Final L to R
A nurse is preparing a client for discharge from the cardiac unit and observes cigarettes in the client's belongings. The nurse asks the client to consider the client's health and that of the client's spouse. This is an example of: values clarification. moral distress. ethical dilemma. social justice.
values clarification. Explanation: Values clarification is a process that allows an individual to examine and understand what choices to make. Moral distress is the emotional state that arises from a situation when a nurse feels that the ethically correct action to take is different from what the nurse is tasked with doing. An example of this is the nurse taking away the cigarettes out of the client's belongings bag. Ethical distress occurs when a decision is made regarding what one believes to be the right course of action, but barriers prevent the nurse from carrying out or completing the action. The nurse can expect ethical distress if removing the cigarettes from the client's belongings bag. Social justice is a concept of fair and just relations between the individual and society. An example is the selling of cigarettes to those who had a cardiac event. Moral distress, ethical dilemma, and social justice are not reflected in this scenario.
Socialization into the nursing profession may have the most significant effect on: roles. values. documentation. planning.
values. Explanation: Socialization into a culture refers not only to the adoption of practices, such as documentation and planning, and ways of relating to one another (roles) but to the very beliefs that one holds to be most important (values). Because values guide one's practices and roles, the most significant effect of socialization into nursing would be its effect on values
A client asks the nurse how cortisol works. What is the appropriate nursing response? "It strengthens lymphoid tissue." "It increases capillary permeability to prevent tissue swelling." "It suppresses the immune response." "It causes release of proinflammatory mediators."
"It suppresses the immune response." Explanation: Cortisol suppresses the immune response, causes atrophy of lymphoid tissues, decreases capillary permeability to prevent tissue swelling, and prevents release of proinflammatory mediators. It does not strengthen lymphoid tissue, increase capillary permeability, or cause the release of proinflammatory mediators.
Tanner's Clinical Judgement Model
4 FEATURES OF HIS CLINICAL JUDGEMENT MODEL: (NIIR) Noticing (What did you notice?) Interpreting ( What does it mean?) Responding (What will you do?) Reflecting (Did it work?)
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: 6 L/minute. 1 L/minute. 4 L/minute. 10 L/minute.
6 L/minute. Explanation: In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A Penrose drain promotes passive drainage into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.
A Penrose drain promotes passive drainage into a dressing. Explanation: A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure
Which are examples of meeting self-actualization needs according to Maslow's hierarchy of needs? (Select all that apply.) A nurse attains a master's degree in nursing. A nurse refers a client's spouse to an Al-Anon group meeting. A nurse takes a course in communication to better relate to clients. A nurse raises the side rails on the bed of a client at risk for falls. A nurse administers insulin to a client with diabetes mellitus.
A nurse attains a master's degree in nursing. A nurse takes a course in communication to better relate to clients. Explanation: The highest level on the hierarchy of needs is self-actualization needs (Level 5), which include the need for individuals to reach their full potential through development of their unique capabilities.
Which best defines value clarification? A process by which people come to understand their own values and value systems A belief about the worth of something, about what matters, that acts as a standard to guide one's behavior An organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct A systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct
A process by which people come to understand their own values and value systems Explanation: Value clarification is a process by which people come to understand their own values and value systems. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. Ethics is a systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply pressure to insertion site for at least 3 minutes. Ask client to perform Valsalva maneuver. Instruct client to remain flat for 30 minutes. Apply petroleum-based ointment and sterile occlusive dressing.
Apply pressure to insertion site for at least 3 minutes. Explanation: The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.
A middle-aged adult was rushed to the emergency department after sustaining a broken ankle due to a fall. The client only speaks German and the nurse only speaks English. An interpreter was asked to help. Which action(s) should be implemented? Select all that apply. Use metaphors and analogies. Look at the interpreter when asking questions. Ask questions that are answerable by a yes or no. Allow adequate time for the interpreter to translate. Choose an interpreter of the same gender and approximate age as the client. Obtain the interpreter's advice when dealing with sensitive or delicate topics. Allow a family member to help with the translation.
Ask questions that are answerable by a yes or no. Allow adequate time for the interpreter to translate. Choose an interpreter of the same gender and approximate age as the client. Obtain the interpreter's advice when dealing with sensitive or delicate topics.
A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? Asking the client when he or she had last urinated Determining any pain when palpating the lower abdomen Palpating the bladder above the symphysis pubis Obtaining the bladder scanner to check the urine volume
Asking the client when he or she had last urinated Explanation: In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.
When examining values, a nurse notes that one country allows assisted suicide and another outlaws it, making it punishable by imprisonment. Which factors best explain the differences in values between these two countries? Economic Spiritual Ethical Cultural
Cultural Explanation: Daily living is expressed in many traditions and customs; understanding these differences is cultural value orientation. Because it is primarily culture that determines a society's values, cultural factors best explain the differences in values between these two countries. Although economic, spiritual, and ethical factors may be involved in value formation, a society's value system is most influenced by culture.
Which ethical principle refers to the obligation to do good? Fidelity Beneficence Veracity Nonmaleficence
Beneficence Explanation: Beneficence is the duty to do good and the active promotion of benevolent acts. Fidelity refers to the duty to be faithful to one's commitments. Veracity is the obligation to tell the truth. Nonmaleficence is the duty not to inflict, as well as to prevent and remove, harm; however, there will be times when the action may cause "harm" to promote the "good" such as chemotherapy being used to treat and eliminate cancer, but it causes various adverse effects while trying to reach the ultimate goal..
A client is scheduled for a colonoscopy. The nurse realizes immediately after administering medications to induce conscious sedation that the client has not signed the informed consent. If the nurse has the client sign the informed consent at this point, which element of informed consent would be violated? Disclosure Comprehension Competence Voluntariness
Competence Explanation: The client under conscious sedation would not be considered competent to make a decision to undergo an invasive procedure such as a colonoscopy. Disclosure ensures that the following information has been given to the client: the nature of the treatment, possible alternative treatments, and potential risks and benefits of the treatment. Comprehension is met when the client demonstrates understanding by describing in the client's own words to what he is consenting. The client's consent must be given voluntarily
Which action should the nurse associate with outcome identification and planning in the nursing process? Decides whether to continue, modify, or terminate nursing care. Develops a prioritized list of problem-based nursing concerns. Develops an individualized plan of nursing care. Determines the client's health status, self-care ability, and need for nursing.
Develops an individualized plan of nursing care. Explanation: In the process of outcome identification and planning, the nurse adapts the identified nursing concern to address the client's strengths, thereby individualizing the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.
Which step of the nursing process involves reporting or analysis of data to identify and define health problems? Assessment Diagnosis Planning Implementation
Diagnosis Explanation: During the second phase of the nursing process (diagnosis), the nurse reports or analyzes data to identify and define health problems that independent or health care provider-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.
The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs? Discussing the client's strengths and dialoguing about body image Encouraging the client to talk about previous accomplishments and goals for the future Reorganizing care and facilitating a day pass so that the client can spend Thanksgiving with family Encouraging the client's friends and family to take an active role in the client's care at the hospital
Discussing the client's strengths and dialoguing about body image Explanation: Aspects of self-actualization include focusing on clients' strengths and fostering a positive body image. Addressing accomplishments and goals is likely to meet clients' self-esteem needs. Facilitating contact and connection between clients and their families is an action that promotes meeting love and belonging needs, as is reorganizing care and facilitating a day pass so that the client can spend Thanksgiving with family.
Which statement best conveys the concept of ethical agency? Ethical practice requires a skill set that must be conscientiously learned and nurtured. Individuals who enter the nursing profession often innately possess ethical characteristics. Ethical practice is best learned and fostered by surrounding oneself with people who exhibit ethical character. A nurse's understanding and execution of ethical practice is primarily a result of increased years of experience.
Ethical practice requires a skill set that must be conscientiously learned and nurtured. Explanation: Ethical agency must be cultivated in the same way that nurses cultivate the ability to do the scientifically right thing in response to a physiologic alteration. It is inaccurate to assume that it will passively develop from the presence of other ethical practitioners, or from years of experience. It is not an innate characteristic of personality
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner? Gentamicin 70 mg intramuscular (IM) every 8 hours Blueberry juice 10 oz by mouth (PO) daily Urine dipstick four times a day Encourage fluids intake - 2 to 3 L per day
Gentamicin 70 mg intramuscular (IM) every 8 hours Explanation: Gentamicin is known to be nephrotoxic, so the nurse will check with the health care practitioner before administering it. Because glucose acts as an excellent medium for bacteria to grow, a client with diabetes would be monitored for spillage of glucose using a dipstick. Blueberry juice is given to inhibit bacteria from adhering to the urinary bladder. Fluids are encouraged to help flush the renal system.
A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. Help the client into a Sims' position. Cool the container holding the solution. Compress the container as the solution instills. Wipe the lubricated tip of the container before insertion. Encourage the client to retain the solution.
Help the client into a Sims' position. Compress the container as the solution instills. Encourage the client to retain the solution. Explanation: When administering a hypertonic enema solution to a client, the nurse should assist the client in a Sims' position because this position promotes gravity distribution of the solution. Compressing the container as the solution instills provides positive pressure, rather than gravity, to instill fluid. Encouraging the client to retain the solution for 5 to 15 minutes promotes effectiveness. The nurse should warm, not cool, the container containing the solution for client comfort. The nurse should apply additional lubricant, not wipe the lubricated tip of the container, before insertion.
A nurse manager receives negative survey results citing a decrease in the quality of client care. Which areas should the nurse manager research as causative factors in the decrease of quality care delivery? Select all that apply. Inadequate staffing patterns Increase in acuity of clients on the unit Nurses working 12-hour shifts Decreased satisfaction of nurses in the workplace Nurses working weekends
Inadequate staffing patterns Decreased satisfaction of nurses in the workplace Explanation: Two of the chief reasons nurses cite for the declining quality of nursing care at their facilities are inadequate staffing and decreased nurse satisfaction. Nurses working 12-hour shifts and on weekends and increased acuity of clients are not cited in the literature as causes of declining quality of client care.
A parent of a 17-year-old high school student is allowing the child to decide which college the child will attend. When the child requests direction from the parent in making this decision, the parent responds by stating, "You will need to make this decision on your own." What type of value transmission is the parent displaying? Laissez-faire Modeling Moralizing Responsible choice
Laissez-faire Explanation: This situation demonstrates laissez-faire value transmission, which is characterized by allowing the adolescent to explore values independently and the development of a personal value system. The laissez-faire approach involves little or no guidance and can lead to confusion and conflict. Through modeling, children learn that which is of high or low value by observing parents, peers, and significant others. The moralizing mode of value transmission teaches a complete value system and allows little opportunity for the weighing of different values. Responsible choice encourages children to explore competing values and to weigh their consequences while support and guidance are offered.
A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? Remove the tubing and discontinue the procedure. Lower the solution container and check the temperature and flow rate. Place the client on a bedpan in the supine position while receiving the enema. Reposition the rectal tube and check for any fecal content.
Lower the solution container and check the temperature and flow rate. Explanation: If the client experiences severe cramping when the enema solution is introduced, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. A client should not be placed on a bedpan until after the rectal tube is removed. The rectal tube does not need to re-positioned or removed.
A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal. For each assessment finding click to specify if the finding indicates the client's condition is normal or abnormal. Assessment Finding Normal or Abnormal round thorax irregular respiratory pattern thoracic breathing respiratory rate of 28/min inspiration longer than expiration
Normal irrrespiratory rate of 28/min``` irrregular respiratory pattern. Abnormal thoracic breathing inspiration longer than expiration irregular respiratory pattern round thorax Explanation: The normal respiratory rate for a 3-year-old child is between 20 and 32 breaths/min, depending on the source used. It is a normal finding for children up to 5 years of age to have an irregular respiratory pattern. It would be abnormal for a 3-year-old child to have thoracic breathing, because children up to 5 years of age demonstrate irregular breathing patterns. For these children, the parent can expect to find the expiration is longer than the inspiration. The thorax of a 3-year-old child should be eliptical, not round
A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training? "Your child will tell you when there is a sensation of bladder fullness." "One signal of preparedness is when your child is dry for at least 2 hours." "Your child should be at least 2 years old before you start toilet training." "Girls typically take longer than boys to be ready for toilet traini
One signal of preparedness is when your child is dry for at least 2 hours." Explanation: A child is typically 2 to 3 years old before beginning toilet training, although this does depend on the culture. The child signals readiness by staying dry for longer periods, usually at least 2 hours. The child may feel a sensation of bladder fullness, but may not necessarily be able to express this. Boys may take longer to be ready for toilet training than girls.
A student nurse has been benefiting from the experiential learning in the simulation laboratory. In this setting, the student has gained a wide variety of experiences and has the goal of transforming nursing behavior. To link experiences with transformation, what will the student do? Perform intentional personal reflection. Replicate familiar experiences whenever possible. Teach a more junior student how to perform entry-level skills. Provide self-feedback before receiving feedback from others.
Perform intentional personal reflection. Explanation: In experiential learning, the cyclic nature of learning is driven by concrete experience, termed prehension, followed by reflective observation, which leads to the formation of abstract concepts that are then tested in new situations through experimentation, the integration of which is termed transformation. Reflection is the key to deriving growth from experiences, more so than delaying feedback, repeating experiences, or teaching others
The nurse is caring for an older adult client who has had a condom catheter applied. Which intervention will the nurse include in the care of this client? Perform thorough skin care daily. Change the condom catheter every other day. Make sure the condom sheath is secured tightly to the penis. Ensure the tubing is flush to the tip of the penis.
Perform thorough skin care daily. Explanation: Clients with condom catheters (also known as urinary sheaths), require thorough skin care daily to prevent skin breakdown. The condom sheath should be changed daily, not every other day. The condom sheath should be secured in place, but should not be tight on the penis for risk of reduced blood flow/damage. Drainage tubing should be 1 to 2 in (2.5 to 5 cm) from the tip of the penis to prevent urine irritating the glans
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged? Recalling a sequence of events Identifying a positive situation Thinking about relationships involved Reevaluating experience in light of ideas
Reevaluating experience in light of ideas Explanation: Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.
The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication? Administer 10 gtt/min over 30 seconds Ensure 50 gtt/min is given over 1 minute Regulate flow to allow 25 gtts every 15 seconds Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds
Regulate flow to allow 25 gtts every 15 seconds Explanation: Administration may be achieved by gravity infusion, which requires the nurse to calculate the infusion rate in drops per minute. If using a gravity or free-flowing IV, calculate the drip rate required to achieve the desired infusion rate. A standard formula using dimensional analysis method to calculate is gtts/min (drops per min) is below. 1000 mL X 1 hour X 60 gtt = gtt/min = 60000 = 100 gtt/min (Why = Cancel units = mL units cancel each other, hours cancel each other, left with the units = gtts/min) 10 hours 60 min mL 600 The nurse can consider placing a time tape on the infusion bag to monitor hourly infusion rates and serve as a quick reference to monitor the rate at which the solution is entering the client. The tape gives an hourly indication of where the fluid level should be at a given time to avoid fluid infusing too quickly.
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? Safety and security Self-esteem Love and belonging Self-actualization
Safety and security Explanation: Nurses carry out a wide variety of activities to meet clients' physical safety needs, such as moving and ambulating clients. Assisting the client to ambulate ensures that the client will not experience a fall. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self-actualization. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes interpersonal relationships. Human behavior is driven by needs, one of which is the need for a sense of personal importance, value or self-esteem. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life, in particular.
The nurse is holding a cholesterol screening at a local pharmacy this Saturday morning. What level(s) of health promotion is this screening an example of? Primary Secondary Tertiary All three levels
Secondary Explanation: Screenings, such as those for blood pressure, cholesterol, glaucoma, HIV, and skin cancer, are considered nursing activities that fall under the category of secondary health promotion. Secondary health promotion and illness prevention focus on screening for early detection of disease, with prompt diagnosis and treatment of those found. Secondary health promotion involves measures that actually help prevent disease from occurring in the first place, such as a presentation to school children about healthy food choices and the importance of being active
The nurse recognizes that the client who makes the decision to accept a new diagnosis and follow the prescribed treatment plan is in which stage of an illness? Stage 1-Experiencing symptoms Stage 2-Assuming the sick role Stage 3-Assuming a dependent role Stage 4-Achieving Recovery
Stage 3-Assuming a dependent role Explanation: Stage 3 is characterized by the client's decision to accept the diagnosis and follow the treatment plan. Stage 1 is the beginning of symptoms. Stage 2 is where a client describes himself or herself as being sick and seeks validation from others. Stage 4 is recovery and rehabilitation and is the final stage of the illness.
The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion? Primary Secondary Tertiary Chronic
Tertiary Explanation: Tertiary health promotion and illness prevention begin after the illness is diagnosed and treated, with the goal of reducing disability and helping to rehabilitate to a maximum level of functioning. Educating a client with diabetes on how to recognize areas of risk for the disease is one such example of tertiary promotion. Primary promotion is focusing on educating the client to potential risks. Secondary promotion is screening. There is not a chronic promotion component.
When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor? The client eats five to six small meals per day. The client traveled to South America two weeks ago. The client takes bisacodyl every day. The client drinks 8 glasses of fluid daily.
The client takes bisacodyl every day. Explanation: Habitual use of laxatives such as bisacodyl may cause of chronic constipation. Traveling to South America usually causes a client to develop traveler's diarrhea. Drinking eight glasses of fluid daily promotes bowel elimination. Consuming five to six small meals per day should not contribute to constipation.
The nurse is preparing a care plan for a client with altered gas exchange in the lower airways. What short-term outcome is best for this client's care plan? The client will have clear breath sounds. The client will have decreased work of breathing. The client will maintain a pulse oximeter reading of greater than 94% (0.94). The client will maintain a respiratory rate between 12 and 20 breaths/min.
The client will maintain a pulse oximeter reading of greater than 94% (0.94). Explanation: Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Outcomes are created to specify a resolution to the identified nursing concern, such as altered gas exchange in the lower airways. Maintaining a pulse oximeter reading greater than 94% (0.94) specifies a resolution to this concern. Having clear breath sounds, decreased work of breathing, and a normal respiratory rate only assures that the airway is established but not that gas exchange is taking place to its fullest extent
Which is the best definition of ethics? The formal, systematic study of moral beliefs The informal, systematic study of moral beliefs The adherence to formal personal values The adherence to informal personal values
The formal, systematic study of moral beliefs Explanation: Ethics is a formal, systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil as they relate to human conduct and human flourishing. "Morals" usually refers to personal or communal standards of right and wrong
A client is being prepared for an elective surgical procedure and the consent form has not been signed. Who should the nurse have obtain consent for the procedure? The health care provider performing the surgical procedure The client's family or significant other The perioperative nurse The nursing supervisor
The health care provider performing the surgical procedure Explanation: The nurse should inform the surgeon the consent has not been signed. Obtaining informed consent is the responsibility of the person who will be performing the diagnostic or treatment procedure or the research study. In this particular case, the surgeon, the client, and a witness, all need to sign the consent form. The nurse's roles are to confirm that a signed consent form is present in the client's chart and to answer any client questions about the consent.
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? The largest part of a regular bedpan should be placed under the client's buttocks. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.
The largest part of a regular bedpan should be placed under the client's buttocks. Explanation: The rounded, smooth upper end of the regular bedpan is designed to be placed under the buttocks. Because a regular bedpan is much larger than a fracture bedpan, it is usually less comfortable. Choice of bedpan is based on client characteristics rather than type of elimination. A fracture bedpan can be used for any client
Which description clearly indicates that the nurse is applying Tanner's Clinical Judgment Model (CJM) in clinical practice? The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting. The nurse consistently follows a sequence of assessing, diagnosing, intervening, and evaluating. The nurse prioritizes the needs of the client, followed by the family, the support network, and the community. The nurse demonstrates situational awareness by reconciling competing demands according to risk and immediacy.
The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting. Explanation: Tanner's Clinical Judgment Model (CJM) is a cyclical, iterative process that encompasses the domains of noticing, interpreting, and reflecting. Situational awareness is consistent with the use of a CJM but does not directly suggest the use of this particular CJM. The use of the nursing process is consistent with the CJM, but it is possible to follow the nursing process without applying Tanner's CJM. Similarly, it is possible to prioritize client needs and assign importance to other groups on a stepwise basis without implementing Tanner's CJM.
The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client? excessive use of laxatives diaphoresis acute kidney injury increased cardiac output
acute kidney injury Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive acute kidney failure. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.
The nurse is caring for a client who has an upper gastrointestinal bleed as a result of excessive use of nonsteroidal anti-inflammatory drugs (NSAIDs). The nurse recognizes that the root of the client's health problem is inhibited platelet action. The nurse considers the inhibited platelet action to be: an etiologic factor. a sign. a symptom. a diagnosis.
an etiologic factor. Explanation: Etiologic factors are the root phenomenon that results in signs and symptoms, such as bleeding. The client's bleeding is a result of the inhibitory action of the NSAIDs on platelet function. "Upper GI bleed" is the client's diagnosis
A novice nurse has entered a two-bed hospital room to discover a client acting out physically and another client reporting a new onset of chest pain. In addition, the overhead P.A. system is reporting a code blue in a nearby room. These rapid and numerous changes are likely to immediately challenge the nurse's: cognitive load. evaluation of care. level of arousal.
cognitive load. Explanation: Cognitive load refers to the amount of information a person can hold in their memory at one time. Disparate and numerous stimuli can overwhelm the nurse's cognitive load, especially among novices. Reflection-on-action is a phenomenon that occurs after a clinical encounter has been completed, similar to evaluation. Multiple stimuli will increase, rather than challenge, the nurse's level of arousal
A nursing student has drawn on resources from many organizations while learning and practicing as a student nurse. For which action will resources from the American Nurses Association be appropriate? determining whether an advanced wound care technique is within the scope of practice preparing for the National Council Licensure Exam (NCLEX) identifying the conceptual framework that underlies the nursing curriculum participating in a unionization campaign in a local health care system
determining whether an advanced wound care technique is within the scope of practice Explanation: The American Nurses Association (ANA) performs several important roles related to nursing practice. However, it is unique in producing the Nursing: Scope and Standards of Practice. The ANA does not administer the NCLEX nor does it participate directly in labor matters related to collective bargaining.
A 57-year-old man is suffering from polyuria. What can cause polyuria? diabetes insipidus renal disease urinary tract infection renal calculi
diabetes insipidus Explanation: Untreated diabetes insipidus can cause an increase in the formation and excretion of urine without a concurrent increase in fluid intake. Renal disease often leads to oliguria and even anuria, a decrease in urine outputs. Urinary tract infections cause an increase in frequency but not necessarily an increase in the amount of urine that is produced. Renal calculi can cause hematuria.
The nurse applies Tanner's Clinical Judgment Model while providing care on a busy medical unit. Which of the nurse's actions demonstrates reflection-in-action? debriefing with the care team following a code blue that resulted in a client's death gauging the effectiveness of a teaching session by monitoring the client's changing body language journaling about a client's family conflict that the nurse observed participating in an in-service focused on building empathic listening skills
gauging the effectiveness of a teaching session by monitoring the client's changing body language Explanation: Reflection-in-action occurs when actively engaged in the situation and during ongoing monitoring and assessment; reflection-on-action, which mirrors a debrief or postconference, occurs after the situation and drives clinical learning. Journaling also exemplifies reflection-on-action. In-service learning equips the nurse to provide better care but does not have the immediacy of reflection-in-action.
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? hyponatremia hypokalemia hypercalcemia hypermagnesemia
hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing: oliguria. anuria. nocturia. polyuria.
oliguria. Explanation: Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output. Nocturia is nighttime awakening to void. Polyuria is greatly increased urine production
The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of: protein. calculi. pus. casts.
pus. Explanation: Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI
The nurse is applying the NCSBN's Clinical Judgment Measurement Model during an encounter with a client. Place the steps of the Clinical Judgment Measurement Model in the correct sequence. Use all options. 1recognize cues 2analyze cues 3prioritize hypotheses 4generate solutions 5take actions 6evaluate outcomes
recognize cues analyze cues prioritize hypotheses generate solutions take actions evaluate outcomes Explanation: NCSBN's Clinical Judgment Measurement Model is a linear model with six discrete steps: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes.
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply. apply deep pressure rub in a side to side motion rub in a circular motion use a back and forth motion apply alcohol after the chlorhexidine
rub in a side to side motion use a back and forth motion Explanation: The nurse would prepare the site with a single application of 2% chlorhexidine in 70% isopropyl alcohol, using gentle pressure in a side to side, back and forth motion. For clients with chlorhexidine allergies, the nurse would use povidone-iodine swabs, using an expanding circular motion, allowing one minute contact time and removing the povidone-iodine with an alcohol pad.
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation secondary intention tertiary intention
secondary intention Explanation: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.
