PN Live Review Fundamentals 2020
A nurse is documenting information in a client's electronic health record. Which of the following information should the nurse include? A) "The client slept well." B) "The client's status is unchanged." C) "The client refused his bedtime snack." D) "The client's vital signs are normal."
"The client refused his bedtime snack." Rationale: The nurse should use information that is objective and specific when documenting a client's response to an intervention in the client's electronic health record. The nurse should record the client's response to interventions, such as refusing a snack, meal, or medication when offered. --------------------- The nurse should use information that is objective and specific when documenting information in the client's electronic health record. The nurse should avoid using a vague term such as "well" when documenting the client's condition because it is a subjective term. The nurse should use information that is objective and specific when documenting information in the client's electronic health record. The nurse should avoid using a vague term such as "unchanged" when documenting the client's condition because it is subjective and nonspecific. The nurse should use information that is objective and specific when documenting information in the client's electronic health record. The nurse should avoid using vague terms such as "normal" when documenting the client's condition.
A nurse is observing the actions of other nurses on the unit. Which of the following actions should the nurse identify as adhering to the code of ethics for nurses? A) A nurse informs a client's family member that the client refused morning medications. B) A nurse spends less time with a client who frequently tells long stories. C) A nurse delegates the task of inserting a urinary catheter for a client to an assistive personnel (AP). D) A nurse declines a new client's request to connect and communicate on an online social network.
A nurse declines a new client's request to connect and communicate on an online social network. Rationale: The nurse should not connect with a new client on social media platforms because this can interfere with the nurse's ability to maintain a therapeutic relationship. Friendship with a client compromises the ability of the nurse to remain objective. This action upholds the nursing code of ethics. ----------------------- A nurse informs a client's family member that the client refused morning medications. The nurse should only discuss a client's personal information, diagnosis, treatment, or assessment with members of the health care team who are involved in that client's care. This upholds the ethical principle of confidentiality. ------------------- A nurse spends less time with a client who frequently tells long stories. The nurse should try to divide their time evenly between clients according to each client's individual needs, regardless of the client's personal interactions with the nurse. The nurse can schedule tasks in the client's room to allow time to listen to the stories while performing care because this upholds the ethical principle of justice. -------------------- A nurse delegates the task of inserting a urinary catheter for a client to an assistive personnel (AP).The nurse should only delegate interventions and tasks that are within the delegate's training and ability according to each state's Nurse Practice Act. The task of inserting a urinary catheter should not be delegated to an AP because this action is not within the AP's range of function. Ensuring that delegated tasks are within the AP's range of function upholds the ethical principle of nonmaleficence.
A nurse is reinforcing teaching with a client about breast self-examination (BSE). Which of the following statements by the client indicated an understanding of the teaching? A) "I should begin my BSE by looking at my breasts while standing in front of the mirror." B) "I should perform my BSE each month on the first day of my menstrual cycle." C)"I should expect a small amount of white discharge when I gently squeeze my nipples." D) "I should feel each of my breasts at the same time to check for any differences."
A) "I should begin my BSE by looking at my breasts while standing in front of the mirror." Rationale: The client should begin their BSE by standing in front of the mirror and inspecting the appearance of each breast. The client should observe for symmetry and changes in appearance. The nurse should instruct the client to report to the provider any indications of dimpling, puckered skin, rashes or scaling of the skin, or nipple discharge. These findings, or any other changes, warrant further assessment by the provider. ----- Why the other options are incorrect: The client should perform a BSE each month 4 to 7 days after menstruation ends. During this time of the menstrual cycle, the client's breasts are less tender than at the beginning of the cycle. Performing the BSE when the breasts are less tender allows the client to perform a more thorough self-examination and increases the likelihood that they will detect changes or abnormalities. The client should gently squeeze each nipple during the BSE to check for any discharge. The nurse should instruct the client to report any discharge from their nipples to the provider. After childbirth, the client might have clear yellow discharge from the nipples. Otherwise, this finding warrants further assessment by the provider. The client should palpate one breast thoroughly in a vertical strip, circular, or wedge pattern, checking for any lumps or masses in the breast. After completing the palpation of one breast, the client should repeat the process on the other breast. The nurse should instruct the client to report any lumps, masses, or changes to the provider for further assessment.
A nurse is reinforcing teaching about aseptic precautions with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A) "I should maintain a closed urinary drainage system placed below the level of the client's bladder." B) "I should change a client's IV tubing every 48 hours." C) "I should consider the sterile area of a gown to be from the shoulders to the knees." D) "I should remove my eyewear before my gloves when removing personal protective equipment."
A) "I should maintain a closed urinary drainage system placed below the level of the client's bladder." Rationale: The nurse should maintain a closed urinary drainage system with a downhill flow of urine to prevent urinary tract infections. The collection bag is kept below the level of the client's bladder to prevent backflow of contaminated urine into the bladder from the drainage bag. Urine should flow freely into the drainage bag. If the tubing is kinked, obstructed, or twisted, urine that becomes static in the tubing can cause infection. ----------------------- The nurse should change intravenous tubing no more often than every 96 hr to minimize the risk of contamination from micro-organisms. The nurse should understand that a gown is sterile from the shoulders to the waist area. Only the front portion of the gown is sterile. Anything below the waist is considered contaminated. The nurse should remove gloves first because they are the most contaminated piece of personal protective equipment. This measure will prevent the soiled areas of the gloves from touching the skin. The nurse should perform hand hygiene prior to removing protective eyewear.
A nurse is assisting with the plan of care for a client who has Clostridium difficile (C. difficile). Which of the following supplies should the nurse ensure is available in the room? A) Antimicrobial soap B) N95 respirator mask C) Sterile gloves D) Alcohol-based hand sanitizer
A) Antimicrobial soap Rationale: The nurse must perform hand hygiene by washing their hands with antimicrobial soap and water after each client contact or contact with the surfaces in the client's room. Alcohol-based hand sanitizers are not effective against spore-forming organisms like C. difficile. The nurse should also perform appropriate hand hygiene after removal of personal protective equipment, when hands are visibly soiled, or after caring for clients with known or suspected infectious diarrhea. ---------------------- The specially fitted N95 respirator mask has a higher filtration rate than a regular face mask. The nurse should wear this type of mask when caring for a client who requires airborne precautions, such as a client who has tuberculosis. The use of sterile gloves is not cost effective or necessary for a client who requires transmission-based precautions. The nurse should use clean gloves when providing care for a client who has C. difficile. Alcohol-based hand sanitizers are not effective against spore-forming organisms like C. difficile. The nurse should use an antimicrobial soap and water when performing hand hygiene after caring for a client who has C. difficile.
A nurse is assisting with the plan of care for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse recommend including in the plan to prevent the development of skin breakdown? A) Apply a moisture barrier ointment to the client's skin.
A) Apply a moisture barrier ointment to the client's skin. Rationale: Skin that is left in contact with urine for prolonged periods of time is at risk for maceration and breakdown. Cleansing the skin and removing items that are wet (e.g., incontinence pads, sheets, undergarments) is a priority to prevent breakdown. The nurse should apply moisture-barrier ointments and creams to the client's skin after cleansing to prevent urine from coming in contact with the skin. ------------------- The nurse should clean the client's skin with soap and water after each episode of incontinence. Chlorhexidine is used to cleanse hands and can be used for bathing. However, chlorhexidine should only be used on the perineum for thorough cleansing and not after each episode of incontinence. The nurse should change the client's position every 2 hr to prevent skin breakdown. Catheterization of the bladder can introduce bacteria into the bladder, creating a risk for bacteremia, a life-threatening bacterial infection of the blood. Indwelling retention catheterization results in a high rate of urinary tract infections as compared to intermittent catheterization.
A nurse is collecting data from a client who is receiving enteral tube feedings. Which of the following findings should the nurse identify as an indication that the tube is displaced? A) Coughing B) Diarrhea C) Peripheral edema D) Abdominal cramping
A) Coughing Rationale: The nurse should identify that coughing or vomiting can be an indication that the client's tube feeding is displaced. The nurse should replace the tube and confirm placement prior to restarting the tube feeding formula. ------------------------- Diarrhea Diarrhea can be caused by medications, hyperosmolar formula, antibiotics, or a possible bacterial infection due to contamination of the tube feeding formula. ----------- Peripheral edema Peripheral edema can be caused by fluid overload related to excess fluids. --------------- Abdominal cramping Abdominal cramping can be caused by cold tube feeding formula or a rapid rate of infusion.
A nurse is caring for a client who has had a bilateral mastectomy. The client states, "I can't even look at my scars." Which of the following actions should the nurse take? A) Establish eye contact with the client. B) Use a closed position when listening to the client. C) Inform the client that most people feel this way after this procedure. D) Reassure the client that everything will be okay now that the surgery is over.
A) Establish eye contact with the client. Rationale: The nurse should establish eye contact with the client when listening. This promotes a therapeutic environment and conveys to the client that the nurse is interested and actively listening to what the client is saying. ------------------------- The nurse should use an open position with their body when listening to the client to promote a therapeutic environment and convey that the nurse is interested and actively listening to what the client is saying. The nurse should be facing the client with arms at the sides and legs uncrossed. This response is nontherapeutic because the nurse is providing false reassurance to the client. This can minimize the client's feelings and can block the line of communication between the nurse and client. This response is nontherapeutic because the nurse is providing false reassurance to the client. This can minimize the client's feelings and can block the line of communication between the nurse and client.
A nurse on a pediatric unit is teamed with an asisstive personnel (AP) for the upcoming shift. Which of the following assignments is within the range of function for the AP? A) Feeding formula to an infant B) Evaluating an adolescent's understanding of dietary needs C)
A) Feeding formula to an infant Rationale: When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel. Formula-feeding an infant is an appropriate task for the nurse to delegate to the AP. ---------------------------- When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel. Evaluation is part of the nursing process and requires professional education. It is not an appropriate task to delegate to an AP. When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel. Providing instruction requires assessment of the client's ability and readiness to learn. It is not an appropriate task to delegate to an AP. When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel. Interpreting data is part of the nursing process and requires professional education. It is not an appropriate task to delegate to an AP.
A nurse is caring for a client who has manifestations of tuberculosis and a prescription for sputum specimen collection to test for acid-fast bacillus (AFB). Which of the following actions should the nurse plan to take? A) Obtain a sputum specimen on 3 consecutive days. B) Schedule collection of the sputum specimen just before bedtime. C) Ensure the collected specimen is kept at room temperature. D) Collect the specimen 30 min before performing postural drainage.
A) Obtain a sputum specimen on 3 consecutive days. Rationale: The nurse should plan to obtain an early-morning sputum specimen on 3 consecutive days when testing for AFB. When obtaining a sputum specimen, the nurse should provide oral care to decrease the risk of specimen contamination. -------------------- The nurse should plan to collect the sputum specimen early in the morning when the client awakens. It is often easier for the client to expectorate a specimen at this time of day due to the accumulation of sputum while sleeping. The nurse should immediately transport the sputum specimen to the laboratory or place it in a refrigerator until transport. This action decreases the risk of a false positive due to growth of organisms within the specimen. The nurse can perform postural drainage to assist the client in expectorating a sputum specimen. If postural drainage is needed, it is performed prior to specimen collection. Postural drainage improves the client's oxygenation by improving drainage and expectoration of secretions through appropriate positioning and turning of the client.
A nurse is caring for an older adult client who has early dementia and is about to be admitted to a facility. The client currently lives in a private home with their adult child and states, "I think my child is stealing my money." Which of the following responses should the nurse make? A) "We're going to make sure all of your needs are met while you're here." B) "Tell me more about what you think about your living situation." C) "Let's find some music or a book you would enjoy to pass the time." D) "You're probably misunderstanding the cost of your health care bills."
B) "Tell me more about what you think about your living situation." Rationale: The nurse should collect further data from the client when there are possible indications of abuse. The nurse should follow ethical principles such as beneficence, doing what is best for the client, in promoting safety for the client. This statement by the nurse will further explore the client's concerns so the nurse can take proper action if there is a legitimate concern. ----------------------- This statement by the nurse changes the subject from the client's statement. The nurse should respond in a way that promotes a therapeutic relationship with the client, rather than avoiding uncomfortable discussion. Although music or books can be a useful distraction to a client who is confused or in pain, it is inappropriate for the nurse to suggest a distraction at this time. There is no indication that the client is currently confused, and the nurse must promote the client's right to self-expression through therapeutic communication. This statement by the nurse challenges the client's point of view, which negates the client's feelings. The nurse should avoid making judgments of client statements. This prevents the client from feeling free to express personal opinions and information, which could hinder the nurse-client relationship.
A nurse is preparing to administer a narcotic medication to a client who reports experiencing pain. Which of the following actions should the nurse plan to take? A) Place any wasted portion of the narcotic in the sharps container. B) Ask a second nurse to witness the discarding of any part of the narcotic. C) Remove the medication before counting the remaining narcotics. D) Report a narcotic discrepancy to the provider.
B) Ask a second nurse to witness the discarding of any part of the narcotic. Rationale: The nurse should ask a second nurse to witness the discarding or wasting of parts of any narcotic. Both nurses should sign the control inventory form. This verifies that the narcotics were disposed of in a manner that adheres to the Controlled Substances Act (CSA). The narcotics disposal process will be directed by facility policy. ---------------------- The nurse should plan to dispose of a narcotic, or any other medication, according to agency policy. The nurse should never dispose of or waste parts of narcotics or medications into the sharps container. The nurse should verify the number of narcotics with the inventory record before removing any of the narcotics. If there is a discrepancy, the nurse must investigate and correct it before removing the narcotic dose. The nurse should report a narcotic discrepancy immediately to the nurse manager, nurse supervisor, and pharmacy and should follow agency policy to account for the discrepancy.
A nurse is planning to administer digoxin to a client and auscultates and apical pulse of 52/min. Which of the following actions should the nurse take? A) Administer the medication as prescribed. B) Ask another nurse to check the apical pulse. C) Recheck the client's pulse in 2 hr. D) Report the finding to the facility pharmacist.
B) Ask another nurse to check the apical pulse. Rationale: The nurse should ask a second nurse to verify the finding of an apical pulse less than 60/min. If bradycardia is confirmed, the nurse should notify the charge nurse or provider. -------------------- Administer the medication as prescribed. The nurse should withhold the administration of digoxin for an apical pulse below 60/min. The nurse should have a second nurse confirm the apical pulse rate and notify the charge nurse or provider if bradycardia is confirmed. ------- Recheck the client's pulse in 2 hr. The nurse should withhold the medication and have a second nurse confirm the pulse rate. If bradycardia is confirmed, the nurse should notify the charge nurse or provider and recheck the pulse rate within 1 hr. ---------- Report the finding to the facility pharmacist. The nurse should have a second nurse confirm the finding, then report the pulse rate to the charge nurse or provider.
A nurse is assisting with the plan of care for a client who has herpes simplex. Which of the following isolation precautions should the nurse plan to implement? A) Droplet B) Contact C) Airborne D) Protective environment
B) Contact Rationale: Herpes simplex is a viral infection of the mouth, skin, saliva, and genitalia. It is spread by direct or indirect contact with lesions or bodily fluids. The nurse should plan to implement contact precautions using hand hygiene, gloves, and a gown. The nurse should place the client in a private room if possible. However, the nurse can place the client in a room with another client who has the same infection. --------------------- The nurse should plan to implement droplet precautions for clients who have infections spread by droplet nuclei larger than 5 mm, including mumps, pertussis, and mycoplasma pneumonia. The nurse should place the client in a private room and should wear a mask when within 1 m (3.3 feet) of the client. The nurse should plan to implement airborne precautions for clients who have infections spread through droplet nuclei smaller than 5 mm, including measles, chickenpox (varicella), and pulmonary or laryngeal tuberculosis. The nurse should place the client in a private room with negative-pressure airflow of a minimum of 6 to 12 exchanges per hour. The nurse should wear a mask or N95 respirator mask if the client has tuberculosis. The nurse should plan to implement a protective environment for clients who are immunocompromised, such as clients who have cancer or have undergone a transplant. The nurse should place the client in a private room with positive-pressure airflow and a HEPA filter.
A nurse is preparing to witness a client who is scheduled for surgery sign an informed consent form. Which of the following tasks is the nurse's responsibility? A) Inform the client of any complications that might occur. B) Ensure that the client is competent to sign the consent. C) Explain the procedure to the client. D) Notify the provider when the client is ready to sign the consent.
B) Ensure that the client is competent to sign the consent. Rationale: The nurse should ensure that the client is competent, understands the procedure, and is not under the influence of any medications prior to the client giving informed consent. --------------------- Inform the client of any complications that might occur. It is the responsibility of the provider to inform the client of the benefits, risks, and possible complications of the procedure so the client can make an informed decision. This is not the responsibility of the nurse. ------------------------ Explain the procedure to the client. It is the responsibility of the provider to explain the procedure to the client, including the benefits, risks, and possible complications of the procedure so the client can make an informed decision. This is not the responsibility of the nurse. ----------------------------- Notify the provider when the client is ready to sign the consent. The nurse should notify the provider only when the client has questions about the procedure. The provider has the responsibility to inform the client of the benefits, risks, and possible complications of the procedure so the client can make an informed decision. There is no need to notify the provider if the nurse confirms that the client understands this information and is ready to sign the consent form.
A nurse is caring for a client who has a new diagnosis of liver failure. The client states, "The doctor told me about the typical treatment for this, but I'm not sure I want to go through all of that." Which of the following actions should the nurse take first? A) Discuss the role of a health care proxy in making treatment decisions. B) Help the client list their concerns about treatment. C) Provide the client with a brochure about liver disease. D) Give the client information about support groups for individuals who have liver disease.
B) Help the client list their concerns about treatment. Rationale: The first action the nurse should take using the nursing process is to collect data from the client. By helping the client make a list of concerns about treatment, the nurse can assist with planning interventions to address the client's concerns and promote the client's ability to self-advocate. ---------------------- The nurse should discuss the role of a health care proxy in making treatment decisions to promote client advocacy when the client is no longer able to make decisions. However, there is another action the nurse should take first. The nurse should provide the client with a brochure about liver disease to inform the client about what to expect following a new diagnosis. However, there is another action the nurse should take first. The nurse should give the client information about support groups for individuals who have liver disease to promote the client's ability to cope with the new diagnosis. However, there is another action the nurse should take first.
A nurse is preparing a client for a routine gynecoligical examination. Which of the following actions should the nurse take? A) Assist the client into a dorsal recumbent position prior to the examination. B) Instruct the client to empty their bladder prior to the examination. C)Advise the client to tighten their abdominal muscles during the internal examination. D) Provide sterile gloves for the provider to wear during the examination.
B) Instruct the client to empty their bladder prior to the examination. Rationale: The nurse should instruct the client to empty their bladder prior to a gynecological examination. This action allows the provider to perform a more thorough palpation of the client's uterus and ovaries and promotes client comfort during the examination. During the gynecological examination, the provider can perform a vaginal examination and can assess the client's reproductive organs and external genitalia for abnormalities. Instructing the client to void also provides a urine specimen for urinalysis, which is often prescribed as part of the examination. ------------------ The nurse should assist the client into a lithotomy position for a gynecological examination. In this position, the client's feet are in stirrups with the buttocks at the end of the examination table, allowing the provider to examine the client's genitalia and genital tract. The nurse should place clients in a dorsal recumbent position for examination of the thorax or abdomen. The nurse should instruct the client to relax their abdominal muscles during the examination. This relaxation promotes comfort during the examination. The nurse should have the client place their arms at the side or across the chest and take deep breaths during the examination. These actions help to prevent the client's abdominal muscles from tightening. Prior to the exam, the nurse should prepare supplies needed by the provider. Supplies include clean gloves, a light source, vaginal speculum, and supplies for collection of cytological specimens. Clean gloves provide protection for the provider from contact with bodily fluids of the genitalia and genital tract. This examination is a clean procedure. Sterile gloves are not necessary.
A nurse is reinforcing teaching with a client who has left-sided weakness and is beginning to use cane for ambulation. Which of the following instructions should the nurse give to the client? A) Hold the cane with the left hand. B) Move the cane forward before advancing the left foot. C) Advance the cane forward 36 to 46 cm (14 to 18 in) with each step. D) Keep three points of support on the floor at all times.
B) Move the cane forward before advancing the left foot. Rationale: The client should move the cane forward while the body weight is on both legs. The client should then advance the weaker leg (left leg) toward the cane and then advance the stronger leg (right leg) forward past the cane. --------------------- The client should hold the cane with the right hand so the cane is on the stronger side of the body. For maximum support when walking, the client should place the cane forward 15 to 30 cm (6 to 12 in), keeping body weight on both legs. The client should keep two points of support, not three, on the floor. For example, the client should have both feet, or one foot and the cane, on the floor at any given time. If the client becomes stronger and is able to maintain balance with minimal support, they can move the cane and weak leg at the same time.
A nurse is preparing to transfer a client who has unilateral weakness from the bed to a bedside commode. Which of the following pieces of equipment should the nurse use to transfer the client? A) Mechanical lift B) Quad cane C) Slide board D) Walker
B) Quad cane Rationale: The nurse should provide a quad cane for a client who has unilateral weakness because it promotes mobility and independence while maintaining safety. The quad cane provides more support than a traditional cane. ---------------------- The nurse should use a mechanical lift to transfer a client who is unable to assist the nurse. The nurse should not lift more than 15.88 kg (35 lb) of the client's weight without the use of an assistive device in order to reduce the risk of injury to the nurse and maintain safety for the client. The nurse should use a slide board to transfer a client from the bed to a stretcher. The slide board helps to reduce friction while moving a client. The slide board is placed under a draw sheet for a client who is lying supine. The nurse should provide a walker for a client who has adequate strength in both arms to move the walker forward. A client who has unilateral weakness cannot perform this function and requires a different piece of equipment for assistance when moving from the bed to a bedside commode.
A nurse is monitoring a client who has a prescription for wrist restraints to prevent removal of an indwelling urinary catheter. Which of the following findings requires intervention by the nurse? A) The restraint is padded at the client's wrist bone. B) The restraint is attached to the side rails of the bed. C) The restraints limit the range of movement of the client's hand. D) The nurse can insert two fingers between the client's wrist and the restraint.
B) The restraint is attached to the side rails of the bed. Rationale: The use of restraints is sometimes necessary to provide for the safety of a client. The nurse can request a prescription for restraints if a client is at risk for falls, is confused, is at risk for removing support equipment or treatment, or is a threat to others. The provider should perform a face-to-face assessment and prescribe the restraints for a specific period of time and never PRN. The nurse should secure the restraint to a movable part of the bed frame and never to the side rails. This will allow for the restraints to move with the client when the nurse moves the head of the bed up or down. ---------------------------- The nurse should ensure that boney prominences, such as the wrist bones, are padded when applying restraints to prevent friction that can lead to skin breakdown. The intention of the restraints is to limit the client's movement and to prevent client removal of the indwelling urinary catheter. However, the nurse should avoid totally immobilizing the client to prevent injury. The nurse should review facility protocol regarding restraints and perform circulatory checks according to protocol. The nurse should be able to insert two fingers between the restraint and the client to ensure the restraint is not too tight, which can cause neurovascular injury. The nurse should check the client frequently, according to facility policy, for signs of injury. These checks should include skin integrity, pulses, color, temperature of skin, and sensation.
A nurse is performing a straight catheterization of a client in order to obtain a urine specimen for culture and sensitivity. Which of the following actions should the nurse make? A) Collect urine specimen from the catheter port. B) Use a sterile specimen container for collection. C) Ensure sterile water is used to inflate the balloon. D) Unwrap the catheter kit before washing the client's perineal area.
B) Use a sterile specimen container for collection. Raitonale: A catheter urine specimen for culture and sensitivity requires a sterile specimen from a straight or indwelling catheter using sterile technique. The nurse should use a sterile specimen container to prevent contamination of the specimen by micro-organisms outside of the bladder. ------------------------ The urine from a straight catheter (single lumen tube) flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the client has an indwelling urinary catheter in place. A straight catheter has a single lumen for draining urine directly from the bladder into a sterile collection container. A straight catheter does not remain in the bladder and does not have a second lumen with a balloon. The nurse should include this step if inserting an indwelling urinary catheter. The nurse should clean the client's perineal area with soap and water before opening the sterile catheter kit to maintain aseptic technique.
A nurse is preparing to remove the sutures from a client's abdominal incision. Which of the following actions should the nurse plan to take? A) Clean the suture site with full-strength hydrogen peroxide prior to removal. B) Use suture scissors to cut the suture close to the skin before removal. C) Pull the visible portion of the suture through the skin using forceps. D) Remove each suture, one by one, moving from proximal to distal on the incision.
B) Use suture scissors to cut the suture close to the skin before removal. Rationale: The nurse should use sterile suture scissors to cut the suture as close to the skin as possible prior to removal. This action reduces the risk for infection by preventing exposed suture material, which is considered contaminated, from being pulled through the skin. ---------------------- The nurse should cleanse the incision site with 0.9% sodium chloride solution prior to removing sutures. This allows the skin to remain moist and promotes wound healing. The use of a disinfectant such as full-strength hydrogen peroxide can irritate the wound tissue and delay healing. The nurse should use forceps or hemostats to grasp the suture and pull it out without pulling the visible portion through the underlying skin. This technique prevents micro-organisms on the visible portion of the suture from being introduced into the sterile underlying skin. This helps to decrease the risk for infection. The nurse should remove the sutures in small groups or in an alternating pattern (e.g., the second, fourth, and sixth sutures) to decrease the client's risk for dehiscence. If dehiscence occurs, the remaining sutures serve to help maintain approximation of the incision edges while the charge nurse and provider are notified.
A nurse is providing postmortem care to an adult client. Which of the following actions should the nurse take? A) Place the client in a side-lying position B) Determine whether an autopsy has been ordered C)Cover the client's body with a sheet D) Ask the client's loved ones about their religious rituals E) Remove the client's dentures
B, C, D Rationale: Place the client in a side-lying position is incorrect. The nurse should place the client in a supine position with their head on a pillow. Determine whether an autopsy has been ordered is correct. The nurse should determine whether an autopsy has been ordered prior to performing any care to the body. Cover the client's body with a sheet is correct. The nurse should cover the client's body with a sheet and provide privacy for the family to view the body. Ask the client's loved ones about their religious rituals is correct. The nurse should ask the client's family or loved ones about any religious or cultural practices that might need to be included in the postmortem care of the client's body. Remove the client's dentures is incorrect. The nurse should ensure that the client's dentures remain in place to maintain the client's normal facial appearance.
A nurse is caring for a client who is 8 hr postoperative following a transurtheral resection of the prostate (TURP) and has a continuous bladder irrigation system in place. Which of the follwoing actions should the nurse take?? (Select all that apply). A) Add the amount of bladder irrigation to the total output. B)Keep the tip of the tubing sterile when connecting it to the irrigation solution C) Ensure the drainage tubing is patent D) Contact the surgeon if the client reports a continual need to void. E) Notify the surgeon if the urine is bright red in appearance or has large clots
B, C, E Rationale: Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract the amount of bladder irrigation solution from the total urine output amount. Keep the tip of the tubing sterile when connecting it to the irrigation solution is correct. Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. The nurse should observe the client closely for manifestations of infection, such as fever and an elevated WBC count. Ensure the drainage tubing is patent is correct. The nurse should make sure the outflow drainage tubing of the three-way catheter system is not obstructed, kinked, or clamped. This will prevent excess accumulation of urine and irrigant in the bladder, which can cause distention and possible injury. Contact the surgeon if the client reports a continual need to void is incorrect. Following a TURP, the client will have a large catheter that is pulled taut and secured to the client's leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client might experience the sensation of a continual need to void. The nurse should inform the client that the urge to void is expected. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and initiate bleeding. Notify the surgeon if the urine is bright red in appearance or has large clots is correct. It is important to document the characteristics of the drainage. It is expected to see blood with a few small blood clots. However, urine that is bright red, ketchup-like, or has large clots is an indication of excess bleeding and the nurse should report these findings to the surgeon. The nurse should also monitor the client's Hgb and Hct to help determine the degree of blood loss.
A charge nurse in a long-term care facility is assisting in the orientation of a newly licensed nurse. When discussing equipment and supply use, which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "I should sterilize blood pressure cuffs after each use." B) "I will store extra supplies in the client's room in case I need them." C) "I should tag any equipment not in working order and notify my supervisor." D) "I will keep the client's urinal on the overbed table for convenience."
C) "I should tag any equipment not in working order and notify my supervisor." Rationale: The nurse should tag malfunctioning equipment to prevent the use of the equipment by other staff members. The nurse should then notify the supervisor or the biomedical department to have the equipment replaced or repaired. ----------------------------- "I should sterilize blood pressure cuffs after each use." It is not necessary for noncritical items like blood pressure cuffs, stethoscopes, and bedside trays to be sterilized. The nurse should ensure that noncritical items are disinfected. ------- "I will store extra supplies in the client's room in case I need them." To provide cost-effective care and maintain an organized care environment, the nurse should return unopened supplies to designated storage areas and should not store them in the client's room. ------------------- "I will keep the client's urinal on the overbed table for convenience." The nurse should not place the client's urinal or bedpan on the overbed table because the table is used for meal trays, toiletry items, and performing procedures. The overbed table should be cleaned with an antiseptic cleaner prior to use.
A nurse is reinforcing teaching regarding bladder retraining with a client who has urinary incontinence. Which of the following statements by the client indicated an understanding of the teaching? A) "I should go to the bathroom whenever I feel the urge to void." B) "I will increase my intake of drinks that contain citrus juices." C) "I will keep a diary of my voiding patterns each day." D) "I will limit my fluid intake between the hours of 10:00 a.m. and 2:00 p.m."
C) "I will keep a diary of my voiding patterns each day." Rationale: In order to help track the effectiveness of bladder retraining, the client should keep a diary of their voiding patterns each day. This will not only assist in evaluating the effectiveness of the retraining program but will make the client more aware of usual voiding times to help avoid instances of incontinence. -------------------- During initial bladder training, the client should go to the bathroom to void at regularly set intervals. Initially, the client should attempt to restrict voiding to once every 2 to 3 hr during waking hours and every 4 to 6 hr during the night The client should avoid excessive intake of beverages containing caffeine, citrus juices, and artificial sweeteners to prevent urinary frequency and urgency. The client should consume liquids between the hours of 0600 and 1800 to promote urinary continence. Limiting fluid intake overnight and taking prescribed diuretics in the early morning will help the client to prevent incontinence during the night.
A nurse is caring for a client who has a new diagnosis of terminal lung cancer. Which of the following statements by the client indicated the denial phase of the grief process? A) "The doctor has been so good to me. I know he has tried everything he can. It is just my time." B) "I can't believe that doctor graduated from medical school. He doesn't know a thing about treating cancer." C) "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." D) "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed."
C) "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." Rationale: This client statement is an example of denial. In this phase of the grief process, clients have difficulty believing a terminal diagnosis or loss. ------------------- "The doctor has been so good to me. I know he has tried everything he can. It is just my time." This client statement is an example of acceptance. In this phase of the grief process, clients accept what is happening and find ways to plan for the future. -------- "I can't believe that doctor graduated from medical school. He doesn't know a thing about treating cancer." This client statement is an example of anger. In this phase of the grief process, clients lash out at other people or things. --- "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed." This client statement is an example of depression. In this phase of the grief process, clients are saddened about their inability to change the situation.
A nurse is collecting data from a client who states, "I just don't know what to do about my partner's drinking. Every time I see my partner drinking beer, I get very anxious." Which of the following responses by the nurse is therapeutic? A) "Try not to feel so anxious about something that is your partner's problem, not yours." B) "At one time, you told me you were drinking with your partner. Are you continuing to do that?" C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?" D) "I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."
C) "The next time your partner starts drinking, what is something you might do to decrease your anxiety?" Rationale: The nurse is using therapeutic communication in the form of an open-ended question to encourage the client to focus on identifying an alternate course of action for the situation in question. --------------------- The nurse is using nontherapeutic communication by being dismissive and minimizing the client's concerns. The nurse is using nontherapeutic communication by making a value judgment toward the client. The nurse's response implies that the client is doing something wrong. This type of response can cause the client to stop talking and not share anything else with the nurse. The nurse is using nontherapeutic communication by giving advice. This response discourages further expression of the client's feelings and takes away from the client's own ability to demonstrate decision-making.
A nurse is assisting with the orientation of an assistive personnel (AP). For which of the following clients should the nurse instruct the AP to use a gait belt? A) A client who has a history of falls B) A bariatric client who requires assistance with repositioning in bed C) A client who requires minimal assistance ambulating D) A client who has a bilateral foot amputation
C) A client who requires minimal assistance ambulating Rationale: A gait belt should be used for an ambulatory client who is weight-bearing and requires minimal assistance. The gait belt is used to stabilize the client when ambulating to reduce the risk for client injury. ------------------------ A gait belt should not be used for clients who are at high risk for falls because it provides minimum support to stabilize the client. The nurse should use a lift with an ambulation sling to assist a client who has a history of falls. A gait belt should not be used on bariatric clients as it can cause injury to the client. A gait belt should be used for a client who is weight-bearing and requires minimal assistance.
A hospice nurse is providing care for a client who is actively dying. Which of the following acitons should the nurse take? A) Place the client in a supine position. B) Encourage the client to increase calorie intake. C) Ask if the client prefers to have the room lights on or off. D) Speak with an increased voice volume.
C) Ask if the client prefers to have the room lights on or off. Rationale: The nurse should ask if the client prefers to have the lights in the room remain on or off as a palliative measure. Some clients who are actively dying prefer a dark environment while others prefer to be able to easily see their surroundings. ---------------------------- The nurse should place the client in a lateral position if the client is unconscious, or in Fowler's position if the client is conscious, to maintain an open airway. The nurse should encourage the client to take liquids as tolerated. The client might have altered nutrition, anorexia, or feelings of nausea. Therefore, the nurse should never force the client to eat. The nurse should speak to the client clearly and at a normal volume, without either whispering or speaking loudly. Hearing usually remains unchanged for the client while dying and can remain unchanged until death.
A nurse is caring for a client who has a supine blood pressure of 86/58 mm Hg and reports feeling dizzy. Which of the following actions should the nurse take? A) Request a prescription for a diuretic from the provider. B) Ask an assistive personnel to recheck the blood pressure in 2 hr. C) Compare the result to the client's baseline. D) Assist the client to a sitting position.
C) Compare the result to the client's baseline. Rationale: Comparing baseline measurements of the client's blood pressure provides a reference for identification and accurate interpretation of any noted changes. ------------------- A diuretic is a medication that reduces reabsorption of water by the kidneys, which lowers circulating fluid volume. This medication would further decrease client's blood pressure. The client's blood pressure requires further assessment and intervention by the nurse as it is below the expected reference range. Hypotension with dizziness increases the client's risk for injury due to a fall. The client's blood pressure is below the expected reference range in a supine position. It would be unsafe for a client to move into a sitting position as this could further decrease the blood pressure.
A nurse is reinforcing teaching with a client about home safety precautions to reduce the risk of falls. Which of the following instructions should the nurse include in the teaching? A) Use a low toilet seat. B) Place throw rugs over noncarpeted surfaces. C) Install night lights in dark areas. D) Move the living areas to the second floor.
C) Install night lights in dark areas. Rationale: Night lights should be installed in the bedroom and other dark areas so that the client is able to see their path in the dark to reduce the risk of falling.
A nurse is collecting data from a client who has an acute infection and is shivering. The client's temperature is 40.2 C (104.4 F). Which of the following actions should the nurse take? A) Give the client a cold sponge bath. B) Bathe the client with an alcohol and water solution. C) Request a prescription for an antipyretic medication. D) Apply ice packs directly to the skin of client's groin area.
C) Request a prescription for an antipyretic medication. Rationale: The nurse should implement actions to reduce the client's body temperature without causing the client to experience further shivering. Methods of restoring a normal body temperature include the administration of antipyretics like ibuprofen and acetaminophen. Antipyretic medications serve to increase the heat lost by the client's body, which helps to reduce fever. Antipyretics can be used along with a hypothermia blanket and a bath sheet as a skin barrier to achieve additional temperature reduction. ---------------------- Give the client a cold sponge bath. The nurse should avoid giving the client a cold sponge bath because this action could increase the client's shivering. If a sponge bath is used, the bath should be performed with tepid water. However, this therapy can increase the risk of shivering, which is counterproductive to restoration of a normal body temperature. ------- Bathe the client with an alcohol and water solution. The nurse should avoid bathing the client with an alcohol and water solution. This action is not recommended because of the risk of increased shivering, which is counterproductive to restoration of a normal body temperature. The alcohol in the bath can also remove moisture from the client's skin. ------------------- Apply ice packs directly to the skin of client's groin area. The nurse should avoid applying ice packs to the client's groin and axillae. This action is not recommended because of the risk of increased shivering, which is counterproductive to restoration of a normal body temperature. There should always be a cloth barrier between ice packs and the client's skin to insulate the skin from damage that can occur due to the extreme cold.
A nurse is reviewing the medical records of a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy to detect colorectal cancer (CRC)? A) A 53-year-old client who had a sigmoidoscopy 3 years ago B) A 34-year-old client who reports a new onset of constipation C) A 32-year-old client who had a double-contrast barium enema 2 years ago D) A 51-year-old client who is being seen for an annual physical examination
D) A 51-year-old client who is being seen for an annual physical examination Rationale: Starting at 45 years of age, clients considered to be at average risk and who have no family history of CRC should have a screening colonoscopy every 10 years. Clients who are at increased risk for CRC might have the screening earlier and more often. ---------------------- Screening recommendations for adults 45 years of age and older who are at average risk for CRC include the option of a flexible sigmoidoscopy every 5 years. Unless the client has risk factors for CRC or the constipation becomes chronic, the nurse should not anticipate scheduling this client for a colonoscopy. Screening recommendations for adults 50 years of age and older who are at average risk for CRC include the option of a double-contrast barium enema every 5 years.
A nurse is reviewing the plan of care for a client who is malnourished and has several referrals. Which of the following services should the nurse expect a social worker to provide? A) Showing a client how to use special utensils for cooking B) Prescribing nutritional requirements for the client C) Recommending food choices for the client D) Accessing food resources for the client
D) Accessing food resources for the client Rationale: Following an illness, clients might require special supplies or face financial hardship. The social worker helps connect the client with financial support and resources for self-care and may be asked to determine the safety of the client's living conditions. Social workers also provide counseling for a client facing role or life transitions. ----------------------- The nurse should expect an occupational therapist to provide functional assistance to perform ADLs. An occupational therapist can provide a client with special utensils for cooking and eating if the client's grip is impaired. The nurse should expect the provider to prescribe nutritional requirements for the client. The provider should select to increase or restrict certain nutrients in the diet based on the client's diagnosis and individualized needs. The provider's prescription guides how other interprofessional team members will assist the client to meet nutritional needs. The nurse should expect a dietitian to educate the client about following a prescribed therapeutic diet. The dietician may assess cultural preferences affecting the client's diet, review the client's eating habits, calculate the client's calorie needs, and provide information about food selection and meal preparation.
A nurse is providing end-of-life care to a client who has a metatstic lung cancer. Which of the following interventions should the nurse take to support the client's family? A) Discourage family members from long visits so the client can rest. B) Avoid discussing the manifestations of impending death with the client's family. C) Encourage family members to feed the client. D) Encourage the family to offer the client a back massage.
D) Encourage the family to offer the client a back massage. Rationale: The nurse should encourage the client's family to continue to touch the client through the use of massage, holding the client's hand, or brushing the client's hair because this provides reassurance and comfort for both client and family. --------------------------- The nurse should encourage family members to remain with a client who is at the end of life. This can involve making exceptions to visitation policies and providing privacy for the family. Supporting the grieving family is important during end-of-life care. The nurse should discuss manifestations of impending death with the client's family to reduce anxiety, stress, and fear. The nurse should reinforce with the client's family that, in the last days of life, clients often develop anorexia or feel nauseated by food, and eating can cause pain and discomfort. In addition, the nutrients in food are not able to be absorbed as the client's body is shutting down.
A nurse is contributing to the plan of care for an older adult client who is experiencing weight loss. Which of the following interventions should the nurse include? A) Select foods with less complex carbohydrates. B) Discourage visitors at mealtime. C) Provide the largest meal in the evening. D) Instruct the client to eat nutrient-dense foods first.
D) Instruct the client to eat nutrient-dense foods first. Rationale: The nurse should plan to have the client eat nutrient-dense foods first in order to consume the greatest amount of vitamins and calories. ----------------- The nurse should assist the client to select foods with more complex carbohydrates, such as legumes, potatoes, cereals, rice, and breads. The nurse should also assist the client to select less sugar-rich foods that are more appealing but can curb the client's appetite. The nurse should plan to encourage the client to have visitors while eating, establishing mealtime as a positive social event to interact and converse with others. This is conducive to maintaining the mealtime for a longer period of time, which helps to facilitate the client to eat more during the meal. The nurse should plan to have the client eat the largest meal at noon to aid in the digestive process and promote more restful sleep at night.
A nurse is collecting data from a client whose laboratory report indicated a potassium level of 3.1 mEq/L. Which of the following findings should the nurse expect? A) Increased bowel sounds B) Hyperactive reflexes C) Bounding peripheral pulses D) Muscle weakness
D) Muscle weakness Rationale: A potassium level of 3.1 mEq/L is below the expected reference range of 3.5 to 5.0 mEq/L, indicating hypokalemia. The nurse should expect this client to manifest ascending muscle weakness that starts in the quadriceps and can eventually impair respirations. Additional expected findings include decreased bowel sounds, constipation, hypoactive reflexes, weak and irregular pulses, and cardiac dysrhythmias. After reporting findings to the provider, the nurse should monitor the client and administer oral potassium if prescribed. --------------------- Increased bowel sounds. The nurse should expect the client who has hypokalemia to have decreased bowel sounds and constipation. After reporting findings to the provider, the nurse should monitor the client and administer oral potassium if prescribed. ---------------------------- Hyperactive reflexes The nurse should expect the client who has hypokalemia to manifest hypoactive deep-tendon reflexes. After reporting findings to the provider, the nurse should monitor the client and administer oral potassium if prescribed. ------------------- Bounding peripheral pulses The nurse should expect the client who has hypokalemia to have irregular and weak pulses. After reporting findings to the provider, the nurse should monitor the client and administer oral potassium if prescribed.
A charge nurse is observing a newly licensed nurse preparing to administer an intermittent tube feeding via an NG tub to a client. For which of the following acitons should the charge nurse intervene? A) The nurse initiates the feeding after obtaining 50 mL residual. B) The nurse flushes the tube with 30 mL of air before aspirating gastric fluid. C) The nurse administers the feeding through a syringe barrel by gravity. D) The nurse allows the client to sleep in supine position during the feeding.
D) The nurse allows the client to sleep in supine position during the feeding. Rationale: The nurse should keep the head of the bed positioned at a minimum of 30° (preferably 45°) to prevent aspiration from reflux during feedings and for at least 30 min afterward. The nurse can place the client in reverse Trendelenburg if unable to elevate the head of the client's bed. ----------------------- Prior to administering an intermittent gastric tube feeding, the nurse should check the stomach for residual volume. The nurse should check the facility policy if a single residual check is more than 100 mL or more than half the last feeding. If a single check is more than 500 mL, or two consecutive checks are 250 mL or more, the nurse should withhold the feeding. The nurse should flush the tube with 30 mL of air before aspirating gastric fluid to open and clear the feeding tube. After medication administration, the nurse should flush the NG tube with 30 to 100 mL of water to prevent clogging. The nurse should remember to note the amounts of water on the I&O record. The nurse can administer intermittent feedings by using a large barrel syringe or feeding bag. The nurse should fill the syringe with formula and hold it high enough for the formula to empty gradually via gravity. The nurse should continue to refill the syringe until the prescribed amount is administered. Following the feeding, the nurse should flush the tube with 30 mL water.
A nurse is caring for a client who is unresponsive. The client's family members disagree about the provider's recommendation for placement of a feeding tube. What process should the nurse follow when assisting with resolution of this ethical dilemma? (Move steps in correct order.) Determine that an ethical dilemma is present. Collect data about the ethical dilemma. Identify possible solutions to the dilemma. Verbalize the dilemma in a simple statement. Negotiate a plan with client's family.
The first step the nurse should take is to determine whether an ethical dilemma is present. Once an ethical dilemma is determined to exist, the nurse should follow key steps to resolve the problem. The nurse should collect data relevant to the client's problem, including individual perspectives about the problem from the provider and the client's family. Next, the nurse should verbalize the ethical dilemma in a simple and easily understood statement to help promote discussion. Then, the nurse should identify possible solutions to the dilemma. Finally, the nurse should work with the family and provider to negotiate an agreed upon plan to resolve the dilemma.
