Capstone Exam 1
What is necessary to change a clients code to DNR?
A written prescription from the provider.
(see full question) The nurse has taught the wife of a client who experienced traumatic vision loss strategies for effectively interacting with her spouse. Which statement by the wife indicates that the health teaching was successful?
"Today I used the clock suggestion to state where things were located in the room." Explanation: If the wife is giving directions by using clock cues, then the teaching has been effective. When the wife unilaterally makes decisions like deciding to obtain a service dog, determining that the spouse must be seated first, and insisting that she guide her husband rather than just offering assistance, then the nurse recognizes that additional teaching is necessary.
A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if he/she is allowed to perform this skill. What is the nurse's most appropriate response?
"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."
(see full question) To prepare the community for the possible threat of anthrax, a nurse must teach that:
Anthrax can infect the integumentary, GI, and respiratory systems. Immunizations are appropriate only for those at risk of anthrax exposure. Isoniazid, rifampin, and pyrazinamide are used to treat tuberculosis, not anthrax. Penicillin is the most common drug used to threat anthrax.
For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority?
Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
In a client with AIDS, central nervous system (CNS) deterioration can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury. Although Bathing or hygiene self-care deficit and Complicated grieving may be relevant in AIDS, these diagnoses don't take precedence in a client with AIDS-related dementia. Because CNS deterioration results from infection, Ineffective cerebral tissue perfusion isn't applicable.
A nurse is performing a sterile dressing change. Which action contaminates the sterile field?
Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.
(see full question) A nurse performs care on the client's Hickman catheter according to hospital policy. The client develops an infection and is considering litigation. The nurse's practice is:
Respondeat superior is Latin for "The master is responsible for the acts of his servants." The nurse, as an employee of the hospital, acted according to the established policy of the hospital. Because the nurse followed hospital policy, it is unlikely that this incident involved malpractice, negligence, or tort law
The nurse has obtained a urine specimen from a multiparous client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near childbirth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a birth in the bathroom. Applying a fetal monitor may reassure the nurse that the fetus is doing well; however, it does not help to determine if the fetus is ready to be born, which is the higher priority in this situation. Regardless of the client's prior experience with back labor pain, the fetal head moving lower into the birth canal causes pressure in the lower back area similar to the feeling of pressure with a bowel movement.