Nursing Fundamentals - Comprehensive Scenarios

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements regarding the purpose of a critical pathway should the nurse plan to include?

"A critical pathway is a multidisciplinary tool that guides client care and bases outcomes on an externally imposed timeline."

A nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

"Donate autologous blood before the surgery."

A nurse is caring for a client who has injuries from a motor-vehicle crash. Which of the following client statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up."

A nurse is assisting with preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements indicates that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is reinforcing teaching with a client about organ donation. Which of the following statements by the client indicates an understanding of the teaching?

"People age 18 and over have the right to decide to make an organ donation."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is examining a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland?

"Tilt your head back and swallow."

A nurse is caring for a child who has leukemia and is receiving chemotherapy. The child's parent is upset and says, "I just can't believe my child is going to lose her beautiful hair!" Which of the following responses should the nurse offer?

"You are feeling a sense of loss right now."

A charge nurse is assisting with teaching a group of clients in an assisted-living facility about clients' rights. Which of the following pieces of information should the charge nurse include in the teaching?

"You can request to review your personal medical records at any time."

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

Airborne

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempting to increase the clients' self-motivation

A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain?

Brainstem

A nurse is planning to perform a negotiation to manage a conflict between herself and another staff member. Which of the following actions should the nurse plan to take?

Create a solution in which all parties are satisfied

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac.

During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing clients' information?

In the unit medication room

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is performing a physical examination of a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

Palpation

A nurse is preparing a liquid medication from a multi-dose bottle prior to administering it to a client. Which of the following actions should the nurse take?

Place the cap of the bottle upside down on a clean surface

A nurse is preparing to reinforce teaching about self-care with a client who is 4 days postoperative following the creation of a colostomy. The client refuses to look at the stoma. Which of the following actions should the nurse take?

Postpone any teaching with the client at this time

While orientating newly licensed nurses to a facility, a nurse manager is emphasizing the importance of practicing within standards of care. To which of the following legal concepts is the manager referring?

Professional negligence

A nurse is contributing to the plan of care for a client with COPD who requires continuous oxygen therapy and is being discharged to return home. Which of the following referrals should the nurse recommend?

Social worker

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presence of the client's gag reflex

A charge nurse is planning a performance appraisal interview for a newly hired assistive personnel (AP). Which of the following factors should the charge nurse take into consideration?

The AP should have a copy of the performance standards before the appraisal interview

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain.

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take?

Wrap the client's finger in a warm washcloth