WEADGAA

The organization of a client's care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?

? It is based on communication and cooperation between disciplines

A client scheduled for surgery has a blood pressure of 186/90 mm Hg. After documenting this in the medical record, which action will the nurse take?

?Notify the health care provider of the blood pressure.

The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery?

Blood pressure 80/50 mm Hg

The nurse is caring for a client who has been NPO since admission two days ago and was admitted with vomiting as a primary symptom. The client has been receiving intravenous therapy at 100 mL/hr. since admission with Lactated Ringers (LR) as the intravenous solution. What nursing diagnosis is most appropriate for this client?

Altered Nutrition: Less than body requirements R/T lack of adequate caloric intake

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

Durable power of attorney for health care

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery.

The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest nursing priority?

Maintaining a patent airway

An operating room (OR) nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

Mask covering the nose and mouth

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

Offer the client a bedpan or urinal.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing?

Older clients should receive a reduced dose

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?

Older people experience reduced sensory perception.

The nurse is caring for a client who has been receiving intravenous therapy via a central venous catheter inserted through the subclavian vein. Suddenly after the tubing to the intravenous solution is changed, the client develops shortness of breath, chest pain, and tachycardia. What should be the PRIORITY action of the nurse at this time?

Place the bed in Trendelenburg position with the client on the left side

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room?

Pressure points should be assessed and well padded.

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing potential contamination of the peritoneum

A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth?

Provide gentle oral care after each meal

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection?

Red, warm, tender incision

A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do?

Request the analgesics be prescribed by an alternative route.

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?

Respect the client's and family members' choice

A client who is resuscitated reports to the nurse having had a "near-death experience." Which of the following characteristics would the nurse expect the client to report?

Seeing familiar people who have already died Being told that it is not time yet for them to dieRegretting having to return to their resuscitated body

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute)

The hospice nurse is providing in-home care for a 45-year-old parent of three young children. During the most recent visit, the nurse has observed that the client has a new onset of altered mental status. What intervention should the nurse implement?

Teaching family members how to interact with, and ensure safety for, the client with impaired cognition

The nurse is caring for a client who is having difficulty adjusting to a terminal diagnosis. The nurse notes the client's tears and sits down by the bedside. The client tells the nurse, "There are so many things I still want to accomplish." Which response would be most therapeutic and appropriate for the nurse to make?

Tell me what's most important to you now."

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement and flatus.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?

The pump will deliver a preset amount of medication.

A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care?

To improve the client's and family's quality of life

A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim?

To prevent and relieve suffering

In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea?

Use imagery, humor, and progressive relaxation

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations?

When the client has disorders that affect the absorption of medications

The nurse expects informed consent to be obtained for insertion

a gastronomy tube

The nurse has received a health care provider's order to initiate intravenous therapy and will check the client's medical record for what prior client condition that would impact placement of the client's intravenous site?

History of a mastectomy for breast cancer

The nurse evaluates that a dying client is in the anger stage of reacting to her prognosis. Which of the following statements is most consistent with this interpretation?

I took care of myself and it's not fair that this has happened."

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?

Increased restlessness

How would the operating room nurse place a patient in the Trendelenburg position?

On his back with his head lowered so that the plane of his body meets the horizontal on an angle

Which action should the nurse perform to prevent deep vein thrombosis in a client recovering from abdominal surgery?

Reinforce the need for the client to perform leg exercises every hour while awake.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings or applying pressure if bleeding is frank

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates?

Severe, credible impending threat, usually with a site specified

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room.

Sit with the client's daughter privately and encourage her to express her feelings frankly

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation?

Sit with the client's daughter privately and encourage her to express her feelings frankly

A client receiving intravenous therapy is experiencing circulatory overload. Which of the following nursing actions is correct

Slow the infusion rate elevate the head of bed and contact the psychian

The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care?

Supporting the client's and family's values and choices

The nurse is supervising a new graduate nurse who is caring for a client receiving total parenteral nutrition for the last two weeks. The health care provider has just written an order to discontinue this therapy according to policy. What action by the new nurse would cause the supervising nurse to intervene in relation to intravenous therapy?

The new graduate replaces the total parenteral nutrition intravenous solution with 0.9% saline.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock

The nurse is caring for an older adult client who is receiving intravenous therapy (IV). Which assessment data would indicate that the client is experiencing a complication of IV therapy?

The client's jugular veins are distended.

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?

The donor blood was incompatible with that of the client.

The nurse is preparing to administer a unit of blood to a client and should know that which is the FIRST action of the nurse prior to the administration?

The nurse will check that the numbers of the client's wrist band and the unit of blood match and that this information is confirmed by another nurse

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?

Verifies that operative consent is signed

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use?

burning

When taking a client history, the nurse notes that the client has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the client is experiencing which type of pain?

chronic pain

A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?

elective

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner?

evidence based practice

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

first intention

The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color?

green

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit?

latex allergy

As a client approaches death, respirations become noisy. This is the result of which type physical event?

musculoskeletal change

A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?

neuropathic and chronic

The nurse is assuming the care of an adult client who has been experiencing severe and intractable pain. When reviewing the client's medication administration record, the nurse notes the presence of gabapentin. The nurse is justified in suspecting which phenomenon in the etiology of the client's pain?

neuropathy

A type of comprehensive care for clients whose disease is not responsive to cure is

pallative care

The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that

palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms.

A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client?

palliative sedation

What complication is the nurse aware of that is associated with deep venous thrombosis?

pulmonary embolism

The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color?

red

The first step in decontamination include

removing the client's clothing and jewelry and then rinsing the client with water

A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used?

soap and water

Which is defined as the potential of an agent to cause injury to the body?

toxicity

The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury?

tympanic membrane rupture

A client with type O blood and a history of anemia is scheduled for a blood transfusion. To avoid a transfusion reaction, this client must receive which blood type?

type O

The nurse is assessing a client with end-stage liver failure for the presence of hope. What should the nurse identify as a hope-fostering category?

uplifting memories

Shortly after a client's death from a long-term illness, his daughter says to the nurse, "Things changed so suddenly. I told him yesterday how much I loved him but that it was OK to let go if that's what he wanted." The nurse would identify this as what phenomenon for the daughter?

waiting for permission

Which route of administration of medication is preferred in the most acute care situations?

iv

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia

A client is receiving IV fluid administration and consuming a rather large amount of fluids orally. In calculating the client's fluid intake for the past 24 hours, the nurse notes the amount and immediately notifies the physician of this finding. Notification of a physician regarding fluid intake should occur after exceeding how many milliliters in 24 hours?

3000

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7

The client vomits during the surgical procedure. The best action by the nurse is:

: Suction the client to remove saliva and gastric secretions.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

Age, nutritional status,physical condition and health status

A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the characteristics of assisted suicide. Which of the following would be an example of assisted suicide?

Administering a lethal dose of medication to a client whose death is imminent

Which issue has most often presented challenging ethical issues, especially in the context of palliative care?

Ability of technology to prolong life beyond meaningful quality of life

A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care?

Accept the client's denial of the situation.

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible, and before the surgical procedure

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to

Assess the reason for the client's anxiety

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?

Be vigilant in identifying the client and the blood component

An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply?

Clearly explain any information that the client seek

An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply?

Clearly explain any information that the client seeks

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?

Client's goals

Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services?

Clients and families view hospice care as giving up

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?

Dantrolene sodium

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

coordinating the surgical team

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?

"I'll eat plenty of fruits and vegetables."

The nurse is caring for a patient newly diagnosed with metastatic bone cancer. The patient asks the nurse why they had to keep getting larger doses of pain medication. What is the nurse's best response?

"Over time you become more tolerant of the drug.

A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident

A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?

"This must be very difficult for you."

A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?

"This must be very difficult for you

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation?

? Encourage the family members to express their feelings and listen to them in their frank communication.

The nurse is admitting a client with a diagnosis of ovarian cancer. The client has just been told that her ovarian cancer is terminal. What question should the nurse include in a spiritual assessment of the client?"

"Do you have a sense of peace of mind and a purpose to your life?"

The nurse is describing palliative care and hospice services to a client with end-stage congestive heart failure. The client and family have many questions about the differences between palliative care and hospice. Which statement should the nurse provide the family?

"Hospice is the application of palliative care at the end of life."

A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying?

"I just want to see my daughter graduate from college. That's all."

The nurse manager of an oncology unit is concerned that the staff are experiencing symptoms of chronic loss caused by the death of many long-term clients. Which action will the manager take to support the staff's resilience?

Allow flexibility in scheduling. Promote collaborative relationships. Ensure fairness with assignments.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes

Ambulating the client as soon as possible

The nurse learns that a computed tomography scan a client underwent to investigate new seizure activity revealed a brain tumor. When the client later asks about the results of the scan, which therapeutic response should the nurse give the client? "What is your understanding of your condition?" Which is also known as a proxy directive?

Durable power of attorney for health care