Lab Intensive 2 PrepU's
A client with depression is ready for discharge from the hospital and tells the nurse, "It would be good for me if we could meet for coffee if I start feeling down again." Which statements indicate that the nurse understands the boundaries of the therapeutic relationship?
"Before you leave the hospital, I will make sure you have information about the crisis center."
During a conversation with the client, the nurse observes that the client is shaking his leg and tapping his fingers on the table next to him. Which statement by the nurse is best?
"I noticed that your leg is shaking and you're tapping your fingers on the table. How are you feeling now?"
client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client's disturbed thought process?
"I think these thoughts are frightening to you."
The husband of a client to be discharged from the hospital after an episode of major depression and a suicide attempt asks, "What can I do if she tries to kill herself again?" Which response is mostappropriate?
"Let's talk about some behavioral clues and resources that can help."
A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit telephone calls to 10 minutes. Which response should the nurse make?
"Stop! Swearing is not appropriate behavior."
As the nurse is turning off the television, a client with bipolar disorder, manic phase, says, "I want the television on so I can watch the late show. I'm not tired, and you can't tell me what to do. I want it on!" What should the nurse tell the client?
"Television hours are from 1900 hours to 2200 hours. It's 2200, and the television goes off so everyone can sleep."
A client tells a nurse he was involved in a car accident while intoxicated. What would be the most therapeutic response for the nurse to make?
"Tell me how you feel about the accident."
The nurse has presented an educational inservice about caring for patients who have newly created ostomies. The nurse asks participants, "How will you know when a patient begins to accept the altered body image?" Which of the following responses by participants indicate a correct understanding of the material? Select all that apply.
"The patient is willing to look at the stoma." "The patient expresses interest in learning self-care." "The patient makes neutral or positive statements about the ostomy."
A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate?
"This subject seems to be troubling you. Let's walk to the activity room."
A client with Alzheimer's disease tells the nurse, "I'm so afraid. Where am I? Where is my family?" What is the best response by the nurse?
"You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now."
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
: 30 mL
A patient with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this patient's needs?
An implanted central venous access device (CVAD)
A patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply.
Liquid stool softener AND Sublingual nitroglycerin
Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura?
Pneumothorax
. A client is voluntarily admitted to a substance abuse unit. The client admits to drinking at least 1 qt (1 liter) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings support the nurse's suspicions?
Pulse rate of 135 beats/minute, tremors, and nervousness
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.
The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
Solid
.A charge nurse enters a client's room and observes a physician instructing another nurse on how to insert a central line into the client's neck. The nurse is holding the cannula and inserting the line. What would be the appropriate response by the charge nurse?
Stop the procedure and inform the nurse that this is outside of a nurse's legal scope of
A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patient's nutritional needs?
TPN administered via a peripherally inserted central catheter
A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially?
Tell the client to seek out staff when feeling agitated.
An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patient's care may have increased susceptibility to CLABSI?
The patient's central line was placed in the femoral vein.
A nurse assessing a patient with an ostomy appliance documents the condition "prolapse" in the patient chart and notifies the physician. Which of the following statements describes this condition?
The stoma is protruding into the bag and may become twisted.
When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location?
Tip of patients nose
During the initial interview, a client with schizophrenia suddenly turns to an empty chair and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?
When people are under stress, they may see things or hear things that others don't. Is that what just happened?"
A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:
Wipes catheter ports from distal end to insertion site
A nurse must provide total parenteral nutrition (TPN) to a client through a triple-lumen central line. To prevent complications of TPN, the nurse should
cover the catheter insertion site with an occlusive dressing.
A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?
ensuring the safety of this client and other clients on the unit
One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority?
explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)
A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which complication should the nurse be prepared to treat?
pneumothorax
A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?
r: Instruct the client to take a deep breath and hold it.
