Hurst 6
While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.
1. CORRECT. The client is confused and likely will not remember any verbal instructions. Therefore, the safest priority action would be to check on the client at regular intervals and assist the client with any bathroom needs at those times. 2. INCORRECT. A restraining vest would not guarantee client safety. This client was able to crawl out of bed over a raised side rail; therefore, this client could struggle against the vest with the potential to get entangled and become seriously injured. 3. INCORRECT. Placing gauze over the IV site does not address client safety. The issue is we do not want the client to fall. 4. INCORRECT. This action would not ensure safety because the client is confused. So, it is very unlikely the client would remember to ring for the nurse before getting out of bed.
Which interventions should the nurse include in the plan of care for a client who has been admitted with a head injury? 1. Pad side rails. 2. Place hips in flexed position for 15 minutes every 4 hours. 3. Elevate head of bed 35 degrees. 4. Maintain neck in neutral position. 5. Cluster nursing activities. 6. Maintain a quiet environment.
1., 3., 4., and 6. Correct: The client with a head injury is at risk for seizures. Padding the side rails is a safety precaution. Elevate the HOB 30-45 degrees to facilitate venous drainage and reduce ICP. Maintain the client's head midline to facilitate blood flow. A quiet environment is necessary to keep the client calm. An increase in environmental stimuli can increase ICP. 2. Incorrect: Do not allow pronounced neck or hip flexion as ICP will increase. Maintain HOB at 30-45 degrees and body in neutral position to avoid an increase in ICP. 5. Incorrect: Clustering nursing activities will increase ICP. Activities should be spaced out. Remember, the client needs a quiet environment.
The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Upon discharge, the nurse must teach the client about the need for adequate electrolyte intake through foods and/or dietary supplements. Which foods should the nurse suggest to the client? 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries
2. Correct: Avocados, apricots, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium.1. Incorrect: Cereals and breads are good sources of B vitamins. Since the client is losing potassium they need foods that are high in potassium. Cereals and breads are not high in potassium. 3. Incorrect: Table salt and spinach are good sources of sodium, but the hypertensive client usually should limit intake of sodium. The client is taking a potassium depleting diuretic and needs potassium rich foods. Spinach is high in potassium but the table salt makes this option incorrect. 4. Incorrect: Blueberries and strawberries both are relatively low in potassium. Clients on loop diuretics are losing potassium and need to consume foods high in potassium.
The nurse is teaching a client diagnosed with salmonellosis about how to decrease the transmission to others. Which statement by the nurse would require follow up? 1. "I will wash my hands after feeding pets." 2. "I will use a meat thermometer to cook food to safe temperature." 3. "I will clean my hands with water before handling food." 4. "I will use disposable dishes until infection free."
3. Correct. Salmonellosis is caused by the bacteria salmonella. Hands should be washed with soap and warm water. Only washing with water is not correct and requires the nurse to do further teaching with the client. 1. Incorrect: This statement indicates the patient understands teaching. The client should wash hands after contact with animals, their food or treats, and their living environment. 2. Incorrect: A meat thermometer should be used to ensure foods are cooked properly. Undercooked meat and unpasteurized milk is a source for the organism. 4. Incorrect: Disposable dishes help prevent the spread of infection. It prevents the organism from being transferred on dirty dishes.
The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.
3. Correct: Just because a client is a frequent visitor to the emergency department reporting migraines does not mean that the client is addicted to narcotics or that the client is not really experiencing the pain. Pain is what the client says it is and assessment is priority. 1. Incorrect: This is delay of treatment and does not address the pain. The nurse should have the client rate the pain in order to become objective data. 2. Incorrect: This is the primary healthcare provider's decision and also indicates you think the pain is not real. Assessment by the nurse and primary healthcare provide are warranted. Don't delay treatment. 4. Incorrect: Assessment of the eyes could be an option since eye strain can lead to headaches. Rating their pain would be the priority assessment however.
A parent asks the nurse why their child should be immunized against Rubella. What should the nurse tell the parent? 1. Rubella can cause a severe rash over the body, and a high fever which can lead to febrile seizures. 2. Rubella is the most common cause of meningitis and acquired deafness. 3. If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a birth defect. 4. Rubella complications can include swelling of the testicles or ovaries, deafness, encephalitis or meningitis and can lead to death.
3. Correct: The goal of rubella immunization is to protect unborn children from developing birth defects in utero. 1. Incorrect: Rubella can cause a mild rash on the face and low-grade fever. 2. Incorrect: Before the vaccine, mumps was the most common cause of meningitis and acquired deafness. 4. Incorrect: These are complications of the mumps.
The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.
3., & 4. Correct: When a person is confused and has dementia, we need to communicate in a simple manner. Provide simple directions or instructions, short sentences, and gestures. Use pictures. Do not give instructions on multiple things. Do not argue, criticize, or correct the client. This can increase anxiety, agitation, and anger. 1. Incorrect: Use a gentle touch rather than a firm touch with these clients. You do not want to be confrontational or evoke fear in the client. 2. Incorrect: Be flexible. If one approach does not work, try another. 5. Incorrect: Avoid questions or topics that require extensive thought, memory, or words. This can increase anxiety, frustration, and agitation. 6. Incorrect: Do not require or force participation in activities or events. This can increase anxiety, frustration, and agitation.
A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? 1. 3 month old child with nonorganic failure to thrive. 2. 14 year old with exacerbation of cystic fibrosis. 3. 5 year old newly admitted with epiglottitis. 4. 10 year old with type 1 diabetes mellitus.
4. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 1. Incorrect: This client is only 3 months old, which would require specialized skills to evaluate developmental needs. Additionally, nonorganic failure to thrive is a serious situation in which the infant is not getting appropriate nutrition. There could be economic factors, resulting in a lack of food or poor-quality breast milk. Parental beliefs or negligence could also contribute to the situation; therefore, an RN should be assigned to this infant. 2. Incorrect: Although this client is an adolescent, an exacerbation of cystic fibrosis would require careful and frequent respiratory assessments with possible chest physiotherapy. This client would be more appropriate for an RN. 3. Incorrect: A new admission is not appropriate for a nurse sent from the medical surgical unit to the pediatric unit, particularly an LPN, because of the need for initial and frequent assessments. Epiglottitis is a respiratory illness that also impacts the airway. This child should be assigned to an RN.
Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome
4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.
A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.
4. Correct: This position will decrease pressure on the suture line and abdomen. 1. Incorrect: Sims' is a semi-prone position where the client assumes a posture halfway between the lateral and prone positions. If you place the client in this position the bowel contents can protrude out of the wound even more. 2. Incorrect: In this position the client's head and shoulders are slightly elevated on a small pillow. This does not ease the tension as much as supine with HOB elevated 15 degrees and knees and hips flexed. 3. Incorrect: Turning the client on their side will allow the abdominal contents to protrude out of the wound even more.
