ch. 25 20, 26

What ensures continuity of care? reassessment critical thinking communication integration

communication

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? "Let me get that for you." "Only authorized persons are allowed to access client records." "The provider will need to give permission for you to review." "I am sorry I can't access that information."

"Only authorized persons are allowed to access client records."

Routine nasal and rectal swabbing of a newly admitted hospital client has come back positive for methicillin-resistant Staphylococcus aureus (MRSA), indicating that the client is colonized with MRSA. The client is surprised at this finding, since he enjoys generally robust health. What should the client's nurse teach him about this diagnostic finding? This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick." "This finding becomes part of your medical record, but it is not a threat to the health of yourself or others." "You may not develop any symptoms, but you will likely be given a round of antibiotics to eliminate these bacteria." "It's very fortunate that this was detected early, since this had the potential to make you very sick."

"This means that this organism in present on your skin, but it doesn't necessarily mean that you will become sick."

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: factual statement. interpretation of data. important information. relevant data.

A nurse stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client and deduce their own professional interpretations. Relevant and important information and data can be used to support the factual statement, such as documenting that the client is sitting in the room in the chair without lights on or that no visitors visited the client today.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? Avoid contact with mosquitoes Use hand sanitizer after touching any public surface Self-quarantine yourself for 2 weeks if you feel ill Use a face mask when in crowds

Avoid contact with mosquitoes

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? Calling the client information desk to find out the room number of the family member Finding the emergency medical technicians who transported the family members and inquiring about the injuries Asking the emergency department nurse for information on the family member Accessing the electronic health record of the family member to find out extent of injury

Calling the client information desk to find out the room number of the family member

The client is concerned about "catching the flu." What primary information can the nurse teach the client to best prevent the spread of infection? Hand hygiene Good nutrition and getting enough rest Avoid crowded areas and people who have the flu How to properly wear a mask during flu season

Hand hygiene Hand hygiene is the most effective way to control the spread of microorganisms. While it is true that the client may be less susceptible to illness when well rested, exposure to a pathogen can still result in influenza. Avoiding those with the flu is also appropriate; however, hand washing remains the best answer for prevention. Wearing a mask all season may or may not prevent the flu and is not the most reasonable choice.

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform? Hold sterile objects above waist level to prevent accidental contamination. Consider the outside of the sterile package to be partially sterile. Consider the outer 3-in edge of a sterile field to be contaminated. Open sterile packages so that the first edge of the wrapper is directed toward you.

Hold sterile objects above waist level to prevent accidental contamination. Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer 1 in of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse.

Which statement is not true regarding a medication administration record (MAR)? If the client declines the dose, the nurse does not have to document this on the MAR. The MAR distinguishes between routine and "as needed" medications. The MAR identifies routine times for medication administration. After using an electronic MAR, the nurse should log off.

If the client declines the dose, the nurse does not have to document this on the MAR.

Which practice should the nurse adopt when commmunicating and documenting electronically? Seek client permission before posting information on social media Avoid using client names if emailing information on an unencrypted network Include precise measurements in documentation rather than approximations Avoiding using names of health care providers

Include precise measurements in documentation rather than approximations

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to? TJC National League for Nursing American Nurses Association Occupational Health and Safety Administration (OSHA)

TJC

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? The new nurse touches 1.5 in (4 cm) from the outer edges. The sterile field is set up at waist level. Direct visualization of the sterile field is maintained. The top flap of the package is opened away from the new nurse's body.

The new nurse touches 1.5 in (4 cm) from the outer edges. Only the outer 1 in (2.5 cm) of the sterile package is safe to touch. In this case, the nurse touches 1.5 in (4 cm), which is inside the sterile field. It is necessary to call for help if supplies are needed before leaving the sterile field unattended and never turn away from a prepared field so direct visualization is imperative to protect the sterility. The top flap of the sterile packaging should always be opened away from the body.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? The nurse places the client in a private room with the door open. The nurse uses droplet precautions when providing care for the client. The nurse keeps visitors 3 feet away from the infected person. The nurse places the client in a private room with monitored negative air pressure.

The nurse places the client in a private room with monitored negative air pressure.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The blood pressure is elevated. A baseline pulse rate is needed. The carotid pulse is bounding. The radial pulse is difficult to obtain.

The radial pulse is difficult to obtain.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? Not to worry and to take double the dose of BP medication To call her health care provider To take the medication that she missed and retake her BP To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? auscultate the client's apical pulse palpate the client's apical pulse arrange for cardiac monitoring auscultate the client's brachial artery

auscultate the client's apical pulse When peripheral pulses are difficult to palpate, it is appropriate to auscultate the apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse. Cardiac monitoring is not necessarily indicated in this case.

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: dyspnea. fremitus. stridor. wheezing.

dyspnea.

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? ear rectum axilla mouth

rectum