EAQ - Fundamental Skills

Which factors enable the nurse to know a client better?

-Continuity of care by the nursing staff -Collection of data about the client's clinical condition -Engagement in a caring relationship without assumptions The nurse gets to know the client over time with continuity in care. The nurse enters into a caring process by collecting data about the client's clinical condition. The data enable the nurse to use critical thinking and clinical judgments during client care. The nurse would engage in a caring relationship with the client without any assumptions and use knowledge and experience to detect changes in the client's health condition. Economic constraints may lead to the client's spending less time in the health care facility. This acts as a barrier in providing client-centered care. Changes in the organizational structure may result in fewer nurses caring for more clients. This results in fewer interactions with the client.

Which behavior by the client exhibits denial after a recent diagnosis?

Attempts to minimize the illness Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

Which concepts should be included when teaching a young mother about the nutritional needs of the newborn?

Breast-feed for the first 12 months The nurse recommends breast-feeding for the first 12 months. After the first year, the infant may change to whole cow's milk. If breast-feeding is not possible, the newborn would be fed on iron-fortified commercially prepared formula. Whole milk, 2% milk, or alternate milk products would not be given to an infant under 12 months of age because these products can cause intestinal bleeding, anemia, and increased incidence of allergies. Solid foods are not recommended for infants under 6 months of age because the extrusion reflex pushes the food out of the mouth. The breast-fed infant absorbs adequate iron from breast milk during the first 4 to 6 months of life. After 6 months iron-fortified cereal may be given to the infant.

Which nursing intervention is performed for a client in tertiary care?

Determining the coping mechanisms of the client and the family The nurse would determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.

Which action would the nurse take when observing that a postsurgical client has a urine output of 800 mL total in the first 24 hours after surgery?

Document the normal finding A low urine output of 800 to 1500 mL is normal in the first 24 hours after surgery. The nurse would document the normal finding and continue to monitor urine output in the postoperative period. It is not necessary to increase oral or intravenous fluid intake or notify the provider unless urine output does not increase.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?

Explanation Explanation requires knowledge and experience for choosing strategies for care for clients. Analysis is a critical thinking skill that requires open-mindedness while looking at the client's information. The skill of inference is associated with noticing relationships in the findings. Interpretation is associated with ordered data collection.

Which should the nurse include when teaching a client with Clostridium difficile about decreasing the risk of transmission to family members?

Soap and water for hand washing Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs.

Which is an example of independent thinking in nursing practice?

Talking with other nurses to share ideas about nursing interventions Nurses talking to each other and sharing ideas about nursing interventions reflects independent thinking. Responsibility and authority require referring to a policy and procedure manual for reviewing steps of a skill. Humility involves recognizing the need for more information for making a decision. Curiosity is exploring and learning about clients to help make appropriate clinical judgments.

A client in the second (acute) phase of burn recovery may exhibit an increase in which value?

Urinary output As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

For which condition is fresh frozen plasma (FFP) ordered ?

Clotting factor deficiency FFP is an unconcentrated form of blood plasma containing all of the clotting factors except platelets. It can be used to supplement red blood cells (RBCs) when other blood products are not available or to correct a bleeding problem of unknown cause. Thrombocytopenia is a condition of low platelet count and is not treated with FFP. An oxygen deficiency and low hemoglobin may be improved indirectly with FFP, but it is not a definitive treatment.

Which is most important for the nurse to include in teaching for a client scheduled for a cholecystectomy regarding prevention of postoperative complications?

Coughing and deep breathing The client who has a cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. It is important to instruct the client preoperatively to improve compliance with the procedure in the early postop period. Although ambulation, antiembolism stockings, and maintaining a nasogastric tube, if ordered, are important postoperative procedures, maintaining the airway and preventing further pulmonary problems is the priority.

While caring for a family, the nurse observes that the family has accepted the shifts of generational roles. Which change in the family status would the nurse observe?

Dealing with retirement A family with members in the later life stage may involve the acceptance of the shifting of generational roles. Dealing with retirement would be an appropriate change for the family status that requires a developmental proceeding. The acceptance of new generations of members into the system would be associated with the stage of a family with young children; this stage involves taking on parental roles. An adjustment to a reduction in family size would be associated with the family life cycle stage of launching children and moving on. Midlife material and career issues are refocused during the family life cycle stage of adolescence.

The registered nurse (RN) is teaching a nursing student to use self-disclosure appropriately to promote a therapeutic alliance with the client. Which carative factor is involved in this situation?

Forming a human-altruistic value system The action of using self-disclosure appropriately to promote a therapeutic alliance with a client is a part of a human-altruistic value system. The carative factor of instilling faith-hope is applicable when the nurse is connecting with a client to offer purpose and direction when trying to find the meaning of an illness. The carative factor of promoting and expressing positive and negative feelings is applicable when the nurse is supporting and accepting the client's feelings. Developing a helping, trusting, and human caring relationship is applicable when the nurse learns to develop and sustain help through effective communication with the client.

When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take?

Hang a bad of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse would infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the health care provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless a negative client outcome results.

Which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client?

Increased expired carbon dioxide The first sign of malignant hyperthermia is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.

A client with dementia is having trouble with person, place, and time. Which action by the nurse would be appropriate in this situation?

Let the client continue to think in his or her own way Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in her or his own way. Minimizing environmental stress can help reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.

A client has seeds containing radium implanted in the pharyngeal area. Which would the nurse include in the client's plan of care?

Maintain the client in an isolation room During radiation therapy with radium implants, the client is placed in isolation so that exposure to radiation by family and staff is decreased. Voiding every 2 hours is unnecessary; a full bladder will not disrupt the seeds. Excess exposure to radiation is hazardous to personnel. Gloves will not protect the nurse from radiation.

The nurse preceptor is evaluating the nurse who is preparing to administer digoxin intravenously (IV) to a client. Which intervention by the nurse would require the preceptor to stop the nurse?

Piggybacking the digoxin in an existing infusion The nurse preceptor needs to stop the nurse because this action is unsafe. The manufacturer recommends that digoxin be infused alone, because there may be an incompatibility with other medications. A low serum level of potassium and the administration of digoxin can cause toxicity. An elevated serum level of digoxin and the administration of another dose of digoxin can result in toxicity. Digoxin IV is given over a 5-minute period through a Y-site connector.

The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation?

Power motivation People who tend to be motivated by power generally have more assertive and aggressive behavior. The nurse designs goals in such a way that makes these clients feel like they are in a competition even though the clients are only competing against themselves. Individuals who tend to be motivated by affiliative motivation are generally nonassertive and more dependent on others. The nurse can design the goal according to the client's mental behavior. Avoidance motivation requires the nurse to consider the client's anxiety, fear of failure, and other phobias. People who are motivated by achievement are not characterized by aggressive behavior with a need to engage in competition.

A staff nurse on a medical-surgical unit has been assigned to care for a number of clients. The nurse decides to review their individual records before client contact. Which phase of the nurse-client relationship does this represent?

Preinteraction phase The preinteraction phase is a preparatory phase of the planned therapeutic relationship. The working phase is the period in the relationship when individuals are occupied with achieving goals and sharing facts and feelings. The orientation phase is the initial period of the interaction; it is an introductory or exploratory phase. The termination phase is the period in the relationship when individuals are beginning to separate and move toward independent paths.

Which change in the family life-cycle would the nurse advise the young couple planning to start a family to make?

Realign relationships with extended family The nurse informs the young couple that when they take up parenting roles, they will have to realign their relationships with extended family to include grandparenting roles. An individual who is young and unattached will develop intimate peer relationships and begin to differentiate her- or himself from her or his family. Older individuals in later family life start to explore new social roles. These individuals begin to maintain their own functions and interests. Families with adolescents begin to see a shift in the family system. These individuals refocus on midlife material and career issues.

To prevent hemorrhage of a client who underwent a liver biopsy, the nurse would place the client in which position?

Right side-lying Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation. There is no indication that the prone, high Fowler, and Trendelenburg positions are beneficial or appropriate for the client.

A terminally ill client is visited frequently by the spouse and teenage children. Which nursing interventions would the client's plan of care include?

Teach family members how to assist with the client's basic care Because the family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system.

Which would the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to result in manageable stools Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and produce stools that are manageable depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Foods high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

The nurse is providing care to a client after surgery to correct an upper urinary tract obstruction. Which assessment finding would the nurse report to the surgeon?

Urine output of 20 mL/h A urinary output of 50 mL/h or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse would notify the surgeon of the assessment findings because this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client?

Validation therapy Validation therapy is the psychosocial concern involved in accepting the descriptive statements made by a confused older client. Reminiscence is recalling the past. Reality orientation involves helping a confused older client agree with the nurse's statements. Therapeutic communication enables the nurse to perceive and respect the older client's uniqueness and health care expectations.

A mother of a 7-month-old infant reports that her baby cannot sit without support. Which question would the nurse ask the mother to further assess gross motor skills?

"Can your child hold on to furniture?" The development of gross motor skills in a 7-month-old includes sitting alone without any support. Another development is the infant's ability to hold on to furniture. An infant between 8 and 10 months may show hand preference as a part of the development of fine motor skills. Moving on the hands and knees may represent the development of gross motor skills in an 8- to 10-month-old. A 10- to 12-month-old infant may have the ability to place objects into containers; this action indicates the development of fine motor skills.

Which questions would the nurse ask when gathering a client's physical and developmental health history?

-"Do you have any marital problems?" -"Are you able to complete your activities of daily living?" While gathering information about client's physical and developmental status, the nurse may ask the client about marital problems or the client's ability to perform activities of daily living. While gathering information about a client's emotional status, the nurse may ask the client about emotional control. When the nurse asks about the memories of the client, the nurse is gathering information about the client's intellectual status. When the nurse asks about the number of family members present, the nurse is collecting information about the client's social status.

A primary health care provider examines an 11-month-old infant and suspects anemia. Which questions would the primary health care provider most likely ask the mother?

-"Do you use 2% cow's milk?" -"Do you use whole cow's milk?" -"Do you use alternative milk products?" The use of 2% or whole cow's milk in an infant younger than 12 months is not recommended because it may cause intestinal bleeding, anemia, and allergic reactions. Mothers should avoid using any alternative milk products because their use may cause complications in the infant. Breast-feeding is recommended for the infant's nutrition because breast milk contains essential proteins, fats, carbohydrates, and immunoglobulins that help bolster the infant's ability to resist infection. An average infant of 1 month old should have 18 to 21 ounces of breast milk or formula per day.

Which action would the nurse take for a client whose right radial pulse is weak and thready?

-Assessing all peripheral pulses -Assessing and comparing both radial pulses -Asking a second nurse to assess the client's pulses -Assessing for edema or other issues that may be restricting peripheral blood flow -Observing for pallor/skin temperature differences distal to the weak pulse If the client's radial pulse is weak and thready, further assessment would be indicated and includes assessing all peripheral pulses; assessing and comparing both radial pulses; asking another nurse to assess and verify the findings; assessing for any issues that may be restricting peripheral blood flow; and observing color and temperature differences distal to the weak pulse.

The nurse is preparing to discharge a client who is partially paralyzed after a stroke. Which behaviors would the nurse alert the family of as symptoms of caregiver role strain?

-Disturbed sleep patterns -Reduced appetite and weight -Fearful about administering medications to the client A family should recognize that when the caregiver has disturbed sleep patterns, the caregiver is experiencing strain. Changes in appetite, weight, and sleep patterns are all indicative of caregiver role strain. A caregiver experiences strain while learning about new therapies and administering medications to the client. A caregiver experiencing role strain is not concerned about personal appearance and may withdraw from social groups. A caregiver also does not spend time in any leisure activities if overcome by strain.

Which goals of care are associated with the family health system model?

-Improving family health or well-being -Providing assistance in family management of illness conditions -Achieving health outcomes related to the family's areas of concern When working with families, the goals of care are to improve family health or well-being, assist the family in managing the illness conditions, and achieve health outcomes related to the family's areas of concern. In the developmental stage, the nurse would help the family prepare for later transitions and promote positive family behavior to achieve essential tasks

Which nursing actions reflect the carative factor of promoting and expressing positive and negative feelings, according to Watson's theory of transpersonal caring?

-Supporting and accepting the client's feelings -Showing a willingness to take risks in sharing in the relationships when connecting with clients According to Watson's theory of transpersonal caring, there are 10 carative factors that should be incorporated into the nursing practice. The nurse can include the carative factor of promoting and expressing positive and negative feelings by supporting and accepting the client's opinions and feelings. It also includes showing a willingness to take risks in sharing in the relationship. Transpersonal teaching-learning is promoted by learning together while educating the client. This learning-together session helps in acquiring self-care skills. A healing environment is created by providing a supportive, protective, and corrective mental, physical, and spiritual environment. According to Watson's theory, the nursing process should be used as the creative, problem-solving caring process. It involves applying systematic, scientific problem-solving and decision-making in providing client-centered care.

Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection?

-Surgical incision -Urinary catheter -Antibiotic therapy -Intravenous access Findings that increase the risk of infection in a client would be the presence of a surgical incision, a urinary catheter, and an intravenous access. These are all portals of entry for microorganisms. Antibiotic therapy can lead to a suprainfection that eliminates the normal flora.

Why would the nurse establish "moderately hard" client-centered goals?

-To prevent the client from quitting before the goal is achieved -To prevent the client from losing motivation toward achieving the goal Health care providers generally design moderately hard client-centered goals because, if the goals are too hard to achieve, the client may give up before completely achieving them. However, if the goals are too simple, it may create a feeling that the goal is of no benefit or is not worth pursuing. Designing moderately hard client-centered goals will not decrease the cost of the treatment. Moderately hard client-centered goals will not necessarily be completed in a shorter period of time with less effort. Establishing moderately hard client-centered goals will not necessarily reduce the number of follow-up visits required.

Which emergency equipment is most important for the inpatient unit nurse to have available for a client who underwent a subtotal thyroidectomy?

A tracheostomy tray airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies would be immediately available to the client. A defibrillator, an IV infusion pump, and an ECG monitor are equipment items that would be available to all postoperative clients.

A client is admitted voluntarily to a psychiatric unit for severe depression. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How would the nurse prepare the client for the appendectomy?

Ask the client to sign the operative consent form after the client has been informed of the procedure by the health care provider Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign the consent.