NClex / Basic Physiocal Care

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

All of these tests help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:

An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return.

The nurse is assessing a client for the risk of falls. The nurse should collect:

Assessing the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls.

The physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy?

Chest physiotherapy is best performed before meals to avoid tiring the client or inducing vomiting. Scheduling chest physiotherapy around client or nurse convenience is inappropriate.

A laissez-faire nurse-manager takes which action?

Delegation of a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff for their opinions of the solutions is characteristic of a participative manager.

A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching?

Exhibiting a positive change in behavior best demonstrates that the client understands and is complying with discharge teaching. Merely repeating what has been said, telling the nurse that the client understands, or nodding the head to indicate "yes" wouldn't demonstrate that the client has learned anything.

A client twists the right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by the client suggests that ice application has been effective?

Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application.

A client has a blood pressure of 152/86 mm Hg. The nurse should document the client's pulse pressure as which of the following?

Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg.

When following standard precautions, the nurse's primary responsibility is to:

Standard precautions are based on the concept that all body substances are potentially infectious and direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections; instead, the nurse should wear a mask as a barrier to such infections.

Entering the client's room to get the neonate for an examination by the physician, the nurse on the maternity unit sees the mother holding the crying neonate and slapping the baby's face. Which action is most appropriate in this situation?

The baby's safety and protection is the first priority. The nurse should immediately return the baby to the nursery and inform the physician of the baby's abuse. By being the baby's advocate, the nurse allows the physician to examine the baby for injuries resulting from the incident. Social services should be notified. Follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the revised care plan for this mother and baby, it requires immediate intervention, not simple notification of coworkers.

Which member of the health care team is responsible for obtaining informed consent from a client?

The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature. In some health care facilities, a physician's assistant may obtain informed consent; however, in this case, a physician must act as cosigner.

To help minimize calcium loss from the bones of a hospitalized client, the nurse should:

Calcium absorption diminishes with reduced physical activity. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss, even if the dairy products and feedings contained extra calcium.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

Clients on bed rest suffer from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the 4th postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which step is the best initial action for the nurse to take?

The client most likely has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access device. He's scheduled to receive amphotericin B (Amphotec) I.V. Which action would be most appropriate for the nurse to take?

The client needs the medication to combat the protozoal infection. Because he has been dislodging the I.V. access devices, a staff member should remain with him during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; alternatives allow for the drug's administration.

For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the assessment?

The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT.

Which outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance?

The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems.

In which circumstance may the nurse legally and ethically disclose confidential information about a client?

The nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. The physician is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of the publics' and client's safety. Options 2 and 4 don't affect the welfare of a group of people. Confidentiality of HIV testing is required, but the client, who's HIV positive, should be encouraged to share the information with his family. An HIV-positive test result commonly means the loss of a job, medical insurance, financial security and even housing because family members, friends, and the public may be fearful of the HIV-positive person. Many state legislatures require policies and procedures for maintaining confidentiality for HIV testing.

The nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?

The nurse should document painful urination as dysuria. Oliguria refers to a decrease in the amount of urine excreted; anuria, to a urine output below 100 ml/day; and pyuria, to pus in the urine.

When bandaging a client's ankle, the nurse should use which technique?

The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

Which concept refers to the role of the professional nurse in client advocacy?

The nurse who understands the advocacy role promotes, protects, and, thereby, advocates a client's interests and rights in an effort to make the client well. The nurse recognizes that the first duty is to protect and care for the client's health and safety. True advocacy encourages and helps clients reach decisions that express their own beliefs and values. The nurse doesn't make decisions for clients but provides care for the acutely ill client with the consent of his significant other. If there's no significant other, a power of attorney or the client's living will will designate care. Standards of care are the basis for providing safe competent nursing care and set minimum criteria for proficiency on the job, enabling the nurse and others to judge the quality of care provided. Paternalism violates self-determination and advocacy by acting for another. A nurse acting as a client advocate helps clients exercise their freedom of self-determination.

A scrub nurse in the operating room has which responsibility?

The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

The nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?

To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4″ to 6″ from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, then move the uninvolved leg.

The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?

To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than a wet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will occur next?

Unusual occurrences and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate care, determine potential risks, or discover system problems that could have attributed to the error. This type of error won't result in a report to the state board of nursing or in suspension of the nurse. Some facilities do track the number of errors by a nurse or on particular units; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?

Washing the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician's order. Massaging with an astringent can further damage the skin.

A nurse works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening, when a coworker nurse left the unit, the remaining nurse, who was making rounds on the departed nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should:

When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.

The nurse is assigned to a client with a cardiac disorder. When monitoring body temperature for this client, the nurse should avoid which route?

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

What does the nurse do when making a surgical bed?

When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without touching them, the nurse fanfolds these linens to the side opposite from where the client will enter and places the pillow on the bedside chair. All of these actions promote transfer of the postoperative client from the stretcher to the bed. When making an occupied or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the client to the far side of the bed.

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states that the "side rails were down and the bed was in the high position." Legal charges are filed against the nurse and the hospital. Which charge is the most appropriate for her actions?

: Negligence is a general term that denotes conduct lacking in due care. Carelessness is interpreted as a deviation from the standard of care that a reasonable person would use in a particular set of circumstances. Battery involves harmful or unwarranted contact with the client. Comparative negligence holds the injured parties accountable for their fault in the injury. Collective liability stems from cooperation by several manufacturers in a wrongful activity that by its nature requires group participation.

A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should

Administering pain medication and waiting for its effect before any activity will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and is a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort.

A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should:

Administering pain medication and waiting for its effect before any activity will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and is a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort.

A client's attorney must prove which elements for a professional negligence action?

Any professional negligence action must meet four demands — commonly known as the four D's — to be considered negligence and result in legal action: a duty for the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, the breach of duty resulted in damages and the damages were caused by a direct result of the negligence, (causation).

Which assessment would be most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?

Based on the nursing diagnosis, the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. All of the other options — a heart rate of 88 beats/minute, healing by first intention, and a dry, intact dressing — demonstrate normal assessment findings.

The physician has ordered a wet-to-dry dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?

Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. The wound isn't kept moist and wet-to-dry dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Assessing the temperature every 8 hours isn't frequent enough for a client with a fever. Monitoring fluid intake and output may be required, but the client should be placed in isolation first. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and body fluids and substances.

Which intervention should the nurse use when administering oxygen by face mask to a client?

By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen

A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure the client is placed:

C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. When in direct contact with the client, the nurse should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/μl or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which isn't true of C. difficile diarrhea.

A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the:

Client isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques don't affect the agent, host, or portal of entry.

The nurse is assisting a client with lower motor neuron damage who has difficulty with urination. The nurse shows the client how to apply gentle pressure over the lower abdomen to empty the bladder. By what name does the nurse refer to this procedure?

Credé's maneuver is performed by applying manual pressure over the lower abdomen. This procedure promotes complete emptying of the bladder in clients with lower motor neuron damage that impairs the voiding reflex. Valsalva's maneuver triggers vagal stimulation of the heart. During this maneuver, the client is instructed to take a deep breath and bear down as if defecating. It's commonly used to help terminate atrial arrhythmias. Credé's method is used when a 1% solution of silver nitrate is instilled into a neonate's eyes to prevent gonorrheal conjunctivitis caused by Neisseria gonorrhoeae. Leopold's maneuvers are used to determine fetal position.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

The nurse is caring for a client with emphysema. Which nursing interventions are appropriate?

Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows the client to perform activities without excessive distress. If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform postural drainage and chest physiotherapy. Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client should be placed in high-Fowler's position to improve ventilation.

Which nursing theorist addressed self-care deficits in her nursing theory?

Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps the client balance the changes that occur as the client constantly evolves.

A client complains of dyspnea. To help correct this problem, the nurse should place the client in which position?

Fowler's position — the posture assumed by the client when the head of the bed is elevated 40 to 60 degrees — promotes breathing by allowing expansion of the thoracic cavity. The other options wouldn't promote breathing.

The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

Hand washing is the first line of intervention for preventing the spread of infection. Antibiotics should be initiated when an organism is identified. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions.

A client has left-sided paralysis. The nurse should document this condition as left-sided:

Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

The nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate?

If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae should be moistened often with isotonic eye drops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent small, well-balanced meals. The nurse should provide the client with rest periods to reduce metabolic demands. The client should be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse should provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

A nurse-manager appropriately behaves as an autocrat in which situation?

In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input characteristic of a democratic or participative manager.

A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?

In rheumatic fever, the joints may be so painful that even the weight of the bed linens can cause pain. A bed cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased when the affected joint is moved; therefore, passive range-of-motion exercises aren't recommended. Pain isn't likely to be relieved by massaging the joints. The child should be encouraged to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain

In which way do nurses play a key role in error prevention?

Nurses must be knowledgeable about drug dosages and possible interactions when administering medications; they must follow appropriate policies to correct dosage errors or potential interactions. The nurse is responsible for questioning unclear or ambiguous physician orders and should never carry out an order for which she's uncomfortable. Notifying OSHA doesn't solve medication errors. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards. The client should be aware of his rights as a client, but that awareness doesn't play a key role in error prevention.

A client with a fecal impaction frequently exhibits which clinical manifestation?

Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and a decreased appetite.

The nurse is performing wound care using surgical asepsis. Which practice violates surgical asepsis?

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

Which of the following is an example of a primary preventive measure?

Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; typically, these measures include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

Which laboratory test result is the most important indicator of malnutrition in a client with a wound?

Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

A nurse-manager works for a nonprofit health care corporation in which there has been significant revenue over expenses for the year. The nurse-manager has been told to anticipate which action?

Revenue over expenses in a nonprofit organization is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls its revenue over expenses a profit and the revenue can be divided as a dividend among stockholders or reinvested in the organization.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can be grouped fairly easily by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS?

Team nursing is efficient and costs less to implement than primary or case management systems. Because the staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost effective, care is commonly fragmented and client satisfaction decreased. Case management and primary nursing require more registered nurses than are available

To follow standard precautions, the nurse should carry out which measure?

To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with the blood, body fluid, mucous membranes, or nonintact skin of any client (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

The nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which instructions should the nurse recommend when teaching this client?

To reduce gastric reflux, the nurse should instruct the client to sleep with his upper body elevated; lose weight, if obese; avoid constrictive clothing, caffeine, and spicy foods; remain upright for 2 hours after eating; and eat small, frequent meals.

When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing?

When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C).

A client with a fever has an increased basal metabolism rate. Therefore, he needs additional calories in his diet. All the other responses — monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket — are therapeutic interventions for a fever.

During assessment, the nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?

A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing.

client has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?

A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation, such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings.

As the nurse-manager of a medical-surgical unit reviews this month's risk management data, she notices that a number of incident reports have been completed because 6 p.m. medications were administered late. Dinner is served between 5:30 p.m. and 6 p.m. Staff take their dinner breaks between 5 p.m. and 6:30 p.m. Based on this information, which is the most appropriate action from the nurse-manager?

An effective nurse-manager knows that to evaluate risk management findings accurately she must look at the entire process and circumstances surrounding each incident. Terminating staff without such evaluation doesn't resolve all of the factors contributing to the problem. She can't change dinner breaks or kitchen delivery times unless she has evaluated how these factors influence medication administration.

Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations?

An effective performance evaluation provides recognition of strengths, identifies areas for improvement, and clarifies performance expectations. Performance evaluations should be done in private, not in front of others. All components of a performance evaluation should be documented in writing. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

The nurse-manager of an outpatient physical medicine and rehabilitation facility isn't satisfied with the policies and procedures governing discharge planning. The manager knows other managers at several similar facilities that are regarded as the "best" in the country. As part of a continuous quality-improvement process, the nurse-manager decides to take which steps?

Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing the delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility, then make recommendations for change in conjunction with her staff. Asking her staff to form a task force is a good idea, but benchmarking is a practice that saves time and effort and allows information to be obtained from excellent resources.

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that he'll require:

Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is reexpanded sufficiently.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client education materials. Which statement illustrates the best method of delegation?

Delegation must be done clearly and precisely. The nurse-manager must assign responsibility, identify the task to be accomplished, explain what outcomes are needed, and the time frame for completing the work. The remaining options don't give clear explanations of work to be done, don't clearly assign responsibility or the specific outcomes desired, or establish a time frame for completion of the task.

Which are the stages of grief that a client or family member goes through?

Denial is the avoidance of death's inevitability and is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that death and loss will actually occur or has occurred for a family member. Bargaining happens when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss that's expressed as profound sadness or deep suffering. Acceptance is the final stage, and it's the ability to overcome the grief and accept what has happened

A client with severe chest pain is brought to the emergency department. He tells the nurse, "I just have a little indigestion." Which mechanism is the client exhibiting?

During a crisis, it's common for a client to use a mechanism called denial, which is exhibited by minimizing symptoms or avoiding discussion. Anxiety is typically indicated by restlessness. If the client verbalizes knowledge that a problem exists, he isn't confused or repressing the incident.

A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client's status?

Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the most accurate indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn't the most accurate indicator because it can be influenced by numerous factors.

A client who's scheduled for open heart surgery in 2 days has been having circulation problems in the feet and legs, so the physician orders antiembolism stockings. Now, the nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs; however, blankets can be used for this purpose.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:

Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

An elderly client becomes confused, dislodges his I.V. access, and attempts to remove his indwelling urinary catheter. The primary nurse for the client calls the physician and receives an order for soft wrist restraints. However, the client's family insists that he not be restrained. The charge nurse informs the family that to avoid restraints, the family must provide an around-the-clock attendant for the client. The family spokesman replies, "You find the attendant; that is your responsibility." It would be most appropriate for the charge nurse to respond:

Offering the family a solution to the situation is therapeutic and can advance rapport with the family. It can also help the problem-solving process, which involves the client, family, and staff. Restating that it's the family's responsibility and saying that they're making the situation more difficult are confrontational approaches. Such statements don't increase rapport with the family or enhance problem-solving. The staff can't dismiss responsibility to the client if the family won't allow restraints.

A community health nurse is working with disaster relief following a flood. Finding safe housing for survivors, providing support for families, organizing counseling, and securing physical care are examples of which type of prevention?

Tertiary prevention involves reducing the degree and quantity of injury, disability, and damage following a disaster or crisis. Aggregate prevention isn't a level of care prevention. Primary prevention focuses on keeping the crisis or disaster from happening. The goal of secondary prevention is to reduce the duration and intensity of the disaster or crisis.

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff?

The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants. A staff nurse isn't licensed to fill prescriptions.

A primary nurse in the unit tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager?

The nurse-manager is responsible for adequate orientation of new staff. Needing additional orientation doesn't mean that a nurse isn't competent. However, the new nurse should know what's expected of her and the time frame in which she must accomplish the expectations. Firing the new nurse isn't the answer because she's apparently close to completing orientation and the primary nurse says the nurse has good skills. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete her orientation as efficiently as possible.

The client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions?

Tumors of the pituitary gland can lead to diabetes insipidus due to deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, weigh the client daily, measure urine specific gravity, and monitor intake and output. Encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect should be avoided

A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should:

A durable power of attorney transfers all rights that the individual normally has regarding health care decisions to the designated agent. It's within the power of the twin sister to change the physician caring for her terminally ill twin. The dismissed physician has no power to interfere with the wishes of the durable power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn't take precedence over ensuring proper colostomy care. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.

While assessing the incision of a client who had surgery 2 weeks ago, the nurse observes that the suture line has a shiny, light pink appearance. Which step would the nurse take next?

During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This is a normal occurrence and requires no further action. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to stay moist.

Which assessment finding by the nurse contraindicates the application of a heating pad?

Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:

Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.

The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

The child should eat a high-calorie, high-protein diet. In cystic fibrosis, the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged. Without these enzymes, the duodenum isn't able to digest fat, protein, and some sugars; therefore, the child can become malnourished. Because fats aren't easily tolerated, they may need to be restricted. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are necessary.

The nurse is preparing to help a client with weakness in his right leg get out of bed to a chair. Where should the nurse place the chair?

The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg.

What is an appropriate nursing intervention for a client with an arm restraint?

The nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow slight joint movement without reducing the effectiveness of the restraint.

In a client who had major surgery 5 days ago, which assessment finding would be the best indication of a wound infection?

Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguineous. Although an elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, they aren't as specific as the drainage and could be related to other problems.

Standard precautions include which of the following measures?

To follow standard precautions, caregivers must wear gloves when there is the potential for contact with a client's body fluids; place used, uncapped needles and syringes in a puncture-resistant container; and wear goggles during procedures that are likely to generate splashes of blood or body fluids.

A nurse-manager receives several complaints from day-shift nurses that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for the nurse-manager to:

When dealing with complaints, a manager should always gather data first. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data about the complaint.

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?

Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

A client hasn't voided since before surgery, which took place 8 hours ago. Which action should the nurse do first?

Before any action is taken, the nurse must assess the client's bladder area for fullness. A common adverse effect of anesthesia is urine retention. After confirming retention, the nurse should call the physician and expect an order to catheterize the client. Telling the client to bear down and try to void is inappropriate.

For healing by second intention, a client's wound has been packed with medicated dressings. During wound evaluation, which finding indicates that healing is taking place?

Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. The other options — red or edematous surrounding tissue and serous drainage — are insufficient evidence that the wound is healing.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and therefore are less effective in evacuating the lower bowel.