Caring Interventions-PrepU
When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?
"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time?
1500
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort?
Apply cool compresses to the skin to stop local itching.
The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?
Check the fetal heart rate for bradycardia.
A client is experiencing difficulty swallowing a large oral tablet. What action by the nurse would be most appropriate?
Check to determine whether the drug can be crushed or mixed with food.
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 measures a blood glucose level of 40 mg/dL (2.22 mmol/L) for a client with type 1 diabetes. Why would it be important for the nurse to institute an intervention to elevate the glucose level in this client?
Glucose is not stored in the brain and is a major fuel source for brain function.
Nearly everyone with pericarditis has chest pain. With acute pericarditis, the pain is abrupt in onset, sharp, and radiates to the neck, back, abdomen, or sides. What can be done to ease the pain of acute pericarditis?
Have the client sit up and lean forward.
At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?
Hospitalization, tocolytic, and corticosteroids
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with chin resting on flexed knees
The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort?
Swaddle and decrease stimulation
A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client
That medication will be prescribed for pain relief
A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:
check the client's pedal pulses frequently.
An 18-year-old pregnant woman asks the nurse why she has to have a routine alpha-fetoprotein serum level drawn. The nurse explains that this:
may reveal chromosomal abnormalities.
For a client with a nursing diagnosis of Insomnia, the nurse should use which measure to promote sleep?
playing soft or soothing music
A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing?
safety and security
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
Progressive muscle relaxation, relaxation with guided imagery, and the Benson relaxation response share which of the following elements?
A mental device (something on which to focus the attention)
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure.
As the nurse comes from morning report, she is instructed to use a bladder scanner on a client following a client's attempt at urination. The client is able to void 300 mL. The client denies any pain on urination. The nurse scans 250 mL of remaining urine in the bladder. Which entry is most correct when documenting the intervention?
Client voided 300 mL with 250 mL residual volume
The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?
Fluid volume deficit
Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client?
Gently massage the arms and legs.
The nurse is caring for a client who is seeking care after being raped. What is the primary reason the nurse does not leave the client alone during the emergency room stay?
Promotes the client's sense of safety
Some clients with acoustic neuromas have vertigo. What is a priority nursing action for clients with vertigo?
Protect the client from injury.
When caring for pediatric clients, which distraction technique is age-appropriate for the nurse to use?
Provide action-oriented video games to a 15-year-old client
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:
instruct the client or her partner to perform light fingertip repetitive abdominal massage.
A 60 year-old man has long managed his type 1 diabetes effectively with a combination of vigilant blood sugar monitoring, subcutaneous insulin administration, and conscientious eating habits. This morning, however, his wife has noted that he appears pale and clammy and appears to be in a stupor, though he is responsive. She suspects that he has made an error in his insulin administration and that he is experiencing a hypoglycemic episode. Which action should be the wife's first choice?
Administration of 15 to 20 g of glucose in a concentrated carbohydrate source.
A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which?
Cognitively understand how to care for the children
The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?
Crackles auscultated bilaterally
When approaching health care holistically, which of the following would the nurse do?
Include physical, emotional, and social elements
There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for:
Ophthalmoscopy.
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival.
palliative care
A nurse is caring for an 81-year-old client in a long-term care facility who takes nine different medications each day. The client has a recent diagnosis of seizure disorder and has begun treatment with phenytoin (Dilantin), a highly protein-bound drug. After 1 month of Dilantin therapy, the client is still extremely drowsy and sluggish. The nurse determines that the prolonged adverse effect is likely due to:
polypharmacy decreasing the number of available protein-binding sites.
A nurse is caring for a child having an arm laceration sutured. What intervention can the nurse provide that will help the child consider the procedure as not a totally negative experience?
Allow the child to choose a treat from the drawer.
Which would be most important for a nurse to do when caring for a client with somatic symptom disorder?
Develop a sound, positive nurse-client relationship
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?
To rest the gastrointestinal tract and promote healing
An adolescent with scoliosis is refusing to wear the prescribed body brace. Which instruction is best to progress the adolescent to the treatment goals?
"It is important to wear the brace now to improve your spinal alignment, decreasing your symptoms."
A physician orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
"To prevent evaporation of water from the hydrated epidermis."
The nurse is providing care for a client who has been prescribed a diuretic to treat hypertension. The client states that the effects of the drug are problematic, causing the client to wake up numerous times during the night to urinate. What assessment question should the nurse prioritize?
"When are you taking your medication?"
A client with severe combined immunodeficiency disease is receiving immunosuppression therapy to ensure engraftment of depleted bone marrow during transplantation procedures. What is the priority nursing care for this client?
Meticulous infection control precautions
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?
Notify the surgeon about the tube's removal.
The nurse at a long-term care facility encourages the older adults to drink even though they may not feel thirsty at the time. Which statement supports the nurse's action?
Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high.
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?
Place the newborn away from drafts and under a blanket.
An admitting nurse on a rehabilitation unit notices that an elderly client with a fractured hip and severe hypothyroidism is dirty and disheveled and that their personal hygiene is very poor. As the nurse gathers admission data, the nurse further notes that the client has few personal connections, is depressed, and doesn't seem to care about personal appearance. How should the nurse improve the client's performance of self-care activities?
Provide initial and routine hygienic care, then evaluate the client daily as treatment progresses.
An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?
Provide oxygen by oxygen hood or ventilator.
The nursing staff at the clinic are discussing the best way to encourage cooperation from young pediatric clients during screenings. Which suggestion would be appropriate?
Purchase stickers or make coloring pages to be given to the children after the screening is completed.
A 16-year-old client has been hospitalized 100 miles from home for 1 week to repair a fractured patella suffered in a skateboarding accident. She was cheerful and chatty when she first arrived, but the nurse notes in recent days she has become increasingly quiet and seems lonely. Which nursing intervention should the nurse prioritize for this client?
Take her to the teen lounge so she can meet other teens, use a phone, and check her e-mail.
The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes?
The tube is radiopaque.
