FOUNDATIONS PASSPOINT "THE NURSING PROCESS"
Which client is the most appropriate candidate for outpatient care? A client with a history of depression who is currently expressing suicidal ideation. A client whose reports of irregular bowel movements have necessitated a colonoscopy. A woman who has previously borne two children and is entering the second stage of labor. A client who is receiving treatment for sepsis after their blood culture came back positive.
A client whose reports of irregular bowel movements have necessitated a colonoscopy. Outpatient services are appropriate for those who are medically stable but require diagnostic testing, such as a colonoscopy. Clients who are in active labor, have sepsis, or are suicidal require close monitoring and frequent interventions that can be safely provided only on an inpatient basis.
A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation that followed myocardial infarction. Keeping in mind that the client speaks English as a second language, how should the nurse conduct the interview? The nurse should ask the client to express himself emotionally. The nurse should avoid using complex medical terminology. The nurse should sit at a long distance from the client. The nurse should ask closed-ended questions.
The nurse should avoid using complex medical terminology. The nurse should avoid using medical terminology and make the examination as simple as possible. People who speak English as a second language may not understand medical terminology. They may feel embarrassed to ask the nurse to repeat the information again. It is not necessary to sit at a long distance and the questions may be either closed-ended or open-ended. The acceptability of emotion is rooted in culture not necessarily in language.
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? "Monitor fluid intake and output every 4 hours." "The client remains free of signs and symptoms of phlebitis." "Edema and warmth are noted at I.V. insertion site." "There is a risk for infection related to I.V. insertion."
"The client remains free of signs and symptoms of phlebitis." "The client remains free of signs and symptoms of phlebitis" is an appropriate expected outcome. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Risk for infection related to I.V. insertion is a nursing diagnosis.
Which approach is the best way for the nurse to begin the preoperative interview? Walk into the client's room and first Ask, "Are you Mrs. Smith?" ask the client's name. Inquire about how the client is feeling. Make an introduction.
ask the client's name. The nurse should first verify who the client is by asking the client to say their name. The nurse should also check the client's identification band. Using the client's name can be misleading as clients with hearing loss, confusion, or dementia or other health problems or who many not speak English may answer yes, even though they are not the client. Once the nurse is assured of the client's identity the nurse can introduce themselves and ask about how the client is feeling.
A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit to suture the laceration. Which issue should be resolved before proceeding with suturing? bupivacaine with epinephrine used as the local anesthetic the cosmetic effect from not having a plastic surgeon do the suturing the client's room as an aseptic environment the intern's ability to suture
bupivacaine with epinephrine used as the local anesthetic The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of extremities. The nurse should suggest that the intern use bupivacaine without epinephrine as the local anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic effect should be acceptable. The client's room should be a sufficiently aseptic environment because there is no other client in the room.
What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home? checking the cleanliness of the home, ensuring removal of clutter, and organizing all essentials on one level of the house. reinforcing the importance of having renovations done before discharge to enable wheelchair access and accessibility to all needs for daily living. checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment. ordering a wheelchair, special utensils, and a raised toilet seat and rearranging the furniture in the home.
checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home.
The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions? delegation advocacy networking clinical coordination
delegation The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation.
A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action? small amount of creamy yellow drainage reddened wound edges moderate pinkish to red watery drainage epithelizing tissue present
small amount of creamy yellow drainage Yellow, creamy drainage describes purulent discharge and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered. Clear pink to red watery discharge describes serosanguinous discharge, which is evidence of some edema at the site; it does not warrant immediate intervention. Reddened wound edges are expected as healing occurs, and epithelizing tissue represent normal findings for a wound.
A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? "I can still eat a ham and cheese sandwich with pickles for lunch." "I will have bacon and eggs for breakfast every day." "I chose a tossed salad with olives and oil and vinegar dressing for lunch." "I chose broiled chicken with a baked potato for dinner."
"I chose broiled chicken with a baked potato for dinner." The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, pickles, olives, and bacon are all extremely high in sodium and should not be included in a low-sodium diet.
A nurse preceptor is reviewing documentation by a new nurse. Which chart entry would require the preceptor to provide instruction about appropriate notation? Angrily stated, "My doctor is rude." Offered the name of another personal healthcare provider. Clonidine given for BP 168/90; after 30 minutes BP 130/80. Sat quietly in bedside chair reading. Applied gauze dressing to a 1-cm draining open sore on left lateral elbow.
Angrily stated, "My doctor is rude." Offered the name of another personal healthcare provider. Documentation should contain data describing information the nurse obtains through the special senses of hearing, touch, vision, or smell. The documentation should be specific, precise, and accurate. It should not contain judgmental information but may contain descriptions of actions and quotes of what a client said. The nurse should support clients' decisions but should not interfere with the doctor-client relationship.
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. What should the nurse do first? Activate the "Emergency Response" button. Assist the client back to bed. Ask what the client was doing out of bed. Assess the client's current condition and vital signs.
Assess the client's current condition and vital signs. The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury. The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury. Although it may be helpful to know what the client was doing out of bed to assess for potential confusion, the client's immediate safety is the first priority. The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.
The nurse uses which part of the SBAR acronym when stating, "The client is dry." Recommendation. Situation. Assessment. Background.
Assessment. SBAR stands for Situation, Background, Assessment, and Recommendation. It is a proven standardized method of communication between members of the health care team and a client's condition. SBAR is used as a standardized method of hand-off communication. A hand-off is a transfer of responsibility from one caregiver to another caregiver. The information communicated during a hand-off must be accurate, with minimal interruptions, in order to meet client safety needs.
A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? Secure the restraints to side rails of the bed. Remove the restraints every 4 hours to provide skin care. Check on the client every 30 minutes while the restraints are on. Instruct the client not to move while the restraints are in place.
Check on the client every 30 minutes while the restraints are on. The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.
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? Confirm that the client is on the unit but offer no further details. Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Notify security that the visitor viewed confidential client information. Validate the relationship of the visitor to the client before discussing the client's status.
Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.
A client with Alzheimer's disease is brought to the emergency department. What would the nurse include in a focused plan of care? Provide consistent and familiar care to the client. Offer varied nursing care to decrease staff burnout. Provide a darkened room with a non-stimulating environment. Plan for two nurses to observe the client, as the care will be challenging.
Provide consistent and familiar care to the client. Familiarity provides a sense of security, promotes safety, and may reduce client stress. All the other choices do not promote a focused care plan reflective of Alzheimer's disease. This disease in an acute phase needs a plan that provides the least amount of change and stress.
The nurse discusses with parents how best to raise the IQ of their child with Down syndrome. Which intervention would be most appropriate? Provide stimulating, nonthreatening life experiences. Serve hearty, nutritious meals. Give vasodilator medications as prescribed. Let the child play with more able children.
Provide stimulating, nonthreatening life experiences. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as beneficial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child's IQ.
A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? arterial oxygen level of 46 mm Hg (6.1 kPa) respirations of 12 breaths/min lack of adventitious lung sounds oxygen saturation of 96% on room air
arterial oxygen level of 46 mm Hg (6.1 kPa) Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with an arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 breaths/min is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.
Which action performed by a nurse will increase the risk of liability? Select all that apply. assisting a client on ordered bed rest to walk to the toilet witnessing a client sign a consent for an ordered medical procedure providing information to a caller about a client's diagnosis and treatment withholding a medication to clarify the ordered dosage asking unlicensed assistive personnel to assess a client's wound
assisting a client on ordered bed rest to walk to the toilet providing information to a caller about a client's diagnosis and treatment asking unlicensed assistive personnel to assess a client's wound Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel, who does not have the proper training or skills to perform the task. The nurse should not act against physician orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client's consent.
A client has received numerous different antibiotics and now is experiencing diarrhea. What type of precautions should the nurse institute? airborne precautions contact precautions droplet precautions standard precautions
contact precautions The nurse should initiate contact precautions to prevent blood-borne infection through percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp objects are handled. Airborne precautions are required for clients with presumed or proven pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridioides difficile. Droplet precautions are used for organisms such as influenza or Neisseria meningitidis that can be transmitted by close respiratory or mucous membrane contact with respiratory secretions. Standard precautions include handwashing and the use of a mask and gown.
After a stroke, a client develops aphasia. The nurse expects to see which assessment finding? arm and leg weakness absence of the gag reflex difficulty swallowing inability to speak clearly
inability to speak clearly Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a stroke but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method? pulling the ear pinna out pulling the ear pinna down pulling the ear pinna back, up, and out pulling the ear pinna back, down, and out
pulling the ear pinna back, up, and out Pulling the pinna back, up, and out helps straighten an adult's ear canal so the nurse can properly place a tympanic thermometer probe. Pulling the ear pinna back, down, and out straightens a child's ear canal. Pulling the ear pinna only out or back does not straighten the ear canal for probe placement.
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? respiratory therapist physician physical therapist speech therapist
speech therapist The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of speech therapists. The physician should be made aware and respiratory therapy may be involved with assessing and promoting the client's oxygenation but swallowing assessment is a task most often performed by a speech therapist.
A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as the relationship between law and culture moral values are considered to be universal the principles that determine whether an act is right or wrong the laws that govern acceptable and unacceptable behavior
the principles that determine whether an act is right or wrong Ethics involves moral or philosophical principles that direct actions as being either right or wrong. Laws are often rooted in ethics but the two terms are not synonymous. Similarly, morals and values are closely associated with ethics but these do not constitute the definition of ethics. Ethics are not universally agreed upon, as many different applications exist.
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in their urine a client at 37 weeks' gestation who is has insulin-dependent diabetes and is experiencing three to four fetal movements per day a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain a client at 17 weeks' gestation who is not feeling fetal movement at this point in the pregnancy
a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain A client with preeclampsia who has +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the client and the fetus. Thus, this client would be the highest priority. The client at 13 weeks' gestation with nausea and vomiting is a concern because the presence of ketones indicates that the client's body does not have glucose to break down. However, this situation is a lower priority than a client with preeclampsia or a client who is insulin dependent. The client with insulin-dependent diabetes is a high priority; however, the fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need additional testing to further evaluate fetal well-being.) The client who is at 17 weeks' gestation may be too early in their pregnancy to experience fetal movement and would be the last person to be seen.
A nurse has made a medication error. Which information is appropriate to include in the incident report? what the nurse saw and did the client's statement about the incident that occurred the extenuating circumstances involved in the situation an interpretation of the likely cause of the incident
what the nurse saw and did The incident report includes only what the nurse saw and did—the objective data. The nurse does not try to interpret the likely cause of the incident, include statements from the client about the incident, or comment on extenuating circumstances.
During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client? use of all drugs taken in the last 18 months over-the-counter medication use in the last 6 weeks current use of medications, herbs, and vitamins steroid use in the last year
use of all drugs taken in the last 18 months The nurse does not need to ask about all drugs used in the last 18 months unless the client is still taking them. The nurse does need to know all drugs the client is currently taking, including herbs and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the amount of alcohol consumed, and use of illegal drugs, because these can interfere with the anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal cortex for up to 1 year, and supplemental steroids may need to be administered in times of stress such as surgery.
The nurse performs wellness checks in the pediatric clinic. Which child would the nurse assess as demonstrating behaviors that need further evaluation? 2-year-old who is indifferent to other children and adults and is mute 10-year-old who frequently tells their parent that they are going to run away whenever they argue 6-year-old who sucks their thumb when tired and has never spent the night with a friend 2-year old who refuses to be toilet trained and talks to themself
2-year-old who is indifferent to other children and adults and is mute Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to themself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child.
Which source of information helps a nurse formulate nursing diagnoses for a specific client? Research articles Essential assessment data Outcome criteria Admission criteria
Essential assessment data The nurse formulates nursing diagnoses after completing the assessment or data collection step in the nursing process. Analyzing essential assessment data and identifying the specific signs or symptoms and probable cause help the nurse diagnose the client. Research articles provide information related to developing current interventions, but they don't help the nurse formulate nursing diagnoses. The nurse formulates outcome criteria after (not before) nursing diagnoses. Admission criteria may help her formulate the diagnoses but won't do so without essential assessment data.
A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which would be the most appropriate response by the nurse to the surgeon? "I will explain the procedure and call you back if the client won't sign the consent." "I will get the consent signed right away and attach it to the chart." "I'll have the client sign, but you must explain the procedure before surgery." "It is your responsibility to obtain informed consent from the client."
"It is your responsibility to obtain informed consent from the client." It is the surgeon's responsibility to obtain the informed consent after explaining the procedure to the client, including the risks, benefits, and alternatives. The other options are incorrect because they place the responsibility for obtaining informed consent on another person.
In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning? assessing the client's needs and identifying problems making home healthcare referrals providing client teaching developing goals with the client
providing client teaching The nurse is teaching the client important information about self-care at home prior to discharge. The initial step in discharge planning is collecting and organizing data about the client because this provides information on the client's healthcare needs. Home referrals may be made after the teaching process based upon orders provided by the physician. Developing goals may occur after the teaching process because the goals need to be realistic.
A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP? "Why weren't you there to help the client get to the bathroom?" "Your behavior in this situation is considered verbal abuse." "You need to have more training in therapeutic communication." "I'm sure you didn't mean to hurt the client's feelings, but you did."
"Your behavior in this situation is considered verbal abuse." Reprimanding a client for something that is beyond the client's control is considered abusive. The other options do not help the UCP understand the abusive behavior.
A nurse wants to ensure inclusiveness in language regarding family when developing a plan of care for a client. Which action is the most important for the nurse to take to ensure that the plan is inclusive? Ask the client who is living in the same household. Ask the client to identify who is considered family. Ask the client who is legally related. Ask the client for a list of blood relatives.
Ask the client to identify who is considered family. In a client's plan of care, family consists of people identified by the client as family members. The other options may be accurate, too, but in order to create a client-centered care plan, all members identified by the client should be included as family.
The nurse works to reduce the number of children involved in automobile crashes who were not wearing seat belts. Which strategy is the most effective? Contact the local government representative to discuss new legislation about child seat belts. Attend a school board meeting to advocate for classes teaching children seat belt safety. Call the town mayor's office with this information so that the mayor can discuss it with the media. Start a letter-writing campaign to the school superintendent about seat belt importance.
Attend a school board meeting to advocate for classes teaching children seat belt safety. The best strategy to affect child seat belt safety is to attend the school board meeting and advocate for educational programming. The programming could be simple and done quickly. This action also targets the best audience.
A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? Keep track of the quantity of medications in the cart throughout the shift. Report the suspicion to the nurse manager. Discuss the suspicion directly with the coworker. Monitor the coworker's behaviors.
Report the suspicion to the nurse manager. The nurse should report the suspicion to the nurse manager. The American Nurses Association does not advise confronting coworkers in these situations. Monitoring the coworker's behavior or keeping track of the quantity of medications in the cart do not solve these problem. These actions allow the coworker to continue working with clients while possibly under the influence of drugs, which is not safe.
The nurse is instructing the unlicensed assistive personnel (UAP) on how to position the wheelchair to assist a client with left-sided weakness transfer from the bed to a wheelchair using a transfer belt. Which statement by the UAP tells the nurse that the UAP has understood the instructions for placing the wheelchair? "I'll place the wheelchair behind the client." "The wheelchair should be placed at the head of the bed." "The wheelchair should be placed on the right side of the bed." "As long as I assist the client with the belt, it doesn't matter where the wheelchair goes."
"The wheelchair should be placed on the right side of the bed." When a client with a weakness is being assisted out of bed, it is important that the client always moves toward the stronger side. This allows the client to assist in the move as much as possible. In this case, the client will need to move toward the right side of the bed to maximize the use of the strong arm and leg. Placing the wheelchair at the head of the bed or behind the client does not allow for a safe transfer of the client. The transfer belt is used to help the client balance and provide safety, not to lift the client; the transfer should be made with the least amount of work for both the client and the UAP while ensuring the safety of the client.
The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill? 45-year-old man who recently experienced a severe myocardial infarction and talks to the nurse about concerns about resuming sexual relations with his spouse. 8-year-old boy who alternately cries for their parent and is angry with the nurse about being hospitalized after a bike accident 32-year-old woman diagnosed with depression related to systemic lupus erythematosus (SLE) who discusses their medication's adverse effects with the nurse 60-year-old woman diagnosed with chronic obstructive pulmonary disease (COPD) who refuses to wear an oxygen mask even though poor oxygenation makes them confused
60-year-old woman diagnosed with chronic obstructive pulmonary disease (COPD) who refuses to wear an oxygen mask even though poor oxygenation makes them confused The 60-year-old female client is acting in a way that worsens their physical and mental condition because they do not want to be sick. The 8-year-old child is acting normally for someone their age who is unexpectedly hospitalized. The cooperation demonstrated by the client with lupus and the client who had a myocardial infarction indicates a level of acceptance of their illnesses and of their role as being ill.
Which source of information helps a nurse formulate nursing diagnoses for a specific client? Research articles Outcome criteria Essential assessment data Admission criteria
Essential assessment data The nurse formulates nursing diagnoses after completing the assessment or data collection step in the nursing process. Analyzing essential assessment data and identifying the specific signs or symptoms and probable cause help the nurse diagnose the client. Research articles provide information related to developing current interventions, but they don't help the nurse formulate nursing diagnoses. The nurse formulates outcome criteria after (not before) nursing diagnoses. Admission criteria may help her formulate the diagnoses but won't do so without essential assessment data.
A client has a history of macular degeneration. What is the priority nursing goal while the client is in the hospital? Provide health care related to monitoring the eye condition. Promote a safe, effective care environment. Improve vision. Provide education regarding community services for clients with adult macular degeneration (AMD).
Promote a safe, effective care environment. AMD generally affects central vision. Confusion may result because of the changes in the client's environment and the client's inability to see the environment clearly. Therefore, providing safety is the priority goal in the care of this client. Educating the client regarding community resources or monitoring their AMD may have been done at an earlier date or can be done after assessing their knowledge base and experience with the disease process. Improving the client's vision may not be possible.
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. Print a copy of the medication record at the nurse's station to use at the bedside in order to administer the medications on time. Wait for a mobile computer to become available, and explain to the instructor that the reason for late administration was related to adhering to safety policy. Use the medication dispensing terminal to prepare the medications, and print a dispensing receipt to use for patient identification at the beside.
Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. When equipment is not readily available, it can be tempting to use work-arounds. Although down-time procedures may exist that allow for printing of the medication record, this is not the problem the student is facing. The student should make every effort to obtain the computer so the electronic medication record can be used appropriately for medication administration. Speaking to the instructor in advance, rather than afterwards, demonstrates superior communication and problem solving skills.
A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse? "We will continue to use antibiotics to treat the pneumonia." "We will honor the family's wishes because the client cannot make decisions." "We will not provide any pharmacologic intervention at this time." "We will resuscitate the client only if there is a respiratory arrest."
"We will continue to use antibiotics to treat the pneumonia." The client has signed a document indicating a wish not to be resuscitated. Treating the client's pneumonia with antibiotics would not be considered a resuscitation measure. The other options do not respect the client's choice.
A registered nurse (RN) is assigning care on the oncology unit and assigns a client with Kaposi sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). The UAP does not want to care for this client. How should the nurse respond? "I will help you take care of this client so you are confident with the care." "I will assign this client to another nurse." "You seem worried about this assignment." "I will review blood and body fluid precautions with you."
"You seem worried about this assignment." The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.
The nurse is making client rounds following the shift report. Which client should the nurse assess first? 23-year-old client undergoing surgery for placement of a central venous catheter 38-year-old client receiving internal radiation therapy for cervical cancer 27-year-old client with leukemia hospitalized for induction of high-dose chemotherapy 75-year-old client with metastatic prostate cancer with a pathologic fracture of the femur who is in pain
75-year-old client with metastatic prostate cancer with a pathologic fracture of the femur who is in pain The nurse should first assess the 75-year-old client with prostate cancer because of the client's age, need for pain management, extended bed rest, and potential for preexisting nutritional deficits. The nurse should plan to spend a focused but short time with the client receiving internal radiation. The client who will receive chemotherapy will require more observation after receiving the medication. The nurse can assess the client who will have a central venous catheter after assuring the older client is comfortable.
Which statement best explains why the nurse should take the client's cultural background into consideration when developing a plan of care? Understanding the client's cultural background will prevent the nurse from making embarrassing mistakes when providing care. Acknowledging cultural differences can help the nurse explain to the client how their health beliefs differ from each other. Acknowledging the client's cultural background demonstrates the nurse's appreciation of the fact that cultural values are very difficult to change. Ignoring cultural differences can cause an increase in the cost of the client's care.
Acknowledging the client's cultural background demonstrates the nurse's appreciation of the fact that cultural values are very difficult to change. Cultural beliefs and values are very difficult to change, and developing a plan of care that does not take the client's cultural background into consideration demonstrates a lack of respect for the client's beliefs. A successful plan of care incorporates the client's values. Ignoring cultural differences does not necessarily lead to an increase in the cost of the client's care. The nurse should strive to acknowledge the client's cultural beliefs; however, it is not appropriate for the nurse to explain how their belief system differs from the client's. Understanding a client's cultural background may help prevent the nurse from making an embarrassing mistake and offending the client, but that is not the primary purpose of assessing and understanding the client's cultural background.
The nurse manager is holding a meeting with the nursing team to discuss management's decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening "to take this decision further." To defuse this situation, which would be the best step for the nurse manager to take? Suspend the nurse who is acting out for the inappropriate behavior. Tell the nurse who is acting out to settle down and to act professionally. Ask the rest of the staff if they also feel the same way. Call a break in the meeting and talk to the nurse in a private place.
Call a break in the meeting and talk to the nurse in a private place. When an individual is verbally acting out and others are present, it is advisable to isolate the individual by either removing the individual from the audience or removing the audience. Doing this gives the person an opportunity to regain control of rational thinking without embarrassment in front of peers. It is not appropriate to initiate a suspension in public. By taking the person aside, it also keeps the audience from encouraging or coaching the acting-out individual and further escalating the situation. Asking the nurse to settle down and act professionally is not enough in this escalating circumstance.
The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? Tell the client's child the blood glucose level because this test is performed on the nursing unit. Explain that this information cannot be disclosed without the client's permission. Ask the client's child if she has her parent's permission to access the parent's health information. Have the child sign a "Disclosure of Health Information" form prior to giving the child the information.
Explain that this information cannot be disclosed without the client's permission. The Health Insurance Portability and Accountability Act in the United States, and the Canadian Privacy Act and the Personal Information Protection and Electronic Documents Act (and often provincial/territorial legislation) prevents family members or friends from acquiring health information without consent of the client involved. Whether the test was performed on the nursing unit or others had given the client's child this information is irrelevant; the client's test results are still protected health information. The nurse should not ask the client's child if the child has permission, the client should be asked. If a disclosure of health information form is signed, it should be the client signing, not the daughter. (Note: the caregiver of a client who is incapacitated CAN be given healthcare information.)
A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment? Accept the assignment and not disclose the relationship with the client. Ask the aunt if she would like the nurse to take care of her while in the hospital. Notify the supervisor and provide care until another nurse can be assigned to the client. Notify the supervisor that this is a relative but the relationship will not be a conflict.
Notify the supervisor and provide care until another nurse can be assigned to the client. The nurse should notify the supervisor of the relationship with the client and ask to be reassigned. If no other nurse is immediately available, the nurse should provide the necessary care until another nurse can assume responsibility for the aunt's care. The other answers are incorrect because the nurse may not be able to ensure that the therapeutic nurse-client relationship can be maintained when caring for a family member.
Which measure should a home healthcare nurse implement to minimize the potential for lawsuits? Apply more conservative interventions than those used in a hospital setting. Integrate the client's learning needs and goals into plans of care. Perform thorough, accurate, and timely documentation. Have the client sign a waiver prior to the entry phase of a visit.
Perform thorough, accurate, and timely documentation. The need for thorough documentation is especially high in home healthcare settings, both to ensure continuity of care and to provide a legally acceptable record of what occurred during nurse-client interactions. The nurse should not implement more conservative interventions solely to minimize liability, and a waiver of rights is not a component of home healthcare. The client's learning needs and goals should indeed by integrated into plans of care but this action does not protect against lawsuits.
A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client? The client will visit the window outside of the newborn nursery to see the new babies. The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. The client will enjoy visits from other clients admitted to the same unit. The client will approach the nurse to ask for a magazine.
The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase the client's social interaction or to involve the client in social activities at least weekly. While socializing with other clients, asking for a magazine or visiting the nursery would potentially increase the client's social interaction, the goals are not measurable.
The nurse is beginning the shift and is planning care for six clients on the postpartum unit. Three of the clients have immediate needs, and three of the clients are listed as "stable." For the best utilization of time and client safety, the nurse should make rounds on which client first? the three clients who are reported to be stable a birth parent who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding the birth parent with a 4-hour-old infant with an initial blood glucose of 33 mg/dL (1.8 mmol/L) and now at 45 mg/dL (2.5 mmol/L) who is breastfeeding their infant a birth parent with a 3-day-old who had a bilirubin level of 13 mg/dL (220 μmol/L) 30 minutes ago and is now in a biliblanket at the parent's bedside
a birth parent who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding The client most in need of validating safety is the client who has received carboprost 1 hour ago for increased bleeding. That client's bleeding level needs to be documented as having been evaluated at the beginning of the shift to determine if it has decreased to within normal limits (i.e., saturating less than one pad per hour). The three stable clients will need to have an initial assessment by the oncoming nurse but can wait until the nurse can first assess the client who is receiving carboprost. The client with the 4-hour-old infant is able to breastfeed to maintain the blood glucose level, and the client with the 3-day-old infant in the biliblanket is stable at this point.
An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply. Attend to the client's physical needs. Provide explanations and support to the client. Ask the client to leave. Report any signs of abuse to appropriate agencies. Tell the client their secret is safe.
Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies. Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.
A nurse on the mental health unit tells the nurse manager, "Kids with conduct disorders might as well be jailed because they all end up as adults with antisocial personality disorder anyway." What is the best reply by the nurse manager? "You sound really frustrated. Let's talk about the meaning of their behavior." "These children are more likely to have problems with depression and anxiety disorder as adults." "You really sound burned out. Do you have a vacation coming up soon?" "My experience hasn't been that negative. Let's see what the other staff members think; maybe I'm wrong."
"You sound really frustrated. Let's talk about the meaning of their behavior." The nurse manager needs to focus on the frustration that the nurse is expressing. Additionally, the nurse manager needs to correct any misinformation or misinterpretation that the staff nurse has. Saying that the nurse sounds burned out and asking about a vacation do not focus on the nurse's frustration or address the inaccuracy of the nurse's statement. There is no evidence to suggest that children with conduct disorder have more than the average adult's risk for depression or anxiety. Therefore, this response is inaccurate and inappropriate. Anecdotal information from personal experience does not supply the nurse with accurate, reliable information.
A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? Inform the nurse that selling supplements to clients is a conflict of interest. Tell the client that the client should not purchase anything from the nurse. Report the nurse to the nurse manager and the nursing regulatory body. Interview the nurse's other clients to see if the nurse attempted to sell supplements to them.
Inform the nurse that selling supplements to clients is a conflict of interest. The first nurse is offering advice outside the scope of practice for an RN and could be accused of diagnosing and prescribing. The nurse is also working outside the therapeutic relationship. The client may feel pressured to purchase the supplements to get nursing care or further assistance from the nurse, which puts the nurse in a position of power over the client. It is not appropriate to tell the client to not purchase supplements from the nurse. It is also not appropriate to interview the nurse's other clients. Finally, as a professional, the second nurse should address the behavior with the colleague first and provide a teaching opportunity. If the first nurse does not agree to stop, or is found engaging in the behavior again, then reporting to the manager and regulatory body is appropriate.
The nursing staff on the antepartum unit has leuprolide acetate and medroxyprogesterone acetate in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. To promote client safety, the nursing staff should take which action(s)? Select all that apply. Petition the pharmacy to relocate one drug away from the other product. Move the drugs to a new position within the medication administration system during the night shift. Communicate concerns, measures to remedy, and final decisions to all staff. Leave repositioning of drugs to pharmacy staff to resolve. Collaborate with pharmacy staff to develop a location that works well for both groups.
Petition the pharmacy to relocate one drug away from the other product. Communicate concerns, measures to remedy, and final decisions to all staff. Collaborate with pharmacy staff to develop a location that works well for both groups. Notifying the pharmacy of the nursing concerns is an appropriate first action. The nursing staff should work cooperatively with the pharmacy to develop a system that works well for both the nursing staff and the pharmacy. Constant communication with all nursing staff during the quality improvement process is integral to the final approval process of both groups. Moving the drugs to a new position within the medication system during an off shift may create errors as medications are inserted into the system in a certain position. Leaving the decisions to the pharmacy staff eliminates the input provided by the nursing staff, which is a vital link between medication and the client.
A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? Make sure the UAP has practiced sterile technique on at least one other occasion. Reassign the UAP to a client requiring basic tasks that the UAP has mastered. Supervise the UAP during the treatments involving sterile technique. Provide the UAP with a list of resources to guide the implementation of care.
Reassign the UAP to a client requiring basic tasks that the UAP has mastered. The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.
The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semiprivate room. The 6-year-old's birth parent is upset because the parent staying with the other child is male, and the girl's parent believes the arrangement violates their social norms. What should the nurse do? Reassign the children to different rooms. Offer the parent another place to sleep. Refer the parent to the customer service representative. Explain to the parents that this room arrangement facilitates teaching.
Reassign the children to different rooms. Sleeping in the same room with a person of the opposite sex may be viewed as a violation of norms by persons of conservative faiths. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be distressing enough to create a learning barrier. Offering the parent another place to sleep deprives the child of their parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the parent's needs.
A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take? Ask the charge nurse to receive the telephone prescription from the HCP. Receive the prescription over the phone and repeat it back to the HCP to verify accuracy. Reinforce that all client prescriptions must be entered directly by the HCP into the EHR. Request the HCP text the prescription via mobile phone to reduce the risk for misinterpretation.
Receive the prescription over the phone and repeat it back to the HCP to verify accuracy. The nurse should repeat every telephone prescription back to the HCP to ensure that the nurse correctly understands what was prescribed. Texting prescriptions over mobile phones is not an approved practice due to confidentiality concerns. Although it is ideal that the HCP enter the prescription directly into the EHR, when this access is not possible, the nurse can receive the telephone prescription to avoid delays to client treatment. Any registered nurse can receive telephone prescriptions so the nurse does not need to have the charge nurse perform the task.
The parent of a 17-year-old client who is hospitalized for complications related to type 1 diabetes requests to review the adolescent's medical record. The client reported receiving mental health counseling during their admission history but did not want their parent to know. The nurse is uncertain of how to protect the adolescent's privacy and accommodate the parent's request. Who is the most appropriate person to consult? organization's privacy officer customer service representative health care provider (HCP) unit nurse manager
organization's privacy officer Confidentiality legislation specifies that institutions designate a "privacy officer" who is responsible for developing and implementing privacy policies. This would be the very best resource for the nurse to contact. Depending on the nurse manager's experience, they may or may not know the answer and may have to consult the privacy officer. While HCPs would have an understanding of confidentiality laws, it is unlikely they understand the specifics of nursing policies. Customer service representatives typically address client concerns. At this time, the family has not voiced a concern.
A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? depression pain self-consciousness sexual dysfunction
pain The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.
