Nurs 222 Chapter 17 CoursePoint

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? a) Discuss the risks and benefits of a blood transfusion with the client. b) Discuss possible alternatives to a blood transfusion with the physician. c) Discuss the client's options with other church members. d) Discuss the client's refusal with hospital risk managers.

b) Discuss possible alternatives to a blood transfusion with the physician.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a) Continue assisting the client to the bathroom to ensure the client's safety. b) Consult with the physical therapist to determine the client's ability. c) Instruct the client's family to assist the client to ambulate to the bathroom. d) Revise the care plan to allow the client to ambulate to the bathroom independently.

d) Revise the care plan to allow the client to ambulate to the bathroom independently.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? a) Educational b) Psychomotor c) Maintenance d) Surveillance

d) Surveillance

Before implementing any intervention, which questions should the nurse ask oneself? Select all that apply. a) "Is the client prepared for what needs to be done?" b) "Do I have all the necessary supplies and equipment needed?" c) "Do I have the skills to perform the intervention?" d) "Can I do the intervention alone or do I need help?" e) "Have I obtained permission from the physician to perform this intervention?"

a) "Is the client prepared for what needs to be done?" b) "Do I have all the necessary supplies and equipment needed?" c) "Do I have the skills to perform the intervention?" d) "Can I do the intervention alone or do I need help?" e) "Have I obtained permission from the physician to perform this intervention?"

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? a) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen. b) An older adult with pneumonia who is being discharged to the son's home tomorrow. c) A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall. d) An adult client who is being treated for kidney stones.

a) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen.

Which type of nursing intervention is oxygen administration and why is it considered to be so? a) A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order b) A collaborative nursing intervention, because it is ordered by the respiratory therapist c) An independent nursing intervention, because nurses have the necessary skill to administer oxygen d) An interdependent intervention, because physicians, nurses, and respiratory therapists have the necessary skill to administer oxygen

a) A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? a) Assess the client to determine the cause of the pain. b) Consult with the physician for additional pain medication. c) Discuss the frequency of pain medication administration with the client. d) Assist the client to reposition and splint the incision.

a) Assess the client to determine the cause of the pain.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a) Assess the client's blood pressure to determine if the medication is indicated. b) Determine the client's reaction to the medication in the past. c) Ask the client to verbalize the purpose of the medication. d) Tell the client to report any side effects experienced.

a) Assess the client's blood pressure to determine if the medication is indicated.

Which nursing action can be categorized as a surveillance or monitoring intervention? a) Auscultating of bilateral lung sounds b) Providing hygiene c) Administering a paracetamol tablet d) Use of therapeutic communication skills

a) Auscultating of bilateral lung sounds

Which parties are essential for the nurse to include in the implementation of a client's plan of care? a) Client, family, and physician b) Client, physician, and hospital director c) Client, physical therapist, and nursing staff d) Client, surgeon, and physician

a) Client, family, and physician

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a) Collaborate with other disciplines to revise the discharge plans. b) Instruct the client to make alternate living arrangements. c) Communicate with the physician about additional orders. d) Inform the family that it is not possible to change the discharge plans.

a) Collaborate with other disciplines to revise the discharge plans.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? a) Determine the client's willingness to follow the regimen. b) Identify changes from the baseline. c) Ensure physician approval for the education plan. d) Instruct the unlicensed assistive personnel on what to teach the client.

a) Determine the client's willingness to follow the regimen.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a) Encourage the client to provide as much self-care as possible. b) Perform all care activities for the client to facilitate rest. c) Teach the family to anticipate the client's needs to care for the client. d) Arrange with the nurse case manager for an early discharge.

a) Encourage the client to provide as much self-care as possible.

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client understands proper wound care techniques? a) Include family members or other caregivers in the education. b) Delegate teaching to unlicensed assistive personnel (UAP). c) Provide a video demonstration of abdominal wound care. d) Document client education prior to discharge from the unit.

a) Include family members or other caregivers in the education.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? a) Perform vital signs and blood glucose level. b) Discuss the need to change positions slowly, especially when moving from sitting to standing. c) Perform a full review of systems. d) Initiate an intravenous line and administer 500mL of normal saline.

a) Perform vital signs and blood glucose level.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a) Recognize the nurse's own limitations and ask for another nurse to be assigned. b) Recognize that the nurse may be faced with this issue again and care for the client. c) Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d) Recognize the issue and care for the client to the best of the nurse's ability.

a) Recognize the nurse's own limitations and ask for another nurse to be assigned.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. a) The client's respiratory rate decreases. b) The client states, "I can breathe easier now." c) The client is watching television. d) The client's family asks if the client is going to be okay. e) The client's oxygen saturation level increases.

a) The client's respiratory rate decreases. b) The client states, "I can breathe easier now." e) The client's oxygen saturation level increases.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a) "It is extremely important to your health to strictly follow your plan of care." b) "It seems like you are having difficulty with your care regimen." c) "Should I arrange for a home health nurse to coordinate your care?" d) "Should I instruct your family to do the glucose checks for you?"

b) "It seems like you are having difficulty with your care regimen."

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? a) Ask the gastroenterologist to explain the treatment plan to the client and family again. b) Ask the client to verbalize the medication regimen and diet modifications required. c) Ask the nutritionist to give the client strict meal plans to follow. d) Refer the client to available community resources and support groups.

b) Ask the client to verbalize the medication regimen and diet modifications required.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? a) Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. b) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. c) Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. d) Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

b) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? a) Explain the effects of a high-salt diet and smoking on blood pressure. b) Identify what barriers the client feels are preventing adherence with the plan. c) Collaborate with other health care professionals about the client's treatment. d) Change the nursing care plan.

b) Identify what barriers the client feels are preventing adherence with the plan.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? a) Restrict intake of foods and fluids b) Monitor for lactic acidosis c) Monitor for noncompliance d) Administer B12 injections

b) Monitor for lactic acidosis

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? a) Nurse manager b) Nurse case manager c) Physician d) Insurance company

b) Nurse case manager

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? a) Registered nurse b) Nursing assistant c) A senior nursing student present for clinical d) Licensed practical nurse

b) Nursing assistant

Before implementing any planned intervention, which action should the nurse take first? a) Have the required equipment ready for use. b) Reassess the client to determine whether the action is needed. c) Ask the client whether this is a good time to do the intervention. d) Record the planned intervention in the client's medical record.

b) Reassess the client to determine whether the action is needed.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? a) Medications used to treat diabetes mellitus b) Risk factors for and prevention of diabetes mellitus c) The severity of the client's disease d) The cellular metabolism of glucose

b) Risk factors for and prevention of diabetes mellitus

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? a) Algorithm b) Standing orders c) Protocol d) Order set

b) Standing orders

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? a) Supportive b) Surveillance c) Collaborative d) Maintenance

b) Surveillance

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. a) The client tells the nurse that the client's spouse will handle the care. b) The client verbalizes understanding of the instructions. c) The client asks the nurse to repeat the instructions. d) The client is able to answer the nurse's questions. e) The client discusses the specifics of what was taught during the session.

b) The client verbalizes understanding of the instructions. d) The client is able to answer the nurse's questions. e) The client discusses the specifics of what was taught during the session.

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present? a) The nurse is using the standards of care for clients with MIs. b) The nurse is operating under standing orders for clients with suspected MIs. c) The nurse is experienced in the needs of clients with MIs. d) The nurse is ordering what the physician usually orders.

b) The nurse is operating under standing orders for clients with suspected MIs.

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a) "It is a habit that nurses develop in school." b) "It is a hospital policy to reduce the potential for errors." c) "We ask your name to ensure that we are treating the right client." d) "We ask your name to show that we respect your rights."

c) "We ask your name to ensure that we are treating the right client."

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? a) Remind the client that the client is responsible for the client's own health care decisions. b) Ask the client whether the client is afraid that the spouse will be angry. c) Ask the surgeon to wait until the client has had a chance to talk to the spouse. d) Inform the surgeon that the nurse will not sign the informed consent form.

c) Ask the surgeon to wait until the client has had a chance to talk to the spouse.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? a) Document the interventions and the result. b) Reassess the client for improvement in 30 minutes. c) Communicate with the physician for additional orders. d) Determine the client's code status in case of an emergency.

c) Communicate with the physician for additional orders.

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 mostappropriately remedy this conflict? a) Assess the client to determine whether the client is capable of ambulation. b) Instruct the client to ask the physicians for clarifications of instructions. c) Communicate with the physicians to coordinate their orders. d) Collaborate with the physical therapist to determine the client's ability.

c) Communicate with the physicians to coordinate their orders.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? a) Continue the education and remind the client that it is essential to learn self-care. b) Medicate the client for anxiety and continue the education later. c) Discontinue the education and attempt at another time. d) Discontinue the education and ask the client for permission to teach a family member.

c) Discontinue the education and attempt at another time.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? a) Providing medication for agitation b) Repositioning to prevent pressure injuries c) Ensuring that the endotracheal tube is secure d) Changing the dressing to prevent infection

c) Ensuring that the endotracheal tube is secure

Which is an independent (nurse-initiated) action? a) Executing physician orders for a catheter b) Meeting with other health care professionals to discuss a client c) Helping to allay a client's fears about surgery d) Administering medication to a client

c) Helping to allay a client's fears about surgery

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? a) Request that the UAP place the steps of the task in the framework of the nursing process. b) Inform the UAP of the importance of following each step listed in the procedure manual. c) Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. d) Ask another UAP to observe and assist the UAP in performing the task.

c) Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? a) Inform the client that it is not necessary to wash hands before vital signs. b) Reassure the client that the nurse knows when to perform hand hygiene. c) Praise the client for taking an active role in the client's care. d) Tell the client that gloves are required for this procedure.

c) Praise the client for taking an active role in the client's care.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a) Secure the client's jewelry before surgery. b) Reassess the client's sacrum for redness when doing a bed bath. c) Provide the client with assistance in transferring to the bedside commode. d) Retrieve a unit of blood from the blood bank.

c) Provide the client with assistance in transferring to the bedside commode.

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? a) The client expresses a desire to learn how to manage the medication regime. b) The parents verbalize acceptance of the need to closely monitor their child's condition. c) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. d) The parents have comprehensive insurance coverage for their family's medical care.

c) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

The primary purpose of nursing implementation is to: a) improve the client's postoperative status. b) identify a need for collaborative consults. c) help the client achieve optimal levels of health. d) implement the critical pathway for the client.

c) help the client achieve optimal levels of health.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? a) Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose b) Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment c) Changing a client's advance directive after the prognosis has significantly worsened d) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

d) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? a) Research other treatment options available for the client. b) Remind the client that positive thoughts are essential for recovery. c) Ask if the client would like to speak with a spiritual adviser. d) Collaborate with other disciplines to plan end-of-life care for the client.

d) Collaborate with other disciplines to plan end-of-life care for the client.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? a) Review with the client the risks and benefits of surgery. b) Ask the client to discuss the decision with family members. c) Notify the physician of the client's refusal. d) Discuss with the client the reasons for declining surgery.

d) Discuss with the client the reasons for declining surgery.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? a) The client's condition b) Time and resources c) Feedback from the family d) Finances of the client

d) Finances of the client

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a) Determine the frequency of pain medication. b) Medicate the client with the ordered pain medication. c) Instruct the client in nonpharmacologic pain management. d) Go to the client and assess the client's pain.

d) Go to the client and assess the client's pain.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? a) Registered nurse b) Licensed practical nurse c) A senior nursing student present for clinical d) Nursing assistant who is a nursing student

d) Nursing assistant who is a nursing student

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's mostappropriate course of action? a) The nurse should ask another nurse who was previously assigned to the client for instruction. b) The nurse should request that the blood transfusions be delayed until the next shift. c) The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. d) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

d) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.