The Nursing Process

A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery?

surrogate decision maker

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client?

use of all drugs taken in the last 18 months

The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which information in the report? Select all that apply.

vehicle's description current location of parties involve

A nurse has made a medication error. Which information is appropriate to include in the incident report?

what the nurse saw and did

Under which circumstance may a nurse communicate medical information without the client's consent?

when treating the client with a sexually transmitted disease

A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which of the following is the most appropriate response by the OHN?

"Accurate results will be obtained by testing at 3 months and again at 6 months."

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data?

"Client seems very nauseated."

A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

"I chose broiled chicken with a baked potato for dinner."

An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which of the following responses by the nurse is the most appropriate?

"I understand your concern. I'll call the physician to review the results with you."

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which of the following would be the most appropriate response by the nurse to the surgeon?

"It is your responsibility to obtain informed consent from the client."

A public health nurse is responsible for contact tracing of individuals identified in confirmed cases of sexually transmitted infections. The nurse telephones an individual named by a client as a contact. The individual demands the name of the person who identified the individual as a contact. Which of the following is the most appropriate response from the nurse?

"Just as I will protect your privacy, I must protect the privacy of the other people involved."

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond?

"You seem worried about this assignment."

A nurse on the mental health unit tells the nurse manager, "Kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway." What is the best reply by the nurse manager?

"You sound really frustrated. Let's talk about the meaning of their behavior."

A nurse wants to ensure inclusiveness in language regarding family when developing a plan of care for a client. Which action is the most important for the nurse to take to ensure that the plan is inclusive?

Ask the client to identify who is considered family.

The nurse uses which part of the SBAR acronym when stating, "I think the client is dry."

Assessment.

The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which factors when planning the process? Select all that apply.

CQI processes are required by accrediting agencies. The approach to CQI can be retrospective or concurrent.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in the abortion. What should the nurse manager of the operating room do?

Change the assignment without comment.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

Check on the client at regular intervals to ascertain the need to use the bathroom.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on.

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first?

Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order.

When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do?

Cover the wet packing with a dry sterile dressing.

After the surgeon's meeting with a client to obtain the client's informed consent for a modified radical mastectomy, the client asks the nurse many questions about breast reconstruction that the nurse finds difficult to answer. The nurse should:

Inform the surgeon that the client has questions about reconstruction before she signs the consent.

A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do?

Initiate a time-out.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

Nurses at a healthcare facility maintain client records using a method of documentation known as charting by exception. Which is a benefit of this method of documentation?

It provides quick access to abnormal findings.

A nurse suspects that a coworker is self-administering illegal drugs during work hours. What is the first action the nurse should take?

Notify the nurse manager and document the situation.

A nurse on the crisis team in the emergency department is caring for a client who is angry and is experiencing delusional episodes. The client says to the nurse, "I'm going to kill my wife and chop her up to get rid of her." What is the nurse's priority action in this situation?

Notify the wife that she may be in danger.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies.

The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which intervention would be most appropriate?

Provide stimulating, nonthreatening life experiences.

A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take?

Report the situation to the nursing supervisor.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem?

Speak to the coworker upon return to the unit.

The nurse creates a program to decrease the primary cause of disability and death in children. What is the most important action to include in the plan?

Teach health and safety practices to children and their parents.

The client receiving moderate sedation became oversedated and a reversal medication was administered. How should the nurse perform postsedation monitoring for this client?

The client should be monitored for a longer than normal period.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated?

Wetness in the sterile cloth on top of the nonsterile table has been noted.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. WhicH actions would be appropriate for the nurse to take to address this situation? Select all that apply.

a communication plan for the family and client a thorough explanation of the isolation procedures acknowledgement of the family's concerns

The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately?

a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria

he nurse can be an important advocate for the client who is considering an alternative method of cancer treatment. Which statement best demonstrates the nurse as client advocate?

allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions.

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.

anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min lung sounds clear bilaterally with non-labored respirations noted

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions?

delegation

A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply.

edema skin discoloration skin temperature changes

A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which violation?

invasion of privacy

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as

moxifloxacin 400 mg daily

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply.

needs oxygen at 2 L/minute. has a "do not resuscitate" prescription. uses the bedpan. has been in normal sinus rhythm for 6 hours.

A 56-year-old client is experiencing withdrawal from alcohol and placing the client at risk for falls by repeatedly attempting to scale the bedrails. Benzodiazepines have failed to alleviate agitation and the nurse is considering obtaining an order for physical restraints to ensure the client's safety. The nurse should recognize that this measure may constitute

paternalism

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

providing client teaching

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment?

speech therapist

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

the principles that determine whether an act is right or wrong

A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent?

the surgeon

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. What are purposes of the "read-back" requirement? Select all that apply.

to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy?

ensuring that clients receive medications but omitting full bathing when possible

The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill?

a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused

The nurse is making client rounds following shift report. Which client should the nurse assess first?

a 75-year-old man with metastatic prostate cancer with a pathologic fracture of the femur who is in pain

The nurse has just received the change of shift report on the following clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia

What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?

achieving a controlled level of pain and fatigue throughout the day.

Which intervention is an example of primary prevention?

administering a measles, mumps, and rubella immunization to an infant

During the planning step of the nursing process, the nurse

establishes short- and long-term goals.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

excess fluid volume

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be?

The nurse should ask the person to talk to the family directly.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan.

A nurse is admitting a client to the palliative unit and discussing advanced directives. Which statement made by the client leads the nurse to believe the client requires clarification around advanced directives?

"This will stop my daughter-in-law from putting me in a home."

The nurse is caring for a client about to receive the first chemotherapy transfusion. When planning how to conduct the teaching session, what action would assist the nurse in determining the client's learning preferences?

asking the client which is preferred--brochure, video, or podcast

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask?

Are you comfortable performing the tasks assigned?

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take?

Arrange for the pump to be refilled in the hospital.

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care?

Ask clients for their views of their health and health care.

Which strategy is the most effective for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts?

Attend a school board meeting to advocate for classes teaching children seat belt safety.

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response?

Explain that this information cannot be disclosed without the client's permission.

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information?

Give the client written material to read, and follow up with time for questions.

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform after finishing the incident report?

Include the time and date of the incident.

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

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

The nurse is assessing a 16-year-old nulligravida, who asks for information on natural family planning methods of contraception and reports that her menstrual cycle occurs every 28 days. Which information would be important to include in the teaching plan for this client?

Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.

The nurse is beginning the shift and is planning care for six clients on the postpartum unit. Three of the clients have immediate needs, and three of the clients are listed as "stable." For the best utilization of time and client safety, the nurse should make rounds on which client first?

a mother who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding

The nurse is preparing to administer a flu shot to an adult client. How would the nurse proceed? Place the steps in sequential order. All options must be used.

Put gloves on. Locate the deltoid muscle. Clean the injection site with an alcohol pad. Gently stretch the skin taut at the site. Inject it into the muscle at a 90-degree angle. Wait 10 seconds before removing needle.

A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?

Report back to the nurse immediately if any client has an output less than 240 mL.

Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?

Temperature of 102° F (38.9°C)

A nurse asks a client to sign the consent for surgery. Which situation is appropriate for giving valid consent?

The client has cognitive capacity to make decisions.

A young adult is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?

The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital?

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious

Which child should the nurse assess as demonstrating behaviors that need further evaluation?

a 2-year-old who is indifferent to other children and adults and is mute

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first?

a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN?

a 72-year-old client with diverticulitis

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the special care nursery (SCN) for respiratory distress. The nurse should place the new client in a room with which client?

a G4 P4 who is 2 days postpartum with infant, Spanish speaking only

A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest?

charting by exception

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?

checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply.

providing skin care following bowel movements maintaining intake and output records obtaining the client's weight

When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?

pulling the ear pinna back, up, and out

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.

that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complication

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

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

Which activities should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply.

Empty and measure indwelling urinary catheter collection bags. Reposition clients for pain relief. Tell the nurse if clients report they are having pain

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

Essential assessment data

A client has received numerous different antibiotics and now is experiencing diarrhea. What type of precautions should the nurse institute?

contact precautions

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

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

The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a birthing center. Which tasks should the nurse delegate to the UAP? Select all that apply.

emptying a urinary catheter from a preeclamptic client assisting an active labor client with breathing and relaxation ambulating a postcesarean client to the bathroom