Leadership and Management (77)

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent?

- Acting as a witness that the client signed the consent form voluntary - Documenting in the medical record the date and time the signature was obtained - Verifying that the client is competent to provide consent The nurse's role in informed consent is to witness a client signature and ascertain

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order

Gather supplies and position client Don mask, goggles, and clean gloves Remove soiled dressing Don sterile gloves; remove old disposable cannula and replace new one Clean around stoma with sterile water or saline; dry and replace sterile gauze pad

When injecting a prefilled enoxaparin syringe

A nurse should choose an injection site on the right or left side of abdomen, at least 2 inches from umbilicus; avoid expelling the air bubble in the syringe; Insert the needle at a 90-degree angle into a pinched-up area of skin; and discourage the client from rubbing the site.

The nurse preceptor observes a graduate nurse collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptors best action?

Advice the graduate nurse to discard the collected urine specimen and record the output

How to collect the urine specimen

Clean the collection port with an alcohol swab Aspirate urine with a sterile syringe Use aseptic technique to transfer the specimen to a sterile specimen cup A urine specimen is collected aseptically from the specimen port of an indwelling catheter. Urine that has been collected from a bag does not yield accurate urinalysis and culture results

Thoracentesis

During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. THIS POSITION ENSURES THAT THE DIAPHRAGM IS DEPENDENT, FACILITATES ACCESS TO THE PLEURAL SPACE THROUGH THE INTERCOSTAL SPACES, AND PROMOTES CLIENT COMFORT.

How to use incentive spirometry

Exhale normally and place the mouthpiece in the mouth Seal lips lightly in mouth piece Inhale deeply, until ball or piston rises to predetermined level Hold Breath for at least 2-3 seconds exhale slowly around the mouthpiece

Which steps should the nurse take to decompress the stomach for a client with abdominal distention and vomiting after insertion of a large bore nasogastric (NG) tube

Flush the tubing with water regularly leave the blue pigtail air vent open to air Use an adaptor to connect main NG lumen to suction tubing

After Liver Biopsy

Lies on the Right side (for 2 hours) and then supine (12-14 hours) after liver biopsy

Steps for inserting a nasogastric tube for gastric decompression.

Measure, mark, and lubricate Instruct client to extend neck back slightly gently insert tube just past nasopharynx Ask client to flex head forward and swallow Advance tube to the marked

To insert an indwelling urinary catheter on a female client

Perform hand hygiene Apply sterile gloves Use non dominant hand to spread the labia Cleanse labial fold with antiseptic swab insert catheter until urine is visualize Maintain sterile technique throughout the procedure

Paracentesis

Position client in high Fowler's for a paracentesis related to end stage cirrhosis. Make sure patient empty bladder

Air Embolism

Position client trendelenburg on left side if air embolism is suspected

Chest Tube Placement

Position client with arm raised above head for chest tube placement

Correct use of meter dose inhaler

Shake canister well for 3-5 seconds Tilt head back slightly and exhale slowly for 3-5 seconds Place mouthpiece between teeth and wrap lips around the mouthpiece Compress canister while inhaling slowly through the mouth for about for about 3-5 seconds Hold breath for 10 seconds, if possible, before exhaling Wait at least 1-2 minutes before taking a second puff if prescribed

Abdominal examination

Stand on the client Right side Inspection Auscultation Percussion Palpation

When working with a medical interpreter

The nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short simple sentence; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences

The nurse helps the health care provider perform at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?

Upright leaning forward over the bedside table, with arms supported on pillows

care of a client receiving enteral feedings

elevating the head of the bed monitoring for acidic pH <5 assessing for excessive residual volume returning aspirated residual volume to the stomach and flushing the tubing before and after bolus intermittent feeding

Lumbar Puncture

is side lying with the head back and knees flexed for lumbar puncture

When administering otic medication to children age 3 and older

pull the pinna upward and back to straighten the ear canal. The child is place in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal