Brunner & Suddarth's Textbook of Medical-Surgical Nursing

A client has been diagnosed with cardiac dysfunction and admitted to a health care center. The nurse notices that the client's ankles and feet are swollen. Using critical thinking skills, which nursing intervention does the nurse know to perform next? Assess oxygen saturation level Weigh client daily at the same time Organize activities to provide frequent rest periods Assess client for dependent edema

Assess client for dependent edema

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?

Turn the client every 2 hours.

Which ethics theory focuses on ends or consequences of actions?

Utilitarian theory

Which of the following is stated in a living will? Legal consent regarding healthcare Wishes regarding healthcare if terminally ill Medical prescriptions for end-of-life instructions Designation of another person as healthcare proxy

Wishes regarding healthcare if terminally ill

A terminally ill client asks the nurse, "Am I dying?" The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question? Select all that apply. -Communicate the client's wishes to the family. -Consult with the health care provider -Provide correct information to the client. -Tell the client, "You will be fine." -Have the health care provider disclose the information the client requires.

-Communicate the client's wishes to the family. -Consult with the health care provider -Provide correct information to the client.

Which of the following patient age groups is currently one of the fastest growing age groups in the population?

Adults 65 years of age and over

The use of patient restraints limits which ethical principle?

Autonomy

A nurse is working in a rural nurse-managed agency that provides immunizations, health assessments, and screening services. The nurse is most likely working in which of the following?

Community nursing center

Which is a primary task of nursing research?

Contributing to the scientific base of nursing practice

Which term is defined as a formal systematic study of moral beliefs and values as they relate to well-being?

Ethics

According to Maslow's hierarchy of needs, which of the following is the lowest-level need?

Physiological needs

Which intellectual skill is used by nurses when thinking critically?

Supporting evidence with facts

Which type of nursing diagnosis identifies an existing condition that the client is experiencing?

problem-focused

Many skills are needed in critical thinking. The nurse knows that the following skills are involved with critical thinking. Choose all that apply. -Self-regulation -Inference -Analysis -Interpretation -Independence

-Self-regulation -Inference -Analysis -Interpretation

Which critical thinking skill involves identification of client problems indicated by data?

Analysis

Which element would be included as a goal of case management?

Appropriateness of services

A client has been diagnosed with cardiac dysfunction and admitted to a health care center. The nurse notices that the client's ankles and feet are swollen. Using critical thinking skills, which nursing intervention does the nurse know to perform next?

Assess client for dependent edema

While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client? Monitor intake and output every 4 hours. Order a heparin bolus. Assess the respiratory status every 4 hours. Consider discharge placement.

Assess the respiratory status every 4 hours.

The nurse provides care for a client who is diagnosed with shock and who is at risk for multiple organ dysfunction syndrome (MODS). Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of __________ as evidenced by ____________.

Based on the first organ system that is typically affected by MODS, the nurse prioritizes monitoring the client for symptoms of acute lung injury (ALI) as evidenced by shortness of breath(SOB).

Which ethical principle refers to the duty to do good?

Beneficence

The nurse is assessing a 78-year-old female client admitted with a stroke of recent onset, within 2 hours of admission. Vital signs: blood pressure, 150/90 mm Hg; pulse, 112 beats/min; respirations, 20 breaths/min; temperature, 100.4°F (38°C); pulse oximetry, 96% on room air. An audible murmur is heard upon auscultation. The client is awake but somewhat lethargic and cannot respond to questions. The client is exhibiting neurologic deficits and impaired mobility of the left side of the body. The client is being evaluated for tissue plasminogen activator (t-PA) therapy. What parameters indicate whether the t-PA can be used? Blood pressure reading computed tomography (CT) confirmation of ischemic stroke international normalized ratio (INR) results of 2.0 National Institutes of Health Stroke Scale (NIHSS) scale results of 17 heart murmur

Blood pressure reading computed tomography (CT) confirmation of ischemic stroke National Institutes of Health Stroke Scale (NIHSS) scale results of 17

A nurse is unsure how best to respond to a client's vague complaint of "feeling off." The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition?

By examining the way that she thinks and applies reason

The nurse assesses a radial pulse rate of 48 beats per minute (bpm). Using critical thinking, what will be the best action for the nurse to take? Call the health care provider to get orders. Assess blood pressure with the client lying supine. Check the client's previous pulse rates to validate the findings. Ask a fellow nurse to double-check your pulse rate assessment.

Check the client's previous pulse rates to validate the findings.

A nurse is caring for a team of clients, each with an orthopedic injury. Click to indicate which interventions are included in a plan of care between the different orthopedic repairs. Specificy if the action is taken for clients with an internal fixation device and/or with an external fixation device. Administer nonopioid analgesics as needed. Administer prescribed antibiotic. Complete pin care per prescribed guidelines. Provide assistance with physical therapy. Encourage isometric and muscle-setting exercises. Encourage performance of activities of daily living. Bear weight as determined by the surgeon.

External fixation Complete pin care per prescribed guidelines. Internal fixation Bear weight as determined by the surgeon. Both Administer nonopioid analgesics as needed. Administer prescribed antibiotic. Provide assistance with physical therapy. Encourage isometric and muscle-setting exercises. Encourage performance of activities of daily living.

While reviewing the chart of a client who was recently admitted, the nurse will use the nursing process to set up a plan of care. Order the activities the nurse will do in the most likely sequence from 1 to 5. Inquire about the reason for the admission. Confer with the client about the desire for pain control. Choose the nursing diagnosis of Acute Pain. Administer the prescribed 4 mg of IV push morphine. Re-assess the pain level.

Inquire about the reason for the admission. Choose the nursing diagnosis of Acute Pain. Confer with the client about the desire for pain control. Administer the prescribed 4 mg of IV push morphine. Re-assess the pain level.

The nurse moves a confused, disruptive patient to a private room at the end of the hall so that other patients can rest, even though the confused patient becomes more agitated. The nurse's intervention is consistent with what moral theory? "Consequentialism," by which good consequences for the greatest number are maximized "Paternalism," in which the action limits the patient's autonomy "Veracity," in which the nurse has an obligation to tell the truth "Duty of obligation," by which an action, regardless of its results, is justified if the decision making was based on moral principles

"Consequentialism," by which good consequences for the greatest number are maximized

Which of the following best describes the health-illness continuum? -A person on the continuum remains at the point based on his or her initial state of health. -A person with high-level wellness is free of any disease or infirmity. -A person may be considered neither completely healthy or completely ill. -A person with chronic illness is at the far end of the continuum reflecting illness.

-A person may be considered neither completely healthy or completely ill.

What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis? -Fluid volume excess -Fever of unknown origin -Sleep-pattern disturbances -Risk for falls

-Fever of unknown origin

A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need?

Physiologic needs

The nurse is preparing to administer medication to a client who has been diagnosed with glaucoma. Which information should the nurse include related to client teaching for each of the identified medications? -Pilocarpine -Timolol maleate -Acetazolamide

Pilocarpine -"Use safety measures in dim lighting." Timolol maleate -"It can cause hypotension" Acetazolamide -"Have your electrolyte levels monitored."

A terminally ill client the nurse is caring for is reporting pain. The physician has prescribed a large dose of intravenous opioids by continuous infusion. When the nurse assesses the client's respiratory status, the rate has decreased from 16 to 10 breaths per minute. What action should the nurse take?

Report the decreased respiratory rate to the physician.

The community health nurse is assessing the risk factors for osteoporosis in a female client at a health fair. Specify if the finding is a risk factor for osteoporosis or is not a risk factor for osteoporosis. -66 years of age -large frame -Asian heritage -postmenopausal status -Nonsmoker -alcohol intake of 3 drinks/week -takes fluticasone inhaler for asthma -walks 2 miles, 3 days/week

Risk factor -66 years of age -Asian heritage -postmenopausal status -takes fluticasone inhaler for asthma Not a risk factor -large frame -Nonsmoker -alcohol intake of 3 drinks/week -walks 2 miles, 3 days/week

A nurse is caring for a patient who is experiencing fear, anxiety, and feelings of powerlessness after receiving a diagnosis of cancer. The nurse develops a teaching plan focusing on the patient's diagnosis and treatment options to promote the patient's sense of control over the situation. Using Maslow's Hierarchy of Human Needs, which of the following categories is the nurse attempting to meet? Esteem and self-respect Safety and security Physiology Belongingness and affection

Safety and security

The nurse working in the clinic has had several incidences of positive chlamydia cultures return in women with pelvic pain. The nurse understands that early diagnosis and treatment are essential measures in which to reduce contagion and limit the complications related to this infection. What type of prevention will the nurse use when these infections are treated? Secondary prevention Primary prevention Tertiary prevention Prevalence

Secondary prevention

The nurse plans care for a client who is diagnosed with atopic dermatitis. Specify if the instruction addresses skin hydration, itchy skin or both. - Use an emollient containing glycerol on the skin after bathing. - Take short showers using a mild soap for cleansing. - Wear cotton fabric. - Wash clothes using a mild detergent. - Take an antihistamine before bed.

Skin hydration - Take short showers using a mild soap for cleansing. Itchy skin - Wear cotton fabric. - Wash clothes using a mild detergent. - Take an antihistamine before bed. Both - Use an emollient containing glycerol on the skin after bathing.

Who should be involved in establishing specific and realistic outcomes, so the client does not become frustrated in trying to achieve them?

The client and family

The nurse provides care for a client, with a history of atherosclerosis, who is hospitalized for the initiation of pharmacotherapy for the treatment of hypothyroidism. The client is at highest risk for developing _______________ as evidenced by _______________.

The client is at highest risk for developing cardiac dysfunction as evidenced by angina.

The nurse provides care for a client who is critically ill due to a diagnosis of pneumonia and is at risk for developing shock. Assessment data reveals a white blood cell (WBC) count of 15 × 103 cells/mm3 (15 × 109/l) (normal: 4.5 to 10.5 × 103 cells/mm3 (4.5 to 10.5 × 109/l), a temperature of 102.2°F (39°C), and warm, flushed skin. The client is at the highest risk for developing _________ as evidenced by ______.

The client is at the highest risk for developing septic shock as evidenced by altered mentation.

When a nurse delegates a task to another person, who is ultimately responsible for the action and its outcome?

The nurse

Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the client. Which of the following is the best example of a collaborative practice model?

The nurse and the physician jointly making clinical decisions.

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. The nurse anticipates that the client has developed __________ and that __________ will be ordered.

The nurse anticipates that the client has developed chronic subdural hematoma and that computed tomography (CT) imaging of the brain will be ordered.

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. The nurse monitors the client for ___________ , a finding indicative of _____________.

The nurse monitors the client for purulent nasal drainage, a finding indicative of rhinosinusitis.

A client has just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

as often as needed

How is assessment defined as part of the nursing process?

careful observation and evaluation of a client's health status

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. client has developed ______________ that the laboratory results will reveal __________

client has developed hemorrhage that the laboratory results will reveal thrombocytopenia.

The physician has ordered cimetidine for a client with gastric ulcers, and the nurse administers the first dose. The nurse's actions are noted in the medical record. This notation is an example of which aspect of implementing the plan of care?

documentation

The nurse has documented an assessment on a 45-year-old male client on the third postoperative day following an open abdominal appendectomy. Client has 3 in (7.6 cm) right lower abdominal incision. Proximal 2 in (5 cm) of incision edges are red and well-approximated. Distal portion of incision has separated and has yellow drainage on dressing. Bulb drain has serosanguinous drainage and clumps of yellow pus. Oxygen saturation on room air 97%. Blood pressure, 112/60 mm Hg; heart rate, 102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2F (38.4C) orally. Denies chills. Bowel sounds hypoactive in all 4 quadrants. Client reports passing flatus, no Abdomen firm and slightly distended bowel movement. Lungs clear to auscultation bilaterally. Client reports incisional pain level of 3/10 red blood cell count 4.2 million/mcl, thirty (30) minutes following oxycodone 5 mg orally. Reports an increased, but tolerable, level of pain while performing cough and deep-breathing exercises while splinting incision. Reports minimal pain on abdominal palpation. White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l), hemoglobin 14 g/dl (140 g/l), blood glucose level 130 mg/dl (7.21 mmol/l). What the assessment findings that will require follow up

-has separated and has yellow drainage on dressing -clumps of yellow pus -102 beats/min; respiratory rate, 22 breaths/min; temperature, 101.2°F (38.4°C) orally -White blood count 12.9 x 103 cells/mm3 (12.9 x 109 /l) -blood glucose level 130 mg/dl (7.21 mmol/l).

Several days this week, a nurse takes time after work to read to a visually impaired client who has no family close by. This behavior demonstrates that ethical values ___________.

...concern the treatment of others.

A nurse is planning a medical client's care with consideration of Maslow hierarchy of needs. Within this framework of understanding, what should the nurse prioritize? Teaching the client to self-administer insulin safely Administering pain medication Allowing the family to see a newly admitted client Ambulating the client in the hallway

Administering pain medication

The nurse assesses a client who is diagnosed with human immunodeficiency virus (HIV) for adverse reactions associated with the prescribed medication, abacavir. The nurse provides emergency intervention when the client exhibits the following symptoms: _________, ____________, and ___________.

Dyspnea, sore throat, and cough

The nurse monitors a male client for symptoms of urethral strictures following a transurethral resection of the prostate (TURP) for the treatment of prostate cancer. Client symptoms indicative of this complication that the nurse monitors for following a TURP include _________, __________, and _______________.

Client symptoms indicative of this complication that the nurse monitors for following a TURP include straining, dysuria, and a weak urinary stream.

The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager?

Contact the ethics committee for their input.

A nurse has been using the nursing process as a framework for planning and providing client care. What action would the nurse do during the evaluation phase of the nursing process? Remove a client's surgical staples on the scheduled postoperative day. Have a client provide input on the quality of care received. Provide information on a follow-up appointment for a postoperative client. Document a client's improved air entry with incentive spirometry use.

Document a client's improved air entry with incentive spirometry use.

Which of the following is involved in the implementation step of the nursing process? Identifying measurable outcomes Selecting nursing interventions Documenting nursing care and client responses Documenting the plan of care

Documenting nursing care and client responses

A nurse is caring for a client who was admitted with pain, tenderness, and rigidity of the upper right abdomen, suggesting a gall bladder issue. The client has also been experiencing nausea and vomiting for the past 3 days. The admitting service is planning for tests to be conducted in the morning. What is the implication for the following testing: Laboratory Assessments Ultrasonography Cholescintigraphy

Laboratory Assessments -Cholesterol is elevated in biliary obstruction. Ultrasonography -It is used to visualize calculi in the gallbladder. Cholescintigraphy -A series of x ray images from different angles will create images of the soft tissues of the gallbladder.

A nurse in a hospice facility cares for clients with terminal illnesses and witnesses a great deal of pain and emotional distress. Which factor that affects healthcare ethics determines how the nurse must respond when a client asks for help in ending his or her suffering?

Legislative and judicial decisions

A client had a total hip replacement earlier in the day. The nurse sits with the client to establish some goals. One goal they agree on is to ambulate 1 to 2 miles each day. This is an example of which type of goal?

Long-term

A group of nursing students are reviewing the various types of advanced practice nurses. The students demonstrate the need for additional review when they identify which of the following as an advanced practice nurse?

Nurse manager

The basic difference between nursing diagnoses and collaborative problems

Nurses manage collaborative problems using physician-prescribed interventions. Nursing diagnoses can be managed by independent nursing interventions.

The nurse is caring for a client who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The client has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?

Obtain a physician's order to restrain the client.

A nurse is a member of which entity within the larger health care environment?

health care team

Patient health education provided by the nurse...

is an independent function of nursing practice.

A client recently diagnosed with pancreatic cancer asks the nurse not to share the diagnosis with the client's family members. After visiting the client, the client's daughter approaches the nurse and states, "Mom just did not seem herself today. Are biopsy reports back and do they confirm pancreatic cancer?" What is the best response from the nurse to the client's daughter? "It is unethical and illegal for me to discuss your mother's medical information with you." "It is illegal for me to discuss biopsy results with anyone but the client involved." "It is unethical and illegal for me to give you the biopsy results; please ask your mother." "It is unethical of me to discuss biopsy results with anyone but the client involved."

"It is unethical and illegal for me to discuss your mother's medical information with you."

The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time. Triage if the client requires immediate intervention or can wait to be seen. - 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) - 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots - 25-year-old male client who presents with a small laceration on the left upper arm - 52-year-old female client who presents with severe back pain of recent onset

- 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) - 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots - 52-year-old female client who presents with severe back pain of recent onset

A nurse is reviewing the history of a client who has been admitted for a pressure injury. A 74-year-old female client is admitted from the emergency department. The client arrived by ambulance. The client's adult son, the primary caregiver, accompanied the client. The client is bedridden due to a right-sided stroke sustained 6 months ago. The client lives with the adult son and the son's spouse. The family has 24-hour home care. The client is incontinent of urine and feces. Care is provided by home health assistants, who bath, feed, and provide companionship when the family is not available. The client is alertbut confused with time and place. The client refuses to eat most meals but will drink a high-calorie milkshake daily. The reason for the ambulance is that the client attempted to get out of bed and fell. What findings are risk factors associated with pressure injuries?

- bedridden due to a right-sided stroke - confused with time and place

Based on the nurse's knowledge of the increased risk for bleeding in a client undergoing chemotherapy or radiation, which of the following interventions does the nurse need to include in the client's plan of care? Select all that apply. -Monitoring the platelet count -Monitoring for signs of abnormal bleeding -Instructing the client to use a soft toothbrush -Instructing the client to use an electric razor -Instructing the client to add low-dose aspirin to daily medication regimen -Increasing the patient's injections for pain control

-Monitoring the platelet count -Monitoring for signs of abnormal bleeding -Instructing the client to use a soft toothbrush -Instructing the client to use an electric razor

The nurse is collaborating with the health care provider on a plan of care for a 54-year-old male client with osteomyelitis of the left femur secondary to uncontrolled type 1 diabetes. What prescriptions for care that the nurse should anticipate for this client. -Place the left foot in a dependent position. -Perform neurovascular checks of lower extremities every 8 hours. -Administer IV antibiotic based on culture and sensitivity report. -Encourage ambulation with weight-bearing on the left leg. -Administer ibuprofen 400 mg orally three times daily, as needed for pain. -Make referral to dietitian to discuss nutrition for healing and blood glucose control. -Provide education on self-blood glucose monitoring and insulin administration.

-Perform neurovascular checks of lower extremities every 8 hours. -Administer IV antibiotic based on culture and sensitivity report. -Administer ibuprofen 400 mg orally three times daily, as needed for pain. -Make referral to dietitian to discuss nutrition for healing and blood glucose control. -Provide education on self-blood glucose monitoring and insulin administration.

The nurse is caring for a 24-year-old female client with a right tibial fracture treated with a cast 2 hours ago. The client now reports unrelenting pain, rated as 7/10, despite taking oxycodone, and decreased sensation in the right foot. A nursing assessment reveals the right foot is cooler and paler than the left foot, with delayed capillary refill and a weak pulse. Based on the nursing assessment, the priority action the nurse should take is to _________________________ and prepare the client for _________________.

Based on the nursing assessment, the priority action the nurse should take is to notify the orthopedic health care provider immediately and prepare the client for bivalving of the cast.

A 47-year-old male client presented to the medical unit and the health care team suspects tuberculosis (TB). The nurse is admitting the client to a reverse isolation room. QuantiFERON testing and chest x-ray are pending. Urinalysis results are negative. No other testing was performed prior to admission to isolation. The client denies any chest pain, shortness of breath (SOB), or respiratory difficulty. The client presents with productive yellow sputum. Based on the provided assessment status, the nurse should utilize __________ to prevent exposure and __________ to collect specimens for additional testing.

Based on the provided assessment status, the nurse should utilize airborne precautions to prevent exposure and sputum to collect specimens for additional testing.

Which of the following is a cognitive or mental activity that nurses use in critical thinking?

Drawing on past clinical experiences and knowledge to explain what is happening

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Due to the client's high risk for developing _________ as a result of the prescribed medication, the nurse focuses on monitoring the client for __________.

Due to the client's high risk for developing hypokalemia as a result of the prescribed medication, the nurse focuses on monitoring the client for ventricular arrhythmia.

A nurse is caring for a client who was admitted for an asthma exacerbation. In the past year, the client has been admitted for three asthma events. What will the nurse include in the client teaching about preventing repeat hospitalizations? The nurse should teach about __________ followed by ___________.

The nurse should teach about triggers to avoid followed by knowing medications.

The nurse assesses a client who is diagnosed with bulimia nervosa and at risk for alterations in both fluid and electrolyte balance. During the assessment, the nurse focuses on monitoring the client for _________ as evidenced by ________________.

During the assessment, the nurse focuses on monitoring the client for hypokalemia as evidenced by cardiac arrhythmia.

Which is not an important reason that nurses utilize research in nursing practice? -financial obligation -validation -replication -dissemination -evaluation of research findings

Financial obligation

The community health nurse is preparing a teaching plan for a middle-aged client with hypertension, hypercholesterolemia, and obesity. Specify whether the information is focused on health promotion or health maintenance. - Exercise for 45 minutes at least three times per week. - Take medications as prescribed. - Avoid cigarette smoking and alcohol use. - Practice stress reduction techniques such as yoga or meditation. - Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests.

Health promotion - Exercise for 45 minutes at least three times per week. - Avoid cigarette smoking and alcohol use. - Practice stress reduction techniques such as yoga or meditation. Health maintenance - Take medications as prescribed. - Adhere to scheduled laboratory tests such as lipid profile, basic metabolic panel, and glucose tests.

The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans?

Healthy People 2030

The definition of nursing has evolved over time since Florence Nightingale first attempted, in 1859, to explain nursing's scope of practice. In 2003, the American Nurses' Association, in its Social Policy Statement, included which of the following activities as a significant role of nursing? Diagnosing chronic illness in the elderly Diagnosing acute illnesses in children Identifying human responses to illness Modifying a medical plan of care to include nursing activities

Identifying human responses to illness

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). Specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression. - Keep legs in a dependent position. - Increase in physical activity each day. - Wear warm clothing in the winter. - Do not use of bicotine products. - Avoid crossing the legs.

Increase Arterial Blood Supply to the Extremities - Keep legs in a dependent position. - Increase in physical activity each day. Promote Vasodilation and Prevent Vascular Compression - Wear warm clothing in the winter. - Do not use of bicotine products. - Avoid crossing the legs.

The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease. Specify if the intervention is indicated or contraindicated for this client. -Take blood pressure readings in the left arm. -Auscultate for a bruit over AV fistula every 8 hours. -Assess for redness, swelling, and drainage at AV fistula site. -Use AV fistula site to draw blood. -Palpate for a thrill over the AV fistula every 8 hours. -Wrap the AV fistula site in the left arm with a compression dressing.

Indicated -Auscultate for a bruit over AV fistula every 8 hours. -Assess for redness, swelling, and drainage at AV fistula site. -Palpate for a thrill over the AV fistula every 8 hours. Contraindicated -Take blood pressure readings in the left arm. -Use AV fistula site to draw blood. -Wrap the AV fistula site in the left arm with a compression dressing.

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The client is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse's action is an example of which therapeutic communication technique?

Informing

Which set of nursing actions demonstrates that the nurse understands the nursing process? - Assessing for allergies, administering analgesic, obtaining baseline vital signs, and documenting the nursing diagnosis as acute pain - Prioritizing client goals, documenting all health records precisely, conducting the health history, and documenting the nursing diagnosis - Reviewing the health record, documenting client goals, identifying the etiology of the nursing problem, and evaluating treatment outcomes - Obtaining vital signs and pain scale rating, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level

Obtaining vital signs and pain scale rating, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level

The nurse plans nonpharmacologic interventions for a client who is approaching discharge after a left knee arthroplasty to address the client's pain. specify if the therapy indicates a physical modality, cognitive and behavioral method, or movement therapy for the treatment of pain. - application of heat or cold - relaxation breathing - yoga - aquatic therapy - distraction - Thai Chi - proper body alignment - imagery

Physical Modality - application of heat or cold - aquatic therapy - proper body alignment Cognitive and behavioral method - relaxation breathing - distraction - imagery Movement therapy - yoga - Thai Chi

A client will undergo abdominal surgery. The nurse provides preoperative education regarding the importance of diaphragmatic breathing exercises to prevent postoperative complications. The nurse will educate the client about the risk for developing _________, ____________, and ____________, if the client does not implement diaphragmatic breathing exercises in the postoperative period of care.

The nurse will educate the client about the risk for developing pneumonia, bronchospasm, and atelectasis, if the client does not implement diaphragmatic breathing exercises in the postoperative period of care.

The nurse provides care for a client who is diagnosed with bladder retention following urinary catheterization. The nurse should first ask the client to ________ then perform the prescribed _________.

The nurse should first ask the client to urinate then perform the prescribed bladder scan.

A nurse is assessing a client who is experiencing significant stress due to septicemia. The nurse should monitor __________, __________, and ____________.

The nurse should monitor temperature, administer oxygen therapy, and obtain the lactate level.

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day." On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client?

The outcome is not achieved, and the plan requires critical reevaluation and revision.

The nurse is preparing a client for a colonoscopy at the hospital. Who does the nurse understand is responsible for obtaining the informed consent from this client?

The primary care provider

Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for clients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when clients return to their homes, what action should the nurse prioritize?

Thorough and evidence-based discharge planning

The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. Specify if the finding indicates understanding or the need for reinforcement of the teaching. -"I will take the antibiotics until the secretions clear up." -"I should get the PPSV23 this year because I got the PCV13 last year." -"I will drink 1 liter of fluid each day." -"Sleeping with a humidifier can help loosen secretions." -"I will seek medical attention if my cough worsens." -"I will rest and avoid overexertion." -"A persistent or recurring fever is normal after starting antibiotics." -"I will perform deep-breathing exercises once per day."

Understanding -"I should get the PPSV23 this year because I got the PCV13 last year." -"Sleeping with a humidifier can help loosen secretions." -"I will seek medical attention if my cough worsens." -"I will rest and avoid overexertion." Requires reinforcement of teaching -"I will take the antibiotics until the secretions clear up." -"I will drink 1 liter of fluid each day." -"A persistent or recurring fever is normal after starting antibiotics." -"I will perform deep-breathing exercises once per day."

A client has just been told she has cancer. The client tells the nurse that she is not sure if she wants her family to know. The nurse encourages the client to consider sharing this information with her family members so they can support her through future treatment-related decisions. What ethical principle is the nurse demonstrating? Fidelity Justice Veracity Confidentiality

Veracity

A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse's duty to tell the truth?

Veracity Veracity is the nurse's duty to tell the truth in all professional situations.

A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this client. What key component of critical thinking is most likely missing from this student's practice?

Withholding judgment

A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document?

advance directive

The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias. Specify if the finding indicates microcytic anemia or megaloblastic anemia. - decreased mean corpuscular volume (MCV) - decreased reticulocytes - increased mean corpuscular volume (MCV) - increased total iron-binding capacity (TIBC) - decreased vitamin B12 - decreased folate

microcytic anemia - decreased mean corpuscular volume (MCV) - decreased reticulocytes - increased total iron-binding capacity (TIBC) megaloblastic anemia. - increased mean corpuscular volume (MCV) - decreased vitamin B12 - decreased folate

A nurse using critical thinking interprets data and determines appropriate interventions. What factor will affect the nurse's ability to employ critical thinking with data interpretation? the nurse's personal biases the nurse's gender the date of the client's admission the client's admission diagnosis

the nurse's personal biases