Professional nursing concepts and practice final
The nurse is providing an education demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?
A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves
Which situations observed by a nurse should the nurse report to the nurse report to the nurse manager for quality assurance?
A nurse refuses to provide care to a client with HIV, a nurse administers medications to the wrong client, a nurse assesses a client after sneezing into the nurses hands, a nurse delays answering call lights to an abusive client
A client who recently became a quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select?
A syndrome nursing diagnosis
Which nursing intervention would be appropriate for a client diagnosed with deficient fluid volume?
Nutrition management, Electrolyte management, intravenous therapy
A nurse asks a client to rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. What information will the nurse gather next to establish the client's baseline pain experience?
location
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse would recognize that the client is experiencing
oliguria
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?
"I will use clean gloves to handle the catheter and other equipment."
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?
"Actually, people's bowel patterns can vary a lot and some people don't tend to go everyday."
A female client is asked to provide a specimen for a routine urinalysis. Which instructions should the nurse give the client?
"After cleansing the labia, urinate into the toilet first and then fill the container midstream."
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?
"Antibiotics have no effect on viruses."
The nurse is assessing a client's postoperative pin. Which statement demonstrates accurate documentation of objective pain assessment?
"Client rates pain 4 on a scale of 0 to 10."
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?
"Do you experience incontinence?"
A nurse is carrying out a prescription to remove an indwelling catheter. Which explanation should the nurse use with the client prior to removing an indwelling catheter?
"I am going to remove the catheter after withdrawing the fluid from the balloon."
The nurse conducting an in service on hand hygiene determines that additional education is needed when a participant states:
"I do not need to wash my hands if I am using gloves."
A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome that states, "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care related to this outcome?
"I'm not interested in wearing an artificial hand."
Before implementing a nursing intervention, which questions will the nurse ask oneself?
"Is the client prepared for what needs to be done?", "Do I have the skills to perform the intervention?", "Can I do the intervention alone or do I need help?", "Do any health care provider prescriptions need to be clarified?", "Do I have all the necessary supplies and equipment needed?"
A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?
"Make each breath deep enough to move the bottom ribs."
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?
"That is necrotic tissue, which must be removed to promote healing."
A client who has a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
Which question would be most helpful to the nurse in facilitating critical thinking during outcome identification and planning?
"What problems require my immediate attention of that of the team?"
Which question would be most helpful to the nurse in facilitating critical thinking during outcome identification and planning?
"What problems require my immediate attention or that of the team?"
The client tells the nurse, "I think the nurse last night may have given me the wrong medications, but I was afraid to say anything." What is the nurse's most appropriate response?
"You should always speak up if you have any questions about your care."
The nurse is preparing to perform handwashing. Place the following steps in the correct order
1. Turn on the faucet and adjust force and temp of water 2. Wet the hand and wrists 3. Apply soap 4. Wash the palms and backs of the hands for at least 20 sec 5. Pat the hands dry with a paper towel 6. Turn the faucet off with a paper towel
The nurse working in the community is assigned to the care of several clients. Which clients may require assistance to overcome a barrier to accessing adequate care?
A client who has been unemployed for 6 months, an older adult client living independently, a client who is a migrant and works on a farm
Which client likely faces a risk for the nursing diagnosis of disturbed sleep pattern: Difficulty remaining asleep?
A client who receives IV antibiotics every 3 hours
The nurse is assessing a group of clients who were brought into the ED after a motor vehicle accident that resulted in a fire. What client should the nurse give the highest priority for care?
A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious.
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
A client 68 years of age who is bedfast related to severe head trauma
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?
A client sitting in a chair who slides down
The nurse is caring for a client with terminal bone cancer. The client states, "my pain is getting worse and worse, and the morphine doesn't help anymore." The nurse determine the clients pain is:
Chronic malignant
A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment?
safety
A nurse is preparing a room for client admission. Which actions follow recommended guidelines for this process?
Adjust the physical environment of the room including lighting and temp, fold back the top bed linens, assemble the necessary equipment and supplies, including a hospital admission pack
The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing intervention. Which intervention should the nurse complete first?
Administer a dose of digoxin that is 2 hours behind schedule
For which client would the use of standard precaution alone be appropriate?
An incontinent client in a nursing home who has diarrhea
The nurse is educating a client about nonpharmacologic measures to alleviate restless leg syndrome (RLS). Which education points would the nurse include in the plan?
Applying heat or cold to the extremity can help relieve the symptoms, massaging the legs may relieve symptoms, biofeedback and TENS can help relax the client and relieve symptoms
When performing an assessment on a client with chronic pain, the nurse notes that the client frequently shifts conversational topics. What does the nurse determines that this may be an indicator of?
Anxiety
A 19 year old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 bpm. what would be the most appropriate way for the nurse to determine the significance of the client's heart rate?
Ask the client whether the heart rate is normal for the client
A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?
Asking the client when he or she has last urinated
The nurse is caring for a client who frequently comes to the ED reporting a headache that is an 8 or 9 on a pain scale of 1 to 10. The client is noted to be laughing while on the phone and chatting with the staff after reporting a headache that is a 10. Which action will the nurse perform prior to initiating treatment?
Assess for nonverbal cues to pain
The nurse is delegating care to an UAP. Which intervention would be most important for the nurse to perform independently?
Assess the client with difficulty breathing
The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?
Assess the need for assistance with ambulaiton
The nurse is preparing to don a gown to care for a client requiring contact precautions. When should the nurse don the gown?
Before entering the client's room
While caring for a client recovering from a CV accident, the nurse determines that the client would benefit from the services of PT. How should the nurse plan to involve PT in the clients care?
By formulating a collaborative problem
When preparing to irrigate a foley catheter, which is the appropriate initial nursing action?
Check health record for providers order
The nurse is doing preoperative teaching with a client who has a prescription for golytely before undergoing intestinal surgery. For tolerance of drinking the solution, the nurse would advise the client to drink it in which manner?
Chilled
A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurses best action?
Collaborate with other disciplines to plan end-of-life care for the client
Which activities does the nurse engage in during the evaluation phase?
Collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, adjusts the time frame to achieve the desired outcomes
A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform?
Compress the container as the solution instills, encourage the client to retain the solution, help the client into a Sims' position
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
Confusion
The client has diabetes and an elevated blood glucose level. During the nursing assessment, the client states, "I can't afford the pill used to control my blood sugar." What are appropriate actions by the nurse for this client?
Consult with the primary care provider about prescribing a medication that is free at some stores, make a referral to the social worker to find what financial assistance is available for the client, write a new nursing diagnosis "noncompliance related to inability to afford treatment."
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?
Contact the health care provider
Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action?
Contact the health care provider to ask for an order for catheter discontinuation, perform or allow client to perform perineal hygiene at least once daily
A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the clients bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurses actions?
Contaminants can be transferred onto the furniture and spread microorganisms
Two children need a kidney transplant. One is the child of a famous sports figure, whereas the other child comes from a low-income family. What ethical consideration is relevant to the nurse as an advocate for these clients?
Cost-effectiveness and allocation
The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain?
Deep somatic
A client has just given birth to the clients first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. What is the priority nursing diagnosis for the nurse to address prior to discharge of this client?
Deficient knowledge
What verbs should the nurse use to write outcomes that are measurable?
Define, verbalize
A post operative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound
A nurse has developed a plan of care for a client whose spouse recently died. The nurse assigned the client a nursing diagnosis of: Risk for Loneliness. When the nurse is evaluating the plan, the client tells the nurse new information about having an active social life and being satisfied with social activities. What should the nurse do next?
Delete the nursing diagnosis
The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?
Diminished breath sounds in left lower lobe
A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance?
Discover a problem, implement a change, plan a strategy using indicators, assess the change
A nurse is considering the delegation of administering topical medications to an UAP. What is the first question the nurse must ask oneself before doing so?
Do the nurse practice act and agency policy allow this delegation?
A nurse is responsible for recognizing significant date when developing nursing diagnoses. Which significant data would indicate a health problem may exist?
During assessment the client is sweating and SOB, the client only answers yes or no questions, the client has a blood pressure reading of 150/90 mmHg
The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included?
Encourage deep breathing, play the client's favorite music, promote a restful environment
The home health nurse is caring for a noncompliant client who has been diagnosed with type 2 diabetes. Which nursing interventions would be effective in helping the client change behaviors?
Encourage participation in a diabetes support group, include the client in creating a list of benefits for exercising, set short-term goals for modifying eat habits
A nurse is developing a plan of care for a client with heart failure brought to the ED. The client was experiencing SOB and pitting edema of the lower extremities. Which statement would the nurse identify as the problem to be addressed in the clients nursing diagnosis?
Excess fluid volume
A nurse is providing care for a client with cancer. The client's spouse requests that the client not be told that the client is terminal. The nurse complies with the request. The nurse's action is a breast of which ethical principle?
Fidelity
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
Fish
Which quality is essential to being a nurse leader?
Flexibility
Which statement about ostomy irrigation is true?
For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination
A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider.
Foul-smelling the drainage that is grayish in color
A RN is delegating activities to UAP on a hospital unit. Which activities could this nurse normally delegate?
Giving a bed bath to a client, taking routine vital signs, transferring a client to another floor
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?
Having the client sign a consent form for the procedure
A nurse is educating a client on medication techniques to provide mental calmness and physical relaxation. Which nursing intervention facilitates this process?
Helping the client to assume a specific, comfortable posture
To drain the apical section of the upper lobes of the lungs, the nurse should place the patient in which position?
High-Fowler's position
The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?
Hypertonic saline
Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?
If the client is in pain, administer analgesics in advance of the transfer
The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids and solids, has weakness on the right side of the body, and is incontinent of bowel and bladder. Which priority nursing diagnosis should the nurse identify and document in the care of this client?
Impaired swallowing, impaired physical mobility, bowel incontinence
The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?
Impaired tissue integrity
The nurse is disposing of an old dressing that is saturated with a client's blood. How should the nurse dispose of the dressing?
In a bag marked "biohazards"
A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?
Include the client and the clients power of attorney in the discussion
Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses?
Increased BP, Nausea and vomiting, muscle tension and rigidity
The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?
Increases the risk of infection by contaminating the wound
The RN and UAP are working together to admit a pediatric client to a nursing unity. Which task would be inappropriate for the RN to delegate to the UAP?
Initiating intravenous therapy
A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impactation?
Insert a lubricated, gloved finger into the rectum
A nurse caring for a client who ahs a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?
Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement
The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which?
Laissez-faire
The nurse is managing the care for a post operative client. How does the nurse demonstrate advocacy?
Limiting visitors due to the client reporting pain
A student is walking down the hall carrying soiled linen against her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student?
Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms
The nurse is administering a large volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?
Lower solution container and check temp and flow rate
The nurse and UAP are working together to admit a client newly diagnosed with diabetes to a nursing unit. Which task would be inappropriate to delegate to the UAP?
Monitoring insulin requirements
Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?
Not all of the heartbeats are reaching the periphery
The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion?
Notify the national abuse hotline
During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?
Notify the physician and prepare for surgery
The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client>
Offer client a small carbohydrate and protein snack before bedtime
The nurse is caring for a client with a latex sensitivity. Which resource would be most appropriate for the nurse to access when developing the clients plan of care?
Policy for clients with latex sensitivity
What technique should the nurse use to implement infection control in the home?
Practice hand hygiene when beginning and ending the home visit
A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document
Presence of abnormalities that would impede healing
A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation?
Prime the tubing with the solution
Which interventions will be the most effective in preventing the spread of infection in the health care setting?
Proper handwashing
A client 75 years of age is being discharged to home following a fall in the kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need?
Protection from potential harm
A nurse in the ICU has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment?
Recognize the nurse's own limitations and ask for another nurse to be assigned.
Which nursing actions reflect the implementing step of the nursing process?
Referring the client to community resources when necessary, using evidence-based interventions individualized for the client, providing health education to reduce health risks
A client who visits a health care facility for routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client?
Regular toileting routine
An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse?
Remind coworker that artificial nails increase infections
The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?
Removes hardened fecal impactions from the rectum
Which are correctly written nursing interventions?
Reposition the client from side to side every hour around the clock, provide 5 to 6 small meals daily, provide opportunities for the client to express concerns and verbalize feelings.
A nurse finds a fire has broken out in a client's room at the health care facility. Which intervention is the highest priority?
Rescue the client
The nurse is caring for a client who has reported to the ED with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:
Second degree or partial thickness
A nurse is asked to serve on an ethics committee. Which roles would the nurse be required to fill on the committee?
Serving as a liaison between the family and the committee members, presenting explanations about technical terminology, advocating for the client's wishes
A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:
serosanguineous
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?
Stage IV
The nurse who is caring for a client in contact isolating is preparing to conduct an assessment. How will the nurse listen to the clients heart?
Stethoscope that remains in the clients room
The nurse begins a task and then realizes that personal protective equipment is needed. What is the correct action by the nurse?
Stop and obtain appropriate PPE
A nurse is performing a sterile dressing change on a client and notices that there is a hole in one of the sterile gloves. Which would be the appropriate action to take to maintain a sterile field?
Stop the procedure, remove damaged gloves, perform handwashing, and put on new sterile gloves
When creating the teaching plan for a client who will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse?
Stress, exercise, fever
An older adult client assumed care of a parent with dementia and had to decrease work hours to stay and home and care for the parent. Due to the decrease in hours, it is difficult to meet financial obligations. What actions by the nurse would be appropriate for this client?
Suggest the client join a support group for caregivers of parents with dementia, make a referral to the case manager to determine available resources, have the client make and appointment with social services to assist with financial resources
While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action?
Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped
An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessments should the nurse prioritize for this client?
Temp of skin, Pedal pulses, Tenderness to palpation
Which examples are essential components for delegating nursing care to an UAP?
The UAP has sufficient knowledge and skill for completing the task, the UAP can verbalize what information to report to the nurse, the nurse has clearly communicated instructions to the UAP
The RN has received orders to perform an unsafe practice on a client. The RN voices concern with the physician who gave the order, but the physician refuses to change the order. Whom should the nurse consult next regarding the order?
The charge nurse
Which client outcome is an example of a physiologic outcome?
The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula
A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output?
The client's urinary output will be increased
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?
The largest part of a regular bedpan should be placed under the clients buttocks
The nursing team, consisting of a nurse and experienced UAP, have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?
The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure
A nurse prefers to use an alcohol-based rub when providing care for clients. In which case is this practice contraindicated?
The nurse is caring for a client with a C.difficile infection
Which nurses are acting as advocate for the client?
The postoperative client expresses an inability to void in the urinal in bed. The client believes that standing would allow the client to void. The nurse assists the client to a standing position. The nurse informs the family of a terminally ill client that the client does not want further treatment and wants to go to hospice care. The PCP informed the client about needing to have a surgical procedure performed. After the PCP left, the nurse asked the client, "What are you feeling after being told you need surgery?"
A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
To be sure the intervention is safe
When creating a care plan, which is the purpose of identifying the client outcome?
To design a plan of care to address the health problem
The nurse is massaging an older adult client's back and notices a reddened area on the client's sacrum. What actions would the nurse perform in response?
institute a turning schedule, report the finding to the primary care provider, document the reddened area on the client's medical record
A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called?
Urinary incontinence
Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly?
Used legally inadvisable terms
Which action should the nurse perform first after an exposure to a client's body fluids?
Wash the exposed area with soap and water
The nurse in the pediatric unit is caring for a 10 year old client admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?
Washing hands before and after providing the client care
A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?
Wearing gloves when handling the urine
Which scenario is the best example of the nurse acting as an advocate?
Writing legislation for insurance coverage for screening colonoscopies
Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence?
Yes, this defines a possible nursing diagnosis
A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:
a lack of cues, or premature closure
When collecting subjective and objective data for a database in a clients home, it is important to:
ask the client to turn off the television
Which client would benefit from a PRN drug regimen?
client who had thoracic surgery 4 days ago
The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:
deflate the balloon, insert the catheter further, and slowly attempt reinflation
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?
developing accountability
The nurse is preparing to apply a roller bandage to the stump of a client who has a below-the-knee amputation. What is the nurse's first action?
elevating and supporting the stump
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?
increased bowel sounds