The Nursing Process
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give "hand-off reports" at which of the following times? Select all that apply. a) Change of shift. b) When unit clerk goes to a staff meeting. c) When nurse goes to lunch. d) Change of nurses. e) When new medication orders are written.
A. Change of shift. C. When nurse goes to lunch. D. Change of nurses. Effective communication is essential when managing client safety and preventing errors. "Handoff reports" should be made at shift change, when there is a change of nurses or when the nurse leaves the unit, and when the client is discharged or transfers to another unit. There does not need to be a handoff report when the unit clerk leaves the unit or when new medication orders are written.
The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. a) Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. b) Client's dressing is intact with scant amount of serous drainage. c) Client ambulated to end of hallway. d) Client seems to be very depressed. e) Client appeared angry and belligerent all shift.
A. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. B. Client's dressing is intact with scant amount of serous drainage. C. Client ambulated to end of hallway. Client vital signs, observation of a dressing, and documentation of the activity of a patient represent objective data. Using words such as "seems" or "appears" implies subjectivity on the part of the nurse.
The family of a hospitalized client demonstrates understanding of the teaching about advance directives when they make which of the following statements? Select all that apply. a) "Advance directives give instructions about future medical care and treatment." b) "Ethics experts agree that the family is the sole deciding factor when the client is competent." c) "Medical power-of-attorney gives primarily financial access to the designee." d) "Advance directives give details about the client's past medical history." e) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." f) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself."
A. "Advance directives give instructions about future medical care and treatment." E. "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." F. "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." Advance directives are written statements of person's wishes related to health care if they are unable to decide for themselves. These documents relate to current or future health care and not past medical history. Competent adults are responsible for their own health care decisions and their own right to accept or refuse treatment. Advance directives are used when the person cannot make the decision. Medical power-of-attorney is a term used to describe the person who makes health care decisions should someone be unable to make informed decisions for himself or herself. The focus is not primarily financial access.
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? a) Focus charting. b) SOAP notes. c) Narrative notes. d) Charting by exception.
C. Narrative notes. One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.
The nursing team on an oncology unit consists of a registered nurse (RN), a licensed vocational nurse (LVN-LPN), and unlicensed assistive personnel (UAP). Which client should be assigned to the registered nurse? a) A 45-year-old client receiving tube feedings. b) A 65-year-old client diagnosed with endometrial cancer who underwent an abdominal hysterectomy 3 days ago. c) A 28-year-old client being evaluated for a bone marrow transplant. d) A 52-year-old client with lung cancer admitted for acute dyspnea.
D. A 52-year-old client with lung cancer admitted for acute dyspnea. Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, she will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be assigned safely, according to the abilities of the LVN-LPN and UAP.
A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? a) Notify the licensing body of the nurse's behavior. b) Inform the nurse that he/she can be accused of negligence. c) Ask the nurse if this is acceptable practice for this unit. d) Advise the nurse that he/she can be accused of battery.
D. Advise the nurse that he/she can be accused of battery. Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior.
A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? a) Impairment of primary body system defenses b) Inadequate secondary defenses c) Chronic disease d) Proper nutrient intake
D. Proper nutrient intake Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.
A client has been prescribed a narcotic analgesic to be given around the clock for cancer-related pain. The client is competent and has actively been involved in decisions regarding care. What should the nurse do when the client refuses the next dose of pain medication? a) Ensure that the client understands the rationale for taking the medication. b) Document the client's choice and reassess the pain in 1 hour. c) Ask the spouse to place the medication in the client's mouth. d) Try to persuade the client to take the medication as ordered by the physician.
B. Document the client's choice and reassess the pain in 1 hour The client has the right to choose whether to take the medication. The nurse should assess the client's pain on a regular basis and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.
A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation? a) Call out to attract attention from bystanders. b) Leave the area in her car, provided she can get to it safely. c) Confront the group of men in an assertive but non-aggressive manner. d) Perform the home visit and ensure that the group is gone before she leaves.
B. Leave the area in her car, provided she can get to it safely. The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove herself from the situation, provided this can be achieved without incurring further risk.
The charge nurse on the postpartum unit has received report about a client with a fetal demise who will be ready for transfer out of Labor and Birth in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take? a) Request a room for this client on a unit without newborns. b) Ask the nurse in labor and birth to discharge the mother as soon as she is physically able to leave. c) Talk to the mother first and decide on a location that is mutually agreeable. d) Admit the mother to a private room on the postpartum unit.
C. Talk to the mother first and decide on a location that is mutually agreeable. The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future needs of the client experiencing this type of loss as the client may or may not be thinking well or clearly at the moment. The postpartum unit is full of sounds of infants, and although being in a room by herself may support the need for separation, it is often in the best interest of the client to locate her away from the noise of the babies. Placing the client on another unit will remove her from the support she is seeking. On the other hand, she will not be hearing crying infants. This has often been the location for someone experiencing a loss. Discharging the mother home as soon as she is stable physically is also a possibility, but the nurse must also assess the client's emotional stability and preferences for grieving.
