal reasons, the nurse must always check that the consent form has been signed prior to administering preoperative medication. Clients cannot give consent if medications that cause cognitive alterations have been administered.
When transcribing the orders for a client admitted with an exacerbation of systemic lupus erythematosus (SLE), a newly licensed nurse notes that the provider has prescribed a medication with which the nurse is unfamiliar. The nurse should
consult the medication reference book available on the unit. The nurse should become familiar with the medication by researching it in the latest medication reference available. Another appropriate resource is the hospitals pharmacy staff.
A nurse is caring for a female client who has an indwelling urinary catheter. The nurse determines that the assistive personnel (AP) performing hygiene care for the client requires further education about the care of indwelling catheters when she observes the AP
hanging the collection bag at the level of the bladder. The collection bag must be kept below the level of the bladder to prevent backflow of urine into the bladder. TEST-TAKING STRATEGY: With a negative-format question, the CORRECT answer will be an INCORRECT action.
A nurse is caring for a 5 year old child returning from the surgical suite following an exploratory laparotomy and removal of a ruptured appendix. When writing the child's nursing care plan, the nurse lists the priority intervention as
having the child turn, cough, and breathe deeply every 2 hr. Keeping in mind the nursing guideline of ABC (Airway-Breathing-Circulation), the nurse realizes that a child recovering from abdominal surgery is at increased risk of atelectasis and impaired breathing. Coughing and deep breathing are a priority because the immediate risk for the client is atelectasis, and this presents the greatest risk to the client immediately following surgery.
Two days postoperative following a small bowel resection, a client reports gas pains in the periumbilical area. The nurse notes abdominal distention and revises the client's care plan based on the knowledge that postoperative gas pains develop as a result of
impaired peristalsis of the intestines. Normal bowel function is delayed up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The client needs to get out of bed and ambulate.
A nurse caring for a client who is immobilized knows that, without interventions to prevent constipation and fecal impaction, this client is at risk for
intestinal obstruction. A fecal impaction is the presence of either hardened or putty-like feces in the rectum and sigmoid colon. If the condition is not relieved, intestinal obstruction can occur.
During the termination phase of a therapeutic nurse client relationship, the nurse should initiate discussion about the concept of
loss. At the close of a relationship, even one that is planned, a person will feel loss. The nurse should recognize the client's feelings of imminent loss and help her deal with these feelings. This is the essential part of the termination phase.
A nurse is to planning to insert a nasogastric (NG) tube. The nurse understands that an improper use of the NG tube would be for
maintaining NPO status. Maintaining NPO status is an inappropriate use of an NG tube. Instillation of liquid nutritional supplements of feedings for clients unable to swallow fluid is an appropriate and common use of an NG tube.
A nurse caring for a preoperative client administers atropine as prescribed to
minimize oral and respiratory secretions. Anticholinergic medications, such as atropine, are given to dry the oral and respiratory mucous membranes.
A client who reports shortness of breath requests the nurse's help in changing positions. In addition to repositioning the client, the nurse's highest priority should be to
observe the rate, depth, and character of the client's respirations. Before initiating 15-min checks, calling the provider, or giving a back rub, the nurse should assess the client. Following the assessment, one or more of the other actions may be appropriate. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.
A client is admitted to the hospital with generalized weakness. At dinner time, the nurse should
open the milk and juice containers for the client. Opening containers makes it easier for the client to eat.
A nurse has organized a discussion session for assistive personnel (AP) at an extended care facility about cultural and religious traditions and rituals at the time of death. The nurse determines that one of the participants has a misconception when the AP states that
organ donation is strictly forbidden by the Baptist Church. Some people may believe that donation conflicts with their faith. However, most major religions accept or encourage organ donation. Although specific teachings and requirements related to donation vary, there is general agreement that donating organs or tissues to benefit others demonstrates love for other people. The Baptist Church leaves the decision to the individual, but donation is supported as an act of charity. TEST TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer is an INCORRECT belief.
A client is prescribed a hypothermia blanket. When caring for the client, the nurse
places a layer of cloth between the client and the blanket. A hypothermia blanket is used to cool a client with a high fever unresponsive to antipyretics. To prevent tissue damage, the client's skin should never come in direct contact with any method used for cooling or heating purposes. Placing a layer of cloth between the client and the cooling blanket will protect the client from injury.
A nurse is caring for a client on strict bed rest. When entering the client's room, the nurse notices flames in the waste basket. The nurse's priority action is to
pull the client out into the hall in the bed. The client in the room with a fire is at high risk for injury. The smoke from a fire can deprive a client of adequate oxygenation, and the fire poses a direct threat to the safety of this client. Moving this client to safety is the first priority. Because the client is on strict bed rest, the nurse removes the client from the room while still in the bed. The acronym RACE: Remove, Alarm, Contain, and Extinguish.
Hot coffee spills and scalds a client's arm. The nurse's priority action is to
remove the clothing from the burned area and apply cold water. Removing the hot clothing and applying cold water helps stop the burning process. This is the nurse's priority in this situation.
A client admitted to a long term care facility requires total care. In providing mouth care to the client, the appropriate nursing action is to
turn the client on his side before starting mouth care. Placing the client on his side allows excess fluids to run out of his mouth into a basin, thus reducing the risk of aspiration of fluids and secretions.
A provider has prescribed restraints for a client who is agitated. When applying restraints, the nurse would put the client at risk by
tying the restraint with a knot that cannot be easily undone. Restraints should be tied with knots that can be undone easily in case the client's well-being necessitates quickly removing the restraints. To protect the client from releasing the restraints, the knot should be placed where the client cannot easily reach it. TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer has to be an INCORRECT action.
Within the context of the nurse client relationship, congruence on the part of the nurse implies
using communication tools in a genuine and spontaneous manner. Congruence is an expression of genuineness on the part of the nurse accomplished by consistently using therapeutic verbal and nonverbal communication.
