NURSING INTERVENTIONS
After a modified radical mastectomy a client has two portable wound drainage systems in place. What is an important intervention as the nurse cares for these drainage systems?
Compressing the drainage receptacles after emptying them to maintain suction
What is the most appropriate way for the nurse to help a severely depressed adolescent client accept the realities of daily living?
Helping the client fulfill personal hygiene needs
A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client?
Maintaining a calm, consistent approach with the client
A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective?
Maintaining a supportive, structured environment
When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," how should the nurse respond?
Telling the client that these words cannot be understood
A client is admitted to the birthing unit because fluid is leaking from her vagina. She is unsure whether her "bag of water" has broken. What should the nurse do to help determine whether the fluid is amniotic fluid?
Test the fluid with nitrazine paper
The nurse plans to provide a back massage to a client. What should the nurse do first in this situation?
Assess the client's preference for touch and massage.
A primary healthcare provider notes that all conventional treatment procedures have proved to be ineffective in managing a client's disorder. The primary healthcare provider decides to try an experimental treatment. The nurse ensures that the client has understood the implications of the new treatment plan thoroughly and then signs the client's consent form as a witness. Which basic healthcare ethic does the nurse follow in this situation?
Autonomy
Which nursing interventions would help to ensure the safe administration of antiepileptics to children? Select all that apply.
Avoid carbonated beverages while taking valproic acid Use a graduated device to deliver an oral dose Encourage the wearing of a medical alert bracelet Maintain a record of symptoms of seizures before, during, and after treatment with anti-epileptics
During a clinic visit a 4-year-old girl suddenly yells, "Don't sit on Erin!" The parent whispers that Erin is an imaginary friend. What is the nurse's best action?
Avoiding sitting where the child says her imaginary friend is located
A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from an indwelling urinary catheter?
Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine
A nurse approaches a depressed client who is sitting alone in the dayroom. What is best for the nurse to say to the client?
"I'll be sitting with you for a while today."
What nursing action best promotes parent-infant attachment behaviors?
Keeping the new family together immediately after the birth
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our son have to have restraints?" How should the nurse respond?
"Because we're keeping the arms straight your baby won't be able to touch his mouth."
A nurse caring for a pregnant client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client does the nurse consider to be a self-esteem need?
"I deserve ill treatment from my husband as I'm incapable of doing even simple things perfectly."
An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic?
"You seem upset. Let's talk about what's bothering you."
Which statement accurately demonstrates an act of nursing negligence?
A nurse instructs the nursing assistive personnel to administer medication through an intravenous line.
After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority.
Administer oxygen to the mother and monitor fetal heart tones Call for assistance and don sterile gloves Insert two fingers into the vagina and exert upward pressure against the fetal presenting part Put a rolled towel under one hip and place in the modified Sims position
A hospitalized 7-year-old boy wakes up crying because he has wet his bed. What is it most appropriate for the nurse to do?
Change the child's bed while he changes his pajamas
A 9-year-old child who has successfully completed the emergency (resuscitative) phase of treatment for a severe burn injury is started on a high protein, high calorie diet. Which snacks should the nurse encourage between meals? Select all that apply.
Crackers and cheese Banana pudding and whipped cream Frozen yogurt and chocolate sprinkles
During the fourth stage of labor, the assessment of a primipara who has had a vaginal birth reveals a moderate to large amount of lochia rubra, a firm fundus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. What is the priority nursing action?
Helping the client void
A nurse instructs a client who avoids bathing to take a bath or shower each day as a means of maintaining hygiene and preventing infection. Which of these reactions should the nurse expect if the client is in the action stage? Select all that apply.
"I try to take a shower every day, but I skip it sometimes because of my tight work schedule." "I understand that bathing regularly is a good habit, but my bathroom is very cold in the mornings." "I want to take a bath regularly, but I don't have time because I need to look after my kids and my parents."
The nurse is teaching a student nurse about caring for a client with decreased bone density. Which statements made by the student nurse indicates effective learning? Select all that apply.
"I will instruct the client to be very careful to prevent injuries." "I will instruct the client to perform weight-bearing activities."
A nurse enters a depressed client's room on the evening of admission and observes the client sitting in a chair crying. What is the most therapeutic response by the nurse?
"You're crying. Let's talk about it."
A client is agitated and threatening staff and other clients with physical harm. The nurse prepares to administer the prescribed PRN haloperidol (Haldol) after other means to deescalate the behavior have failed. The prescription calls for the administration of 5 mg of haloperidol intramuscularly PRN for severely agitated/aggressive behavior. The haloperidol is available in a vial labeled "2 mg/mL." How many milliliters of solution should the nurse administer? Record your answer rounding to one decimal place. __________ mL
2.5
A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area. The mother becomes concerned when she discovers that the nurse has left her infant without a diaper. What is the nurse's explanation for this action?
Cleansing of the skin followed by air-drying reduces skin breakdown
A nurse is caring for a child with sickle cell anemia. During the child's hospital stay, edema, impaired range of motion, and pain in the hands and feet develop. The primary health-care provider tells the nurse that the child will require palliative care and management. Which palliative management therapies does the nurse anticipate will be beneficial for the child? Select all that apply.
Hydration Analgesics Oxygen therapy
A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent?
Keep the infant in an upright position after feedings
While in the playroom a 7-year-old child exhibits twitching of the right arm and leg that progresses to a generalized tonic-clonic seizure. What is the nurse's initial action?
Moving toys and furniture away from the child
An intravenous infusion of 30 mg of an antibiotic in 50 mL of D5W every 6 hours is prescribed for an adolescent. It is to run over 30 minutes. At what hourly rate should the nurse set the infusion device? Record your answer using a whole number. __________ mL/hr
Multiplying 50 mL by 2 (for the two 30-minute segments in an hour) equals 100. This rate will deliver the 50 mL of antibiotic solution in 30 minutes as prescribed.
The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.
Observe for chest wall trauma Assess breath sounds and respiratory effort
A client who has had a cesarean birth seems upset. She has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action?
Observing the client's breastfeeding technique
An infant has noncommunicating hydrocephalus, and a ventriculoperitoneal shunt is inserted. What should the nurse do when caring for the infant during the initial postoperative period?
Place the infant flat with the head on the unaffected side
What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?
Placing a tracheostomy unit by the bedside
A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child?
Positioning the child on the right side after the feeding
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?
Remove secretions from the pharynx
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
Acetaminophen (Tylenol) 15 mg/kg is prescribed for a preschooler who weighs 44 lb. Each 5 mL of solution contains 160 mg. How many milliliters of acetaminophen should the nurse administer? Record your answer rounding to one decimal place. __________ mL
Use ratio and proportion to solve the problem. One kilogram equals 2.2 lb; 44 lb divided by 2.2 = 20 kg; 15 mg x 20 = 300 mg.
What should the nursing care of an 8-month-old infant with tetralogy of Fallot include?
Prevention of increased respiratory effort to promote oxygenation
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply.
Clean the eyelid and eyelashes Apply clean gloves before beginning of procedure. Press on the nasolacrimal duct after instilling the solution
A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity?
Have the client perform simple, repetitive tasks
An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do?
Help the client select appropriate attire and offer to help the client get dressed
A nurse determines that a client who, although ambivalent, is considering an abortion because of financial difficulties is in crisis. How should the nurse intervene to alleviate the crisis?
Helping the client express her feelings
A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time?
Promotion of maternal and fetal well-being during labor
Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate?
Rubber-tipped syringe
What strategy should the nurse employ to be effective when using play therapy with a 6-year-old child with autism?
Use mechanical and inanimate objects for play
A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply.
Using informatics Using evidence-based practice Providing patient-centered care
An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.
Weak pulse Difficulty swallowing Loss of bladder control
A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?
Elevate the legs
Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?
Encouraging them to express their concerns
A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Select all that apply.
Increasing food intake gradually Limiting mealtime to half an hour Providing privileges for goal achievement
A female client in the mental health clinic has pressured speech and mumbles incoherently. What is the most appropriate nursing intervention?
Indicating to the client that she needs to slow down because what she says is important and cannot be understood
When providing preoperative teaching, what should the nurse focus primarily on?
Providing general information to reduce client and family anxiety
What intervention is included in the nursing care plan for a 4-month-old infant with tetralogy of Fallot and heart failure?
Providing small, frequent feedings.
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine?
Serum glucose level
What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa?
Set limits
A woman who abused drugs during pregnancy gave birth to a drug-dependent neonate. Which nursing interventions would be beneficial to the neonate? Select all that apply.
To administer smaller doses of the dependent drug To monitor the neonate carefully and closely To educate the mother about the risks of drug abuse