PrepU: The nursing process

An older adult patient presents at the emergency department (ED) with reports of fatigue and diarrhea. The patient reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply. a. Provide explanations and support to the patient. b. Attend to the patient's physical needs. c. Ask the patient to leave. d. Tell the patient their secret is safe. e. Report any signs of abuse to appropriate agencies.

a) Provide explanations and support to the patient. b) Attend to the patient's physical needs. e) Report any signs of abuse to appropriate agencies. Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation? a. "I need to inform you that your behavior is within the definition of assault." b. "You need to think of a more creative way to stop the client from playing with the I.V." c. "You will save the client from another I.V. insertion by restraining the client's hand." d. "I'm sure the client knows you were joking, but it was still inappropriate to say."

a. "I need to inform you that your behavior is within the definition of assault." The nurse's response is threatening and could legally be interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding the comments and potential actions.

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? a. 1 Unit of glucose b. 1 bottle of glucose c. one U of glucose d. 1U of glucose

a. 1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the Joint Commission "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit," instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? a. Create the client assignment by considering available staff's skill level and client needs. b. Refuse to create the client assignment and tell management that a nurse must be found. c. Call charge nurses on other units to request a registered nurse come assist on the unit. d. Notify the local nursing regulating body about the unsafe working conditions at the facility.

a. Create the client assignment by considering available staff's skill level and client needs. When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members.

The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take? a. Put on a gown. b. Apply a face mask. c. Put on goggles. d. Apply foot protection.

a. Put on a gown. Contact precautions should be implemented when a client has or is suspected of having an organism that can be transmitted by direct contact. This can occur when a nurse provides direct care or through indirect contact, in which the organism is transferred to an object and then touched by a person. Contact precautions require that the nurse wear an isolation gown and gloves when entering the room.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent? a. Take the client to the operating room for surgery without informed consent. b. Contact the hospital chaplain to sign the consent on the client's behalf. c. Ask the nursing supervisor to contact the hospital lawyer. d. Keep the client in the emergency department until the family is contacted.

a. Take the client to the operating room for surgery without Informed consent. All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client? a. The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. b. The client will enjoy visits from other clients admitted to the same unit. c. The client will approach the nurse to ask for a magazine. d. The client will visit the window outside of the newborn nursery to see the new babies.

a. The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase the client's social interaction or to involve the client in social activities at least weekly. While socializing with other clients, asking for a magazine or visiting the nursery would potentially increase the client's social interaction, the goals are not measurable.

When planning care for a patient with ulcerative colitis who is experiencing an exacerbation of symptoms, which patient care activities can the nurse appropriately delegate to the nurse assistant? Select all that apply. a. assessing the patient's bowel sounds b. maintaining intake and output records c. providing skin care following bowel movements d. obtaining the patient's weight e. evaluating the patient's response to antidiarrheal medications

b) maintaining intake and output records c) providing skin care following bowel movements d) obtaining the patient's weight The nurse can delegate these activities to the nurse assistant.

A nurse is working in a long-term care facility when a fire erupts in the kitchen. The fire alarm is sounded and the building is to be evacuated. The nurse is thinking about legal responsibilities and duties during the fire emergency. Which statements indicate the nurse understands the nursing legal responsibilities during this fire emergency? Select all that apply. a. "The kitchen staff is liable for any injuries." b. "The nurse can be negligent for failure to evacuate residents safely if a facility elevator is used." c. "A family of a resident can bring criminal charges to the facility for the loss of life during an emergency." d. "A bariatric resident can determine that a civil crime was committed if the facility staff cannot evacuate the resident safely during an emergency." e. "The facility can be charged with negligence for failure to have a working plan in place during a fire emergency."

b. "The nurse can be negligent for failure to evacuate residents safely if a facility elevator is used." c. "A family of a resident can bring criminal charges to the facility for the loss of life during an emergency." d. "A bariatric resident can determine that a civil crime was committed if the facility staff cannot evacuate the resident safely during an emergency." e. "The facility can be charged with negligence for failure to have a working plan in place during a fire emergency." The nurse's legal responsibilities and duties during the fire emergency include preventing the loss of life, evacuating a bariatric resident safely, and executing a working plan to deal with the fire emergency. The nurse can be negligent if an elevator is used during the fire emergency. The kitchen staff is not liable for injuries if the staff acted according to the facility fire plan.

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN? a. a 41-year-old client with unstable angina b. a 72-year-old client with diverticulitis c. a 32-year-old client hospitalized for chemotherapy treatment d. a 5-year-old client with Kawasaki's disease

b. a 72-year-old client with diverticulitis The client with diverticulitis will need care that the LPN should be able to provide safely.The client with angina is unstable and requires a registered nurse for continuous assessment.The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration.A child with Kawasaki's disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? a. a woman who is 5 months pregnant with no apparent injuries b. a middle-aged man with no injuries who has rapid respirations and coughs c. a 10-year-old with a simple fracture of the humerus who is in severe pain d. a 20-year-old with first-degree burns on her hands and forearms

b. a middle-aged man with no injuries who has rapid respirations and coughs The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do? a. Ask the unlicensed assistive personnel (UAP) to place restraints on the client's upper extremities. b. Check on the client at regular intervals to ascertain the need to use the bathroom. c. Put all four side rails up on the bed. d. Request that the client's roommate put the call light on when the client is attempting to get out of bed.

b. check on the client at regular intervals to ascertain the need to use the bathroom.

A nurse has made a medication error. Which information is appropriate to include in the incident report? a. an interpretation of the likely cause of the incident b. what the nurse saw and did c. the client's statement about the incident that occurred d. the extenuating circumstances involved in the situation

b. what the nurse saw and did The incident report includes only what the nurse saw and did—the objective data. The nurse does not try to interpret the likely cause of the incident, include statements from the client about the incident, or comment on extenuating circumstances.

A float nurse is assigned to a surgical unit. The nurse is receiving two clients from the post-anesthesia care unit (PACU) at the same time. When delegating tasks to other unit personnel who are not known to the nurse, which question would be most important to ask? a. What is your highest educational level? b. How long have you worked on this floor? c. Are you comfortable performing the tasks assigned? d. Which task would you prefer to perform?

c. Are you comfortable performing the tasks assigned? Because the float nurse is not familiar with staff, it is important to ask the other staff if they are comfortable and had instruction in the task assigned. Principles of delegation state that the right task in the right situation by the right personnel is essential to client care.

The nurse uses which part of the SBAR acronym when stating, "The client is dry." a. Situation. b. Background. c. Assessment. d. Recommendation.

c. assessment SBAR stands for Situation, Background, Assessment, and Recommendation. It is a proven standardized method of communication between members of the health care team and a client's condition. SBAR is used as a standardized method of hand-off communication. A hand-off is a transfer of responsibility from one caregiver to another caregiver. The information communicated during a hand-off must be accurate, with minimal interruptions, in order to meet client safety needs.

A nurse is caring for a client who is well-known in the community. A person inquires about the medical details of the client, saying that they are a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which ethical rule of professional-client relationships has the nurse violated? a. veracity b. fidelity c. confidentiality d. autonomy

c. confidentiality The nurse has violated the principle of confidentiality by revealing the client's personal medical information to a third person. Confidentiality is a professional duty and a legal obligation. What is documented in the client's record is accessible only to those providing care to that client.

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP's prescriptions? Contact the health care provider (HCP) and: a. suggest adding potassium to the fluids. b. request an increase in the volume of intravenous fluids. c. verify the prescription for 5% dextrose in water. d. determine if the client should be placed in isolation.

c. verify the prescription for 5% dextrose in water. The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the prescription for IV dextrose with the HCP due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids, and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time.

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse? a. "Thank you, this is very generous of you. I'm really humbled by this token of your appreciation." b. "I'm not allowed to accept gifts of money, but if you wanted to give me something else, that would be acceptable." c. "Although I can't accept this money, you could just let my supervisor know you're pleased with my work!" d. "I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift."

d. "I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift." Because the nurse is in a position of power, it would be an abuse of power to accept the gift; specifically, it would be considered financial abuse. This is also true of non-monetary gifts. Asking the client to speak to the manager on the nurse's behalf is unprofessional.

Which child should the nurse assess as demonstrating behaviors that need further evaluation? a. a 2-year old who refuses to be toilet trained and talks to himself b. a 6-year-old who sucks her thumb when tired and has never spent the night with a friend c. a 10-year-old who frequently tells his mother that he is going to run away whenever they argue d. a 2-year-old who is indifferent to other children and adults and is mute

d. a 2-year-old who is indifferent to other children and adults and is mute Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to himself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child.

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using? a. assessment b. diagnosis c. implementation d. evaluation

d. evaluation Although the nurse is assessing pain relief, this action is considered part of evaluation, not assessment, because the nurse is evaluating whether a performed intervention has met its goal. During the nursing diagnosis step of the nursing process, the nurse labels or describes the client's health condition or needs such as pain. During implementation, the nurse attempts to meet the client's needs through such interventions as administering medication.