PassPoint: Fundamentals of Nursing

The nurse is recording the intake and output for a client with the following: D5NSS 1,000 ml; urine 450 ml; emesis 125 ml; Jackson Pratt drain #1 35 ml; Jackson Pratt drain #2 32 ml; and Jackson Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654 The nurse must add all the output volumes together: 450 ml + 125 ml + 35 ml + 32 ml + 12 ml = 654 ml; D5NSS 1,000 ml is considered input, not output.

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? Nasal cannula Venturi mask Simple mask Nonrebreather mask

Nonrebreather mask A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

A client admitted to the hospital for chemotherapy states that he's been using a peppermint-scented candle at home to help control nausea. Which interventions would the nurse plan to promote comfort for this client? Telling the client she may use his scented candles Asking the client to try using peppermint oil in place of scented candles Asking the physician to increase the client's antinausea medication Asking the physician to order a sedative for the client to use during chemotherapy

Asking the client to try using peppermint oil in place of scented candles Aromatherapy may affect the brain's limbic system, causing relaxation, evoking positive emotional memories, and decreasing the need for antiemetics. Such alternative therapies may increase a client's feeling of control over illness. Because this client associates positive feelings with the scent of peppermint, the nurse should encourage him to continue using that scent, but she should ask the client to use scented oil rather than a candle. Fire of any kind, even a candle, is a hazard in the hospital — especially when oxygen is being used. Increasing the client's nausea medication or ordering a sedative could cause dangerous adverse effects and wouldn't be best practice.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility. The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the fall, and finally, document the event on the client's health record

The nurse is caring for an elderly patient who needs help with ADLs. Which of the following is most important for the nurse to understand when implementing care in order to avoid injury? Bending and twisting while providing care may cause injury. The center of gravity is located at the waist. A client's level of consciousness and ability to cooperate are not important factors during transfer. Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

Bending and twisting while providing care may cause injury. Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? History of increased aspirin use Recent pelvic surgery An active daily walking program A history of diabetes mellitus

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN? a 41-year-old client with unstable angina a 72-year-old client with diverticulitis a 32-year-old client hospitalized for chemotherapy treatment a 5-year-old client with Kawasaki's disease

a 72-year-old client with diverticulitis The client with diverticulitis will need care that the LPN should be able to provide safely. The client with angina is unstable and requires a registered nurse for continuous assessment. The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration. A child with Kawasaki's disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

Which statement reflects appropriate documentation in the medical record of a hospitalized client? "Small pressure ulcer noted on left leg." "Client seems to be mad at the physician." "Client had a good day." "Client's skin is moist and cool."

"Client's skin is moist and cool." Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

When assessing pain in a client from Mexico, the nurse should understand the implications of which statement from the client about the pain experience? "Enduring pain is a part of God's will." "This pain is killing me." "I have got to see a health care provider right away." "I cannot go on in pain like this any longer."

"Enduring pain is a part of God's will." Although individuals differ, the most likely attitude of a Mexican-American client is to bear pain stoically, to endure pain as a part of God's will, and to delay seeking treatment.

The health care provider writes an order that a client may have 12 ounces of clear liquids at each meal and may supplement this with an additional 10 ounces at each shift (7-3, 3-11, and 11-7). How many milliliters would the nurse document for the day shift (7-3) if the client took in all of the ordered volumes? Record your answer using a whole number.

1020 The nurse must add all the volumes together, knowing that 1 ounce equals 30 milliliters. There are two meals in the day shift (7-3). 12 oz x 30 ml = 360 ml; 360 ml x 2 meals = 720 ml; 10 oz. (supplement) x 30 ml = 300 ml; 720 ml + 300 ml = 1020 ml

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? At the top of the wound In the middle of the wound At the base of the wound Over the total wound

At the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? Refuse the assignment because he/she has never irrigated a nasogastric tube. Irrigate the nasogastric tube by following the steps outlined in the procedure manual. Ask another nurse to irrigate the nasogastric tube for him/her each time it is required. Contact the nurse educator for an in-service and support in performing the skill.

Contact the nurse educator for an in-service and support in performing the skill. The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? Instilling eye drops Nasogastric tube irrigation I.V. catheter insertion Colostomy irrigation

I.V. catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

The nurse is preparing the room for a client diagnosed with Varicella. Identify which sign the nurse would place on the room door.

In addition to contact precautions, the nurse would place the client diagnosed with Varicella in airborne precautions. Airborne precautions include a facemask for the client/respirator for the nurse and personal protective equipment including gown and gloves. Droplet precautions are indicated for viruses, B. pertussis, group A streptococcus. Contact precautions are indicated anytime a nurse may come in contact with any body fluids.

An inmate from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation? Perform morning care while the client is handcuffed. Insist that the officers stay in the room at all times. Ask another nurse to accompany the nurse into the room. Ask one of the officers to remove the handcuffs.

Insist that the officers stay in the room at all times. A correctional officer should be with the inmate/client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? A heart rate of 88 beats/minute Wound healing by primary intention Oral temperature of 101° F (38.3° C) Dry and intact wound dressing

Oral temperature of 101° F (38.3° C The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should: irrigate the tube with 20 mL of normal saline every 4 hours. unclamp the t-tube and empty the contents every day. assess the color and amount of drainage every shift. monitor the multiple incision sites for bile drainage.

assess the color and amount of drainage every shift. A t-tube is inserted in the common bile duct to maintain patency when there is a likelihood of edema. The tube remains in place until edema from the duct exploration subsides. The bile color should be gold to dark green, and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.

The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give "hand-off reports" at which times? Select all that apply. change of shift change of nurses when the nurse goes to lunch when the unit clerk goes to a staff meeting when new medication prescriptions are written

change of shift change of nurses when the nurse goes to lunch Effective communication is essential when managing client safety and preventing errors. "Hand-off reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not need to be a handoff report when the unit clerk leaves the unit or when new medication prescriptions are written.

The nurse should instruct the client with a platelet count of less than 150,000/?L (150 × 109/L) to avoid which activity? walking for more than 10 minutes straining to have a bowel movement visiting with young children sitting in semi-Fowler's position

straining to have a bowel movement When the platelet count is less than 150,000/?L (150 × 109/L), prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present

that there was adequate disclosure of information that the client understood the information that there was voluntary consent on the client's part that the client has full awareness of the potential complications The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.

A client is scheduled for an elective splenectomy. The last thing the nurse should do before the client goes to surgery is to determine that the client has: voided completely. signed the consent. vital signs recorded. name band on wrist.

vital signs recorded. An elective surgical procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for. The first assessment that will be completed in the preoperative holding area or operating room will be the client's vital signs. The client should have emptied the bladder before receiving preoperative medications so that the bladder is empty when it is time for transport into the operating room. The client should have signed the consent before the transport time so that if there were any questions or concerns there was time to meet with the surgeon. Also, the consent form must be signed before any sedative medications are given. The client's name band should be placed as soon as the client arrives in the perioperative setting, and it remains in place through discharge.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He reports shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: diminished or absent breath sounds on the affected side. paradoxical chest wall movement with respirations. tracheal deviation to the unaffected side. muffled or distant heart sounds.

diminished or absent breath sounds on the affected side. In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.

A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she has been validated on obtaining fingerstick glucose readings. The nursing assistant says she did not have the skill validated, but she has seen it done many times and knows she can do it. What should the nurse do? Give the nursing assistant the glucose meter, and let her perform the fingerstick. Provide the nursing assistant with an article on the procedure. Go with the nursing assistant into the client's room, and validate her ability to perform the procedure. Perform the fingerstick glucose testing herself.

Go with the nursing assistant into the client's room, and validate her ability to perform the procedure. The nurse should validate the nursing assistant's ability to perform the fingerstick glucose procedure. The nursing assistant may not perform the procedure without having her skills validated by actually performing the procedure. Providing reading material about the procedure is not enough. If the nurse performs the procedure on her own, she forfeits the opportunity to validate the nursing assistant's skills, and therefore underutilizes the nursing assistant.

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment? Speech therapist. Respiratory therapist. Physical therapist. Physician.

Speech therapist The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation, but swallowing assessment is a task most often performed by a speech therapist.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

What should the nurse instruct a client who has cerumen build-up in the ear to do? Select all that apply. Wash the external ear with a washcloth. Instill cerumenolytic drops in the ear canal. Use cotton tip applicators to remove the wax from the ear canal. Use small forceps to extract the wax. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

Wash the external ear with a washcloth. Instill cerumenolytic drops in the ear canal. Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution. The nurse can advise the client with cerumen that is impacted in the ear to use a wash cloth to clean the exterior part of the ear. The client can also instill cerumenocyltic drops to soften the ear wax. The client can then irrigate the ear canal with sterile water using a small bulb syringe. The client should not use cotton tipped applicators as they often push the cerumen further into the ear canal. The client should never put forceps in the ear.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM? Functional nursing Case management Team nursing Primary nursing

Team nursing Team nursing is efficient and less costly to implement than primary or case management systems. Because staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost-effective, care is commonly fragmented and clients are less satisfied. Case management and primary nursing require more registered nurses than are available.

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay? Referring the client for anger-management therapy upon discharge When the infant is crying, always offer the bottle or breast first Proper methods for dealing with stressful situations, such as crying infants Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems

Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. The infant may not be crying due to hunger; assessing the mother's coping will help provide the basis for teaching the essential skills.

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first? Change the staffing schedule on nights to include a medication nurse. Consult the nursing supervisor. Consult the nurses on the evening shift about their evaluation of the night nurses regarding these concerns. Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity.

Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. To determine the cause of this problem, a quality improvement study should be conducted. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Consulting with the evening nurses may result in biased observations because the evening nurses are not conducting care under the same environment as the night nurses. Including a medication nurse is not the first step in understanding the problem and may be an unrealistic or expensive solution. The supervisor is not directly involved with the problem and should only be consulted if the problem cannot be solved by those involved.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs. Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery.

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

A nurse who works on an obstetrical inpatient unit has been assigned to the client safety committee. What client safety goals are most applicable to this setting? Select all that apply. providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff ensuring that preprocedure verifications are completed by health care providers (HCP) for any invasive procedure involving clients in education to cord infections identifying safety risks specific to the unit, such as infant abduction car seat instruction allowing infants to ride facing backward in the front seat

providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff ensuring that preprocedure verifications are completed by health care providers (HCP) for any invasive procedure involving clients in education to cord infections identifying safety risks specific to the unit, such as infant abduction Specific safety concerns on an obstetrical unit include a very specific "hand-off report" after birth and recovery has been completed and the couplet is transitioned to mother-baby care. In any invasive procedure including tubal ligations and circumcisions, preprocedure verification is a standard procedure. Client education concerning the potential for infection in obstetrics is essential for any incision areas. Infant abduction is an ever-present concern for those working in a mother-baby unit. Car seat instructions for new parents involve the infant being in the back seat of a car facing backward—not in the front seat. Education for the family includes this important area.