Basic Physical Care

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next? A. Ask another nurse to attempt to start a peripheral intravenous line. B. Notify the health care provider. C. Set up for placement of a triple-lumen central venous catheter. D. Try to start the peripheral intravenous line in the left forearm.

A. Ask another nurse to attempt to start a peripheral intravenous line. Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

A nurse-manager is preparing for annual staff performance evaluations. Which action is most appropriate for the nurse-manager to include? A. Provide feedback on strengths as well as areas for improvement while formulating a plan to improve. B. Ask primary nurses to conduct performance evaluations to help them achieve professional growth. C. Conduct performance evaluations in a group setting so input from peers may be used. D. Provide written documentation of areas for improvement and establishing goals.

A. Provide feedback on strengths as well as areas for improvement while formulating a plan to improve. An effective performance evaluation recognizes strengths, identifies areas for improvement, and clarifies performance expectations. Recognizing strengths increases employee morale, so limiting the evaluation to areas of improvement and goals may leave an employee feeling defeated. The nurse-manager should conduct performance evaluations privately, not in front of others. The nurse-manager should document in writing all components of a performance evaluation. Although input from staff members can be useful in preparing performance evaluations, asking other nurses to conduct performance evaluations is inappropriate. The nurse-manager is responsible for the performance of the staff.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client? A. Stand at the head of the stretcher and push the device. B. Stand at the foot of the stretcher and pull with the arms. C. Stand at the foot of the stretcher and pull the client's feet. D. Stand at the side of the stretcher and push with the arms.

A. Stand at the head of the stretcher and push the device. Equipment should be pushed rather than pulled whenever possible. When transporting a client on a stretcher, the nurse should stand at the head of the stretcher and push, using the weight of the entire body and not just the arms. Pulling the stretcher with the arms or entire body is not appropriate because it would be safer for the device to be pushed. Standing at the side of the stretcher and pulling with the arms could cause injuries to both the arms and back from twisting the spine.

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay? A. assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems B. when the infant is crying always offer the bottle or breast first C. proper methods for dealing with stressful situations such as crying infants D. referring the client for anger-management therapy upon discharge

A. assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. The infant may not be crying due to hunger; assessing the mother's coping will help provide the basis for teaching the essential skills.

After suctioning a client, a nurse should expect to find A. clear breath sounds. B. a respiratory rate of 28 breaths/minute. C. brisk capillary refill. D. a heart rate of 104 beats/minute.

A. clear breath sounds. Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? A. primary prevention B. secondary prevention C. tertiary prevention D. passive prevention

A. primary prevention Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything themselves.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? A. Ask staff members to quickly meet among themselves and decide what procedures to follow. B. Determine that the procedures currently in place must be followed and direct staff to follow them without question. C. Tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do. D. Tell staff members to use whatever procedures they feel are best.

B. Determine that the procedures currently in place must be followed and direct staff to follow them without question. In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client evacuation because no one will know how to function effectively as a team during the crisis. A staff meeting would waste valuable time.

An adult client who is alert and oriented requires surgery. The client cannot read. Which nursing interventions is the best? .A. Tell the client in the nurse's own words what the surgical procedure involves. B. Read the consent form to the client and have the client verbalize understanding. C. Have a family member that can read sign the consent form. D. Ensure that the healthcare provider signs the consent form for the client.

B. Read the consent form to the client and have the client verbalize understanding. The client is alert and able to make an informed consent. The consent should be read to the client and two nurses should witness verbal understanding. It is not appropriate for a healthcare provider or a family member to sign consent for an alert and oriented client.

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder? A. to assist in collection of wound drainage products from the incision B. to reduce stress on the abdominal incision C. to reduce abdominal pain through pressure support D. to maintain blood flow and circulation in the abdominal incision

B. to reduce stress on the abdominal incision Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.

A nurse is caring for an elderly client who is being discharged to a skilled nursing facility. What should the nurse consider as a priority intervention in developing the discharge plan for this client? A. Send all of the client's belongings to the skilled nursing facility. B. Instruct the client's family to go to the facility during mealtime. C. Provide instructions that ensure continuity of care. D. Give the facility the client's therapy schedule.

C. Provide instructions that ensure continuity of care. The goal of discharge planning in all settings is continuity of care. This action aids the client's transition to a new setting and can shorten facility stays. Sending the client's belongings would be important; however, this action does not ensure that the plan of care developed in the acute care setting will continue. Instructing the family to go to the facility at mealtime may be helpful for the client, but does not ensure the continuity of care.

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain? A. irrigating it with normal saline B. connecting it to low intermittent suction C. compressing it and then plugging it to establish suction D. connecting it to a drainage bag and clamping it off

C. compressing it and then plugging it to establish suction After emptying a Jackson-Pratt drainage bulb, the nurse should compress the bulb, plug it to establish suction, and then document the amount and type of drainage emptied. Irrigating a Jackson-Pratt drain is inappropriate because it could contaminate the wound. The Jackson-Pratt drain is not usually connected to wall suction. The purpose of the Jackson-Pratt drain is to remove bloody drainage from the deep tissues of the incision; clamping the drain would be counterproductive.

The nurse is preparing to administer a continuous enteral feeding. Which action is most important for the nurse to include in the plan of care? A. Position the client on the left side. B. Inject air into the feeding tube to verify placement. C. Warm the formula before administering it. D. Elevate the head of the bed.

D. Elevate the head of the bed. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Injecting air into a feeding tube to verify placement is highly unreliable and should only be used to help confirm a test of the pH of the gastric aspirate.

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate? A. Irrigate the drain with normal saline to ensure patency. B. Leave the drain open to the air to ensure maximum drainage. C. Attach the tube to straight drainage to monitor the output. D. Ensure that the drainage receptacles are kept compressed to maintain suction.

D. Ensure that the drainage receptacles are kept compressed to maintain suction. Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? A. Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs. B. Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. C. Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery. D. Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia.

D. Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

Three victims with gunshot wounds are brought to the emergency department. The nurse should take which action to preserve forensic evidence on the clients' clothing? A. Cut around blood stains to remove clothing. B. Place all wet clothing in a plastic bag. C. Request that a law enforcement officer observe the removal of clothing. D. Place each item of clothing in a separate paper bag.

D. Place each item of clothing in a separate paper bag. Preserving forensic evidence is essential for investigative purposes following injuries that may have resulted from criminal activity. The nurse places each item of clothing in a separate paper bag and labels it; wet clothing is hung to dry. Paper bags are used because moisture can collect in plastic bags and alter the evidence. The nurse does not cut or otherwise unnecessarily handle clothing, particularly clothing with evidence such as blood or body fluids. It is not necessary to have law enforcement personnel present at this time, but the nurse should document all nursing care and use quotes around the clients' exact words where possible; documentation will become a part of the clients' medical records and can be subpoenaed for subsequent investigation.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? A. The tissue surrounding the wound is red and hot. B. The wound drainage is serous. C. The skin around the wound is edematous. D. The granulation tissue is at the wound edges.

D. The granulation tissue is at the wound edges. Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.

Protection and Electronic Documents Act) regulations? A. A nurse talks with the spouse about a client's condition. B. Two nurses in the cafeteria are discussing a client's condition. C. A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor. D. The healthcare team is discussing a client's care during a formal care conference.

D. The healthcare team is discussing a client's care during a formal care conference. To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations. Looking up laboratory results for a neighbor is a violation of those acts, as is discussing a client's condition with one's spouse.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? A. requesting an indwelling urinary catheter to avoid incontinence B. prescribing adult diapers for the client so she will not have to worry about incontinence C. padding the bed with extra absorbent linens D. placing a commode at the bedside and instructing the client in its use

D. placing a commode at the bedside and instructing the client in its use A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care? A. documenting the situation and providing support for the victim B. counseling the person committing the abuse C. counseling the victim D. protecting the client's safety by completing an incident or occurrence report

The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.