Nursing Process

A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? Select all that apply.

- Supervising nutritional intake - Using familiar cues about the environment - Providing a calm, quiet environment Appropriate interventions when caring for a patient with delirium include maintaining a calm, quiet environment, supervising and monitoring nutritional and fluid intake, and using familiar environmental cues.

The nurse is reviewing the results of a total cholesterol level for a client who has been taking simvastatin. What results display the effectiveness of the medication?

160-190 mg/dL Simvastatin is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.

A nurse obtains the serum digoxin level and immediately reports a level greater than which value?

2.0 ng/mL. A nurse must immediately report serum digoxin levels greater than 2.0 ng/mL. Therapeutic drug levels are between 0.8 and 2 ng/mL.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery.

The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the

Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side.

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for?

Cardiac tamponade The inflammatory process of pericarditis may lead to an accumulation of fluid in the pericardial sac (pericardial effusion) and increased pressure on the heart, leading to cardiac tamponade (see Chapter 29).

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?

Drugs administered may cause a wide variety of adverse effects. Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber

The nurse needs to understand the teaching-learning process when administering

educational interventions. Educational interventions require the application of the teaching-learning process.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

normal. Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes.

The nurse is preparing a plan of care for a client with nutritional deficits. Which is the priority intervention for this client?

teaching about intake of food and vitamins Priority management, according to Maslow's hierarchy, starts at physiological needs and includes the need for oxygen, food, water, rest, and elimination. Therefore, teaching the client about intake of food and vitamins is most appropriate for the client who has nutritional deficits.

A patient reports increasing the intake of herbal therapy because it is "cold and flu season." The patient is currently receiving hydrocortisone therapy for asthma. What is the first question for the nurse to ask the patient related to this statement? "Do you take the herbs daily?" "What herbal therapy are you taking?" "Does anyone in your family have the flu?" "Did you receive a flu shot?"

"What herbal therapy are you taking?" Certain herbs, such as Echinacea, interact with hydrocortisone, which can increase the drug's effects. The nurse should ask the patient which herbs are being taken, because Echinacea is commonly taken to decrease the effects of colds and the flu.

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply.

- Advise the client's health care provider of the client's condition. - Control the client's pain with prescribed medication. - Encourage the client to explain his or her wishes. This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation.

In determining goals for clients, the expected outcomes need to:

- be derived from nursing diagnoses. - include measurable goals. - include time estimate for achievement of short- and long-term outcomes. When writing expected outcomes, the nurse should relate them directly to the nursing diagnoses; make them clear, specific, and measurable and include the appropriate timeframe for completion.

A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation?

Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.

A 62-year-old man is admitted to the hospital with a diagnosis of chest pain. He has an order for 0.3 mg of sublingual nitroglycerin prn for chest pain. Which action should the nurse do first when he reports chest pain?

Administer a tablet under the tongue and repeat the action in 5 and 10 minutes if the pain has not subsided. The initial action by the nurse should be sublingual administration of the drug by placing one tablet under the client's tongue and repeating the action in 5 and 10 minutes if necessary. Asking the client to relax is important and should be done, but administering the tablets would need to be done first.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit. The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit.

The nurse should review which lab result before advising a client about taking the first dose of ibandronate (Boniva)?

Calcium When bisphosphonates are administered, serum calcium levels are monitored before, during, and after therapy.

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?

Client's goals When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly

A nurse is planning an in-service program for a group of staff nurses about heart failure and its treatment. The nurse would identify which agent as the most commonly used drug for treatment?

Digoxin Digoxin is the drug most often used to treat heart failure. Human B-type natriuretic peptide, ACE inhibitors, or hydrochlorothiazide also may be used, but these drugs are not the most common ones used.

Which type of nursing diagnosis has as its goal to increase well-being and enhance specific health behaviors?

Health promotion Health promotion nursing diagnoses identify existing problems.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange Airflow is decreased with atelectasis, which is a bronchial obstruction from collapsed lung tissue.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position.' The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered

A client with a history of a brain tumor is undergoing diagnostic testing to evaluate whether current symptoms are the result of the tumor or scar tissue. The nurse would prepare the client for which test?

Positron emission tomography (PET) PET, which measures the brain's activity rather than simply its structure, is useful in differentiating tumor from scar tissue or radiation necrosis.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes?

Presence of autoantibodies against islet cells There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

Pulmonary embolism Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.

The nurse is assessing a client taking an anticoagulant. What nursing intervention is most appropriate for a client at risk for injury related to side effects of medication enoxaparin?

Report any incident of bloody urine, stools, or both. The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both.

A nurse is completing the history and physical examination of an older adult patient. When assessing the pateint's eyes, which of the following would the nurse document as a normal finding?

Reports of being sensitive to glare In the older adult, normal age-related changes include a sensitivity to glare, the need to hold objects, such as reading materials, far away from the face, slowed pupil dilation, and difficulty discerning blue from green.

A client is having a surgical procedure that requires the client to be in the prone position. What is an expected client outcome?

The client remains free of perioperative positioning injury. The potential for transient discomfort or permanent injury is present because many surgical positions are awkward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period of time.

A client stalks a person the client met briefly 3 years earlier. The client believes the person loves and eventually will marry the client, who has been sending the person cards and gifts. When the client violates a restraining order the person has obtained, a judge orders the client to undergo a 10-day psychiatric evaluation. What is the most probable psychiatric diagnosis for this client?

delusional disorder — erotomanic type In delusional disorder of the erotomanic type, the client has an erotic delusion of being loved by another person and tries to contact the object of the delusion through such behaviors as sending gifts, calling, and stalking. The object of the undesired attention may be a complete stranger or someone the client knows, and usually is of higher status.

A client who recently developed paralysis of the arms is diagnosed with functional neurologic symptom disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan for this client?

exercising the client's arms regularly To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should help the client perform regular passive range-of-motion exercises withthehis arms.

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

lie The nurse is assessing fetal lie, the relationship of the fetal long axis to the maternal long axis. When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal.

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

monitoring circulatory status every 2 hours A 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.

The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a

nontunneled central catheter. Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy in acute care settings. The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored; it allows the client freedom of movement and provides easy access to the dressing site.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels. In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness.