PN PASSPOINT: THE NURSING PROCESS

The family of a client who is unconscious following a stroke tells the nurse they feel "pressured" by the resident physician to insert a feeding tube. They are reluctant to agree to the procedure because they believe this action is not something the client would want. Which response by the nurse illustrates ethical practice?

"I can arrange for you to talk with the healthcare team about your loved one's situation."

The nurse reinforces the client's teaching on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional instruction has been effective?

"I chose a baked potato with broiled chicken for dinner."

A nurse is caring for a client who's taking the anticoagulant warfarin (Coumadin). Which instruction regarding warfarin therapy should the nurse give to the client?

Limit foods high in vitamin K.

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first?

Report the suspicion to the nurse manager.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school?

This is an appropriate request and arrangements will be made as soon as possible.

The nurse is assigned to care for a group of clients on the medical-surgical unit. Following report, which client should the nurse see first?

a client that a family member states is having a new onset of slurred speech and left facial drooping

A newly hired licensed practical nurse (LPN) is establishing priorities for morning client evaluations with the assistance of a preceptor. Which client should the nurses evaluate first?

a newly admitted client with acute abdominal pain

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

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

speech therapist

The nursing staff is developing a care plan for a 10-year-old child who is receiving palliative care for end-stage leukemia. The child is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the child's care plan?

Meet with the pain management team to devise a more effective pain control plan.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?

Check the computerized care plan to determine what test was scheduled.

A client in her second trimester tells the nurse that she feels very anxious because she is not sure of what will happen when she goes into labor to give birth. Which intervention by the nurse would be most appropriate for this client?

Help her enroll in birth preparation classes at the facility where she plans to give birth.

Which action should the nurse take before applying the next dose of a topical medication to a client's skin?

Locate the previously applied medication for removal.

A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best?

Performing mouth care

A nurse is caring for a client who is experiencing an Addisonian crisis. Which nursing intervention should the nurse include in the client's care?

Place the client in a private room.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which nursing consideration is most important for the nurse to be aware of when providing care for this client?

Taking a blood pressure reading on the affected arm can cause clotting of the fistula.

An older adult client admitted to the hospital with an exacerbation of heart failure is confused, has inadvertently pulled out the IV catheter, and is attempting to get out of bed. The health care provider orders the use of physical restraints. Which nursing action reflects safe nursing care?

Tie the restraints to the bed frame using a quick-release knot.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis cariniipneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client.

The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take?

put on a gown.

A client with a history of duodenal ulcers states to the nurse, "I take antacids once in a while to relieve the pain." Which statement by the client should be reported immediately?

"My bowel movements have been sticky and black."

After collecting data on a client, the nurse helps formulate relevant nursing diagnoses. Which is a complete nursing diagnosis statement that the nurse would suggest be implemented?

Ineffective airway clearance related to mucus plugs and nonproductive cough

A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is a neighbor's son. What action should the nurse take?

Inform the nurse director reading the chart is a violation of the client's right to privacy and ask the nurse director to return the chart.

A nurse has been voicing concerns to colleagues about unfair client assignments being assigned by the charge nurse with some nurses consistently having less complex client assignments than others. What action should the charge nurse take upon learning this information?

Meet with the nurse privately and provide an opportunity to express concerns.