Basic Physical Care

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.), 60 ml (9 a.m.). Based on these amounts, what should the nurse do? 1. Continue to monitor and record hourly urine output. 2. Notify the physician. 3. Irrigate the indwelling urinary catheter. 4. Increase the I.V. fluid infusion rate.

1. Continue to monitor and record hourly urine output. RATIONALES: Normal urine output for an adult is approximately 1,500 ml/24 hours, which averages to about 60 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. The nurse should report urine output less than 30 ml/hour, which may indicate dehydration or altered renal function.

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply. 1. Instill isotonic eye drops, as necessary. 2. Provide several small, well-balanced meals. 3. Provide rest periods. 4. Keep the environment warm. 5. Encourage frequent visitors and conversation. 6. Weigh the client daily.

1. Instill isotonic eye drops, as necessary. 2. Provide several small, well-balanced meals. 3. Provide rest periods. 6. Weigh the client daily. RATIONALE: If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae should be moistened often with isotonic eye drops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent small, well-balanced meals. The nurse should provide the client with rest periods to reduce metabolic demands. The client should be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse should provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair? 1. Parallel to the bed on the right side 2. Perpendicular to the bed on the right side 3. Parallel to the bed on the left side 4. Parallel to the bed on either side

1. Parallel to the bed on the right side RATIONALES: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg.

Several residents in a long-term care facility ask the nurse if they can share their aromatherapy with other clients in the dining area. Why shouldn't the nurse permit them to practice aromatherapy in the group environment? 1. Some residents may have an adverse sensitivity to the oils and fragrances. 2. The nurse should have no reason for concern because the oils and fragrances are mild. 3. There's no scientific evidence to support the use of aromatherapy. 4. Aromatherapy can suppress appetite.

1. Some residents may have an adverse sensitivity to the oils and fragrances. RATIONALES: The nurse shouldn't permit the clients to perform aromatherapy in a group environment because some clients may experience adverse reactions to the oils and fragrances. Studies have shown that aromatherapy can, in fact, improve mood and promote relaxation. Aromatherapy hasn't been shown to suppress appetite.

When the nurse enters a client's room, she finds him slumped over in his chair. What actions should the nurse take? Rank in chronological order. Use all the options. 1. Activate the resuscitation team. 2. Establish unresponsiveness. 3. Check breathing; give two breaths if absent. 4. Place the client on a firm surface. 5. Check pulse; if absent begin compressions. 6. Open client's airway.

2. Establish unresponsiveness. 1. Activate the resuscitation team. 4. Place the client on a firm surface. 6. Open client's airway. 3. Check breathing; give two breaths if absent. 5. Check pulse; if absent begin compressions. RATIONALES: The nurse should first establish unresponsiveness. After unresponsiveness is confirmed, the nurse should activate the resuscitation team. Next, she should place the client on a firm surface, open his airway, and check for breathing. If the client isn't breathing, the nurse should give two slow breaths using a pocket mask or bag mask. Next, the nurse should check for signs of circulation (breathing, coughing, movement, or presence of carotid pulse). If there are no signs of circulation, the nurse should initiate chest compressions.

The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? 1. Number scale from one to ten 2. Face rating scale 3. Body diagram 4. Questionnaire

2. Face rating scale RATIONALES: The face rating scale, which depicts five or more faces with expressions that range from happy to very unhappy, is the best way for this client to communicate his level of pain because he can simply point to the face that illustrates how he's feeling. A number scale, body diagram, or questionnaire may be difficult for this client to use.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action can the nurse institute independently? 1. Cleaning the wound three times per day with a povidone-iodine wash 2. Gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary 3. Applying an antibiotic cream to the area three times per day 4. Cleaning the wound with a wound cleanser and applying a hydrogel wound dressing

2. Gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary RATIONALES: Gently irrigating the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash, an antibiotic cream, and a hydrogel wound dressing require a physician's order.

The nurse is caring for a client who sustained a chemical burn in his right eye. She is preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply: 1. Tilt the client's head toward his left eye. 2. Place absorbent pads in the area of the client's shoulder. 3. Wash hands and put on gloves. 4. Place the irrigation syringe directly on the cornea. 5. Direct the solution onto the exposed conjunctival sac from the inner to outer canthus. 6. Irrigate the eye for 1 minute.

2. Place absorbent pads in the area of the client's shoulder. 3. Wash hands and put on gloves. 5. Direct the solution onto the exposed conjunctival sac from the inner to outer canthus. RATIONALES: The nurse should place absorbent pads in the area of the shoulder to prevent saturating the client's clothing and bed linens. She should also wash her hands and put on gloves to reduce the transmission of microorganisms. The solution should be directed from the inner to outer canthus of the eye to prevent contamination of the unaffected eye. The head should be tilted toward the affected (right) eye to facilitate drainage and to prevent irrigating solution from entering the left eye. The irrigation syringe should be held about 1" (2.5 cm) above the eye to prevent injury to the cornea. In a chemical exposure, the eye should be irrigated for at least 10 minutes.

To follow standard precautions, the nurse should carry out which of the following measures? 1. Recapping needles after use 2. Wearing a gown when bathing a client 3. Wearing gloves when administering I.M. medication 4. Wearing gloves for all client contact

3. Wearing gloves when administering I.M. medication RATIONALES: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with the blood, body fluid, mucous membranes, or nonintact skin of any client (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client or providing other types of care that aren't likely to cause contact with blood or body fluids.

A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying in bed. Ten hours after his admission, the nurse is collecting data and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time? 1. Documenting that the client is resting quietly and denies pain 2. Calling a family member to obtain information about the client 3. Giving the client the prescribed as-needed pain medication 4. Checking vital signs and looking for nonverbal indications of pain

4. Checking vital signs and looking for nonverbal indications of pain RATIONALES: The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs (heart rate and blood pressure may increase with pain) and looking for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may lead to inadequate intervention. Calling the family or giving pain medication may be warranted if the client indicates that he's having pain.

A laissez-faire nurse-manager takes which action? 1. Completes the vacation schedule without staff input 2. Delegates responsibility for evaluating the effectiveness of new equipment to the staff members who use that equipment 3. Identifies possible solutions to staffing problems and asks staff members for their opinions about each one 4. Delegates to staff responsibility for selecting a new nursing care delivery system

4. Delegates to staff responsibility for selecting a new nursing care delivery system RATIONALE: Delegating a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff members for their opinions of the solutions is characteristic of a participative manager.