Exam 2

When giving a change of shift report, which statement by the nurse is not appropriate?

"Mr. Levi is just contrary today, and nothing is going to please him."

6 Factors to Consider during Selection of Interventions

1. Medical diagnosis 2. Expected outcomes 3. EBP 4. Feasibility of interventions 5. Acceptability to patient 6. Nurses competency

Critical Thinking

A continuous process characterized by open- mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique pt. situation and determine which identified assumptions are true and relevant

Steps in Nursing Process (5)

Assess Prioritize Plan Implement Plan Evaluate

Interventions

Assess Do Teach

Besides accessing medical records, which form of communication should the nurse use to provide client details to the health care team coming on duty in the next shift?

Change-of-shift reports.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele?

Cover the defect with moist, sterile saline dressings.

What intervention should the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis?

Encourage the child to eat nutritious foods.

A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take?

Inform the nursing supervisor.

Clinical Reasoning Skills (6)

Interpretation Analysis Inference Evaluation Explanation Self-Regulation *Always ask WHY?*

Critical Thinking

Learned tool in the Nursing Profession

The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will:

Obtain more sleep.

What should the nurse do to help a client prevent atelectasis and pneumonia after surgery?

Offer pain medication before having the client deep-breathe and use incentive spirometry.

A nurse is performing a baseline assessment of a client's skin risk assessment. Which finding will most impact the goal of the plan of care?

Overall potential of developing pressure ulcers

A client has a history of macular degeneration. What is the priority nursing goal while the client is in the hospital?

Promote a safe, effective care environment.

What would the nurse recognize as a common goal of discharge planning in all care settings?

Providing continuity of care for the client

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician?

SBAR

SBAR

SBAR S = Situation B = Background A = Assessment R = Recommendation

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which of the following statements should the nurse document in the incident report?

The client was found lying on the floor.

A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?

The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization.

Basic Clinical Reasoning

The learner trusts that experts have the right answers for every problem Thinking is concrete and based on a set of rules

A nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

To help the client and his family manage the terminal illness

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation.

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?

a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line

This statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of

a client outcome

Which component of an outcome criterion must the nurse consider when setting goals for a client?

a time frame

The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report?

an elderly client with pneumonia who is exhibiting periods of confusion

The nurse is assessing a client who has a chronic mental illness. What early signs of relapse should the nurse monitor for? Select all that apply.

decrease in sleep and self-care increase in social isolation and withdrawal more fears and suspiciousness

During the planning step of the nursing process, the nurse

establishes short- and long-term goals.

After a stroke, a client develops aphasia. The nurse expects to see which assessment finding?

inability to speak clearly

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

A mother who gave birth some three hours ago asked the nurse why her baby is so difficult to keep awake. The nurse informs the mother that this behavior indicates

normal progression into the sleep cycle.

The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should instruct the client to:

obtain frequent rest periods.

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to:

realign fracture fragments.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

using sterile technique during the dressing change

The unlicensed assistive personnel (UAP) states to the nurse, "My client talks about how awful and useless she is. Sometimes, she sounds angry for no reason. I'm tired of listening to her." Which response by the nurse is most appropriate?

"It's important for you to listen to her because she needs to verbalize how she's feeling."

Writing Interventions will start with......

"Nurse Will" *remember interventions are nursing actions*

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis."

Expected/Desired Outcomes starts with??????

*Pt WILL* + *Action Verb* = look, walk, eat, stand, sleep *avoid nursing terminology*

Evaluation is a ?

"Ongoing Process"

Revising Plan of Care: To minimize errors and ensure that the patient's plan of care is _________ and __________

Appropriate Relevant

Steps in Nursing Process: APPIE

APPIE A = Assess (Data gathering/diagnose problem now) P = Plan I = Implement E = Evaluate

The nurse is preparing a teaching plan for an adult recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?

Assess the client's learning needs.

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

The nurse uses which part of the SBAR acronym when stating, "The client is dry."

Assessment.

When teaching the diabetic client about foot care, what should the nurse instruct the client to do?

Avoid going barefoot.

A nurse at a healthcare facility has just reported for duty. What should the nurse do to ensure maximum efficiency of change-of-shift reports?

Come prepared with the material required to take notes.

Concept Mapping Steps: Expected Outcomes

Measurable criteria to evaluate goal achievement (SMART GOALS)

7 Guidlines for Writing Outcomes

Patient centered Singular goal or outcome Observable Measurable Time Limited Mutual Factors Realistic

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes.

When obtaining a client's history, the nurse should

ask questions about the client's reason for seeking care.

When teaching parent workshops about measures to prevent lead poisoning in children, the nurse should identify which preventive measure as being the most effective?

educating the public on common sources of lead

Which nutritional deficiency may delay wound healing?

lack of vitamin C

Which activities would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

obtaining a client's routine glucose reading using a glucometer

During a home visit to an older adult with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day Promote relaxation before bedtime with a warm bath or relaxing music

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication?

Give the charge nurse information about what care should be given while the nurse is at lunch.

A 22-year-old client exhibits memory loss, confusion, and wandering behavior. Which comment by the nurse would provide the best reality orientation for the client when she first awakens in the morning?

Good morning. This is your 2nd day in Memorial Hospital, and I'm your nurse for today. My name is Rachel."

Nursing Process

Guides all nursing actions Purpose: Help the nurse provide goal-oriented *patient* centered care

Student Concept Maps

Helps apply knowledge classroom to a practice situation More elaborate than a care plan used in hospital - purpose is to teach process of planning care

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?

IV catheter insertion

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?

Increase the oxygen flow rate from 2 to 4 L/min.

3 Levels of Critical Thinking in Nursing

Level 1: Basic Level 2: Complex Level 3: Commitment

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first?

Maintain adequate oxygenation.

Nursing Diagnosis

NANDA

Nurse will recognize what is important _____.

NOW! (recognizes how co-morbidities can effect current problem)

Prioritization of Care is based on?

Nursing Assessment

Interventions: Also called

Nursing actions Measures Strategies Activities *Implement care to meet patient outcomes*

Outcomes of Care

Patient-Centered Outcomes Short-term Outcome Long-term Outcome

The client's identification armband was cut and removed to start an IV line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on either wrist. What should the nurse do?

Place a new identification armband on the client's wrist before transport.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?

Place a pressure-reducing mattress on the client's bed.

The team leader has noticed a sharp increase in medication errors associated with IV antibiotic administration over the last 2 months. The group that could offer resources for tracking medication errors and improving care outcomes is the:

Quality Improvement and Risk Management Department.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

Remove elastic stockings once per day and observe lower extremities

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?

Reposition the client off the reddened skin and reassess in a few hours.

SMART Goal

SMART: S = Specific M = Measurable A = Attainable R = Realistic T = Time-Based

SOAP

SOAP S = Subjective O = Objective A = Assessment P = Plan

Critical Reasoning Includes: (6)

See Big Picture (thinking holistically) Think Smart (recognize important information) Open-mindedness Creativity Confidence Continual Inquiry

APPIE: Planning

Set priorities Select *Goals* Establish expected *outcomes* Decide on appropriate interventions

Commitment (Reasoning)

The nurse anticipates the need to make choices without assistance from others Assumes accountability for their choices Defends & is able to support his or her choices

Complex Critical Reasoning

The nurse begins to detach from authorities and analyze and examine alternatives more independently The answer to many questions asked is "It depends" The nurse begins to look beyond expert opinion Realizing that alternative solutions exist

A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation that followed myocardial infarction. Keeping in mind that the client speaks English as a second language, how should the nurse conduct the interview?

The nurse should avoid using complex medical terminology.

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?

Using incentive spirometry every 2 hours while awake.

The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I cannot sleep." Which outcome is important for the client to achieve first?

Verbalize the desire to stop drinking alcohol.

The nurse can be an important advocate for the client who is considering an alternative method of cancer treatment. Which statement best demonstrates the nurse as client advocate? The nurse will:

allow the client to make health care choices but will assist in ensuring the client is fully informed when making those decisions.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

an 86-year-old with burns from using a heating pad

The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which task cannot be delegated to the UAP?

assessing the incision site

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

elevated temperature

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (foot drop) for a client on complete bed rest. The UAP should:

encourage active range of motion to unaffected extremities.

When documenting information in a client's medical record, the nurse should:

end each entry with her signature and title.

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?

evaluation

A nurse, when documenting the health details of a client in an acute care agency, fills out all the details under assessment, diagnosis, planning, and implementation. What did the nurse miss as per the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) standards?

evaluation of outcomes

A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective?

increase in peak expiratory flow rate

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

inspiratory and expiratory wheezing.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first:

mark the area of drainage.

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply.

nutrition and hydration needs capillary refill continued need for restraints skin integrity

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

oxygen saturation (SaO2) of 89%

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

providing client teaching

A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation?

right lateral

Which approach is the best way for the nurse to begin the preoperative interview? Walk in the client's room:

sit down, maintain eye contact, and make an introduction.

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate?

sitting quietly with the client at the bedside until the medication takes effect

The Goal of Clinical Reasoning as a Professional Nurse?

CONSISTENTLY make objective and appropriate clinical decisions Nursing JUDGMENT Care for pateints as their advocate Make better informed choices LIFE LONG LEARNING

The nurse from the postanesthesia care unit (PACU) is transferring the client to an orthopedic unit. Which is the most appropriate way for the nurse in the PACU to communicate the "hand-off-of-care" report with the nurse on the orthopedic unit?

Call the nurse on the orthopedic unit and give a verbal report.

Nursing Process

Collect and analyze data Make a plan Meet Pt needs Decision making problem solving

Needed Nursing Attitudes

Confidence Independence Fairness Responsibility Risk Taking Discipline Perseverance Creativity Curiosity Integrity Humility

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error. Which is the best technique for correcting the error made in documentation?

Cross out the incorrect statement with a single line.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?

Administer pain medication 30 minutes before therapy to help manage pain

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness?

can be roused with stimulation

A 12-year-old child is sent home for pediculosis after being at camp for 1 week. The mother thinks others at camp have it. The mother asks the nurse how her son could have gotten pediculosis. How should the nurse reply?

"Children who sleep close to someone who has it get it more easily."

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply.

Add baking soda to the water in a tub bath Keep nails short and clean Rub the skin when it itches with knuckles instead of nails

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Administer oxygen by nasal cannula as ordered.

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first?

Administer oxygen via mask.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first?

Administer oxygen.

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response?

Ask the parent for more information about the infant's sleep patterns.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first?

Assist the client to take several deep breaths and cough.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply.

Monitor serum creatinine and blood urea nitrogen levels Administer humidified oxygen Auscultate the lungs

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor?

Remain in a side-lying position with the head elevated.

A girl in second grade with no remarkable medical history experiences a generalized tonic-clonic seizure in the classroom. Immediately after the seizure, the nurse arrives and notices that the child has been incontinent of urine and is difficult to arouse. Which action would be most appropriate at this time?

Stay with the child, and allow her to sleep in a side-lying position.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyper oxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn him regularly.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do?

Turn the client every 1 to 2 hours

A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

Yellow, purulent drainage

The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill?

a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultating the lungs for bilateral breath sounds

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The client has understood the instruction when the client identifies which potential complications? Select all that apply.

becoming increasingly short of breath at rest weight gain of 2 lb (0.9 kg) or more in 1 day having to sleep sitting up in a reclining chair

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise?

better elimination of carbon dioxide

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor?

lacking understanding of body integrity

Which is the appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer?

medicated cool baths

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

oxygen saturation of 90%

The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the expected outcome of using pursed-lip breathing?

prolonged exhalation

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:

promote drainage of wound exudates.

A client is scheduled for cardiac catheterization the next morning. The physician ordered temazepam, 30 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that:

sedatives reduce excitement; hypnotics induce sleep.

Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease?

enhance myocardial oxygenation

A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention?

heart rate less than 60 beats/minute

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first?

impaired gas exchange

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction?

in a widening circle around the drain, outward from the center

The health care provider (HCP) prescribes pulse assessments through the night for a school- age child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by which factor?

routine activity during waking hours

A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to:

smell the cast for foul odors.

A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:

try to get more rest by going to bed earlier.

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.

Apply lanolin or petroleum jelly to intact skin Encourage a reduced-calorie, reduced-fat diet Inspect the involved areas daily for new ulcerations Use an electric razor to shave

A client receiving radiation therapy for lung cancer is having difficulty sleeping. What should the nurse do first when teaching the client about promoting sleep?

Ask the client about usual sleep patterns.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first?

Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

Decreased oxygenation of the blood.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?

Decreasing environmental stimulation

A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, suspicious, and easily startled. He signs a no harm contract and then asks to go to sleep. What is the best initial plan for this client?

Develop trust and allow him to talk about his memories and feelings.

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation?

Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first?

Establish an airway.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

Reposition the client every 2 hours Perform range-of-motion exercises Encourage the client to eat a well-balanced diet

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema?

Separate opposing skin surfaces with soft cloth.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?

an inhaled beta2-adrenergic agonist

The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client?

buccal mucosa

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase?

ineffective breathing pattern related to neuromuscular impairment

A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position?

knee-to-chest

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching?

"Ecchymoses are large, purple skin bruises."

A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep-breathing exercises after surgery. What should the nurse tell the client to do?

"Hold your abdomen firmly with a pillow, and take several deep breaths."

The parent of a preschool-age child has been told the child has sleep terrors. Which statement should the nurse include when teaching the parents about sleep terrors?

"Intervention is required only if it is necessary to protect the child."

A client taking clozapine states, "I don't like feeling so sedated during the day. I can hardly keep my eyes open." Which response by the nurse would be most appropriate?

"Let's talk to your health care provider about taking most of the drug at bedtime."

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which suggestion would be most helpful?

Practice relaxation techniques before bedtime.

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task?

Raise the bed to approximately waist level.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.

The SpO2 and PO2 have decreased. The client is tachycardic with drop in blood pressure. The face has increased skin breakdown and edema

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?

The granulation tissue is at the wound edges.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do?

Use an alternating air pressure mattress.

The partner of a 22-year-old client dies in a drunk-driving accident. The client complains of difficulty eating, sleeping, and working. The reaction is considered:

a crisis caused by traumatic stress.

A client diagnosed with major depression has sleep and appetite disturbances, a flat affect and is withdrawn. The client has been taking fluvoxamine 50 mg twice daily for 5 days. Which client behavior is most important to report to the next shift?

client sleeping from 2300 hours to 0600 hours

An older adult woman who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/min, and her skin is cold and clammy. Based on these findings, the nurse should further assess the client for which condition?

delirium

A nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits?

encouraging the client use relaxation exercises

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?

endotracheal suctioning

A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that

it is normal for the child to want to sleep with them at night.

After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states she will immediately report which sign or symptom?

longer periods of sleep than usual

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag

The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has:

reduced sensation of pressure.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

partial pressure of arterial oxygen (PaO2)