Foundations of holistic nursing

A healthcare provider orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for two consecutive hours: 8 AM 50 milliliters, 9 AM 60 mL. Based on these amounts, which action should the nurse take?

Continue to monitor and record hourly urine output. Explanation: normal urine output for an adult with an indwelling catheter is at least 30 mL per hour. Therefore this client output is normal.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T tube. Which of the nurse do to determine the effectiveness of the T tube?

Assess the color and amount of drainage every shift

A client admitted to the mental health unit has exhibited physical behaviors that put them and others at risk. The nurse supplies four-point restraints on the client without obtaining a healthcare provider order or the client clients consent. The nurse is at risk of being accused for what?

Battery

A nurse is teaching the parents of a fluid with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

Encourage a high calorie, high protein, diet Explanation: in cystic fibrosis, the pancreatic enzymes, lipase, trypsin, and Amylase becomes so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest, fat, protein, and some sugars; therefore, the child can become nourished a child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels

Which would be the most appropriate measure for preventing the development of a paralytic alias and a client who had renal surgery yesterday?

Encourage the client to ambulate every 2 to 4 hours

A client developed a stage four ulcer to the sacrum while on bedrest. A home care nurse taught the client adult child how to perform wound care with irrigation independently. As the client perform a return demonstration, which action requires the nurse to intervene and correct the action?

Ensure the solution flows from dirty to clean areas of the wound

The children of an older adult client who has suffered an ischemic stroke, having informed the nurse that an herbalist will be coming to their parents bedside tomorrow to make recommendations for client care. Which considerations should the nurse prioritize in light of the practitioners planned visit?

Ensuring any complementary therapies are safe when combined with their prescribed therapy

The selection of a nursing care delivery system is critical to the success of client care in a nursing area. Which factories essential to the evaluation of a nursing care delivery system?

Identifying who will be responsible for making client care decisions

The nurse applies warm compresses to a clients leg. To determine effectiveness of the compress, the nurse should determine if there is:

Improved circulation to the area

A nurse is giving nutritional counseling to the parent of a child with celiac disease. Which statement by the parent includes understanding?

My child can't eat wheat, rye, oats, or barley

Which nursing assessment is recommended to confirm placement of the nasogastric tube into the stomach of a client?

Obtain a chest x-ray and measure the pH of stomach contents

The home health nurse is conducting a safety assessment and an older adults home. On the bathroom floor, the nurse finds a throw rug that the client refuses to remove. What is the appropriate recommendation by the nurse?

Place nonslip backing on the underside of the rug.

The home health nurse has been asked to update the care plan for a family member who provides full-time care for an older adult who has fallen several times. The client has been refusing to use her walker and insist on hanging onto furniture as they walk around. Which is the best response from the nurse?

Reinforce the importance of using the walker to both the client and family member

A nurse is providing client care on a rehabilitation unit that has increasingly diverse population. What nursing actions would be appropriate when providing care to clients?

Review available information and health practices of the common cultures in that area, ask the client if they require any special diet or interventions while they are in the hospital, and keep in mind that clients may be members of multiple religious or cultural groups at the same time

Which is the correct technique when the nurse is applying an elastic bandage to a leg?

Start at the distal end of the extremity and move toward the trunk

A client in a long-term care facility refuses to take oral medication. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurses statement constitute which legal tort?

Assault Explanation: assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply.

The client is to be discharged on a low-fat low cholesterol, low sodium diet. When teaching the client about the diet, the nurse should take which action first?

Assess the clients and families typical food preferences Explanation: before beginning, dietary instructions and interventions, the nurse must first assess the clients and families, food preferences, such as pattern of food, intake, lifestyle, food, preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the clients current knowledge level and then build on this knowledge base.

A charge nurse asks a group of staff nurses to cover part of the next shift because a nurse called off. A staff nurse states " 40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The nurse tells the units nurse manager, " you should just adjust their schedule to make them wish they volunteer." how should the nurse manager respond?

Council the charge nurse about their comment

The nurse is preparing to administer a continuous internal feeding. Which action is the most important for the nurse to include in the plan of care?

Elevate the head of the bed Explanation : elevating the head of the bed during Intero, feeding, minimizes the risk of aspiration and allows the formula to flow into the clients intestines. When such elevation is contraindicated, the client should be positioned on the right side.

The nurse is caring for a client who is using a portable wound suction unit. Six hours after surgery, the drainage unit is full. What should the nurse do first?

Empty the drainage Explanation: portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create section before re-inserting the plug. It is normal for the suction unit to be full six hours after surgery, and the nurse does not need to notify the surgeon.

A nurse is caring for an older adult client with a pressure injury on the sacrum. When teaching the client about dietary intake, which food should the nurse emphasize?

Lean meats and low-fat milk explanation: protein helps build and repair body tissues, while promotes healing.