Management of Care
The nurse is caring for a client with juvenile idiopathic arthritis. What will the nurse include in the client's plan of care? Select all that apply. -keep the client on bed rest -administer ibuprofen for pain -encourage a well-balanced diet -measure growth and development -assess joints for swelling and deformity
A: -administer ibuprofen for pain -encourage a well-balanced diet -measure growth and development -assess joints for swelling and deformity Rationale: Juvenile idiopathic arthritis affects the joints. Ibuprofen is a drug of choice, and eating a well-balanced diet helps in weight management. The joints can become deformed and swollen. Growth and development can be affected due to the changes in the joints.
The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply. -discussion of pertinent information -the client's agreement to the plan of care -freedom from coercion -caregiver preference and opinion -verification from next of kin
A: -discussion of pertinent information -the client's agreement to the plan of care -freedom from coercion Rationale: Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin.
A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This action is an example of: -false imprisonment. -limit setting. -slander. -violation of confidentiality.
A: false imprisonment Rationale: Confining a voluntary client against the client's will may be considered false imprisonment. Limit setting is a technique used with clients who are manipulative to limit manipulative behavior toward nurses and other clients. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
The nurse is assessing a client with pneumonia. The nurse auscultates high-pitched popping sounds during inspiration. How will this finding be documented? -inspiratory wheezes -pleural friction rub -coarse crackles -fine crackles
A: fine crackles Rationale: Crackles result from air moving through airways that contain fluid. Audible during both inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. Fine crackles are soft and high-pitched. Coarse crackles are louder and low-pitched with a bubbling sound. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed visceral and parietal pleurae rub together. Wheezes occur on expiration and sometimes on inspiration. Wheezes are continuous, high-pitched, musical squeaks that result when air moves rapidly through airways narrowed by asthma or infection — or when a tumor or foreign body partially obstructs an airway.
The nurse is managing the care of a client with a gastrointestinal hemorrhage. Which task is appropriate to assign to a unlicensed assistive personnel (UAP)? -Insert an nasogastric tube (NGT). -Assess stools. -Check vital signs every 1 hour. -Notify spouse.
A: Check vital signs every 1 hour. Rationale: Vital signs fall within the UAP's scope of practice. The UAP should not be responsible for notifying the family with/without the client's permission. Insertion of the NGT, assessment of stools, and notifying the family are all within the licensed nurses' scope of practice and require additional education.
The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? -a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling -a 3-year-old with a fever of 100° F (37.8° C), a barky cough, and mild intercostal retractions -a 4-year-old with a fever of 101° F (38.3° C), a hoarse cough, inspiratory stridor, and restlessness -a 13-year-old with a fever of 104° F (40° C), chills, and a cough with thick yellow secretions
A: a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Rationale: This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.
In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? -orders for antibiotics -orders for diagnostic studies -orders for dietary changes -orders for respiratory treatments
A: orders for antibiotics Rationale: Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
An older adult client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. What information should the nurse give the client about how the rings will be secured during surgery? -The rings will be taped on the fingers before the surgery. -The rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe. -The rings will be locked in the narcotics box. -The nursing supervisor will hold onto the rings until the client returns from the recovery room.
A: The rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe. Rationale: Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.
The nurse in the intensive care unit is giving a report to the nurse in the postsurgical unit about a client who had a gastrectomy. What is the most effective way for the nurse to assure essential information about the client is reported? -Give the report face-to face with both nurses in a quiet room. -Audiotape the report for future reference and documentation. -Use a printed checklist with information individualized for the client. -Document essential transfer information in the client's electronic health record.
A: Use a printed checklist with information individualized for the client. Rationale: Using a checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.
The nurse is administering medications to a client who has a gastrostomy tube (G-tube). The nurse reads the order for aspirin PO and crushes the aspirin and administers through the G-tube. What medication error did the nurse commit? -wrong client -wrong time -wrong dosage -wrong route -wrong drug
A: wrong route Rationale: Crushing enteric-coated tablets and caplets via a G-tube would be considered a medication error because the nurse did not administer the medication using the right route. The client could suffer erosion of the esophagus or stomach resulting in a bleeding ulcer, and the medication was enteric coated to move beyond the stomach before dissolving, and prevent erosion of the gastrointestinal tissue.
The nurse overhears two nursing assistants saying that they think it is ridiculous that a female client of the Islamic culture insists that only female nurses care for her. What should the nurse do? Select all that apply. -Speak to the nursing assistants about the importance of culturally competent care on the unit. -Report the conversation to the nursing supervisor so that they are immediately punished. -Explain to the nursing assistants that it is wrong in the client's culture for a male to touch a female that is not their wife. -Remind the nursing assistants that it is inappropriate to talk about clients in any way that does not involve them providing care. -Discuss the situation with another nurse from another unit over lunch to decide the best course of action.
A: -Speak to the nursing assistants about the importance of culturally competent care on the unit. -Explain to the nursing assistants that it is wrong in the client's culture for a male to touch a female that is not their wife. -Remind the nursing assistants that it is inappropriate to talk about clients in any way that does not involve them providing care. Rationale: Explaining to the nursing assistants that it is wrong in the client's culture for a male to touch a female that is not their wife, talking to them about the importance of providing culturally competent care, and reminding them not to discuss clients when it does not involve providing care are appropriate nursing behaviors. Reporting the nursing assistants behavior without talking to them and educating them first is not appropriate. It is just as wrong for the nurse to discuss with a nurse from another unit the client's private needs. If a nurse is unsure what to do in this case, the nurse should discuss it with the charge nurse on the unit involved.
A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint? -"I'm so clumsy." -"I'm afraid I'll lose my job because I'm going to miss so much work." -"Sometimes my spouse gets so angry with me." -"I'm going to need help at home after I'm discharged."
A: "Sometimes my spouse gets so angry with me." Rationale: Legally, the nurse must further investigate the client's statement concerning the spouse's anger. This statement suggests that the client's injury might be caused by domestic abuse. The other statements are common and don't require further investigation, from a legal standpoint, by the nurse.
A client with gastric cancer is having a resection. What is the nursing management priority for this client? -discharge planning -correcting nutritional deficits -preventing deep vein thrombosis (DVT) -teaching about radiation treatment
A: correcting nutritional deficits Rationale: Clients with gastric cancer commonly have nutritional deficits and may have cachexia. Therefore, correcting nutritional deficits is a top priority. Discharge planning before surgery is important, but correcting the nutritional deficits is a higher priority. Radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Preventing DVT isn't a high priority before surgery, but it assumes greater importance after surgery.
A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best? -"You'll need help with your bath and meals for quite some time, which can be difficult for family members." -"The rehabilitation staff can provide you with better, safer care than untrained family members." -"The rehabilitation staff can evaluate your progress and help you recover without risking injury." -"The healthcare provider advises care at a rehabilitation center until you can care for yourself."
A: "The rehabilitation staff can evaluate your progress and help you recover without risking injury." Rationale: The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility and not providing total care. Stating that the client will need help with bathing and meals for a long period does not provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to provide self-care. Telling the client that the rehabilitation staff can provide better care than family is judgmental about care the family might provide and does not adequately explain the role of a rehabilitation center. Telling the client that the heathcare provider wants the client to go does not explain the importance of a rehabilitation center.
The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make? -"Why are you trying to access that infromation on the client?" -"You should contact the information technology department to let them know." -"You are not authorized to view all of the details on the client." -"I can pull up the data for you under my log-in information."
A: "You are not authorized to view all of the details on the client." Rationale: To protect confidentiality, it is important to control the type of information that personnel in various departments can retrieve. Unlicensed nursing assistants can retrieve information from the medical records, but they cannot view information from the social worker. The reason the assistant wants to view that information is irrelevant. The information technology department does not need to be notified, because there is not a problem with the nursing assistant's log-in information. The nurse should not pull up the data for the assistant, because it is information that the assistant is not authorized to have.
The emergency room nurse is caring for a Hispanic client following an anaphylactic reaction to a bee sting. The client needs education on self-administering an EpiPen for future use. Spanish is the client's primary language. Identify the proper steps the nurse needs to follow in order to correctly teach the client to use an EpiPen. All options must be used. 1 Request a Spanish-speaking interpreter. 2 Have the client take the EpiPen out of the carrying tube. 3 Tell the interpreter to tell the client to remove the outer safety release cap. 4 Demonstrate how to swing and inject firmly into the outer thigh region. 5 Show the client how to press firmly against thigh for 10 seconds and then massage. 6Reinforce to the client to seek emergency medical attention if stung again
A: -Request a Spanish-speaking interpreter. -Have the client take the EpiPen out of the carrying tube. -Tell the interpreter to tell the client to remove the outer safety release cap. -Demonstrate how to swing and inject firmly into the outer thigh region. -Show the client how to press firmly against thigh for 10 seconds and then massage. -Reinforce to the client to seek emergency medical attention if stung again. Rationale: The nurses priority action when teaching a client whose language is not the same as the nurse is to get an interpreter or use a phone interpreter. The next nursing actions should be teaching the client to use the EpiPen correctly, It is important to demonstrate the steps as well as just verbalize them. First, the client should remove it from the carrying tube, grasps the unit with the tip pointed downward and remove the gray outer safety-release cap. Then the client then holds the black tip near the outer thigh; swings and injects it firmly into the outer thigh until hearing a click with the device perpendicular to the thigh. Next, have the client hold the device firmly against the thigh for about 10 seconds, then removes it and massages the area for 10 seconds. Lastly, the nurse needs to reinforce that the client should always seek emergency medical attention if stung again.
The managers of the physical and occupational therapy neurologic departments tell a nurse-manager of an adult neurologic rehabilitation unit that they're concerned that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem? -Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff. -Tell the nursing staff that nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists. -Meet with physical and occupational therapy managers to identify scheduling solutions. -Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer the nurse-manager as a resource.
A: Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer the nurse-manager as a resource. Rationale: In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The nurse-manager, however, should be available to help. Meeting with only the managers of physical and occupational therapy reflects an autocratic manager. Without staff input, the nurse-manager won't have the information needed to identify the best solution. By simply telling the nursing staff to follow the therapists' schedules, the nurse-manager has abdicated responsibility for problem solving, yet the problem still exists. Determining problem-solving options without staff input is indicative of a participative manager. A participative manager asks staff members for opinions but staff membres don't have input into actual problem solving. This lack of input may cause resentment and frustration.
After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's child returns to the hospital 6 hours later to find that the client remains on a stretcher in the emergency department hallway. The child begins to shout "I will not allow my insurance to pay for your failure to provide care." What is the best action for the nurse to take in this situation? -Contact the receiving unit to expedite the transfer process. -Contact hospital security to arrange for the removal of the disruptive family member. -Ensure the comfort and security of the client and meet privately with the family member. -Contact the nursing supervisor to insist that this client is transferred immediately
A: Ensure the comfort and security of the client and meet privately with the family member. Rationale: It is imperative to insure that the client who remains in an interim status awaiting admission to a hospital ward bed is safe and comfortable, as well as being reassured that this person is being cared for. The nurse should then meet privately with the family member to address concerns, provide reassurance, answer questions, and provide referrals (to administration or advocacy as may be indicated). It is inappropriate to have the family confronted by security or threatened to be removed. The nurse may contact security as warranted if the family member becomes threatening. Arranging for the client to be moved out of the hallway is a reasonable compromise if this option is, or becomes, available. Contacting the nursing supervisor is appropriate, but it is unreasonable to insist that the client be transferred immediately.
A student nurse is accompanying a community health nurse for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The mother's partner declines this opportunity. What is the nurse's most appropriate response? -Reassure the partner that the student nurse will be professional. -Ask the partner to leave the premises. -Ask the partner about any concerns. -Honor the partner's preference.
A: Honor the partner's preference. Rationale: When providing services such as a postpartum visit in someone's home, the nurse needs to respect the family's values and cultural preferences with how services are provided. The other responses are negating the family's wishes and could be seen as confrontational and not client centered.
A client was admitted to the hospital. During the admission process, the nurse, the physician, and the pharmacist review the client's diagnosis and medications. The next person to see the client is a person from the admitting department. What is the rationale for the person from the admitting department during the admission process? -It is hospital policy for all clients to review the hospital services available for the clients. -It is a federal law that the institution provide a written summary of the client's health care decisions and rights of the institution. -It is a state law that all information collected during the hospitalization be reviewed with client and client's family. -It is local law that all information regarding the privacy of the client not be shared with anyone but the health care team.
A: It is a federal law that the institution provide a written summary of the client's health care decisions and rights of the institution. Rationale: Most hospitals, nursing homes, home health agencies, and HMOs routinely provide information on advance directives at the time of admission. They are required to do so under a federal law called the Patient Self-Determination Act (PSDA). The PSDA simply requires that most health care institutions (but not individual doctors) do the following: 1. Give the client at the time of admission a written summary of the health care decision-making rights (each state has developed such a summary for hospitals, nursing homes, and home health agencies to use) and the facility's policies with respect to recognizing advance directives. 2. Ask if the client has an advance directive, and document that fact in the client's medical record if the client does. (It is up to the client to make sure to give a copy to the institution). 3. Educate the staff of the institution and community about advance directives. 4. Never discriminate against clients based on whether or not they have an advance directive. Thus, it is against the law for health care institutions to require either that the client have or not have an advance directive.
The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first? -Mother: fundus is firm 2 cm below umbilicus, minimal lochia rubra. Infant: color is pink on room air, respirations 67 breaths/minute; bilateral crackles on auscultation. -Mother: fundus is firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute. -Mother: fundus is firm 1 cm above umbilicus, small amount lochia rubra. Infant: color pink with acrocyanosis, respirations 68 breaths/minute and intermittent expiratory grunting. -Mother: fundus is firm at umbilicus, small amount lochia rubra. Infant: pale pink, quiet alert; respiration 65 breaths/minute; periodic breathing noted.
A: Mother: fundus is firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute. Rationale: The mother demonstrates signs of full bladder and vaginal bleeding and requires assistance with bladder emptying and uterine massage to assess the origination of the bleeding. The newborn requires further assessment because turning dusky when quiet and respiration rate of 70 breaths/minute indicates the beginning signs of respiratory distress and requires prompt intervention. All other mothers are recovering normally. While bilateral crackles in a newborn could indicate excessive fluid, a pink color indicates the infant is maintaining oxygenation. Normal respiration is 30 to 60 breaths/minute. While a respiratory rate of 67 breaths/min is slightly elevated, the baby is not demonstrating any other signs of respiratory distress. The newborn with acrocyanosis (bluish hands and feet) is a normal newborn finding and shows the ability to maintain oxygenation. Respirations of 70 breaths/minute and intermittent expiratory grunting would indicate close observation but does not require immediate intervention if the infant is pink. The last newborn is maintaining oxygenation, with respirations just slightly above normal. Periodic breathing, featuring pauses in breathing of less than 15 seconds, is a normal newborn finding.
The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? -Risk for infection -Chronic pain -Impaired gas exchange -Impaired memory
A: Risk for infection Rationale: Clients with endocarditis have a Risk for infection. The nurse should stress to the client that they will need to continue antibiotics for a minimum of 5 years and that they will need to take prophylactic antibiotics before invasive procedures for life. There is no indication that the client has Chronic painor Impaired memory. Because the client doesn't have valvular damage, Impaired gas exchangedoesn't apply.
Which task may be safely delegated to a licensed practical nurse (LPN)? -teaching a client newly diagnosed with diabetes mellitus about insulin administration -admitting a client who underwent a thoracotomy to the nursing unit from -the postanesthesia care unit changing the dressing of a client who underwent surgery 2 days ago -administering an I.V. bolus dose of morphine sulfate to a client experiencing incisional pain
A: changing the dressing of a client who underwent surgery 2 days ago Rationale: The registered nurse may safely delegate dressing changes for the client who underwent surgery 2 days ago to the LPN. Teaching a client newly diagnosed with diabetes mellitus about insulin administration requires careful evaluation of the effectiveness of teaching and may not be delegated to an LPN. Admitting a client to the postanesthesia care unit is beyond the scope of practice for an LPN; LPNs aren't permitted to give I.V. push drugs.
