Ch 9 PCJ
The client tells the nurse "I have a mole on my back that is darker and getting larger.". Which intervention should the nurse implement first
Instruct the client to notify his/her HCP immediately
primary nurse overhears the UAP telling a family member of a client "one of the clients will be going to prison because that person was charged with vehicular manslaughter. Two people in the motor vehicle accident died" which action should the primary nurse implement first?
Interrupt the conversation and tell UAP to go to the nurses station
When staff nurse is assessing the functional ability of a client using the Katz Index of activities of daily living. Which assessment score would require the nurse to delegate feeding bathing and toileting to the UAP?
Katz index of ADLs score 2G
The client in the rehab unit tells the nurse "I will not go to PT again because it hurts so much when I do the exercises" which statement supports the nurses role as a client advocate?
Let me check and see if you can receive pain medication before the therapy
The client is 8 H post spinal surgery. Which priority intervention should the nurse implement?
Log-roll the client w 3 staff members when turning the client side-to-side
using an electric client lift to transfer the client from the bed to a stretcher. Which priority intervention should the nurse implement?
Make sure the clients correctly placed in the lift before moving
Which client should the charge nurse on the rehab unit assess first after receiving a.m. shift report?
Mr. J.L. who is post open reduction and internal fixation of the R hip
The male nurse who has been told by the female nurse on previous occasions not to talk to her about her body says "You really look hot in those scrubs. You have a great-looking body." Which action should the female nurse take next?
Notify the clinical manager of the sexual harassment
The RN staff nurse and UAP are caring for a 74-year-old client who is three days post operative right total hip replacement. Which nursing test should be delegated to the UAP?
Place the abductor pillow between the clients legs
The UAP is transferring the client from the bed to the chair. Which intervention should they are in primary nurse ensure the UAP implements during this procedure? Rank in order of priority
Place the wheelchair at an angle on the client strong side. Lock the wheelchair brakes and secure the chair position. Assist the client to stand and put the strong hand on the wheelchair armrest. Keep the clients weight forward and pivot the client. Assess the client to sit when the client legs touch the edge of the chair.
home health nurse has arranged for a home health aide to assist a 79-year-old client diagnosed with Alzheimer's. Which intervention should the nurse delegate to the home health aide? Select all that apply
Play the client once a week and document the way on the client record. Stay with a client twice a week while the spouse goes out to run errands. Take and record the clients vital signs.
The UAP on the rehab unit is placing the client w a L above-the-knee amputation in the prone position. Which action should the RN rehab nurse implement
Praise the UAP for positioning the client prone
The client has an area on the skin the dermatologist thinks may be basal cell carcinoma. Which intervention will the nurse implement to confirm the diagnosis?
Prepare the client for a biopsy of the abnormal skin growth
Just preparing to ambulate the client diagnosed with full thickness burns on the lower extremities down the hall. Which priority intervention should the nurse implement?
Put a gate belt around the client waste
Priority intervention should the nurse implement to help prevent pressure ulcers in the client he was on strict bed rest?
turn every two hours or more often
The elderly wife of a client w a total hip replacement who is being discharged home tells the nurse, "I am really worried about taking my husband home. I don't know how I will be able to take care of him." Which intervention is most appropriate for the nurse?
Refer the client to the home health nurse
The client in a MVA is in critical condition dx w a pelvic fx, flail chest, bilateral arm fxs, and a L hip fx. The client tells the nurse, "I just want to die. I can't feed myself or clean myself." Which statement is the nurse's best response?
"I can see you must feel helpless; I am here to listen."
The clients husband is frustrated and tells the nurse "Everyone is telling me something different as to when my wife is going to be able to go home. I don't know whom to believe." Which statement is the rehab nurse's best response?
"I will contact the case manager and have her talk to you asap."
The client who was admitted to the rehab unit bc of a debilitative state asks the nurse, "Why do I have to go to PT every day?" Which statement is the nurse's best response?
"The physical therapist will help you w exercises to improve your muscle strength"
The school nurse notes the child has impetigo. Which intervention should the nurse implement? Select all that apply
Administer an antibiotic ointment four times a day. Instruct the parents to keep the child at home until lesions crust over. Tell the parents to use separate towels for the child.
Which intervention should the nurse implement first for the client diagnosed with a fractured femur who is suspected of having a fat embolism?
Administer oxygen via nasal cannula
The 28-year-old male client who sustained Trumatic bilateral amputation secondary to an MVA is being discharged home to live with his wife and three-year-old son. Which priority psychosocial intervention to the rehab nurse discuss with the client?
Ask the client whether he has any sexual concerns he needs to discuss
The Rn charge nurse, a LPN, and 2 UAPs are caring for clients. Which action is most appropriate for the charge nurse to assign or delegate>
Request the LPN to apply anti fungal cream to the client dx w tine pedis
The client is 1 week post for right below-the-knee amputation secondary to arterial occlusive disease. The nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first.
Assess for parathesia and paralysis
The Rn rehab nurse and UAP are caring for clients on a rehab unit. Which nursing task is most appropriate for the RN to delegate to the UAP?
Assist w bowel training by escorting the client to the br
The day nurse is preparing to administer medication to the client who's reporting lightheadedness when getting out of bed. Which medication should the day nurse question administering?
Atenolol 50 mg PO
The nurse is at a local playground and her 10 y/o son falls and reports that his L ankle and foot are hurting? Which intervention should the nurse implement first at the scene of the scene of the accident?
Instruct her son not to move the L leg
The client w bilateral amputations tells the nurse, "I was told I can't go back to my job bc they don't have handicap accessible bathrooms or ramps." Which action by the nurse is most helpful to the client?
Explain the ADA to the client
The client tells the primary nurse "I just finished completing my LivingWell and I need you to witness my signature." Which action should the nurse implement?
Explained that the nurse cannot witness this document
In charge nurse on the rehab unit is making assignments for the dayshift. Which assignment would be most appropriate for the LPN?
Have the LPN called a healthcare provider to obtain an order for a diet change
The RN burn unit nurse is caring for a client diagnosed with a full thickness burn over the right lower extremity. Which task the nurse delegate to the UAP?
Have the UAP cleanse the clients dentures in place in the container
And staff nurse tells the UAP to assist the client who is one day post operative spinal surgery with a.m. care. Which action by the UAP warrants immediate intervention?
He requests the client to turn to the side
The rehab nurse enters a clients room and the client is talking on the phone. The client asked the nurse to talk to his wife because she has some questions. Which action should the nurse take?
Honor the clients request and answer any questions the wife has on the phone
The clinical nurse manager has verbally warned a staff nurse about being late to work on two previous occasions. The nurse was 35 minutes late for today's shift. Which action to the charge nurse take?
Initiate the hospital policy for unacceptable behavior
The client is admitted to the emergency department diagnosed with a third-degree burn over the front of both legs. Which priority intervention should the nurse implement?
Insert too large for IV access routes
The client tells the nurse "I don't like my doctor and I want another doctor." Which statement is the nurses best response?
Tell me what you don't like about your doctors care
The Rn charge nurse on the rehab unit is assigning and delegating tasks to the UAP and LPN. Which task is most appropriate for the RN to delegate or assign?
Tell the UAP to elevate the clients residual limb above the heart
Health nurse is planning to make rounds for the day. Rank in order of priority
The 67-year-old client diagnosed with emphysema who called to report that sputum is rusty color this morning. The 29-year-old client with spinal cord injury post MVA who needs a dressing change on a stage IV pressure ulcer. The 72-year-old client diagnosed with a fib who needs a prothrombin time performed and called to the healthcare provider. The 56-year-old client diagnosed with breast cancer who needs an injection of filgrastim subcutaneously. The 80-year-old client diagnosed with Alzheimer's disease who is confused and wandering around the house.
The client dx w a fractured right ankle needs to be instructed on crutch walking. Which member of the multidisciplinary team should address this problem?
The PT
The RN charge nurse on the busy 36-bed rehab unit must send one staff member to the ED. Which staff members the most appropriate person to send
The RN who transferred to the rehab unit from the med unit
The UAP is applying elastic compression stockings to the client. Which action by the UAP indicates to the Rn primary nurse the UAP understands the correct procedure for applying elastic compression stockings?
The UAP had the client elevate the legs before putting on the stockings
The RN staff nurse in the rehab unit is caring for the clients along w an UAP. Which action by the UAP warrants immediate intervention?
The UAP is assisting the client who weighs 181kg to the bedside commode
Which action by the UAP warrants immediate intervention by the RN staff nurse
The UAP tied the confused client to a chair w a sheet
The nurse is preparing to admin a.m. meds to the following clients. Which med should the nurse admin first
The antihistamine to the client dx w urticaria and pruritus
Place in a double hip spica cast for three months. The clients wife tells the nurse "my husband said we are supposed to talk to his case manager. What is a case manager" which statement is the nurses best response?
The case manager is a nurse who will coordinate the rehab team and keep you informed
The charge nurse received laboratory data on the following clients. Which client warrants immediate intervention by the charge nurse?
The client on anabiotic therapy who has a serum potassium level of 3.3 mEq/L
The nurse is triaging phone calls in a dermatological unit. Which client warrants the nurse making an appointment immediately?
The client reports redness and itching on the hands
The nurse received the a.m. sift report on the following clients. Which client should the nurse assess first?
The client who has full-thickness burns who needs to be medicated before taken to whirlpool
The nurse is working in an ortho unit. Which client should the nurse assess first
The client who is 1 week post for L3-L4 laminectomy who is reporting numbness and tingling of the feet
Overhead page has issued a code black indicating a tornado in the area. Which intervention should the charge nurse implement?
The clients and visitors remain in the hallway with the doors closed
The nurse tells the client "I am going to refer you to the vocational counselor." The client asked the nurse "why are you making this referral" which statement is the nurses best response?
The counselor will assist you with job placement, training, or further education
Action by the primary nurse requires immediate intervention by the charge nurse?
The nurse leaves the computer screen open to the EHR at the nurses station
The nurse on the surgical unit is being sent to the NICU to work bc the unit is short staffed. The nurse has never worked in the NICU. Which response by the nurse supports the ethical principal of nomaleficence?
The nurse requests not to be floated to the NICU
Which action by the RN primary nurse would warrant immediate intervention by the RN charge nurse on the rehab unit?
The primary nurse asks another nurse to admin an injection he prepared
The client w an upper extremity amputation tells the nurse "I do everything with my right hand and now it is gone. I have no idea what I'm going to do after I get discharged. How will I support my family? I will need to get a new job." Which statement is the nurses best response?
The state rehabilitation commission will help retrain you
Administering medication to the client diagnosed third-degree burn on the chest area. Which medication requires a laboratory test?
The vancomycin medication
Client with a right below the knee amputation who has impetigo was admitted to a rehab unit. Which intervention should be included in the nursing care plan? select all that apply
Urge the client to push the residual limb against a pillow. Use warm soap and water to remove the crust secondary to impetigo. Ensure all staff members wear gloves when caring for a client.
Does assessing the clients daily schedule and habits. Which question is most appropriate for the nurse to ask the client?
What time do you prefer bathing and do you take a tub bath or a shower?
The UAP tells the Rn primary nurse the client w the right above the knee amputation has a large amt of bright red blood on the R leg residual limb. Which action should the nurse implement.
assess the clients residual limb dressing
Nurse is discussing complementary and alternative medicine with a client on the rehab unit. Which therapies should the nurse discuss with the client? select all that apply
acupuncture guided imagery music therapy
The nurse is assisting the client to use a cane when ambulating. Rank in order of performance
apply the gait belt around the clients waste The client place is the cane and the strong hand Request the client to move the cane forward Move the weaker leg one step forward Move the stronger leg one step forward
Client has cellulitis on the right lower leg. Which intervention should the nurse implement?
apply warm moist heat to the affected area
A nurse is at the local mall and a young woman starts having shortness of breath has hives on her face and arms and is reporting itching. Which intervention should the nurse implement first?
ask the woman if she has an epinephrine auto injector
The nurse is preparing to change a dressing on an 82 y/o client dx w stage 3 pressure ulcer. Which intervention should the nurse implement first
check to determine whether the client has received pain meds
The client ambulating down the ortho hall unassisted fell to the floor. Which action should the nurse implement first
determine whether the client has any injuries
Which task should the RN rehab unit nurse delegate to the UAP?
encourage the UAP to attend the multidisciplinary team meeting
Diagnosed with an electrical burn, a pt is brought to the emergency department. The entrance wound is on the right hand and the exit wound is on the left foot. Which intervention should the nurse implement first?
put the client on cardiac telemetry
The client who has a hx of CVA is admitted to the ortho unit dx w a fractured R hip. The client is reporting bleeding when brushing his teeth. The nurse reviews the clients MAR. Which intervention should the nurse implement first
request the lab to draw a stat INR
The charge nurse on the acute care rehab unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse?
the client dx w a fractured tibia who has deep, unrelenting pain