Chapter 1: Word Pronunciations
A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first? A.the client admitted after a head injury in a motor vehicle who reports nausea B.the post-stroke client who is ready for discharge who reports being unhappy about the wait to go home C.the postoperative laminectomy client who reports a loose dressing D.the client with a 2-year history of paraplegia admitted with a urinary tract infection who reports anxiety
A The nurse should first assess the client with nausea, because this may indicate increased intracranial pressure (ICP). The client scheduled for discharge, the client who recently had a laminectomy, and the client with paraplegia are all stable.
The nurse on a surgical unit has been assigned five clients. Place the clients in order of priority of care. All options must be used. -client rating pain as 9 out of 10 -client 1-day postoperative transurethral resection of the prostate (TURP) -client with a postoperative infection due to receive oral antibiotics -client being discharged to home in 2 hours -client with a fever documented at 99°F (37.2°C)
When prioritizing care, the nurse would follow the concepts of the airway, breathing, and circulation to guide care. The nurse also prioritizes from least stable to most stable when planning care. The client with a pain rating of 9 out of 10 would be the priority due to the severity of the pain (pain is the sixth vital sign and is an urgent need). The client who is postoperative TURP is at risk for hemorrhage (circulation) and would be assessed next. The client with a postoperative infection would be next as the timing of the oral antibiotic is important to prevent further complications of the infection. The client being discharged home in 2 hours would be seen next to assess for readiness for discharge as well as begin the discharge process. The client with a low-grade fever of 99°F (37.2°C) is the most stable and would be assessed last.
After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. The nurse should: A.inform the surgeon this is not within the safe scope of practice. B.report the surgeon to the Ethics Committee. C.report the surgeon to the nursing supervisor. D.follow the prescription as requested by the surgeon.
A Initially, the nurse needs to inform the surgeon that the task is outside the scope of nursing practice.If the surgeon still requests the activity, the nurse should refuse to perform the task and should follow the chain of communication for reporting unsafe practice according to the facility's policy.The nurse must not comply with any prescription that goes beyond the scope of nursing practice.
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first? A.Administer oxygen via mask. B.Obtain a pulse oximeter reading in a lower extremity. C.Reassess the oximetry reading in 30 minutes. D.Draw blood gases for oxygen and carbon dioxide levels.
A The oxygen levels for this neonate have dropped during the last 8 hours; the nurse should administer oxygen, as the neonate is not obtaining adequate oxygenation on room air. The recommended pulse oximetry reading in a term neonate is 95% to 100%. Obtaining a pulse oximeter reading in a lower extremity is done to screen for congenital heart defects. The priority is to correct the hypoxia first before gathering other assessments. Waiting to reassess the neonate could cause the neonate to have inadequate oxygen levels unnecessarily. While blood gases may be drawn, the first action is to administer the oxygen.
The emergency department nurse is admitting a client who does not speak English. The client is accompanied by the client's adult son, who does speak English. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain because of the language barrier. How should the nurse best communicate with the client? A.Enlist the help of a hospital interpreter; ask the client's son to translate if none is readily available. B.Ask the client's son to describe the client's pain to the best of the son's ability. C.Perform as many components of the assessment as possible, and arrange for an English-speaking family member to come to the hospital. D.Have a hospital interpreter come to the assessment; defer the assessment if none is available.
A Whenever possible, trained interpreters should be used to communicate with clients who do not speak English. If none is available (inlcuding telephone translation services), however, it may be necessary to have a family member translate as long as that family member is not a child. It would be unsafe to delay an emergency assessment pending the arrival of an interpreter.
A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? A.Notify the physicians and explain that they need to teach their clients before inducing labor. B.Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. C.Report the physicians for providing inferior care. D.Initiate a protocol order that allows the nurse to administer promethazine before administering oxytocin.
B The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.
The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: A.an elevated pulse. B.confusion. C.severe abdominal pain. D.constipation.
C A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency.
The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication regimen? A.Teach the client the name and frequency of the new medication. B.Inform the client about the new medication and provide a handout on the use. C.State the new medication, including name, use, and reason for the new medication. D.Use the package insert for medication instruction.
C Medication administration and teaching is in the nurse's scope of practice and a common nursing action. It is important for the nurse to inform the client about the medication, including its name, use, and the reason for the medication change, because teaching the client about treatment regimen promotes compliance. The other responses are not as specific and inclusive.
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? A.Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. B.Review and revise the way client education is conducted in the surgeons' office. C.Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. D.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 needed.
D Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.
The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse use to evaluate the effectiveness of such a program? A.fewer client injuries during restraint procedures B.a reduction in the number of complaints by clients' relatives C.fewer staff injuries during restraint procedures D.a reduction in the total number of restraint procedures
D The primary goal of an aggression management program is to prevent violence. This goal is evidenced by a reduction in the total number of restraint procedures used or needed. Although fewer client and staff injuries are important, these goals are secondary to prevention. Reduction in the number of complaints by clients' relatives is affected by more variables than just restraint procedures.
