Fundamentals - Basic Care & Comfort

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs" 2. "His heart has stopped and we are attempting to revive him" 3. "I don't know how he is but you need to come" 4. "I will have the health care provider talk to you once you arrive"

1. "He is critically ill and we are caring for his needs" The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place.

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for the health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care

1. Arrange for the health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 5. Upon death, provide the family with supplies for postmortem care Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. Ask the mother's permission to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the examination until the mother calms down

1. Ask the mother's permission to touch the child's hand Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward.

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen. Place the following steps for ear irrigation in the correct order. All options must be used. 1. Assess the client for fever, ear infection, or tympanic membrane injury 2. Gently irrigate the ear canal with a slow, steady flow of solution 3. Place a towel and an emesis basin under the ear 4. Place the client in a sitting position with the head tilted toward the affected ear 5. Straighten the ear canal by pulling the pinna up and back

1. Assess the client for fever, ear infection, or tympanic membrane injury 4. Place the client in a sitting position with the head tilted toward the affected ear 3. Place a towel and an emesis basin under the ear 5. Straighten the ear canal by pulling the pinna up and back 2. Gently irrigate the ear canal with a slow, steady flow of solution To perform ear irrigation, assess for contraindications (fever, ear infection, tympanic membrane injury); tilt the affected ear down; straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is clear.

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. 1. Avoid infusion devices in confused clients as alarms can be disruptive 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45 deg angle on insertion because older adults have deeper veins that roll

2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin Important age-related considerations for the older adult receiving IV therapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? 1. Administer an inhaled bronchodilator 2. Check marked insertion depth of the tube 3. Request a prescription for a diuretic 4. Start the client on incentive spirometry

2. Check marked insertion depth of the tube Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? 1. Administer midazolam per protocol 2. Check the client's pulse oximeter 3. Give more morphine per protocol 4. Open the airway with head tilt-chin lift

2. Check the client's pulse oximeter When new-onset restlessness occurs during procedural sedation, oxygenation should be considered first before administering additional medications. If the client is snoring, opening the airway should be considered.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? 1. Client scheduled for discharge who has had a peripheral IV in place for 84 hours 2. Client with a do-not-resuscitate prescription who has swelling at the IV site 3. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago 4. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

2. Client with a do-not-resuscitate prescription who has swelling at the IV site The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the health care provider to prescribe a different calcium channel blocker 2. Consult with the pharmacist to see if an alternate form of the drug is available 3. Open the capsule and sprinkle the medication in a cup of applesauce 4. Warn the client about the dangers of uncontrolled hypertension

2. Consult with the pharmacist to see if an alternate form of the drug is available Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say "goodbye" when leaving room to help orient the client 4. Speak slowly and slightly louder so the client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray

2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say "goodbye" when leaving room to help orient the client 5. Use a clock-face pattern to explain food arrangement on the client's meal tray When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply. 1. Dim lights to prevent overstimulation 2. Post a hearing impairment sign on client's door 3. Raise voice to speak more loudly 4. Speak directly facing the client 5. Tell family to take hearing aids home so they will not be lost

2. Post a hearing impairment sign on client's door 4. Speak directly facing the client When speaking to a client with hearing impairment, the nurse should have the room lights on, directly face the client, speak at a normal volume toward the least-affected ear, and ensure that any hearing aids are functional and in place. Hearing impairment signs may be posted to promote safety.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching activities

3. Rest from pain-aggravating activities Rest from activities that aggravate pain and inflammation is a nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your HCP?" 2. "If I were you, I would be more worried about whether the melanoma has spread" 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications" 4. "There is special make-up you can use to hide any facial scars left from the surgery"

3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications" Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assess for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death

4. The client wants to take care of business before imminent death The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess the client's needs and ensure that the plan of care will facilitate the client's life closure activities (eg, legacy building).