Nurs 125 Test 2
A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate?
"The client and family are in control of the setting, not the nurse."
In which situation would the SBAR technique of communication be most appropriate?
A nurse is calling a physician to report a client's new onset of chest pain.
What is one of the registered nurse's primary roles in the administration of general anesthetic?
Assessing the client's status during recovery from anesthetic
A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent?
Clearly defining the purpose and expectations of the admission
What is the primary purpose of the client record?
Communication
The nurse is preparing to administer a pregnant client's medication when it is noted that the client is prescribed tetracycline for an infection. The nurse should do which of the following?
Contact the physician
A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to:
communicate these feelings to family and friends.
Continuity of care for a particular client is most important to prevent:
fragmentation of services.
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of
graft-versus-host disease.
The nurse is providing care to a child with cancer who is receiving monoclonal antibodies as part of the treatment plan. The nurse notifies the primary health care provider to report assessment of which as possible side effects? Select all that apply.
hypotension fever rigors
The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action
Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.
A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply.
Giving a bed bath to a client Taking routine vital signs Transferring a client to another floor
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
Low-sodium diet
Which diagnostic test is done to determine suspected pituitary tumor?
computed tomography scan
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family.
Which of the following nursing interventions contributes to achieving a client's pain relief?
Collaborate with the client about his or her goal for a level of pain relief
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?
Delay the instruction until the visitors leave
The client with a diagnosis of heart failure reports frequently awakening during the night with the need to urinate. What explanation will the nurse offer to explain the urination?
Edema is collected in dependent extremities during the day; at night when the client lays down, it is reabsorbed into the circulation and excreted by the kidney
The registered nurse (RN) observes the unlicensed assistive personnel (UAP) take a rectal temperature on a 6-month-old client diagnosed with diarrhea. Which action by the RN is appropriate?
Educate the UAP on when to avoid taking rectal temperatures
Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client?
Educator
A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately?
Smell of natural gas
A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate?
"I collaborate with health care teams to promote client care."
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?
Ask the client to verbalize the medication regimen and diet modifications required.
Following the injection of a prescribed vaccination, a client has injected antibodies circulating through the body. The nurse explains the client's body will respond in what manner?
Be able to respond to the presence of antigens more quickly.
Which would be most important for the nurse to do in order to maximize client adherence with the discharge plan?
Call the rapid response team.
The home health care nurse is providing information to a client and family on medication changes. What role is the nurse performing?
Client and family educator
The nurse is working with community groups. At which of the following locations would the nurse anticipate a possible scabies outbreak?
College dormitory
The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?
Communicate with the physicians to coordinate their orders.
The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?
Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.
The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating
Discovering a problem
A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?
High-protein
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?
I provide indirect care to my clients by coordinating their treatment with other disciplines."
The client with blindness is hospitalized following a myocardial infarction. Which care measures would the nurse take with this client? Select all that apply.
Identify self when walking into the client's room. Orient the client to the room using a clock reference. State when the nurse is leaving the room
The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to admit a pediatric client to a nursing unit. Which task would be inappropriate for the RN to delegate to the UAP?
Initiating intravenous therapy
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?
Insertion of a nasogastric (NG) tube
Which points should be included in the medication teaching plan for a client taking adalimumab?
It is important to monitor for injection site reactions.
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?
Scrub role
Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?
Standardized
A nurse is preparing for handoff communication for a client who is being discharged from the hospital to home health care. Which example is not an action performed during this process?
The nurse prepares the new room for the client.
The nursing theorist Peplau identified which as the essence of psychiatric-mental health nursing?
The nurse-client relationship
The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?
The nursing assistant places the drainage bag on the client's abdomen for transport.
When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided?
The registered nurse
A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy?
To prevent metastasis
A client with multiple sclerosis is being discharged. The nurse understands that living with chronic conditions imposes many challenges, including the need for which accomplishments? Select all that apply.
Validate individual self-worth Validate family functioning Alleviate and manage symptoms
A client has undergone diagnostic testing for human immunodeficiency virus (HIV) using the enzyme immunoassay (EIA) test. The results are positive and the nurse prepares the client for additional testing to confirm seropositivity. The nurse would prepare the client for which test?
Western blot assay
A client is about to undergo cardiac catheterization for which informed consent was obtained. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed
Withhold the medication and notify the physician immediately.
The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?
Work effectively in interdisciplinary teams
A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?
Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as neede
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?
acute
The exchange of information among the client, the caregivers, and those responsible for care while the client is in a care setting (and after the client returns home) is key to successful:
community service.
Continuity of care is an important concept for quality nursing practice. The responsible nurse understands the best description of the process of continuity of care is to:
coordinate uninterrupted care and facilitate transfer between units and levels of care.
A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:
have group members confront the dominant member to promote the needed team work.
When moving a client up in bed with the assistance of another caregiver, the nurse should
have the client fold the arms across the chest.
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out)
When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to:
provide for the coordination and continuity of care by the health care providers.
A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of dysrhythmia does the client have?
sinus bradycardia
A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take?
Have the social worker visit the client to discuss care options.
An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?
Support system
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
place a hand gently on the fetal head to guide birth.
A male client diagnosed with bone cancer has an order for clonidine on his chart. The nurse is concerned that this may be a mistake and asks another nurse why clonidine would be ordered for this client. What would be an appropriate response from the second nurse?
"Clonidine is sometimes prescribed for severe pain in cancer clients like this client."
Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node.
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?
A client who has leg strength and can cooperate with the movement
Two nurse managers working on different units in a hospital are planning for a major change to occur on both units. One nurse manager reports to the other having identified a key power player on the unit. Which description most applies to a key power player in this context?
A regular employee who is a natural leader
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?
A standardized care plan
he nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?
Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.
A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success?
Coordinator
The nurse manager is concerned about the large number of teenage mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?
Enlist volunteers to help develop a community outreach project that will educate teenagers on methods to prevent pregnancy.
When initiating home health care services, during which phase is it appropriate for the nurse to implement the initial client assessment?
Entry phase
The nurse is working with a coalition that is creating a global strategy to prevent and control diabetes. The nurse suggests which strategies? Select all that apply.
Focusing on healthy lifestyle programming Monitoring incidence and prevalence rates Creating policies for diabetes prevention Partnering with the American Diabetes Association
A nurse is providing care for a child diagnosed with beta-thalassemia who is receiving a blood transfusion. The child reports being bored and asks to go to the playroom. What is the best action for the nurse to take?
Have a child-life specialist find an appropriate activity to occupy the child during the transfusion.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?
Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly
Which phase of individual psychotherapy involves establishing mutual boundaries of the relationship between the client and the mental health nurse?
Introductory
The nurse manager calls a staff into a unit meeting to discuss patient satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying?
Laissez-faire
A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?
McRoberts maneuver
A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?
Measure blood glucose concentration every 4 to 6 hours
The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize?
Notify the RN who will then notify the health care provider.
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?
Notify the physician for additional orders.
A two-day postoperative client's temperature was 98.5°F (36.9°C) at 3:00 pm. At 6:00 pm, the unlicensed assistant (UAP) notifies the nurse that the client's temperature is 102°F (38.9°C). Which action should the nurse take?
Notify the physician.
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?
Nursing assistant
The client is being discharged to the home setting following a stroke. The client requires assistance in relearning how to cook safely. To which home health care team member should the nurse refer the client?
Occupational therapist
A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered?
Ongoing planning
The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining.
Outcome
A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include?
Participation in decision making that is shared by all involved
Which would be most important for the nurse to do in order to maximize client adherence with the discharge plan?
Partnering with the client from the beginnin
The scrub nurse is responsible for:
Preparing the sterile instruments for the surgical procedure
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?
Providing accurate and complete communication to the new facility.
In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?
Providing client education
A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take
Receive the prescription over the phone and repeat it back to the HCP to verify accuracy.
A triage team is assessing a client to determine if reported chest pain is a manifestation of angina pectoris or an MI. The nurse knows that a primary distinction of angina pain is?
Relieved by rest and nitroglycerin
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician.
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take
Report the findings to the pediatric health care provider.
A client with borderline personality disorder (BPD) tells the nurse, "You are good but the nurse on the afternoon shift is bad. The doctor is bad, too, but the therapist is good." The nurse interprets this statement as reflecting what?
Splitting
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? You Selected:
Standardized
A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation?
Suggest a shared assignment with a senior staff nurse.
A nurse working on the adolescent unit has a strained working relationship with a coworker and finds it difficult to work well with the coworker. What is the best way for the nurse to go about defusing this situation?
Talk with the coworker and try to work out differences so they don't affect client care.
A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services?
The change to shorter hospital stays
What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.
The client is able to answer the nurse's questions. The client verbalizes understanding of the instructions. The client discusses the specifics of what was taught during the session.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
The client with continuous pulse oximetry who requires pharyngeal suctioning.
Which therapeutic factor refers to the group members' relationships to the therapist and other group members?
group cohesion
A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding?
testing the client for the presence of HIV
The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer?
therapeutic play
A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal?
transurethral resection of the prostate (TURP)
A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. What should the nurse discuss with the health care provider before catheterization
type and size of the catheter to be used
The nurse is caring for several families in the home care setting. What additional team member will the nurse have available to assist in the home setting?
unlicensed assistive personnel
In the hospital setting, a nurse is responsible for overseeing the quality and financial outcomes of client care while working collegially with health care providers. What type of professional nursing practice is this considered?
Case management
A client with mental illness is being discharged to a group home. The discharge planning nurse is helping the family to make the transition. The discharge planning nurse is least responsible for what related to the client's discharge?
Chart review for inadequacies
The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?
Data gathering, identification of client strengths, and assurance of client safety during the assessment phase
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying?
Democratic
The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and physicians is exhibiting what style of leadership?
Democratic
A nurse informs the client that the client has no choice and must take a bath in the morning. What type of leadership does this exemplify?
Directive leadership
In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant
Dispose of the disconnected IV set."
A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication?
Double-check the dose with another RN before giving.
During the newborn examination, the nurse notes that an infant who is appropriate for gestational age by birth weight has a head circumference below the 10th percentile and the fontanels (fontanelles) are not palpable. What action would the nurse take?
Report the findings to the pediatric health care provider.
One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting?
The discharge home of clients who are more critically ill
The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?
The new mother attempts to breastfeed the baby again using the new techniques and is successful.
nurse working in a hospital setting is responsible for transferring clients. Which recommended nursing actions would the nurse perform during this process? Select all that apply.
The nurse asks the family of a client moved to a critical care unit to take home the client's personal belongings. The nurse carefully packs the belongings of a client being discharged and sends them to the new facility. The hospital nurse prepares a detailed assessment and care plan to send to the long-term facility to which a client is transferred.
The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?
The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
A nurse is caring for a small child with leukemia who will be hospitalized frequently for chemotherapy. What type of referral can the nurse make that will help the child and family through this time?
child life specialist
Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is t
prepare the client for home care.
A client is a paraplegic, lives alone, and just had a total shoulder arthroplasty. In planning for discharge, the nurse arranges for
Admittance to a rehabilitation unit
A nurse educator is preparing to discuss immunodeficiency disorders with a group of fellow nurses. What would the nurse identify as the most common secondary immunodeficiency disorder?
AIDS
The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
An 8-year-old client is refusing to have an emergency appendectomy. The parents have given informed consent for the surgery. What action is most appropriate for the nurse to take?
Arrange a meeting of the parents, child, and healthcare provider.
An elderly female client who has dizziness and osteoporosis fell at home and fractured her hip. She underwent surgical intervention for repair of the fractured hip and is now being discharged to a subacute care facility. In the comeback phase of the Trajectory Model of Chronic Illness, the nurse
Acknowledges the client's achievement when she walks to the bedside commode with her walker
The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first
Administer a dose of digoxin that is two hours behind schedule.
Conflict has emerged on a nursing unit because new graduates have found that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict?
Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible.
Which statement is inconsistent with the concept of milieu therapy, originally developed by Henry Stack Sullivan?
Clients work independently to solve day-to-day problems.
A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need?
Collaborate with other disciplines to determine the best way to meet the client's medication requirements.
A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?
Collaborate with the physician to make a referral to social services.
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a spontaneous abortion (miscarriage). Which action by the nurse is most appropriate?
Contact the health care provider to report the client's feelings
The nurse educator is planning a teaching session for nursing students related to the treatment and management of gestational diabetes. The nurse educator arranges for a dietitian, pharmacist, and physician assistant to participate in the lesson plan. Which professional nurse competency is the nurse educator demonstrating?
Interdisciplinary teamwork
A health care provider suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside. What is the probable reason for the provider's suggestion
It keeps the nurse close to the source of the data
The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?
SBAR
A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions?
Scientific rationales
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
Scrub nurse
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize:
equipment and personnel.
The client is admitted for a scheduled cardiac catheterization. On the morning of the procedure, while assessing the client's morning laboratory values, the nurse notes a blood urea nitrogen (BUN) of 34 mg/dL and a creatinine of 4.2 mg/dL. What priority reason will the nurse notify the healthcare provider?
he client is at risk for renal failure due to the contrast agent that will be given during the procedure.
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:
increasing birth weight.
A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?
increasing fluid intake to 3 L/day
