UWorld Basic Care and Comfort
A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse?
1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations.
A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse?
1. "I can see that you are very upset. Let's talk about what happened. Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.
The nurse is providing discharge teaching for a client who sustained a fracture of the tibia and is using crutches to ambulate. Which of the following information should the nurse include? Select all that apply. Up with the GOOD, Down with the BAD Interventions to promote safety and reduce the risk of falling when using crutches in the home include maintaining a clutter-free environment, wearing sturdy rubber-soled shoes, looking forward while walking, and stepping with the unaffected leg first when ascending stairs.
1. "Keep a clear path to your bathroom." 3. "Remove throw rugs from the floors in your home." 5. "Wear rubber-soled shoes, preferably without laces." - Resting crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard. - Keeping the rubber tips of the crutches dry and replacing them if worn to prevent slipping.
A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing. Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence? Select all that apply. Wound dehiscence is a surgery complication where the incision, a cut made during a surgical procedure, reopens. Wound healing requires adequate caloric and protein intake. Although this client is obese and needs education to promote weight loss, caloric restriction could delay wound healing.
1. Administer docusate PO daily - Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid pain medications (Option 1) 2. Administer ondansetron IV PRN for nausea - Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting (Option 2) 3. Apply an abdominal binder 5. Monitor blood sugar to maintain tight glucose control
The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply This client's death was expected. It is not necessary to contact the medical examiner for autopsy..
1. Allow a family member to assist with care2 3.Gently close the client's eyes 4.Place a pad under the perineum Dentures are left in place, or replaced if they have been removed, before rigor mortis sets in to maintain the shape of the face. A towel can be folded and placed under the chin to keep the jaw closed.
The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply. Cachexia, wasting syndrome that leads to loss of skeletal muscle and fat, - severe weight loss, including loss of fat and muscle mass. loss of appetite. anaemia (low red blood cells) weakness and fatigue.
1. Allow the client to refuse food if not feeling hungry - Anorexia is a common complication in clients who are dying and may be exacerbated by many factors (eg, medication, anxiety, underlying disease). The client should be allowed to refuse food and drink (Option 1). 2. Ask if the client is experiencing any pain or nausea 3. Involve the client in meal planning and food selection 4. Plan for loved ones to share mealtimes with the client 5. Provide oral care before and after meals to alleviate dry mouth
A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take?
1. Allow the spouse in the room, out of the way of care providers, and explain the events occurring with the client. The presence of family members during invasive procedures supports the psychosocial needs of the client and family. The nurse should reinforce family presence at bedside and provide information to the client's support person about the care being provided.
The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply. 3) Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin.
1. Apply moisture barrier cream to dry skin 2.Clean perineal area after incontinent episodes 4.Place foam-padded seat cushions on chairs Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option 1). Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option 4). Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option 2). Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur.
The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
1. Arrange for the client to receive at least 20 minutes of natural sunlight each day 4.Spend time with the client in a quiet environment just before bedtime 5.Suggest that the client listen to soft music before going to bed = Avoiding heavy meals or large amounts of fluids at bedtime - Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness
A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? ) The nurse should use behavioral-management techniques (eg, reassurance, distraction, redirection) to assist with deescalation. However, the nurse must assess for and address sources of agitation first. When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.
1. Ask about the client's recent bowel and bladder habits Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs (Option 1).
The nurse is preparing to perform ear irrigation for a client with impacted cerumen. Place in the correct order the following steps for performing ear irrigation. All options must be used. To perform ear irrigation, assess for contraindications (eg, fever, ear infection), tilt the head slightly toward the affected ear, straighten the ear canal by pulling the pinna up and back, and irrigate gently, aiming toward the top of the ear canal while using a slow, steady flow of solution.
1. Assess the client for fever or ear infection 4. Place the client in a sitting position with the head tilted slightly toward the affected ear 3. Place a towel and an emesis basin under the affected ear 5. Straighten the ear canal by pulling the pinna up and back 2. Gently irrigate the ear canal with a slow, steady flow of solution
The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply ) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning.
1. Conduct teaching sessions while a family member is present 3.Have client watch a DVD about heart failure management 4.Print out pictures of a food label and review where to look for sodium content The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: - Using pictures and simplified text is beneficial to the older adult with low literacy. - Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. - Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language.
A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain. The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline. What is the nurse's most appropriate action? The HCP's prescription specifies discontinuing IV fluids but not removing the IV catheter or slowing the infusion to a keep-vein-open (KVO) rate. Also, the nurse would need to clarify a KVO prescription with the HCP for a precise rate.
1. Convert to a saline locK The nurse should discontinue the IV infusion of normal saline and apply a saline lock to maintain IV access while preventing clotting. The prescription of the health care provider (HCP) to lock the IV catheter is implied, as the client is currently receiving PRN IV opioids (Option 1). A saline lock is sufficient to maintain the line patency and allows greater mobility than a continuous infusion.
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply.
1. Epoetin alfa 4. Normal saline Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? A digestive enzyme solution may help if warm water flushing is not effective.
1. Flush and aspirate the tube with warm water Enteral feeding tubes are more likely to become obstructed if the tube is not flushed frequently enough, medications are not adequately crushed or diluted before administration, a thick feeding formula is used, or a small-bore feeding tube is required. Interventions to unclog a feeding tube are more successful if they are initiated immediately. The nurse should first attempt to dislodge the clogged contents by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube (Option 1).
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. ) The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment.
1. Palliative care focuses on quality of life & symptom management and can be provided at any time 3. Palliative care is provided by a multidisciplinary team 5 Palliative care provides relief from symptoms associated with chronic illnesses
An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply. - Modification of food consistency (pureed, mechanically altered, soft) Thickened liquids - Having the client sit upright at a 90-degree angle (Option 3) - Placing food on the stronger side of the mouth to aid in bolus formation (Option 4) - Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis - Having the client turn the head during a meal will help the client see everything on the plate (Option 2).
1. The UAP adds milk to mashed potatoes to make them thinner - Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration. 5. The UAP puts a straw in a fruit smoothie to prevent spilling - Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
1. The axillary pads are torn and show signs of wear Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). - Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait).
The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke. Which of the following statements by the GN indicate correct understanding of the teaching? Select all that apply. ) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client. Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication.
2. "Instruct clients with unilateral weakness to dress by donning clothes on the affected side first/first clothe the affected side" - which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance 4."Teach clients with left-sided neglect to turn their heads to scan the environment." - Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side 5."Teach families of clients with right-sided stroke to expect impulsive behaviors." - Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions
Which client is at the greatest risk for development of hospital-acquired pressure injuries? Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk.
2. 50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg (26%) This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells.
The nurse is caring for a client who is experiencing an acute exacerbation of chronic low back pain after performing strenuous activity. Which of the following actions should the nurse take? Interventions for a client with low back pain include alternating hot and cold compresses, administering NSAIDs and acetaminophen, remaining active as tolerated, and sleeping in a side-lying or supine position.
2. Alternate application of hot and cold compresses - Alternating hot and cold compresses to promote circulation and reduce inflammation (Option 2) - Preparing the client for physical therapy to stretch and strengthen muscles - Requesting a prescription for muscle relaxants to reduce muscle spasms - Anticipating massage therapy to stretch low back muscles - Preparing the client for acupuncture to stimulate the nervous system
The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, "It hurts too much. I can't do it." Which action should the nurse complete first? Postoperative pain control is a priority intervention for clients of any age. However, the nurse should first perform an assessment of the client's pain to determine the appropriate pharmacologic or nonpharmacologic measure to implement. This assessment will also provide a baseline against which the effectiveness of the chosen pain relief method can be evaluated.
2. Ask the client to point to a numeric scale to indicate pain level A numeric pain scale can be used with children who can count and understand the concept of numbers, typically starting at age 8. The scale uses a straight line with divisions marked in units from 0-10; 0 is identified as no pain, 5 as moderate pain, and 10 as the worst pain (Option 2).
The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?
2. Ask the client to wait until the health care provider's (HCP's) prescriptions can be verified Because the nurse is unfamiliar with the client, the prescriptions from the HCP should be reviewed before giving any fluids. It is common for clients admitted from the emergency department to be designated nothing by mouth (NPO) until appropriate diagnostics have been completed or in case of possible surgery. Caffeine would be questionable as it can interfere with certain diagnostic tests, such as nuclear cardiac studies.
The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1). - Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. - Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). - Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5). Educational objective:
2. Cardiac and renal changes may put the client at risk for hypervolemia 3.Older adults may have more fragile veins, increasing the risk of infiltration 4.Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin
A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement.
2. Check marked insertion depth of the tube If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately.
The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? (Option 4) If the client is speaking, the airway is open. Opening the airway would be an initial response if there is new onset of snoring respirations (the tongue falling back due to relaxation and blocking the airway). Normal respirations should be effortless and quiet.
2. Check the client's pulse oximeter An acute change in mental status (eg, restlessness, agitation, confusion) is often related to an underlying medical condition (eg, hypoxia, hypoglycemia). Clients with acute mental status changes must first be assessed for precipitating factors. The nurse should check the client's pulse oximeter to assess for hypoxia (Option 2).
The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? ) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority.
2. Client with a do-not-resuscitate prescription who has swelling at the IV site During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. - Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity - Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) - Elevating the affected extremity to decrease swelling - Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop - Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? Diltiazem extended-release is taken by mouth and used to treat high blood pressure and angina (chest pain caused by poor blood flow to your heart). You can take it once or twice daily. It can take up to two weeks before you experience the full benefits of this medication. It's available as a lower-cost generic
2. Consult with the pharmacist to see if an alternate form of the drug is available Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
2. Directly face the client when speaking 3.Ensure hearing aids are properly applied 4.Provide written information to supplement conversation - Obtaining a professional sign language interpreter if the client communicates with sign language - Visibly gaining the client's attention before speaking to avoid startling the client - Using facial expressions and hand gestures to help emphasize talking points
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? (Option 1) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns.
2. Explore the family's thoughts and concerns about the client's refusal of food - The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness.
The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply.
2. Face the client while speaking 4.Turn off the television and close the door 5.Use simple statements and questions Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions (Option 5). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option 2). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option 4).
A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? (Option 3) The source of the client's behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group.
2. I notice that you seem frustrated." The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment.
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement. 4) The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit.
2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3.Say "goodbye" when leaving the room to help orient the client 5. Use a clock-face pattern to explain food arrangement on the client's meal tray = Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. = Orient the client to the room and maintain this orientation for safety.
A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3).
2. Report any redness, swelling, warmth, or drainage from your incisions 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5.Wear an elastic compression hose on your legs and elevate them while sitting
In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?
2. Semi-Fowler's position with the affected side's arm on several pillows Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy.
The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement?
2. The decision whether to provide artificial hydration should consider client preferences and goals The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration; however, client preferences should be respected - clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life.
A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? This statement is nontherapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering information.
2."Tell me about how you feel about your surgery. "Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support.
The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching?
3. "I will read in bed before trying to go to sleep." The nurse should teach clients with insomnia good sleep hygiene such as using the bed for sleep only (no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day). Avoid going to bed hungry or eating a heavy meal just before bed Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia
The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially?
3. "It is upsetting to wait so long. How can I best help you?"
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse?
3. "It sounds like you are angry. Tell me what's bothering you. The nurse's statement, "It sounds like you are angry" reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement, "Tell me what's bothering you," facilitates assessment of the client's concerns without making any assumptions about them. This approach will promote accurate assessment of the client's needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client's anger.
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the registered nurse. Which statement would be the most appropriate response? Urosepsis is a type of sepsis that begins in your urinary tract. It happens when a urinary tract infection (UTI) goes untreated and spreads to your kidneys. Urosepsis can be a medical emergency. Antibiotics, IV fluid and other medications can treat it before it progresses
3. "Let's go together to ask about the client's concerns." Anger is often a symptom of psychological distress associated with anxiety, fear, or loss of control. An appropriate response to an angry client is to listen with an open, accepting attitude, and collaborate with the client and other staff to create a care plan that addresses psychological and physical needs.
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions.
3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.
The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided.
3. "This new diagnosis must be frightening for you. Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts.
A client scheduled for surgery indicates on their preoperative questionnaire a religious preference with spiritual needs. Which action is most appropriate for the nurse to make at this time? (Option 2) The nurse should attempt to gather more information before notifying the perioperative team. Simply documenting the questionnaire response does not address the client's spiritual needs.
3. Follow up with the client regarding the nature of their spiritual needs or religious practices - During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option 3).
A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3 (0.45 ×109/L). What information contained in the admission history of this client will need to be addressed during discharge education? This client has a very low absolute neutrophil count (normal: 2200-7700 cells/mm3 [2.2-7.7 ×109/L]); having <500 cells/mm3 (0.5 ×109/L) indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia.
3. Gardens as hobby Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask.
A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for which finding is most important?
3. Hand and wrist weakness Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch pad. Crutches should be checked for proper lengt
The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply.
3. Hold a pre-conference with the interpreter 4.Identify any gender preferences 5.Speak in short sentences - Address the client directly in the first person - Speak in short sentences, pausing to allow the interpreter to speak (Option 5) - Ask only one question at a time - Avoid complex issues, idioms, jokes, and medical jargon - Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) - Use a qualified professional interpreter whenever possible
The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading? Although tachypnea can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor
3. Hypotension The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning.
The pediatric clinic nurse is educating staff on culturally competent care by describing common dermatologic effects of alternative medicine therapies. Which finding would be inappropriate to include as an expected finding of alternative medicine practices?
3. Marks that appear to be human bites on the arms The culturally competent nurse is aware that some alternative medicine practices of nondominant cultures can present with dermatologic findings. Marks that appear to be human bites require further follow-up as these are not common in alternative medicine (Option 3). Although nurses should be aware of various cultural practices, any marks consistent with child abuse (eg, bite marks, cigarette burns, bruises in various stages of healing) should be reported to the appropriate authoritie
The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? Implementation of containment products (eg, absorbent pads, adult briefs, rectal tubes) can be considered after hygiene practices fail.
3. Provide perianal skin care with barrier cream Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3). Clean, dry linens and clothing should be provided.
The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client?
3. Sit with the client during meal selections and assist with identification of low sodium options Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating. The client's age and occupation may help to determine the vocabulary the nurse uses during teaching. Sitting down with the client to assist with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information.
A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image? Although assessing coping techniques and effectiveness is important to the client's ability to cope with the loss of a body part, this question does not evaluate the prosthesis' effect on body image. This question also assumes that the client is or should feel self-conscious.
4. "Since receiving your prosthesis, how do you see yourself differently? When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication
A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse?
4. "Tell me how you think your life would be different if you moved from here. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence.
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?
4. "Tell me more about your need to leave the hospital To get more information, the nurse should assess the client's concern and the motivation behind the request by asking an open-ended question, such as "Tell me more about ______." It is important to gain the client's trust, to actively listen, and to avoid immediately jumping to problem-solving during this assessment (Option 4).
The nurse is talking with a client who has osteoarthritis of the left knee and is using a cane to ambulate. Which of the following statements by the client would require follow-up? The client should advance the cane first, and then step forward with the affected leg For maximum support, the cane is held with the tip approximately 6 inches (15 cm) in front of and lateral to the foot on the unaffected side. The cane should be held on unaffected side (ie, strong side) to help maintain balance, keeping the elbow slightly flexed (20-30 degrees).
4. "The handle of the cane should be level with my waist." Canes are assistive devices used during ambulation to support stability and reduce weight bearing on the affected leg (eg, knee injury, arthritis). The length of the cane should equal the distance from the floor to the greater trochanter of the hip. A cane that is level with the client's waist is too long to provide optimal support and prevent back injury (Option 4).
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? Orchidectomy involves the surgical removal of the testes
4. "What have you and your future spouse discussed about your condition?
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? If the client's temperature continues to rise after moving to cooler temperatures, ice packs placed on the axilla and groin may help to dissipate heat; further medical help may be necessary.
4. Move the client to an air-conditioned booth and provide a cool sports drink Heat exhaustion is the result of prolonged exposure to excessive heat. Heat exhaustion manifests with elevated body temperature (hyperthermia), intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping. If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage (eg, Gatorade), or water (Option 4). The priority is to lower the body temperature to prevent heat stroke, a potentially fatal condition associated with mental status changes (ie, indicating brain damage) and additional organ damage (eg, kidney injury, rhabdomyolysis).
The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before completing other interventions. After the nurse has performed a skin assessment, it may be appropriate to direct the UAP to apply a protective foam dressing to the area.
4. Perform an assessment on the client's skin A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would be appropriate to use as part of the assessment.
The nurse is reviewing laboratory test results for a male client who is receiving treatment for septic shock. Which of the following test results would require immediate follow-up? Click on the exhibit button for additional information. Although a BUN level of 44.4 mg/dL (15.9 mmol/L) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (pre-renal azotemia) or extra-renal factors such as dehydration, fever, or gastrointestinal bleed.
4. Potassium Serum potassium may increase in clients in progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action (Option 4) The most significant manifestations of hyperkalemia are disturbances in cardiac conduction and the development of potentially life-threatening cardiac dysrhythmias.
An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation.
4. Slow the rate of administration of the feeding Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate.
An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior?
4. The client wants to take care of business before imminent death This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death (Option 4).
A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? ) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.
4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow - SIGHT GUIDED TECHNIQUE! When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the clien
An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? . "I will have the health care provider talk to you once you arrive." (Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis.
Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.
Postmortem care (care after death) is an important aspect of nursing care that must be conducted with respect and dignity for the client. The nurse should contact the client's family or next of kin immediately after the death to allow them the opportunity to grieve and exercise any final cultural practices or religious rites related to death. After a client's death, the nurse must verify whether an autopsy has been requested. For clients needing autopsy, the nurse should follow state and agency guidelines regarding care of the client's body and removal of equipment.
Indicated: Cleanse the client's body thoroughly, Notify the organ and tissue donation organization, Allow family to be present during postmortem care, Remove the drains, urinary catheter, and peripheral IV catheters - Positioning the client (eg, straightening the body and limbs) and gently closing the client's eyes because it is difficult to reposition the client once rigor mortis (stiffening of the body after death) occurs. Not Indicated: Remove the client's abdominal staples, Remove identifying name tags from the client - It is critical that the nurse leave body identification tags on the client for transportation to the morgue and/or funeral home. - The nurse should keep the surgical incision (eg, abdominal staples) intact to prevent any signs of trauma to the body (eg, open wound).
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium.
Pneumonia, an inflammatory reaction in the lungs often due to infection, causes production of cellular debris and purulent secretions that obstruct the alveoli and impair gas exchange. Clinical manifestations include fever, tachypnea, hypoxemia, crackles to lung auscultation, and productive cough with purulent sputum. Significant impairment of gas exchange leads to insufficient oxygenation of organs (eg, brain), resulting in altered mental status, restlessness, agitation, and drowsiness. Albuterol is a short-acting beta-adrenergic agonist that promotes rapid bronchodilation (ie, relaxes bronchial smooth muscle) and improves hypoxia. This can be administered after elevating the head of the bed. The nurse should encourage the client to increase fluid intake to thin secretions and encourage deep breathing and coughing to facilitate secretion removal. This can be performed after elevating the head of the bed.
The priority nursing action for a client with pneumonia who is experiencing respiratory distress is to elevate the head of the bed to at least 30 degrees to increase lung expansion and improve gas exchange.
Interventions to prevent wound dehiscence include
administering stool softeners and antiemetics, applying an abdominal binder, and maintaining tight blood glucose control.
