Saunders Unit II

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?

"Living in a prison can predispose a person to different health conditions."

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

.4. A client with asthma who requested a breathing treatment during the previous shift (airway is the highest priority)

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

1. Contact the nursing supervisor. (Do not administer the prescription without clarification, falls on you)

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

1. Reassess the client. (Frequently reassess because complications do not always appear immediately after the fall)

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

1. The acuity level of the clients 5. Client needs and workers' needs and abilities (following delegation and planning guidelines)

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort?

2. Slander

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back (It is the most reliable and ensures safety and mutual understanding)

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

2. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. (Nurse cannot refuse to float, but needs to assure safe assignment)

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. (Focus is protecting clients from flying debris or glass)

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply.

2. Right-click on the entry and modify it to reflect the correct information. 3. Document the correct information and end with the nurse's signature and title. 4. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5. Document in a nurse's note in the client's record detailing the corrected information.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

3. A client who requires urine specimen collections (most appropriate assignment based on the skills of the staff member)

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

3. Call the nursing supervisor and report the occurrence. (Ensure workplace safety)

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

3. Call the nursing supervisor. (Require reporting impaired nurses)

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

3. Transport the victim to the operating room for surgery. (Informed consent is not needed for an emergency)

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

4. Confront the AP to encourage verbalization of feelings regarding the change. (Confrontation is an important strategy to meet resistance head-on)

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. (Provide safety and prepare to administer pain meds)

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." (Mandatory reporter)

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

4. "I will call the nursing supervisor to seek assistance regarding your request." (Has to be witnessed by specific individuals or notarized)

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours (consider skills and educational level of the staff)

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C (possibly infection and this clients needs are the priority)

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce (chest pain is considered emergent until things are proven out)

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. (Team nursing is lead by a RN)

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

4. Observing care provided to the client without the client's permission (unreasonable intrusion into an individuals private affairs)

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck (she should be screened for abuse, common sign)

The nurse caring for a refugee considers which health care need a priority for this client?

Access to mental health care services (mental health is primary issue because of torturous events)

Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply.

Cancer, obesity, HTN, heart disease, diabetes (these disease are most prevalent in this population)

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

Complaints of pain associated with numbness and tingling in both feet (the clients stated concern should be addressed first)

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care (follow up visits are important for promoting health)

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

Glipizide (a major side effect is hypoglycemia which poses a risk to the client)

Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply.

Male to female, female to male, women who have sex with men, women who have sex with women (they should have screenings if they had sexual reassignment surgery and there could still be remaining breast tissue in women)

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk?

Men-who-have-sex-with-men (MSM) (they are at an increased risk for HIV)

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

PTSD (very common, need to lesson risk of suicide risk)

The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group?

Safe sleeping (there is a higher rate of SIDS in this population)

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.

Sleep problems, bipolar disorder, aggressive behavior, ADHD (they are at risk)

Which identifies accurate nursing documentation notation(s)? Select all that apply.

The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage.5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. (Descriptive, objective information, no inferences because it can contain opinions)

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client was found lying on the floor. (Describes facts observed by the nurse)

The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

The history (they tend to be poor historians and it may take more time)

Which therapeutic communication technique is most helpful when working with transgender persons?

Using open-ended questions (refrains from judgement and allows client to express thoughts and feelings)