Fundamentals pt. 1: Basics of nursing & Physiological Aspects of Care

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first?

Assess the catheterization site.

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time?

Conducting a multidisciplinary staff conference early during the client's hospitalization.

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification?

"I should obtain a pneumococcal vaccination each year."

What are the best ways for a nurse to be protected legally? (SATA)

-Provide care within the parameters of the state's nurse practice act. -Document consistently and objectively. -Clearly document a client's non-adherence to the medical regimen.

A nurse is assigned to take care of a group of clients. Which client should the nurse see first?

A 2-yr-old male with diarrhea

On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client?

Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is:

An unconscious means of reducing stress.

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

Autonomy

The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from:

Bleeding posterior to the nasal packing

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?

Contact the prescriber to determine if a change to a suspension form would be possible.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room.

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis.

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring

A client expresses concern about the surgical consent that the client signed. How should the nurse respond?

Inform the health care provider of the client's concern

A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response?

Interview the client to determine whether other mood swings are being experienced.

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are:

Less anxious and more aware of reality and therefore ready to learn

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed:

On the hands.

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is:

Paresthesias

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic?

Relaxation of tensed muscles

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

When nurses are conducting health assessment interviews with older clients, they should:

Spend time in several short sessions to elicit more complete information from the clients

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings?

Wheezes

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Assessing the blood pressure of a client before physical therapy.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action?

-Clients have a right to refuse treatment. -Nurses are required to answer clients truthfully. -The health care provider should have been notified.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing?

Ascorbic acid (Ascorbicap)

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain.

Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with:

Developing meaningful relationships