the nursing process

A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask a nurse if anything can be done to prevent the other children in the family from developing rheumatic fever. What is the best response by the nurse?

"Be sure that if any of the children have strep throat or scarlet fever they are properly treated with antibiotics."

The nurse reinforces information about self-detection for cancer to a group of adolescent male clients. Which statement made by one of the participants indicates that the client understands the information?

"The best time to check for testicular changes is after a warm bath."

A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan?

"The client remains free of signs and symptoms of phlebitis."

A nurse is caring for a postoperative client. Which nursing intervention should the nurse perform to prevent thrombophlebitis?

Apply a sequential compression device.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order.

A client in her second trimester tells the nurse that she feels very anxious because she is not sure of what will happen when she goes into labor to give birth. Which intervention by the nurse would be most appropriate for this client?

Help her enroll in birth preparation classes at the facility where she plans to give birth.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client?

Maintain a patent airway.

The nursing staff is developing a care plan for a 10-year-old child who is receiving palliative care for end-stage leukemia. The child is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the child's care plan?

Meet with the pain management team to devise a more effective pain control plan.

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best?

Performing mouth care

A nurse is caring for an older adult client who is confused. Which nursing intervention can best help to prevent this client from falling?

Place the client in an area where regular or continual monitoring is possible.

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. What action should the nurse take to assist the client with coping?

Provide a referral to the Cancer Society or another support program.

A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP?

Put a washcloth in the sink to prevent damage the dentures.

After her shift, a nurse remembers that she failed to document a medication that she administered. What should the nurse do?

Return to the client care area and document the medication as given.

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician?

SBAR

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be?

The nurse should ask the person to talk to the family directly.

An older adult client admitted to the hospital with an exacerbation of heart failure is confused, has inadvertently pulled out the IV catheter, and is attempting to get out of bed. The health care provider orders the use of physical restraints. Which nursing action reflects safe nursing care?

Tie the restraints to the bed frame using a quick-release knot.

The nurse receives a medication order from a health care provider over the telephone. Which nursing intervention is a priority when receiving a telephone order?

Verify the order by repeating it back to the health care provider over the phone.

A nurse has completed 4 hours of an 8-hour shift on a medical-surgical unit when the nurse receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that the nurse needs to give report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with the current client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

allocation of scarce nursing resources

The nurse cares for a client who is recovering from general anesthesia. Which finding indicates to the nurse that the client is experiencing a complication?

decreased bibasilar breath sounds

A nurse manager is appropriately using an autocratic method of leading the team. Which situation does the staff nurse determine demonstrates this form of leadership?

directing staff activities if a client has a cardiac arrest

At a previous visit, the parents of an infant with cystic fibrosis (CF) received instruction from the nurse in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents are not administering the pancreatic enzymes as instructed?

fatty stools

The nurse is collecting data on a client. She notes clubbed fingers. This finding indicates:

hypoxia.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

keeping the bed in the lowest possible position.

Which finding indicates to the nurse that a client's peripherally placed intermittent infusion intravenous (IV) site is infected?

redness and drainage around the insertion site of the needle

A nurse manager can appropriately delegate which task?

scheduling staff assignments for the next month

The nurse assesses capillary refill in a client admitted with pneumonia and dehydration. Which capillary refill duration is considered abnormal and should be reported?

4 seconds

A client reports extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure the client?

"These symptoms usually diminish after therapy ends."

A nurse manager notices that a new nurse is violating the dress code by wearing hoop earrings while working. Which statement made by the nurse manager is most appropriate to address this situation?

"Hoop earrings present a safety risk for you and your clients."

The nurse's responsibility concerning informed consent is reflected in which client statement?

"I must be fully informed about treatments, tests, alternative treatments, and the risks and benefits of each."

A 1-year-old child is diagnosed with a congenital cardiac defect after cardiac catheterization. The parents have expressed concern about activities at home. Which response by the nurse would be best when reinforcing education with these parents?

"Allow the child to play and be active as long as the child doesn't get fatigued."

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?

A referral.

A client in a same-day surgery recovery area after repair of an inguinal hernia is alert and takes fluids well. He feels the need to void and has tried using the urinal twice without success. The client is anxious to be discharged. Which action should the nurse take?

Assist the client with standing and using the urinal or toilet.

A nurse reinforces discharge instructions to a client who has undergone cataract removal with an intraocular lens implant. What information should the nurse include?

Avoid straining during bowel movements.

Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client's best interest?

Call a family conference and ask social services for assistance.

A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client?

Encourage the client to ambulate.

The nurse finds an adult client collapsed in the hallway. Which action should the nurse take first when arriving to assist this client?

Establish unresponsiveness.

The nurse is caring for a 2-year-old child suspected of having bacterial meningitis. What is the nurse's priority action?

Evaluate the child's neurologic status.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?

Inform the other nurse that the viewed screen resulted in a breach of confidentiality.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

An older adult client with pneumonia is having difficulty managing respiratory secretions and clearing the airways. Which nursing intervention would be most appropriate?

Monitor the need for suctioning every hour.

A client who underwent surgical repair of a herniated lumbar disk has a physician's order to ambulate during the immediate postoperative period. The client states that he has numbness, weakness, and pain in his leg. How should the nurse intervene?

Notify the physician of the client's concerns.

A nurse in a long-term care facility consistently administers clients' medications 60 to 90 minutes after the scheduled administration time. The nurse also leaves scheduled treatment procedures for nurses to complete on the next shift. Which would be an appropriate strategy for this nurse to pursue?

Seek input and direction on time management and priority setting.

When documenting information in a client's medical record, what should the nurse do consistently for each entry?

Sign each entry by name and title.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take?

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

A primary health care provider has instructed a client to check the radial pulse each morning before taking digoxin. After the nurse reinforces education with the client on how to take a radial pulse, which client behavior indicates an accurate understanding of the technique?

The client uses the middle three fingertips to palpate the radial artery.

A nurse is reinforcing education for a client with allergies about anaphylaxis. What should the nurse be sure to include in this discussion?

Wear a medical identification bracelet.

A nurse is providing care for a client who underwent a mitral valve replacement. Which finding indicates to the nurse that the client is making progress toward a priority goal of treatment by the time of discharge?

ambulating from the room door to the end of the hall and back

A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first?

an older adult client with bacterial pneumonia experiencing periods of confusion

Which nursing intervention should the nurse give highest priority to when caring for an unconscious client?

positioning the client with the head of bed at a 15 to 30 degree angle

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment?

speech therapist

A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as

0800 and 2000

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool."

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client?

Inability to speak clearly

A client expresses a desire to walk to the lobby for discharge to home. The unlicensed assistive personnel (UAP) tells the client that all clients being discharged need to be transferred to the lobby by wheelchair. How will the nurse best respond to protect the client's right of care? Select all that apply.

-"An employee will accompany you to the lobby if you choose to walk." -"The client has the right to walk to the lobby for discharge."

A hospitalized client became seriously ill after a nurse inadvertently gave the client another client's medication. The client contacts an attorney and files a lawsuit after recovering from the injury caused by the medication error. Which individuals would most likely be held liable? Select all that apply.

-the hospital -the nurse