Fundamentals of Nursing - Basics of Nursing Practice

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client?

"You are worried about paying your bills?"

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as:

+4 Rationale: Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? (Select all that apply.)

muscle weakness tachycardia

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity?

Blowing the nose

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance.

Avoid confronting the client Redirect negative feelings constructively Help the client identify realistic versus unrealistic goals. Help the client celebrate the simple pleasures in everyday life. Provide maximal comfort measures (ALL IN ORDER FROM DENIAL TO ACCEPTANCE)

A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection

Candida Albicans

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention?

Compress the container before closing the port. Rationale: A portable wound drainage system (e.g., Jackson-Pratt, Hemovac) is compressed before closing the port to reestablish the negative pressure necessary for suction. Encircling the drainage on the dressing is not necessary; a portable wound drainage system usually removes excess drainage before it leaks onto the dressing. Portable wound drainage systems are not irrigated because this will increase the risk of instilling microorganisms into the wound. The nurse should avoid touching the port because it is sterile.

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?

Friction

Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.)

Increased sensitivity to glare Diminished sensation of pain

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response?

Inform the health care provider of the inability to afford the medication.

A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first?

Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort. Rationale:The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive flatus and abdominal discomfort. Nausea and vomiting is not associated with this infectious disease. Clients should follow a nutritionally balanced diet high in fiber and low in fats with no specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread of the infection because the C. difficile spore is relatively resistant

The nurse recognizes that what is the reason the faucets on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on

A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

tubing injection port

A female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.)

Diminished sensation of pain Impaired hearing of high-frequency sounds

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full?

Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding:

Is a normal occurrence Rationale: When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result from impaired flow of the lymphatic system.