PassPoint - Nursing Fundamentals 2

A new nurse will be monitoring a client during a moderate sedation procedure for the first time, and is discussing this with the charge nurse. Which statement made by the newly graduated nurse will the charge nurse verify as accurate?

correct response: "Complete vital signs should be charted at least every 5 minutes during the procedure." Complete vital signs should be charted at least every 5 minutes during the procedure. Moderate sedation is a high-risk procedure, and requires frequent monitoring. Client status and vital signs can change rapidly, and must be accurately charted, alongside interventions performed to paint an accurate picture of client care. Both capnography and pulse oximetry should be monitored to allow for more complete evaluation of the client's ventilatory status. Cardiac monitoring is essential, as the medications given for moderate sedation are high-risk medications and can impact cardiac function. Continuous monitoring is appropriate, but vital signs must be charted rather than just monitored. Charting is a standard of care, and invaluable in the legal aspect of client care, particularly during a procedure.

A nurse observes a student auscultating a client's lungs. Which action by the student indicates a need for further instruction on respiratory assessment skills?

correct response: The student places the stethoscope over the posterior chest and only listens during inspiration. At each placement of the stethoscope, the student should listen to at least one cycle of inspiration and expiration. All other assessment techniques are correct and do not require additional intervention.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

correct response: "I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?

correct response: "I would like to sit with you and talk about your child." This choice is the focused therapeutic response that would generate client-focused discussion. Calling someone else is not client focused and nursing intervention based. Stating that this is a normal response is nontherapeutic, and calling the health care provider is incorrect because the it is within the nurse's scope of practice to resolve this issue.

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient?

correct response: readiness for Enhanced Spiritual Well-Being The most appropriate diagnosis for this patient is Readiness for Enhanced Spiritual Well-Being. The patient desires to experience and integrate meaning and purpose in life through connection with self, others, art, music, literature, nature, or a power greater than themself.

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

correct response: completion of range of motion on limbs restrained Any client assessment and subsequent decision making/judgment is in the scope of practice of the nurse. The unlicensed healthcare worker (UHW)/nursing assistant (NA) is able to complete the task of range of motion.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

correct response: formula in the client's mouth during the feeding, and increased cough Formula in the mouth and cough are indicators of aspiration. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A passage of flatus is not reflected in tolerating a feeding, it is an indication of bowel function. A rapid flow should not be administered by a nurse, and gastric tenderness does not indicate tolerance of tube feed.

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The client has not smoked a cigarette for 3 weeks and tells the nurse about fears of starting smoking again because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?

correct response: "It is good that you can talk about your concerns. Try calling a friend when you want to smoke." It is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client to anticipate failure. Telling the client to exercise more self-control does not provide support. Taking a vacation to avoid job pressures does not address the issue of how to manage the desire to smoke when in a stressful situation.

A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.

correct response: "Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth." Using a spacer, especially with inhaled corticosteroid, can make it easier for the medication to reach the lungs; it can also prevent excess medication remaining in the mouth and throat, which can cause minor irritation. It is important for the client to empty the lungs, breathe in slowly, and hold the breath to draw as much medication into the lungs as possible. Rinsing after using a corticosteroid inhaler may help prevent irritation and infection; rinsing will also reduce the amount of drug swallowed and absorbed systemically.

A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? Record your answer using a whole number.

correct response: 24 First, calculate how many units are in each milliliter of the medication. 25,000 units/500 mL = 50 units/1 mL. Next, calculate how many milliliters the client receives per hour. 1,200 units/1 hour divided by 50 units/1 mL = 1,200 units/1 hour X 1 mL/50 units = 24 mL/h.

A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?

correct response: Clamp the catheter. The nurse should instruct the caretaker to clamp the catheter to prevent the client from experiencing an air embolism. The client should be positioned on the left side with head lower than the feet, not higher. The catheter should not be removed by the caretaker; it will need to be removed in an acute care or outpatient setting by a healthcare provider. As the client is not experiencing signs or symptoms of an air embolism or other complication, there is no need to contact 911 at this time.

Prior to administering an opioid prescribed for pain management, the nurse assesses the client using the Pasero Opioid-Induced Sedation Scale (POSS) (see chart). The nurse assigns a score of 3 based on assessment criteria for the scale. What should the nurse do next?

correct response: Contact the health care provider (HCP) to request a decreased dose of the medication. A standardized sedation scale such as the Pasero Opioid-Induced Sedation Scale (POSS) scale is used to monitor the client for excessive sedation. A score of 3 on this scale indicates the client is over sedated, and the nurse should contact the HCP to request to administer 25% to 50% less of the medication for this dose. The nurse should not administer the medication or increase the dose. A reversal agent, such as naloxone, is not warranted unless the client has reached a POSS score of 4 or is showing signs of respiratory depression.

The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do?

correct response: Ensure there are no kinks in the catheter tubing. The simplest method to ensure drainage of the catheter is to check the tubing for kinks in the tubing that would affect drainage. After this, palpating the bladder for distention, notifying the healthcare provider, and changing the urinary catheter would be the next steps in troubleshooting this situation.

The nurse is caring for a young adult with end stage leukemia. The client asks the nurse to "help end my suffering in this life because it has gotten to be too much to endure." Based on the ANA Code of Ethics for nurses, what would the nurse do next? Select all that apply.

correct response: Explain to the client that nurses cannot participate in assisted suicide. Allow the client to discuss their feelings and explore other options for comfort. The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate, but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. A nurse should encourage clients to discuss their feelings and assist them to explore other options. The client may need an antidepressant, but this does not deal with the current issue of suicidal ideations.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?

correct response: Perform thorough hand washing before and after touching any child in the day care center. Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

A graduate nurse is assessing a client with Meniere's Disease and a positive Romberg's sign. What is the nurse's highest priority when delivering care?

correct response: Place client on fall precautions. To test for Romberg's sign, which assesses balance, the nurse instructs the client to stand with feet together and arms at the sides. The nurse observes the client's ability to maintain balance; first with eyes open and then with eyes closed. Management of a client with balance disorders such as Meniere's Disease include providing a quiet, dark environment, low-sodium diet, antihistamines, antiemetics, and a mild diuretic. The nurse's greatest concern is balance and the risk of falls.

When measuring gastric residual volume in a client receiving continuous tube feeding through a gastrostomy tube, the nurse attaches a large syringe to the tube and withdraws all fluid remaining in the stomach. After noting the amount of fluid, what should the nurse do?

correct response: Readminister the aspirated fluid through the feeding tube The aspirated fluid should be readministered to the client through the feeding tube when measuring gastric residual volumes. This prevents the loss of fluids, electrolytes, nutrients and medications that are in that gastric fluid. Discarding the aspirated fluid, either into a biohazard container or down the toilet, results in the loss of important fluids, electrolytes, nutrients and possibly medications, putting the client at risk for a wide variety of complications. Adding the aspirated fluid to the bag of formula would contaminate the entire bag of formula, making it spoil quicker than normal, and could also put the client at risk for infection or complications from spoiled formula.

A client's husband has asked that his wife be cared for exclusively by female nurses, a request with which the client herself agrees. What action would the care team take in response to this request?

correct response: Take a reasonable measure to accommodate the request. While cultural assessment in a tactful and respectful manner is likely appropriate in this situation, the care team's guiding principle and obligation in this situation is to accommodate and respect the couple's request. It would be inappropriate for the care team to attempt to convince the couple to change their minds.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do?

correct response: Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via email is unacceptable due to potential security and privacy issues.

The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to assess in a 1-month-old infant? Select all that apply.

correct response: bulging fontanels; high-pitched cry; irritability Signs and symptoms of increased ICP in a 1-month-old include full, tense, bulging fontanels; a high-pitched cry; and irritability. With increased ICP, blood pressure rises while heart rate falls. The infant may have a headache but the nurse cannot assess this finding in an infant.