Passpoint Week 4

A an adolescent client has undergone an examination and had evidence collected after being sexually assaulted. Her father is overheard yelling at his daughter, "You're going to tell me who did this to you. What's his name?" Which is the nurse's best response?

"Please come with me, sir. I need some important information."

A client with bleeding esophageal varices and cirrhosis of the liver due to alcoholism asks the nurse, "Will I survive and make it out of the hospital? One of my friends died from the same problem." What is the best nursing response?

"That's a difficult question to answer, and this must be very frightening for you."

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly."

A client gives birth to a neonate at 30 weeks' gestation. The neonate is stable on minimal ventilator settings. The client's previous infant, who was born at 24 weeks gestation, did not survive. The family is Roman Catholic and requests that neonate be baptized as soon as possible. What response by the nurse is most appropriate?

"What would you like me to do to help arrange the baptism?

A nurse is assessing a client's spiritual needs when the client becomes angry and defensive about the questions being asked. What would the nurse say to make the client comfortable?

"You appear upset about these questions. Is this true?"

What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness?

How is your condition affecting your family members and their usual roles?

When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do?

Cover the wet packing with a dry sterile dressing.

What information must a medication order include?

Doctor Signature

The client has decided to continue the pregnancy based on religious beliefs and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate?

Explore the nurse's own feelings about the issues of anencephaly and organ donation.

What should the nurse do to prevent pressure ulcers in an older adult?

Perform a systematic skin assessment at least once a day.

When examining a client who has abdominal pain, a nurse should assess

Sx quadrant last

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 nurse has just received report on four clients. Which client should be seen first?

a client feeling sweaty and requesting antacid for stomach upset

The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should:

inspect the skin at pressure points from the back-lying position.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client?

lactose enzyme deficiency

After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner (NP) program. This nurse has been attracted to the program by the potential after graduation to provide primary care for clients, an opportunity that is most likely to exist in which setting?

A rural health center.

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first?

Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity.

At 8:00 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10:00 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next?

Immediately notify the health care provider of these findings.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. What should the nurse do?

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which is the nurse attempting to enact?

Justice

What is an appropriate nursing action to detect early signs of metabolic complications in a client receiving total parental nutrition (TPN)?

Monitor urine output.

A nurse is completing a home visit to an older adult receiving regular dressing changes for treatment of a venous ulcer. As a provider of home healthcare, the nurse recognizes that the primary goal of this practice is

to maximize the independence and health of clients.