NUR 2449 Mastery Level 3: Basic Care and Comfort

A child with cerebral palsy (CP) is to be taught the four-point alternate crutch gait. The parents ask why this gait was chosen. How would the nurse respond?

"It provides for equal but partial weight-bearing on each limb."

Which interventions are appropriate for the client brought to the hospital with heat exhaustion?

- 0.9% normal saline intravenously (IV) - Placing a moist sheet over the client - Initial fluid bolus to correct hypotension - Placing in a cold area and removing constrictive clothing

According to the nursing process, what is the correct order of steps to take in caring for a client who reports chest pain?

1. Perform a focused assessment on the client. 2. Determine the most appropriate NANDA-I diagnosis for the client 3. Create a care plan to minimize the client's symptoms 4. Administer 2 L of oxygen via nasal cannula

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

Document the normal finding.

Which recommendation would the nurse provide to a pregnant woman who reports leg cramps?

Dorsiflexion of the foot until the spasm passes

Which intervention would the nurse recommend when a client reports moodiness and anxiety a few days before her period?

Exercise three to four times a week in the luteal phase.

Which would the nurse place in temporary shelters without running water that were created for disaster victims to use for toileting?

Hand Sanitizer

According to Hersey's Situational Leadership Model, which type of leadership behavior should the nurse use when delegating client care activities to recently hired, unlicensed assistive personnel (UAP) who appear competent and motivated?

Participating

Which behavior indicates a client has entered the second stage of labor?

Report of feeling pressure on the rectum

Which finding indicates the development of a complication from bilateral cephalohematomas?

Skin Color

Which stage incorporating Meaningful Use is achieved by the nurse documenting basic care in the electronic health record using the system's standardized format?

Stage 1

During an orientation for new nurses, the nurse leader discusses client confidentiality and privacy when using the facility's electronic health record system. Which safeguard would the nurse leader include as the best way to protect client privacy?

System end users