Management of Care - ML4

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse?

"We will continue to use antibiotics to treat the pneumonia."

A client recruited to participate in a clinical trial to treat non-Hodgkin's lymphoma voices concerns about the adverse effects of the treatment preventing the completion of the trial. What will the nurse tell the client to protect the principle of autonomy?

"You may withdraw at any time."

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation?

"Your verbal threats to the client are legally considered assault."

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

An 83-year-old female demonstrating early-stage dementia has just had surgical repair to her fractured left hip. No family member is present at the discharge planning conference to discuss the next appropriate actions. Which members of the healthcare team will be instrumental in securing the client's placement in a rehabilitation center?

All of the responses are correct

A pediatric nurse preceptor working on an oncology floor goes to see if the new graduate nurse caring for a 3-year-old terminally ill child requires assistance. The preceptor finds the new nurse in the lounge crying. What is the preceptor's best action?

Ask the graduate what has caused the crying

A nurse is caring for a client who speaks only French. The client's grandchild is bilingual and assists with translating, but the nurse needs to provide the client with discharge instructions. Which option would be best for the nurse and the client?

Ask the manager to find an interpreter who is able to provide the discharge instructions.

The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take?

Call a break in the meeting and talk to the nurse in a private place.

A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow should be used. Which intervention should the nurse perform to ensure that the oxygen is properly administered?

Consult with a respiratory therapist.

Which source of information helps a nurse formulate nursing diagnoses for a specific client?

Essential assessment data

Radiographic evaluation of a client's fracture reveals that a bone fragment has been driven into another bone fragment. The nurse identifies this as which type of fracture?

Impacted

The nursing students are learning about the immune system in their anatomy and physiology class. What would these students learn is a component of the immune system?

Lymphoid tissues

A nurse is caring for an infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent?

Obtain consent from the foster parents.

A nurse working on an acute care urology unit is assigned to a client who requires hourly urine measurement. The previous two urine measurements have been within normal limits. The next urine measurement is now due, but the nurse is busy and running late with medication administration. Which action should the nurse take?

Obtain the urine measurement as scheduled and request help with medications.

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion?

Pustule

The nurse is caring for a client with a PICC line that requires flushing. The nurse has not previously performed this skill. What is the most appropriate action by the nurse to ensure safe care?

Request a different client assignment and arrange a session on the care of a PICC line.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching?

Risk for infection

The nurse is caring for a client who is prescribed medication for the treatment of hypertension. The nurse recognizes that which medication conserves potassium?

Spironolactone

A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place the client at risk for impaired immune function?

Surgical removal of the appendix

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be:

The importance of complying with CPAP despite the inconvenience associated with its use

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind?

The nurse needs to be creative in integrating the technical and relational aspects of care.

The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?

The principle of autonomy

Which tools do case managers commonly rely on to plan and coordinate client care?

clinical pathways, practice guidelines, and standards of care

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title

A nursing instructor is giving a lecture on the immune system. The instructor's discussion on phagocytosis will include:

neutrophils and monocytes.

The nurse is admitting a female adolescent for a wound debridement post-trauma injury to an ambulatory care unit. What diagnostic results will the nurse report to the surgeon prior to sending the client to the operating room? Select all that apply.

positive pregnancy test chest radiography with atelectasis

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

recent foods ingested.

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as

the principles that determine whether an act is right or wrong

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?

The student accepts a referral to a substance abuse counselor.

A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply.

1. "I will develop a list of questions to use in interviewing potential midwives." 2. "I understand the complications that could occur in a home birth setting." 3. "I realize that I may need to be transferred to a hospital if complications develop."

The nurse working in a critical care unit is a caring for a client that experiences respiratory arrest. In what order will the nurse respond? All options must be used.

1. Call for emergency help. 2. Begin emergency resuscitation. 3. Document the resuscitation. 4. Complete an incident report. 5. Alert the family to the event. 6. Restock the room with emergency equipment

Which task would a nurse choose to delegate to a nursing assistant? Select all that apply.

1. Taking a client's vital signs 2. Documenting a client's oral intake 3. Performing a blood glucose check 4. Assisting with IV insertion

A client with cancer of the stomach tells the nurse, "I cannot bear the pain anymore. Please give me some poison to free myself from this agonizing pain." The nurse faces a value conflict. Which is true in such a condition?

Human need may affect the values conflict.

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?

completion of range of motion on limbs restrained

Your patient has recently completed her first round of chemotherapy in the treatment of lung cancer. When reviewing this morning's blood work, what findings would be suggestive of myelosuppression?

Decreased platelets and red blood cells