NClex / Basic Physical Care 2nd set

In a client who had major surgery 5 days ago, which assessment finding would be the best indication of a wound infection?

Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguineous. Although an elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, they aren't as specific as the drainage and could be related to other problems.

When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?

The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.

A 66-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which of the following statements would be the nurse's best response?

Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When the nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take?

In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client evacuation because no one will know how to function effectively as a team during the crisis. Taking time to have a staff meet is wasting valuable time.

The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include:

In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade.

A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:

Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.

A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best assist the staff nurse?

The nurse-manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several clients with multiple problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrate the priority-setting and decision-making leadership skills that this client load would require. Letting her select her own assignments or giving her fewer patients could impair the morale of other staff nurses.

Which member of the health care team is responsible for obtaining informed consent from a client?

The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature. In some health care facilities, a physician's assistant may obtain informed consent; however, in this case, a physician must act as cosigner.

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?

A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation.

The nurse is transferring a client from the bed to a chair. Which action does the nurse take during this client transfer?

After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse helps the client sit on the edge of the bed and dangle his legs. The nurse then faces the client and places the chair next to and facing the head of the bed.

The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by:

Air leaks commonly occur if the system isn't secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage — not to prevent air leaks. The head of the bed may be elevated to promote drainage. Chest tubes that aren't patent may lead to tension pneumothorax but wouldn't cause an air leak.

The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize?

Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole-grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

The care plan is revised for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan include early in this mother's hospital stay?

Assessment of the mother's strengths and weaknesses in her coping mechanisms and the presence or absence of support systems is important in the implementation process. Assessment will also help identify situations that the mother perceives as stressors. Providing education about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. It hasn't been established that the mother is angry, so anger management therapy may not be necessary. Proper care of a crying infant is necessary, but assessing the mother's coping will help provide the basis for teaching.

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

Because of lethargy, the posttonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler, supine, and high-Fowler positions don't allow for adequate oral drainage of a lethargic posttonsillectomy client and increase the risk of blood aspiration.

The nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:

Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority because it aids healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Maintaining fluid intake at 1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.

Which procedure or practice requires surgical asepsis?

Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. catheter requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:

Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.

Which of the following clients would qualify for hospice care?

Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who had coronary artery bypass surgery 2 weeks before because these health problems aren't necessarily terminal.

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do?

If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

The managers of the physical and occupational therapy neurologic departments have expressed concern to the nurse-manager of an adult neurologic rehabilitation unit that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit has complained that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem?

In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The manager, however, should be available to help. Option 1 reflects an autocratic manager. Without staff input, the nurse-manager won't have the necessary information to identify the best solution. By simply telling the nursing staff to follow the therapists' schedules, the nurse-manager has abdicated responsibility for problem solving (laissez-faire manager), yet the problem still exists. Determining problem-solving options without staff input is indicative of a participative manager. A participative manager asks staff members for opinions, but they don't have input into actual problem solving. This lack of input may lead to resentment and frustration.

The nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?

Sodium, the major cation in the ECF, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

When discussing the Food Guide Pyramid with a 75-year-old client, the nurse should remember that the guide has been modified for older people. Unlike the standard Food Guide Pyramid, the version for elderly individuals:

The Food Guide Pyramid version for older people adds a base that includes eight 8-oz glasses of water to prevent constipation and dehydration. The pyramid sets no upper limits on servings of most food and water. It doesn't increase the milk and dairy recommendation and doesn't eliminate the fats, oils, and sweets recommendation.

The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin

The client should be encouraged to consume foods high in vitamin C because it's essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?

The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because this increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.

When approaching a family for organ or tissue donation, the nurse should keep in mind which guideline?

The family should be offered an opportunity to speak with an organ procurement coordinator. An organ procurement coordinator is knowledgeable about the organ donation process and should have exceptional interpersonal skills for dealing with grieving family members. Physician support in the process is desirable but consent or written orders aren't necessary for a referral to the organ procurement organization. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The family should be approached about speaking to an organ procurement coordinator only after the family has been made aware of the client's condition and prognosis. Approaching a family member who believes there's still hope for recovery will likely result in a negative outcome.

A client suddenly loses consciousness. What should the nurse do first?

The nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate.

The nurse-manager of a 20-bed coronary care unit isn't on duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. The other choices don't accurately reflect the accountability of the nurse-manager's position.

A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this nurse?

The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained. The nursing supervisor can guide the pediatric nurse as to the tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the nurse's nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable manner for managing resources. Option 4 puts the decision and responsibility for performance on ICU nurses. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never take responsibility for a total client care assignment if the nurse doesn't have the skills to plan and deliver that care.

The nurse is assigned to a client with a cardiac disorder. When monitoring body temperature for this client, the nurse should avoid which route?

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first?

When leaving a strict-isolation room, the nurse should remove the gloves first because they're considered the most contaminated. Removing other protective equipment before removing the gloves and washing hands could cause contamination of the hair and uniform and promote pathogen transmission.

Which statement is true concerning informed consent?

When the professional nurse is involved in the informed consent process, the nurse is only witnessing the consent process and doesn't actually obtain the consent. Only a minor who is married or emancipated can give informed consent. Obtaining consent is the responsibility of the physician. Legally, the client must be mentally competent to give consent for procedures.

The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days after discharge. Which client action indicates an accurate understanding of the technique?

When using an incentive spirometer, the client should take slow, deep breaths to ensure maximum ventilation, which elevates the ball (or disc) inside the spirometer. Rapid, shallow breathing doesn't allow maximum ventilation and lung expansion. The client should hold the spirometer upright; when tilted, a spirometer requires less effort to raise the ball. During spirometry, the client should sit upright — rather than lie supine — to promote maximum ventilation.

A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client's status?

Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the most accurate indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn't the most accurate indicator because it can be influenced by numerous factors.

A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention?

Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition but doesn't address poor coughing. Improving airway clearance is too vague. Suctioning isn't indicated unless other measures fail to clear the airway.

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

Which laboratory test result is the most important indicator of malnutrition in a client with a wound?

Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention would help meet this goal?

Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

The nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?

When a child with celiac disease is placed on a gluten-free diet, fat, bulky, foul-smelling stools should be eliminated. This indicates that the disease is controlled and the child is utilizing nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't provide an indication of the effectiveness of diet therapy.

The physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, the nurse identifies which of the following as an intestinal tube?

A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. A Levin tube and a Salem sump tube are nasogastric tubes.

The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother would indicate understanding?

A child with celiac disease must eat a gluten-free diet. If foods containing gluten are eaten, changes occur in the intestinal mucosa that prevent the absorption of foods, especially fats. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch are allowed in a gluten-free diet. Frozen and packaged foods may contain gluten fillers; therefore, they should be avoided.

A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should:

A durable power of attorney transfers all rights that the individual normally has regarding health care decisions to the designated agent. It's within the power of the twin sister to change the physician caring for her terminally ill twin. The dismissed physician has no power to interfere with the wishes of the durable power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit's decision-making process and helps them improve their clinical skills. This nurse is functioning effectively in which role?

A leader doesn't have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager has formal power and authority from the status within the organization and such power and authority are detailed in the manager's job description. An autocrat isn't interested in guiding or encouraging staff or in being an effective role model. Authority, a characteristic of a managerial position, is given by virtue of position within an organization.

To assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:

A pulse oximeter is a noninvasive method of monitoring oxygen saturation. It doesn't measure hemoglobin, PaCO2, or PaO2 levels. Hemoglobin, the main component of the red blood cell that carries oxygen from the lungs, is measured by a simple laboratory test. Arterial blood gas analysis evaluates gas exchange in the lungs by measuring PaCO2 and PaO2.

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

All of these tests help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

A client has suffered an extensive brain injury and can't make his own treatment choices. Which written document is recognized by state law and provides directions for provision of care at a time when the client can't make his own choices?

An advance directive is a document written or completed by the client and used by a facility to provide care at a time when the client can't make his own choices. The living will and durable power of attorney are both examples of advance directives. A living will is a document that's prepared by a competent adult and provides direction regarding medical care if the client becomes incapacitated. Durable power of attorney is an authorization enabling any competent individual to name someone else to exercise decision-making authority on the individual's behalf under specific circumstances. The Patient Self-Determination Act of 1990 allows clients to write instructions for their care and treatment for a time when they become unable to make their own decisions. Those instructions or documents are called advance directives.

Which strategy can help make the nurse a more effective teacher?

An effective teacher always involves the student in the discussion. Using technical terms and providing detailed explanations usually confuse the student and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from the teaching goals.

During discharge teaching, a client with a fractured toe asks the nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?

Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. The other options are inaccurate descriptions of the effects of ice application.

A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication isn't taken, restraints will be applied and the medication will be given by injection. The nurse's statement constitutes which legal tort?

Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standard of care. The client has the legal right to refuse care. In this situation, the correct action is to try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which of the following meals as high in protein?

Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?

Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

When changing the dressing on a pressure ulcer, the nurse notes that the wound has necrotic tissue on the edges. Which action should the nurse anticipate that the physician will order?

Because necrotic tissue won't allow the wound to heal, it must be removed. This is accomplished by debridement. Necrotic tissue can't be removed by incision and drainage, culture, or irrigation. An incision and drainage are performed to drain a wound abscess. A wound culture is taken to identify organisms growing in the wound and to determine appropriate therapy. If the wound is infected, the physician may order irrigation — often with an antibiotic solution — to treat the infection and clean the wound.

During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:

Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective in destroying the hepatitis B virus.

When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?

Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.

Which finding best indicates that suctioning has been effective?

Clear breath sounds, which indicate that secretions have been removed, are the best indicator of effective suctioning. An above-normal respiratory rate, as in option 1, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, as in option 2, may indicate other health concerns. Brisk capillary refill indicates adequate cardiovascular function, not suctioning effectiveness.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed daily.

Standard precautions were designed for the care of all clients in hospitals, regardless of their diagnosis or infection status. Guidelines for standard precautions include:

Disposing of sharp instruments in an impervious container is included in the guidelines for standard precautions. Used needles are never recapped; they should be disposed of in a sharps container. Gloves are used if contact with body fluids is anticipated. Goggles approved by the Occupational Safety and Health Organization are used for eye protection. Eyeglasses aren't an acceptable form of protection because they're open at the sides.

Which nursing theorist addressed self-care deficits in her nursing theory?

Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps the client balance the changes that occur as the client constantly evolves.

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, the nurse will:

Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.

Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?

Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood.

Which nursing action is essential when providing continuous enteral feeding?

Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Because methylene blue can cause adverse effects, it's no longer a recommended enteral feeding additive.

Four clients injured in an automobile accident enter the emergency department at the same time and are immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the:

Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance.

The nurse is preparing to boost a client up in bed and instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) increase the risk of pressure ulcer development. They can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees.

A severe winter storm has prevented most of the staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. The nurse-manager must decide which nursing care delivery system should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which delivery system?

Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system requires the least staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.

Which assessment finding by the nurse contraindicates the application of a heating pad?

Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?

In rheumatic fever, the joints may be so painful that even the weight of the bed linens can cause pain. A bed cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased when the affected joint is moved; therefore, passive range-of-motion exercises aren't recommended. Pain isn't likely to be relieved by massaging the joints. The child should be encouraged to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain.

Which group of clients is at an increased risk for developing a wound infection?

Nutrition plays an important role in wound healing. Vitamins and protein are essential for wound healing; therefore, a malnourished client is at an increased risk for developing a wound infection. Frequent pain medication allows the client to be more comfortable, possibly enabling the client to move about more easily. Ambulation improves circulation and thus promotes better healing. A client who is 15 lb overweight isn't at increased risk.

A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn't volunteered and states, "Forty hours a week of nursing is all I can manage to do. I won't volunteer for overtime." The nurse-manager says to an attending physician on the unit, "I'll adjust her schedule to make her wish she'd volunteered." The physician to whom she commented should:

It's discriminatory and punitive for the nurse-manager to alter the staff nurse's schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It's inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. and indwelling urinary catheters. The nurse should:

It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy.

A client who's scheduled for open heart surgery in 2 days has been having circulation problems in the feet and legs, so the physician orders antiembolism stockings. Now, the nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs; however, blankets can be used for this purpose.

A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn't take precedence over ensuring proper colostomy care. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.

A client with a fecal impaction frequently exhibits which clinical manifestation?

Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite.

A nurse-manager must include which items as part of the personnel budget?

Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Office supplies and videos are part of the day-to-day operating budget. Any expense or single item of equipment costing more than $500 is part of the capital budget

Delegation is the process of transferring work to subordinates. A nurse-manager can appropriately delegate which task?

Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

A client's attorney can file a lawsuit within which time frame?

Statute of limitations is the time period during which a case must be filed or the injured party is barred from bringing the lawsuit. Discovery rule is the actual term for when the client has discovered the injury. The statute of limitations typically gives clients 2 years from the time of discovery to file a lawsuit; however, the time may vary from state to state. Grace period refers to any period specified in a contract during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing is most appropriate for the nurse to apply?

Sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent; however, it can irritate epithelial cells, so it shouldn't be left on an open wound.

Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?

The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.

Which guidelines define and regulate the scope of the nursing professional practice (that is, set rules on what the nurse can and can't do as a professional)?

The Nurse Practice Act is a series of statutes, enacted by each state legislature, that outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice. State legislatures set acts that create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice in that particular facility. Standards of Care, which are criteria that serve as a basis for comparison when evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

A client's blood test results are as follows: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal would be most important for this client?

The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important?

The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.

Which statement is correct regarding the Omnibus Reconciliation Act of 1986?

The federal Omnibus Reconciliation Act of 1986 mandates that all hospitals establish written protocols for the identification of potential organ and tissue donors. The act sets standards for organ procurement agencies. The medical examiner should be notified if the client is a potential organ or tissue donor only if the medical examiner is involved in the case. Requesters for donation are health care professionals who have received special training on properly approaching family members regarding organ or tissue donation

As the nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?

The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.

A client with a history of heart disease is scheduled for cataract surgery when he tells the nurse that he's experiencing chest discomfort and shortness of breath. The nurse administers a nitroglycerin tablet sublingually as ordered by the admitting physician but fails to notify the physician, surgeon, or anesthesiologist. If the client suffers a massive heart attack during surgery, the nurse could be held liable for which malpractice charge?

The nurse has a responsibility to assess and monitor clients who are under the nurse's care. Nurses also have a responsibility to communicate with interdisciplinary health care members particularly if the client's status changes. In this case, the change in the client's status could influence care during surgery and influence the potential outcomes. Failure to act as a client advocate has been recognized by the courts in situations when the nurse fails to develop and implement nursing diagnoses, and fails to exercise good judgment on the client's behalf. Failure to communicate with the client commonly refers to not adequately educating clients regarding care, procedures, or discharge instructions. Failure to protect from harm occurs when health care providers must protect clients because of the client's vulnerable state and inability to distinguish potentially harmful situations.

Which is the role of the nurse in a domestic abuse situation?

The nurse must carefully and adequately document the assessment of the abused victim. The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The victim should be provided with local community resources, social agencies, and legal services as necessary to prevent recurrence of physical abuse. The professional nurse isn't qualified to counsel the abuser or the victim. The abuser as well as the victim should be referred to a professional counselor who's trained in dealing with domestic violence therapy.

Which action by the nurse is essential when cleaning the area around a Jackson-Pratt wound drain?

The nurse should always move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask isn't necessary.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take would be to:

The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense has been broken when the blisters opened; removing the skin exposes a larger area to the risk of infection.

A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time?

The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may lead to inadequate intervention. Calling the family or giving pain medication isn't warranted because the client denies pain.

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?

The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue usually is more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because they can prevent air circulation and hinder drying of the fine-mesh gauze.

The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The other options don't enable communication. The physician must order a tracheostomy plug, which is used when a client is being weaned off a tracheostomy. The call button, which should be in reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable communication

Which concept refers to the role of the professional nurse in client advocacy?

The nurse who understands the advocacy role promotes, protects, and, thereby, advocates a client's interests and rights in an effort to make the client well. The nurse recognizes that the first duty is to protect and care for the client's health and safety. True advocacy encourages and helps clients reach decisions that express their own beliefs and values. The nurse doesn't make decisions for clients but provides care for the acutely ill client with the consent of his significant other. If there's no significant other, a power of attorney or the client's living will will designate care. Standards of care are the basis for providing safe competent nursing care and set minimum criteria for proficiency on the job, enabling the nurse and others to judge the quality of care provided. Paternalism violates self-determination and advocacy by acting for another. A nurse acting as a client advocate helps clients exercise their freedom of self-determination.

A client who's a member of the Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?

The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. Sometimes, the client has signed an advance directive, making his wishes known. An advance directive is a document used as a guideline for starting or continuing life-sustaining medical care; the client commonly has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a decision — based on what's best for the client — is made for an incapacitated client.

A day shift nurse gives a client a medication injection for pain. The nurse forgets to document the injection on the medication administration record (MAR). The day shift nurse reports to the evening shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening shift nurse puts the day shift nurse's initials, date, and time the dose was administered in the appropriate area of the MAR. The action by the evening shift nurse is considered to be which type of documentation error?

This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day shift nurse omitted documenting the administration of pain medication. A late entry refers to an entry entered at a time later than it should have been. If a late entry is necessary, identify it as a "late entry" and document the reference date and time. An improper correction is an entry corrected in an incorrect manner, such as erasing, using "white out," or obliterating the error with a marking pen. Always follow your facility's policy and procedure for documentation guidelines.

When changing a sterile surgical dressing, the nurse first must:

To prevent the spread of microorganisms, the nurse always should wash the hands before providing client care. When changing a sterile surgical dressing, the nurse also must apply sterile gloves, remove the old dressing with clean gloves, open sterile packages, and moisten the dressings with sterile saline. However, these actions follow hand washing.

When moving a client in bed, the nurse can ensure proper body mechanics by:

When moving a client in bed, the nurse stands with her feet apart to establish a wide base of support. To reduce the energy needed to move the client's weight against gravity, the nurse slides, rolls, pushes, or pulls rather than lifts the client. The nurse should flex her knees and use the arm and leg muscles instead of the back. To minimize stress, the nurse stands as close to the client as possible

Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?

Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap dispensers are preferable but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.