Collaborative-Management of Care
Caring is the underlying component of nursing that promotes client care.
To help establish a therapeutic nurse-client relationship, the mental health nurse uses various communication techniques to convey a willingness to listen and a genuine desire to view the client and his or her needs in a respectful manner. What is the primary underlying principle guiding this process?
Keep the stoma covered with a scarf.
What information should the nurse include in a discharge teaching plan for a client who recently had a laryngectomy?
Obtaining the assault history from the client
What should be included in nursing care immediately after a sexual assault?
Down syndrome
While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with:
Arrange for visits by nurses from the postanesthesia and surgical intensive care units
A client is admitted to the hospital for a heart transplant. Which preoperative intervention is most important for the nurse to implement before the surgery?
1.Obtain client's nursing history. 2.State client's nursing needs. 3.Identify goals for care. 4.Develop a plan of care. 5.Implement nursing interventions
Place each step of the nursing process in the order that it should be used.
Check the IV access for a blood return.
A client, receiving a potassium infusion via a peripheral intravenous (IV) site, complains of burning sensation above the IV site. What should the nurse do first?
Midbrain.
The nurse is conducting a neurological assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to the:
Assess for petechiae on the neck and chest.
A client admitted with a femur fracture 24 hours ago becomes confused. A nurse should immediately:
Have the practical nurse perform the initial assessment and the registered nurse verify all findings after the transfusion client is stable.
A client has arrived on the nursing unit scheduled for a cholecystectomy, and there is one registered nurse, a licensed practical nurse, and a certified nursing assistant. Institution policy is that all admissions must have the initial assessment completed by a registered nurse. The registered nurse currently is caring for a client with a transfusion reaction. Which is the best decision?
The Public
A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a registered professional nurse. What group primarily is protected under the regulations of the practice of nursing?
Prepare the client for an electrocardiogram.
During a party, an individual reports intense chest pain and begins to perspire profusely. Which action should the nurse take first when the client is brought to the emergency department?
Sinus rhythm with first degree AV block.
The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. The nurse interprets this rhythm as:
Teaching residual limb care.
The nurse is reviewing a plan of care for a client who has experienced a traumatic amputation of a leg. The nurse recognizes that which intervention listed on the plan is of lowest priority?
Third degree AV block (complete heart block).
The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There are no consistent PR intervals indicating that there is no relationship between the atria and the ventricles. The nurse realizes that the client is in:
Second degree AV block Mobitz II.
The nurse notes that the client's rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. The nurse realizes that the client is in:
Pain relief Antipyresis Reduced inflammation
What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Select all that apply.
Rapid Respirations
The nurse is caring for a child with spasmodic croup. The nurse knows that immediate nursing intervention is required for:
Reassuring the client with the frequent presence of staff
A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found walking down a street, disoriented and semi-naked, the client is admitted to the hospital, and a diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety. What is the best approach for the nurse to take?
Rupture of the graft.
A client had a femoral-popliteal bypass graft. Four hours after surgery the client's blood pressure (BP) increases to 200/110. The nurse concludes that the increase in blood pressure is a specific indicator of what postoperative complication?
"You will be admitted as an outpatient for same-day surgery."
A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching?
Arrange a discussion with both adolescents and follow mandatory reporting guidelines related to child abuse.
A male adolescent with the diagnosis of antisocial personality disorder spends a great deal of time with a female adolescent client on the unit. One day the nursing assistant enters the female client's room and finds them in bed together. The nursing assistant reports the incident to the nurse. The nurse should
History of allergies Duration of clinical findings
An 11-year-old child who recently returned from a camping trip reports chills, fever, and a headache and is taken to the clinic by the parents. What is most important for the nurse to assess initially during the child's history and physical examination? Select all that apply.
Void at least every 4 hours even if you do not feel the need to void.
The nurse is caring for a client being treated in the emergency room for recurrent cystitis. Which instruction should the nurse include before discharge?
Have the surgeon and attending practitioner sign the consent form
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received nalbuphine (Nubain) 10 mg IV 30 minutes ago. Because the client is too sedated to sign the consent form, the nurse should:
1.Cream of mushroom soup, macaroni and cheese, broccoli, and milk 2.Pea soup, roast chicken breast, mashed potatoes, creamed spinach, and orange juice
A chelating agent is prescribed for a child with lead poisoning. Because chelating agents may cause hypocalcemia, the nurse encourages the child to eat foods that are high in calcium. Which meals are good sources of calcium? Select all that apply.
Administer the prescribed morphine and notify the primary health care provider
A client is admitted to the emergency department with a possible myocardial infarction. Three hours after admission, the client experiences a new onset of severe chest pain. The client is diaphoretic with a pulse rate of 110 beats per minute. The nurse should immediately:
Arrange a unit meeting to discuss what has just happened.
A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next?
Motivation
A client with a history of chronic kidney disease is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Before the institution of CAPD, the nurse meets with the client to formulate a plan of care. Primarily, the nurse should assess the client for the presence of:
Assist the client to the bathroom.
A nurse is assessing a multipara who had a spontaneous vaginal birth 2 hours ago after 6 hours of labor. What should the nurse do first after reviewing the vital signs, performing a physical assessment, and transcribing the practitioner's prescriptions?
"I'll keep your comments confidential because I'm your advocate."
A client with a personality disorder tells a nurse, "I want to tell you something, but you have to promise to keep it a secret." Which response could lead to splitting among the staff?
The interval between voidings will increase by 1 hour.
A nurse in the pediatric clinic is planning care for a 7-year-old boy with enuresis. What is an appropriate short-term goal for this child?
Three times a day, halfway between meals
A nurse is caring for a child with a diagnosis of cystic fibrosis. Which schedule of chest physiotherapy (CPT) is best?
Absence of hair on the toes Reports of pain associated with exercising
A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.
Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomforts
A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? Select all that apply.
Assessment
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?
1.Meta-analysis 2.Randomized controlled trial 3.Controlled trial without randomization 4.Cohort study 5..Expert opinion based on scientific principles
A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable.
1. Be supportive 2.Introduce new information. 3.Provide opportunities for ventilation. 4.Offer Feedback
A nurse manager uses a participative leadership approach to change. List the steps in order of priority that the manager should follow to create effective change processes.
Charges of assault and battery may be leveled against nurses who use restraints improperly.
A nurse preparing to apply restraints to a client should understand which of the following principles?
1.Assess airway 2.Receive report from the transferring nurse 3.Obtain the heart rate and blood pressure 4.Assess the client's level of consciousness 5.Check the abdominal dressing
A nurse receives notification that a client will be transferred from the postanesthesia care unit to the inpatient nursing unit following the client's colon resection with an anastomosis. Place the nursing actions in order of priority when the nurse receives this client on the unit.
Instituting a pain management plan
A preschooler with partial-thickness burns on 21% of the total body surface area progresses from the emergency phase to the acute phase of burn care. What is the most important nursing intervention at this time?
1.Initiate monitoring with an electronic fetal/maternal monitor. 2.Give the client a 2-g loading dose of ampicillin (Omnipen) followed by 1 g every 4 hours. 3.Start oxytocin (Pitocin) 30 units in 1000 mL of D5W per protocol. 4.Call the anesthesia department to evaluate the client for an epidural.
A primigravida at 39 weeks' gestation is admitted to the high-risk unit with an acute infection and is to have labor induced. In what sequence should the nurse implement the practitioner's orders?
1.Monitor the fetal heart rate for signs of compromise. 2.Test the fluid's pH with Nitrazine paper. 3.Perform a vaginal examination to ascertain the progression of labor. 4.Notify the practitioner.
A primipara is admitted to the birthing room in active labor. The fetus's head is engaged and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the nursing actions in order of priority.
1.Talk to her in a calm, nonjudgmental manner. 2.Provide her with clear, concise explanations of care that will be provided. 3.Provide care for her laceration and contusions. 4.Encourage her to express her feelings concerning the assault. 5.Advise her of the potential related health risks and the treatments that are available.
A young woman is brought to the emergency department by friends after being sexually assaulted. The client has a small but deep laceration on her chin, as well as contusions on her arms and legs. The client appears withdrawn but calm. Place the following nursing interventions in the appropriate order to best address the client's immediate needs.
The client will demonstrate improved nutrition.
The laboratory values of a client with a new diagnosis of cancer of the esophagus include a hemoglobin of 7 g/dL, hematocrit of 25%, and red blood cell (RBC) count of 2.5 million/mm3. The nurse is creating a plan of care and should include which as the priority outcome?
Normal saline 125 mL per hour continuous intravenous (IV) infusion
The nurse would clarify which provider prescription for the client with acute kidney injury?
Provide care within the parameters of the state's nurse practice act. Document consistently and objectively. Clearly document a client's non-adherence to the medical regimen.
What are the best ways for a nurse to be protected legally? Select all that apply.