Collaboration

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?

Encouraging a fluid intake of 3 L daily Increasing fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse concludes that the surgeon should be contacted immediately because the hypertension may indicate that the:

Graft is leaking Hypertension increases pressure on the suture lines, which can affect the integrity (e.g., leaking, rupture) of the graft

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first?

Notify the health care provider Calf pain may be a sign of thrombophlebitis , which can lead to pulmonary embolism

A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care?

Nurse-to-client ratio on units During a disaster, nursing coverage on all units should remain appropriate for client safety.

The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply.

Performing a bed bath for a client on bed rest Assisting a client who has patient-controlled analgesia (PCA) to the bathroom Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP.

The nurse is reviewing the plan of care to prevent contractures of the joints of the lower extremities in a client with paraplegia. The nurse should question which item that is listed on the plan?

Provide the client with active lower extremity exercise instructions The paraplegic client is unable to exercise the lower extremities actively.

After a storm the rescue team is searching for injured people. A nurse on the team discovers a victim lying next to a broken natural gas line. The victim is not breathing and is bleeding heavily from a leg wound. How should the nurse proceed? Place care in the order of priority .

Remove the victim from the immediate vicinity. Start rescue breathing immediately Apply surface pressure to the foot wound Take the victim's vital signs Transport the victim to the hospital immediately The first action should be to remove the victim from the source of further injury. After further injury is avoided, reestablishing breathing becomes the priority. Applying pressure to stop the bleeding becomes the priority after breathing has been reestablished. The next step is to objectively evaluate the victim's responses to the crisis and the care. Transportation to the hospital can occur after the client has been stabilized physically.

A nurse observes that an unlicensed assistive personnel (UAP) did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurse's best way to handle this situation is to:

Review transmission-based precautions with the UAP Standard and contact precautions require specific handling of potentially infectious matter; therefore, the nursing assistant should be reminded that hospital policies concerning these precautions must be followed for personal protection and the protection of others before the mistake is made again

What should the nurse include in the plan of care for a client who just had a total laryngectomy?

Suctioning the tracheostomy tube whenever necessary Secretions are increased because of alterations in structure and function. A patent airway must be maintained.

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. What health care provider prescription should the nurse question?

Teach isometric exercises This prescription should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure

A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eye drops?

Timolol maleate (Timoptic) Timolol maleate is a beta-adrenergic antagonist that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should be reported to the health care provider immediately?

small amount of yellowish green oozing A small amount of yellowish green oozing indicates infection and should be reported immediately