The Nursing Process - ML8

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take? Arrange for another colleague to sign as a witness. Note that the nurse caring for the client cannot be a witness. State that the physician will be a witness. Inform the physician about the living will.

Note that the nurse caring for the client cannot be a witness. A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the healthcare facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.

A charge nurse is making assignments for a team that includes two registered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should: assign additional UAP to assist the RN. assign the same number of clients to each RN, but with lower acuity. assign each complex procedure to a different RN. assign fewer clients to the RN managing this client's care.

assign fewer clients to the RN managing this client's care. The charge nurse assigns fewer clients to the RN who will be taking care of the client with high-acuity needs. Even though the RN would be assigned clients with lower acuity in addition to the client with high acuity, the RN will be planning care for more clients.Dividing the care for the high acuity client among several RNs increases the risk of error.The UAP will not be able to perform the complex procedures required for the high-acuity client.

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process? providing education about documenting blood pressure readings formulating nursing diagnoses planning to monitor the client's vital signs every shift. collaborating with the client to set exercise goals

providing education about documenting blood pressure readings Implementation involves providing actual nursing care. Education is an intervention that occurs during the implementation phase. Goal setting and formulation of nursing diagnosis do not occur during the implementation phase of the nursing process.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? T wave PR interval P wave QRS complex

P wave The P wave depicts atrial depolarization or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting? problem, Intervention, Evaluation (PIE) charting variance charting charting by exception focus charting

charting by exception Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. Focus charting does not use a problem list of nursing or medical diagnoses but incorporates many aspects of the client and client care into a focus column. The focus may be a client strength, problem, or need. Problem, Intervention, Evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome or a planned intervention is not implemented in the case management model.

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need? inserting a Foley catheter raising the side rails on the client's bed arranging a visit from a support group member placing the client in a double room with another client the same age

inserting a Foley catheter According to Maslow, elimination is a first-level, or physiologic, need and therefore takes priority over all other needs. Inserting a Foley catheter helps meet the client's elimination need. Raising the side rails on the bed meets safety needs, which are a second-level need. Arranging a visit from a member of a support group and placing the client in a room with someone the same age meet the need for belonging and acceptance, which are third-level needs. Second- and third-level needs can be met only after the client's first-level needs have been satisfied.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. that there was voluntary consent on the client's part that there was adequate disclosure of information that the client understood the information that the client has full awareness of the potential complications that the client's relative, spouse or legal guardian was present

that there was voluntary consent on the client's part that there was adequate disclosure of information that the client understood the information that the client has full awareness of the potential complications The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.

A client expresses a desire to walk to the lobby for discharge to home. The unlicensed assistive personnel (UAP) tells the client that all clients being discharged need to be transferred to the lobby by wheelchair. How will the nurse best respond to protect the client's right of care? Select all that apply. "Clients are at risk for falls if they do not use the wheelchair when being discharged." "It is the hospital policy for the client to use a wheelchair to the lobby when being discharged." "The client has the right to walk to the lobby for discharge." "At this hospital clients must be discharged by wheelchair to the lobby." "An employee will accompany you to the lobby if you choose to walk."

"An employee will accompany you to the lobby if you choose to walk." "The client has the right to walk to the lobby for discharge." The nurse will best respond that an employee will accompany the client to the lobby if the client chooses to walk, and the client has the right to walk to the lobby for discharge. At this hospital, clients must be discharged by wheelchair to the lobby and saying it is the hospital policy to use the wheelchair to the lobby are violations of client's rights by not accepting a client's refusal to use a wheelchair. The nurse should not tell the client that they are at risk for falls because of the request to walk to the lobby.

The nurse is coaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which question? "What is required for your family to manage your symptoms?" "What do you know about your medications and condition?" "How much does your family need to be involved in learning about your condition?" "What activities are most important for you to be able to maintain control of your diabetes?"

"What activities are most important for you to be able to maintain control of your diabetes?" Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their self-management practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment.

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? "Do you have a history of GERD (gastroesophageal reflux disease)?" "Have you ever had pain like this before?" "What were you doing when the pain started?" "Do you take any medications on a regular basis?"

"What were you doing when the pain started?" Subjective data (data from the client) about the chest pain helps the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful.

An older adult client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting healthcare provider's prescription, which reads "dimenhydrinate 25 mg intravenously q.i.d.; keep NPO." Based on this prescription, what action would the nurse take? Insert a nasogastric or oropharyngeal tube if necessary. Ensure that the client does not eat or drink anything. Administer the medication twice a day. Give the medication as needed.

Ensure that the client does not eat or drink anything. The abbreviation "NPO" denotes that the client should take nothing by mouth. The abbreviation for "as needed" is "PRN." The prescription indicates to administer the medication four times a day, not twice a day. The prescription does not indicate the need for a nasogastric or oropharyngeal tube.

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply. Be responsible and accountable for individual practice. Ask the hospital for fair compensation for work. Develop, maintain, and improve health care environments. Increase professional competence and personal growth. Maintain integrity and shape social policy.

Maintain integrity and shape social policy. Develop, maintain, and improve health care environments. Be responsible and accountable for individual practice. Increase professional competence and personal growth. The Code of Ethics describes those actions by the nurse that guide their practice. It is the responsibility of each nurse to be active in determining policy for health care for all citizens and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate in the development of health care of the future, while caring for all members of society. In order to be productive in shaping policy, nurses need to be politically astute while growing personally and professionally to meet the needs of clients. The Code of Ethics does not address compensation for work.

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply. Notify the health care providers (HCPs) at the surgery center. Wear a stainless steel medical alert bracelet into the surgical suite. Determine that there will be a latex-safe environment for surgery. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). Ask to have the surgery at a hospital.

Notify the health care providers (HCPs) at the surgery center. Determine that there will be a latex-safe environment for surgery. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs and symptoms of latex allergy may range from mild to anaphylaxis. Clients with latex allergy are advised to notify their HCPs and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a free-standing surgery center as long as latex precautions are observed.

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client? The client's intake and output are balanced. The client verbalized the importance of increasing fluid intake. The client's skin remains dry and intact throughout the hospital stay. The client performs oral hygiene every 4 hours.

The client's intake and output are balanced. During the planning step of the nursing process, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements do not resolve the problem of fluid volume deficiency.

A child with spastic cerebral palsy is to begin botulinum toxin type A injections. Which treatment goals should the health care team set for the child related to botulinum toxin? Select all that apply. enhanced self-esteem improved nutritional status reduced caregiver strain improved motor function decreased pain from spasticity decreased speech impediments

decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain Botulinum toxin injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botulinum does not significantly affect nutritional status or speech.

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client? steroid use in the last year use of all drugs taken in the last 18 months current use of medications, herbs, and vitamins over-the-counter medication use in the last 6 weeks

use of all drugs taken in the last 18 months The nurse does not need to ask about all drugs used in the last 18 months unless the client is still taking them. The nurse does need to know all drugs the client is currently taking, including herbs and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the amount of alcohol consumed, and use of illegal drugs, because these can interfere with the anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal cortex for up to 1 year, and supplemental steroids may need to be administered in times of stress such as surgery.

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

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 nurse is caring for a terminally ill client in the home. The family wants to know how to respond when the client asks whether the client is dying. Which is the best response by the nurse? "Use this opportunity to ask how the client feels about death." "Say that only God knows what is in store for everyone." "Answer truthfully in a caring, gentle manner." "Offer some hope to keep the client strong during this time."

"Answer truthfully in a caring, gentle manner." It is important to be truthful so the client trusts the people providing the client's care. Asking how the client feels about death, telling the client that God knows what is in store, and offering the client some hope take the focus away from the client and do not allow the caregivers to answer truthfully.

A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg, and the pulse is 98 bpm. What should the nurse do? Notify the health care provider. Administer lorazepam. Assign an unlicensed assistive personnel to sit with the client. Administer an antihypertensive.

Administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to decrease the symptoms of central nervous system irritability in the client who is experiencing early symptoms of alcohol withdrawal. An antihypertensive will not treat the underlying CNS irritability. If the lorazepam is effective, it will not be necessary to have someone sit with the client. At this point, it is not necessary to notify the health care provider (HCP).

Which client has a greater risk for latex allergies? a man who works as a sales clerk a woman who is having laser surgery a man with well-controlled type 2 diabetes a woman who is admitted for her seventh surgery

a woman who is admitted for her seventh surgery Clients who have had long-term multiple exposures to latex products, such as would occur with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should explore what types of surgeries these were, how involved the client's recoveries were, and whether signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes, and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.

When obtaining a client's history, the nurse should ask questions about the client's reason for seeking care. auscultate for the client's breath sounds. document medication administered. palpate the client's abdomen.

ask questions about the client's reason for seeking care. When obtaining a client's history, the nurse gathers subjective data by asking questions about the client's reason for seeking care, current health status, and other factors, such as past medical, family, psychosocial, and nutritional history. The nurse performs palpation and auscultation during the physical examination and documents medications administered when implementing the care plan.

The nurse is caring for a client about to receive the first chemotherapy transfusion. When planning how to conduct the teaching session, what action would assist the nurse in determining the client's learning preferences? asking the client if he or she literate and/or health literate asking the client to read a medical brochure asking the client about education level and whether he or she likes to read asking the client which is preferred--brochure, video, or podcast

asking the client which is preferred--brochure, video, or podcast The best way for the nurse to determine a client's learning preference is to ask questions relating to how the client likes to learn. For example, the nurse should ask the client if he or she prefers to read a brochure, watch a video, or listen to a podcast. Asking the client to read something would help the nurse determine the ability to read but not the client's learning preferences. Asking the client about education level and whether he or she likes to read might help the nurse determine at what level to present the information, but not about the client's learning preferences. Asking the client about literacy and/or health literacy may be viewed as insensitive by the client. Additionally, it would not provide the nurse with the client's learning preferences.

Which action performed by a nurse will increase the risk of liability? Select all that apply. providing information to a caller about a client's diagnosis and treatment assisting a client on ordered bed rest to walk to the toilet witnessing a client sign a consent for an ordered medical procedure asking unlicensed assistive personnel to assess a client's wound withholding a medication to clarify the ordered dosage

assisting a client on ordered bed rest to walk to the toilet asking unlicensed assistive personnel to assess a client's wound providing information to a caller about a client's diagnosis and treatment Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel, who does not have the proper training or skills to perform the task. The nurse should not act against physician orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client's consent.

The nurse is monitoring a client under moderate sedation. For which assessment findings will the nurse intervene? Select all that apply. client is drowsy but responds to tactile stimuli capnography of 15 mm Hg blood pressure of 85/40 mm Hg respiratory rate of 20 breaths/min pulse oximetry of 87%

blood pressure of 85/40 mm Hg capnography of 15 mm Hg pulse oximetry of 87% The nurse should intervene if the blood pressure is 85/40 mm Hg, as this is hypotensive for an adult client, and may be in response to medications given. A fluid bolus may easily resolve this abnormal value. The nurse should intervene and provide airway support if the capnography is reading 15 mm Hg because normal values are 35 to 45 mm Hg; this indicates hypoventilation and impaired ventilatory status and may resolve with repositioning the airway or assisted ventilation with a bag-valve mask device. The nurse should intervene by applying oxygen if the pulse oximetry is 87%, because this client is hypoxic. A respiratory rate of 20 breaths/min is a normal value and does not require intervention. The client being drowsy but responding to tactile stimulation is the intended level of sedation during a moderate sedation procedure and is expected, and does not require intervention.

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home? ordering a wheelchair, special utensils, and a raised toilet seat and rearranging the furniture in the home reinforcing the importance of having renovations done before discharge to enable wheelchair access and accessibility to all needs for daily living checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment checking the cleanliness of the home, ensuring removal of clutter, and organizing all essentials on one level of the house

checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home.

A client is scheduled to undergo a moderate sedation procedure for a dislocated shoulder. Which information will the nurse verify during the pre-procedure "time-out" step? Select all that apply. correct procedure correct family members present pertinent laboratory results and images available necessary equipment and medications available correct client identity correct site

correct client identity correct site correct procedure pertinent laboratory results and images available necessary equipment and medications available The time-out step is completed before surgical procedures. This critical step helps ensure client safety: pausing to verify the correct client identity, correct site, correct procedure, as well as that appropriate equipment and medications are available and pertinent images and laboratory results are accessible. Verification of correct family members present would not be part of the time-out procedure, and family members may not be allowed in the room at the time of the procedure. The client should be involved in verifying client identity, site, and procedure when possible.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report? client's admission number current client assessment nursing treatment initiated results of laboratory tests

current client assessment The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions? delegation advocacy networking clinical coordination

delegation The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation.

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? "We can see you without your parents' consent but have to report any positive results to the public health department." "We can treat you without your parents' consent, but they have the right to review your medical record." "We can see you, treat any infections, and will not share your results with anyone." "Because you are underage, we will need your parent's consent to treat you."

"We can see you without your parents' consent but have to report any positive results to the public health department." While some areas may specify a minimum age for treatment (usually 12 to 14 years), generally adolescents have the right to seek treatment for sexually transmitted infections without their parents' permission. These medical records are not shared with parents without the client's permission. However, adolescents must be made aware that certain infections, including gonorrhea, must be reported by law to public health agencies. Partner notification will also take place, but methods vary.

Which client is the most appropriate candidate for outpatient care? A woman who has previously borne two children and is entering the second stage of labor. A client who is receiving treatment for sepsis after their blood culture came back positive. A client whose reports of irregular bowel movements have necessitated a colonoscopy. A client with a history of depression who is currently expressing suicidal ideation.

A client whose reports of irregular bowel movements have necessitated a colonoscopy. Outpatient services are appropriate for those who are medically stable but require diagnostic testing, such as a colonoscopy. Clients who are in active labor, have sepsis, or are suicidal require close monitoring and frequent interventions that can be safely provided only on an inpatient basis.

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

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 client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? Secure the restraints to side rails of the bed. Check on the client every 30 minutes while the restraints are on. Instruct the client not to move while the restraints are in place. Remove the restraints every 4 hours to provide skin care.

Check on the client every 30 minutes while the restraints are on. The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.

A nurse observes another nurse making social plans with a client and disclosing information of a personal nature. What would the observing nurse do in this situation? Find out whether the nurse meets with other clients socially as well. Report the observation to the nurse manager. Discuss the observation directly with the nurse. Let coworkers know what is going on to have witnesses.

Discuss the observation directly with the nurse. Planning to meet a client socially and disclosing personal information could blur the boundaries of the therapeutic relationship, which may result in an unhealthy outcome for the client. The observing nurse should take the nurse aside and point out that this behavior is inappropriate and not in the client's best interest. Sharing the observation with coworkers is gossiping and does not address the issue. As a professional, the nurse has an obligation to help educate the other nurse. It is possible a reminder about professional boundaries will resolve the issue without requiring involvement of the nurse manager. Regardless if the nurse has met with other clients or not, this particular instance should be dealt with by directly discussing the concerns with the nurse.

A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do? Give the nurse the lightest workload on the unit. Tell the nurse to buddy up with someone else and do the best that the nurse can do. Tell the nurse that as an RN, the nurse should be competent to work in any area. Find another nurse to cover the unit and send the nurse back to the surgery unit.

Find another nurse to cover the unit and send the nurse back to the surgery unit. Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies. The other options are incorrect because they do not ensure that the clients are receiving care from the most competent nurse.

The nurse is assessing a 16-year-old nulligravida, who asks for information on natural family planning methods of contraception and reports that her menstrual cycle occurs every 28 days. Which information would be important to include in the teaching plan for this client? Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. The basal body temperature falls at least 0.2°F (0.1°C) after ovulation has occurred. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus. The ovum survives for 96 hours after ovulation, making conception possible during this time.

Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed.In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible.Basal body temperature rises 0.5° F to 1.0° F (0.3° C to 0.6° C) when ovulation occurs.Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious.

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? P wave QRS complex T wave PR interval

P wave The P wave depicts atrial depolarization or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

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

Provide explanations and support to the client. Attend to the client's physical needs. 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.

The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which intervention would be most appropriate? Give vasodilator medications as prescribed. Serve hearty, nutritious meals. Provide stimulating, nonthreatening life experiences. Let the child play with more able children.

Provide stimulating, nonthreatening life experiences. Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as beneficial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child's IQ.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which actions should the nurse prioritize when attempting to establish an effective relationship with the client? Explain and answer questions about the Health Insurance Portability and Accountability Act (HIPAA). Recognize and address the client's anxiety. Assess the client's knowledge of their activity limitations. Address the client's potential learning needs.

Recognize and address the client's anxiety. An early priority when admitting a client to a unit and establishing a relationship is to recognize and take steps to reduce anxiety. Assessing and addressing learning needs are important goals but should be addressed after the client has been settled on the unit. HIPAA should have been explained to the client earlier in the admission process.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do? Report any significant pain to the health care provider at least 2 days before the test. Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. Remove all metal objects on the day of the scan. Consume foods and beverages with a high content of calcium for 2 days before the test.

Remove all metal objects on the day of the scan. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing? narrative charting focus charting PIE charting SOAP charting

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

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 20-year-old with first-degree burns on her hands and forearms a woman who is 5 months pregnant with no apparent injuries a 10-year-old with a simple fracture of the humerus who is in severe pain a middle-aged man with no injuries who has rapid respirations and coughs

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.

Which type of surgery is most likely to cause the client to experience postoperative nausea and vomiting? total hip replacement mastectomy of the left breast mitral valve repair abdominal hysterectomy

abdominal hysterectomy Although any client may experience nausea and vomiting secondary to anesthetics or postoperative analgesics, the client who has had manipulation of the abdominal organs is more prone to postoperative nausea and vomiting than the client who has had a procedure such as a total joint replacement, open heart surgery, or a mastectomy.

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care? an elderly client experiencing chest pain due to suspected pulmonary embolus a middle-aged client who had a laryngectomy 2 days earlier an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea a young client receiving chemotherapy for Hodgkin's disease

an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea The most appropriate client to assign to a UAP is the elderly client with COPD and mild dyspnea because of the relative stability of the client's chronic condition.The client with a new laryngectomy requires close observation to maintain a patent airway, promote comfort, and decrease anxiety.The client who is receiving chemotherapy will need to be monitored for adverse effects related to the chemotherapy.The client with a suspected pulmonary embolus is acutely ill and requires close observation.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? asking frequently whether the client understands the instructions demonstrating the procedure and having the client return the demonstration writing out the instructions and having a family member read them to the client asking an interpreter to relay the instructions to the client

demonstrating the procedure and having the client return the demonstration Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

The nurse is caring for a client with a developmental disability who needs additional education regarding management of type 2 diabetes. What should the nurse assess to determine the amount and level of education to provide to the client? developmental stage chronologic age functional age behavioral disability

developmental stage The nurse should assess the client's developmental stage to determine the amount and level of educational information to provide to the client as this can impact the client's ability and readiness to learn. Chronologic age and functional age are not true indicators of the client's ability/readiness to learn. There is nothing in the question to indicate that the client has a behavioral disability.

In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner? orders for diagnostic studies orders for dietary changes orders for respiratory treatments orders for antibiotics

orders for antibiotics Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.

Which approach is the best way for the nurse to begin the preoperative interview? Walk in the client's room: and ask the client's name. sit down, and take the client's blood pressure. and ask, "Are you Mrs. Smith?" sit down, maintain eye contact, and make an introduction.

sit down, maintain eye contact, and make an introduction. Nurses should provide the preoperative client individual and sincere attention by meeting the client at eye level and introducing themselves by name and role. The nurse should ask the client to tell her full name rather than asking if she is Mrs. Smith because there might be another client by that name on the schedule. Nurses should not start the physical assessment or ask the client's name without first identifying themselves and their role out of courtesy and to relieve the client's anxiety in the new environment of the surgical experience.

A nurse is caring for a client following a tonsillectomy and fails to routinely assess the back of the client's throat for signs of bleeding. The nurse manager reviews the client's chart and notices the omission of the assessments. Which is the best response to the nurse regarding the missing assessments? "I hope you have malpractice insurance to cover your failures." "Failure to complete these assessments constitutes negligent behavior." "I assume that the client has refused to let you do the assessments." "Everyone forgets things once in a while, but please don't do this again."

"Failure to complete these assessments constitutes negligent behavior." By not checking the back of the throat for bleeding after a tonsillectomy, the nurse is negligent. Negligence is the omission of doing something that a prudent nurse would do following this type of surgery. Malpractice occurs when there is actual harm or injury to the client. The other options do not provide the nurse with an understanding of the seriousness of the behavior.

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which would be the most appropriate response by the nurse to the surgeon? "I will get the consent signed right away and attach it to the chart." "I'll have the client sign, but you must explain the procedure before surgery." "I will explain the procedure and call you back if the client won't sign the consent." "It is your responsibility to obtain informed consent from the client."

"It is your responsibility to obtain informed consent from the client." It is the surgeon's responsibility to obtain the informed consent after explaining the procedure to the client, including the risks, benefits, and alternatives. The other options are incorrect because they place the responsibility for obtaining informed consent on another person

The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor? "I will have to report to the supervisor if you can't do it." "Let's discuss how we can meet our clients' needs." "I will take care of any client needs that you can't provide." "All clients have a right to compassionate and timely care."

"Let's discuss how we can meet our clients' needs." The basic element of assertive behavior includes the ability to express feelings and thoughts while respecting the rights of others. Behavior that dominates, humiliates, or ignores the rights of others is aggressive. Passive behavior includes ignoring personal rights and allowing others to infringe upon them in an attempt to avoid unpleasant situations.

After completing the nursing assessment for a client and family entering the palliative care program. Which are appropriate nursing goals at this time? Select all that apply. Prolong life. Provide comfort during the dying process. Offer support for the client's family. Maximize the client's quality of life. Achieve a dignified and respectful death. Modify the family's usual coping strategies.

Achieve a dignified and respectful death. Maximize the client's quality of life. Provide comfort during the dying process. Offer support for the client's family. Palliative care is health care aimed at symptom management rather than curative treatment for diseases. Nursing care goals include providing comfort and support for the client and family and maximizing the client's quality of life. Grief counseling is a component, and efforts would be to enhance the coping of all involved, but the family's usual coping methods would not be altered. Palliative care does not involve advocating to prolong the client's life.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager? Reprimand the nurse for being forgetful. Ask the nurse whether the client refused the assessments. Review the nurse's malpractice insurance policy. Address the nurse's omissions as negligent behavior.

Address the nurse's omissions as negligent behavior. Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.

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? Notify the licensing body of the nurse's behavior. Ask the nurse if this is acceptable practice for this unit. Inform the nurse that an accusation of negligence could be made. Advise the nurse that a charge of battery could be made.

Advise the nurse that a charge of battery could be made. 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 nurse is caring for a client who speaks only French. The client's grandchild is bilingual and assists with translating, but the nurse needs to provide the client with discharge instructions. Which option would be best for the nurse and the client? Ask the manager to find an interpreter who is able to provide the discharge instructions. Document on the medical record that discharge instruction was not provided due to a language barrier. Provide the information to the grandchild, and have the grandchild translate in the nurse's presence. Provide written instructions in English, and ask the grandchild to translate them at home.

Ask the manager to find an interpreter who is able to provide the discharge instructions. The best option would be for an interpreter to provide translation and for the nurse to document the health teaching and discharge instructions. The two can work together to provide the instructions verbally and in writing and answer the client's questions. There is no means for the English-speaking nurse to know whether the grandchild has translated the information accurately and whether the information was understood. The other option does not provide for competent nursing care.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first? Complete an incident report. Call the health care provider (HCP). Reprimand the UAP for the error. Wait and observe the client for symptoms of hyperglycemia.

Call the health care provider (HCP). The error should be reported to the HCP promptly; the HCP may write additional prescriptions. The nurse should complete an incident report because a potentially dangerous event happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the HCP and complete an incident report. The UAP does not need to be reassigned for this error. The nurse does not need to reprimand the UAP for the error because the UAP already knows an error was made and has reported it to the nurse.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? Report to the nurse manager that the nurse needs guidance on documentation. Rewrite the entry on the correct health record indicating who made the error. Contact the previous nurse requesting that the nurse correct the error. Strike through the entry ensuring the original entry is still visible.

Contact the previous nurse requesting that the nurse correct the error. The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which action by the nurse is most appropriate? Call the unit and dictate the entry to another nurse. Enter the information tomorrow stating it is a late entry. Wait to hear if the nurse manager will offer some advice. Call and ask the nurse to leave a blank entry for completion tomorrow.

Enter the information tomorrow stating it is a late entry. The nurse should enter the information on the medical record as a late entry with current date and time. The other options are incorrect because the nurse needs to document the care provided. Blank spaces should not be left in the chart and all care must be documented.

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information? Stand in front of the client, and slowly explain the instructions. Give the client written material to read, and follow up with time for questions. Show the client a DVD with instructions. Provide instructions to the spouse, and have the spouse explain them to the client.

Give the client written material to read, and follow up with time for questions. A client who is deaf benefits most from reading information and then having an opportunity to ask questions and follow up. Verbal communication, while appropriate, may not be sufficient. The spouse can be included in the teaching, but the nurse is responsible for ensuring that the client understands the instructions. DVDs may be helpful, but unless they have closed captioning, key points may be missed in the audio portion.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation? Validate the relationship of the visitor to the client before discussing the client's status. Notify security that the visitor viewed confidential client information. Confirm that the client is on the unit but offer no further details. Inform the other nurse that the viewed screen resulted in a breach of confidentiality.

Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.

A nurse caring for a client being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? Information is documented in separate forms by each healthcare professional. It is compiled to facilitate communication among healthcare professionals. It is a unified, cooperative approach for resolving the client's problems. It is organized at one location according to the client's healthcare problems.

Information is documented in separate forms by each healthcare professional. Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which healthcare personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach for resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among healthcare professionals.

The nurse is preparing to administer a flu shot to an adult client. How would the nurse proceed? Place the steps in sequential order. All options must be used.

Put gloves on. Locate the deltoid muscle. Clean the injection site with an alcohol pad. Gently stretch the skin taut at the site. Inject it into the muscle at a 90-degree angle. Wait 10 seconds before removing needle. To perform the injection, the nurse should first put on gloves. Next, the nurse should locate the deltoid muscle, the muscle most commonly used for immunizations such as flu shots. The deltoid muscle is located on the lateral aspect of the upper arm, 1 to 2 inches (2.5 to 5 cm) below the acromion process of the shoulder. The nurse should then clean the injection site, remove the needle cover, and expel air bubbles from the syringe. The nurse should position the syringe at a 90-degree angle to the skin surface and instruct the client they will feel a prick. Finally, the nurse should thrust the needle into the muscle, inject the vaccine, then wait 10 seconds to remove the needle to allow the medication to diffuse into the tissue.

The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semiprivate room. The 6-year-old's mother is upset because the parent staying with the other child is male, and the mother believes the arrangement violates her social norms. What should the nurse do? Offer the 6-year-old's mother another place to sleep. Refer the 6-year-old's mother to the customer service representative. Explain to the parents that this room arrangement facilitates teaching. Reassign the children to different rooms.

Reassign the children to different rooms. Sleeping in the same room with a person of the opposite sex may be viewed as a violation of norms by persons of conservative faiths. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be distressing enough to create a learning barrier. Offering the mother another place to sleep deprives the child of her parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the mother's needs.

A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take? Tell the RT that you saw her take the pills from the medication room. Report the situation to the nursing supervisor. Tell the nurse who was administering medications not to leave pills out. Report the situation to the supervisor of respiratory therapy.

Report the situation to the nursing supervisor. The nurse should follow the line of authority or chain of command by reporting the observation immediately to the nursing supervisor. The nurse should not confront the person or the medication nurse because the line of authority for reporting incidents should be followed. The RT supervisor may subsequently be involved in the incident, but the nursing supervisor should initiate and follow the policy and procedure.

A client in a long-term care facility is scheduled to have a bath and is taken to the tub room by the nurse. The client does not want to be bathed and refuses to get undressed. Which action should the nurse take? Begin to undress the client, explaining calmly that it is bath day. Return the client to the room and document that the bath was not given. Obtain an order to restrain the client's arms in order to get the resident in the tub. Ask a colleague for assistance with bathing the client in the tub room.

Return the client to the room and document that the bath was not given. The client has the right to refuse treatment, including a bath. With the other options, the nurse would be guilty of physical abuse because the nurse would be forcing the client to do something the client did not want to do and for which consent was not given. Restraining and undressing the client against the client's will would be considered physical abuse, and the nurse could be charged with battery.

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? The client will approach the nurse to ask for a magazine. The client will permit the nurse to speak with them for a 5-minute period by day 2 of hospitalization. The client will visit the window outside of the newborn nursery to see the new babies. The client will enjoy visits from other clients admitted to the same unit.

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.

The nurse working with a group of nursing students. What breaches in client care require the nurse to intervene to protect client privacy? Select all that apply. Transporting a client to radiology on the public elevator Attaching client's hospital labels to a laboratory specimen Keeping the client's door closed during bathing Discussing clients in the cafeteria with other hospital staff Asking a client's name and date of birth prior to medication administration

Transporting a client to radiology on the public elevator Discussing clients in the cafeteria with other hospital staff Transporting a client to radiology on the public elevator and discussing clients in the cafeteria are examples of breaches in client privacy. Asking a client's name and date of birth prior to medication administration, attaching client's hospital labels to a laboratory specimen, and keeping the client's door closed during bathing will allow the nurse to provide client privacy.

Which situation is an indication of the benefit of self-awareness in professional nursing practice by a nurse? Select all that apply. Understands the meaning of cultural diversity Questions all situations for underlying meanings Appears more tolerant to different practices Examines own biases and is open to new ideas No longer is affected by biases and assumptions

Understands the meaning of cultural diversity Examines own biases and is open to new ideas Self-awareness in nurses allows openness and a willingness to examine one's beliefs and consider new ideas. Understanding the meaning of cultural diversity also shows self-awareness. Appearing more tolerant to different practices means willingness to accept others' beliefs, but doesn't necessarily mean examining one's own beliefs. To question all situations for underlying meaning is not an example of self-awareness and self-reflection.

During the planning step of the nursing process, the nurse gathers objective data. determines the client's goal achievement. writes a statement about the client's health problem. establishes short- and long-term goals.

establishes short- and long-term goals. During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.

A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? sexual dysfunction self-consciousness pain depression

pain The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.

The nurse is preparing to begin discharge planning with a client whose pulmonary embolism has recently resolved. Which factor should the nurse prioritize during this process? the client's potential for recurrence the client's identified needs and goals the nursing diagnoses relevant to the client's condition the nurse's knowledge base and experience level

the client's identified needs and goals The central focus of client teaching and the larger discharge planning process should be the identified healthcare needs of the client and the goals that the client identifies or acknowledges. The nurse's skills and knowledge, the potential for recurrence, and the relevant nursing diagnoses are all elements that may inform the discharge planning process, but they are superseded by the client's goals and expressed needs.

The nurse is placing a client with severe neutropenia in reverse isolation. What should the nurse tell the client why this is necessary? Reverse isolation helps prevent the spread of organisms: from the client to health care personnel, visitors, and other clients. by using special techniques to dispose of contaminated materials. to the client from sources outside the client's environment. by using special techniques to handle the client's linens and personal items.

to the client from sources outside the client's environment. The primary purpose of reverse isolation is to reduce transmission of organisms to the client from sources outside the client's environment.

A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to walk from their room to the end of the hall and back before discharge. select special foods from a diet after client education by the nurse. walk with help in the hallway by the end of the evening shift. change their own dressing with clean technique and be able to verbalize the steps.

walk from their room to the end of the hall and back before discharge. Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change their own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used.

Assess the client's respiratory status, including oxygen saturation. Ensure the client does not need toileting or pain medications. Review the client's medications for interactions that may cause or increase confusion. Contact the health care provider (HCP) and request a prescription for soft wrist restraints. The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort.

The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse? Call one of the client's other healthcare providers to request that a copy of the medical records for the client be sent to the clinic. Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Advise the client that the appointment will have to be rescheduled due to the fact that the medical record cannot be located. Document the information about the visit on paper, and transcribe these notes into the client's medical record once it is located.

Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Documentation is an essential and legal component of providing care to clients. Information must be documented as it is collected. The nurse should not send the client away without the client getting the care that was to be provided. Therefore, the nurse creates a new record that contains all the client's appropriate identifiers so this can be added to the client's primary medical record when it is located. The nurse should be truthful about the missing records and should avoid transcribing notes whenever possible to avoid data errors. Another healthcare provider's records are not a substitute for the health record specific to this clinic. Requesting records from another provider would only be appropriate if relevant to the client's current reason for the visit and if the client consented to the transfer of this information.

A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next? Change the consent form. Call the surgeon. Review the client's history. Have the client sign the consent form.

Call the surgeon. Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours? Client 3, Client 1, Client 2, Client 4 Client 4, Client 1, Client 3, Client 2 Client 2, Client 1, Client 3, Client 4 Client 4, Client 3, Client 2, Client 1

Client 4, Client 3, Client 2, Client 1 It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

A client with a long history of paranoid schizophrenia is readmitted voluntarily after missing his last two injections of haloperidol. He reports, "I'm not sleeping much, and my friend says I smell from not showering. God is telling me to protect myself from others. My parents are sick and tired of me and my illness. They wish I were dead." Which admission notes by the nurse contains assumptions and potentially false accusations? Select all that apply. Client has been noncompliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him. Client has missed two injections of haloperidol and was admitted voluntarily. He reports he has decreased sleep and showering and that he hears God's voice telling him to protect himself from others. He stated, "My parents are sick and tired of me and my illness. They wish I were dead." Client has missed two doses of haloperidol. He is not sleeping and showering. Has a strained relationship with his parents and delusions that they want him dead. Voluntary admission to restart haloperidol. Client admitted for noncompliance with haloperidol injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation. Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for 2 days.

Client has been noncompliant with his medications, causing decreased sleep and activities of daily living, increased auditory hallucinations, and paranoid delusions about his parents harming him. Client has missed two doses of haloperidol. He is not sleeping and showering. Has a strained relationship with his parents and delusions that they want him dead. Voluntary admission to restart haloperidol. Client admitted for noncompliance with haloperidol injections, sleep disturbance, poor hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for suicidal and homicidal ideation. Client admitted because of hallucinations and delusions. His parents may be abusing him. He states he has not taken his medications for 2 days. Documentation provided in option 2 is the most factual and without conclusions or assumptions. Stating that the client was noncompliant with medications is not the only cause of decreased sleep and activities of daily living or increased delusions and hallucinations. Also, the client did not say that his parents wanted to harm him directly. Stating that the client's relationship with his parents is strained is an assumption, even if he did indeed state that they wanted him dead. The client does not state a wish to be dead or harm others, although further assessment would be necessary. Documenting that his parents may be abusing him makes an assumption, although the nurse should further assess for this possibility.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? Contact the surgeon for clarification because this is not a complete order. Transcribe the preoperative medication orders the surgeon has ordered. Ask the pharmacist for a list of preoperative medications for the client. Obtain new orders for the client from the physician on call.

Contact the surgeon for clarification because this is not a complete order. After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

A nurse uses the Nurse Practice Act to guide professional standards. Which actions are within the scope of the registered nurse? Select all that apply. Administer conscious sedation. Delegate basic hygiene to an unlicensed assistive personnel. Administer an intravenous medication to decrease blood pressure. Initiate a plan of care for a client with vertigo. Provide insulin injection teaching to a new diabetic client.

Delegate basic hygiene to an unlicensed assistive personnel. Administer an intravenous medication to decrease blood pressure. Initiate a plan of care for a client with vertigo. Provide insulin injection teaching to a new diabetic client. The registered nurse's scope of practice allows for administering intravenous medication to decrease blood pressure, initiating a plan of care for a client with vertigo, delegating basic hygiene to unlicensed personnel, and providing insulin injection teaching to a new diabetic client. The registered nurse needs special certification to administer conscious sedation.

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? Tell the client's child the blood glucose level because this test is performed on the nursing unit. Ask the client's child if she has her parent's permission to access the parent's health information. Explain that this information cannot be disclosed without the client's permission. Have the child sign a "Disclosure of Health Information" form prior to giving the child the information.

Explain that this information cannot be disclosed without the client's permission. The Health Insurance Portability and Accountability Act in the United States, and the Canadian Privacy Act and the Personal Information Protection and Electronic Documents Act (and often provincial/territorial legislation) prevents family members or friends from acquiring health information without consent of the client involved. Whether the test was performed on the nursing unit or others had given the client's child this information is irrelevant; the client's test results are still protected health information. The nurse should not ask the client's child if the child has permission, the client should be asked. If a disclosure of health information form is signed, it should be the client signing, not the daughter. (Note: the caregiver of a client who is incapacitated CAN be given healthcare information.)

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next? Place the incident report on the medical record. Call the family to inform them. Omit mentioning the fall in the medical record documentation. Give the incident report to the nurse-manager.

Give the incident report to the nurse-manager. The incident report should be given to the nurse-manager. The incident report should not be placed on the medical record because it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.

A charge nurse assesses a group of staff nurses as competent individually but ineffective and nonproductive as a team. How should the charge nurse address the staff nurses about these concerns? Have the staff nurses express their feelings and emotions. Incorporate the staff nurses in decision making. Increase staffing to prevent fatigue from overwork and understaffing. Ask the staff nurses if they feel unhappiness about the current leadership.

Have the staff nurses express their feelings and emotions. The most common reason for lack of productivity in a group of competent nurses is inadequate communication or unexpressed feelings and emotions. Unhappiness about leadership, fatigue from overwork and understaffing, and failure to incorporate staff in decision making could contribute to the problematic situation, but they're less likely to be the cause of the problem.

A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? Interview the nurse's other clients to see if the nurse attempted to sell supplements to them. Tell the client that the client should not purchase anything from the nurse. Inform the nurse that selling supplements to clients is a conflict of interest. Report the nurse to the nurse manager and the nursing regulatory body.

Inform the nurse that selling supplements to clients is a conflict of interest. The first nurse is offering advice outside the scope of practice for an RN and could be accused of diagnosing and prescribing. The nurse is also working outside the therapeutic relationship. The client may feel pressured to purchase the supplements to get nursing care or further assistance from the nurse, which puts the nurse in a position of power over the client. It is not appropriate to tell the client to not purchase supplements from the nurse. It is also not appropriate to interview the nurse's other clients. Finally, as a professional, the second nurse should address the behavior with the colleague first and provide a teaching opportunity. If the first nurse does not agree to stop, or is found engaging in the behavior again, then reporting to the manager and regulatory body is appropriate.

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 the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation? Leave the area in the car, provided the nurse can get to it safely. Call out to attract attention from bystanders. Confront the group of people in an assertive but non-aggressive manner. Perform the home visit and ensure that the group is gone before leaving.

Leave the area in the car, provided the nurse 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 themself from the situation, provided this can be achieved without incurring further risk.

A young adult is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. The health care provider (HCP) will get a consultation from another health care provider and proceed with placement of the ICP catheter until the family arrives to sign the consent. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.

The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client's fiancée cannot sign the consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The HCP should insert the catheter in this emergency. He does not need to get a consultation from another HCP. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin.

A nurse is developing a teaching plan for a client who has recently been diagnosed with open angle glaucoma. The healthcare provider ordered pilocarpine 0.25% ophthalmic drops, two drops to eyes each eye four times a day. How should the nurse instruct the client to instill the eye drops? Select the correct order. All options must be used.

Wash your hands. Take top off the medication bottle and place on a clean cloth. Using a tissue or cotton gently pull the skin below the eye downward. Put two drops into the conjunctival sac of the right eye. Close the eye. Using your finger and a tissue place gentle pressure on the nasolacrimal duct for 30 to 60 Hand hygiene prevents spread of microorganisms. Placing the top on a clean cloth prevents contamination. Ophthalmic medications are placed in the conjunctival sac. Pressure is placed on the nasolacrimal duct to prevent systemic absorption.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider? When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. A standard walker needn't be picked up when moved. The hand bar of the walker should be well below the client's waist.

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? When the nurse receives a critical lab value via phone or in-person from the lab When the float nurse gives a written report to the oncoming nurse When the lab report shows up on the computerized medical record When the unit clerk takes a telephone prescription for a stat lab test

When the nurse receives a critical lab value via phone or in-person from the lab For any verbal or telephone prescription or result, it is important to read back the information to assure its accuracy. It is also important to document that it was read back according to facility policy. It is not necessary to use "read-back" procedures when data are entered on the computerized medical record. The Unit clerk is not a licensed health care worker and should not take telephone prescriptions. When giving a written report, it is not necessary to "read back," but the nurse should always clarify if there is any question.

Write out the order, the physician's name, the nurse's name, and the name of a witness. Obtain confirmation of the order from a physician or nurse practitioner present on the unit. Write "T.O." after the order and write out the physician's and nurse's names. Record the order verbatim in the client's charts and follow it with the nurse's printed name and signature alone.

Write "T.O." after the order and write out the physician's and nurse's names. When receiving telephone orders, the nurse should record the orders in the client's medical record, read the order back to the ordering practitioner, date and note the time the orders were issued, record T.O. (telephone orders) and the full name and title of the physician or nurse practitioner who issued the orders, and then sign the orders with name and title. It is unnecessary to obtain a confirmation from another practitioner or to have the order witnessed.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a 20-year-old who is unresponsive and has a high injury to his spinal cord an 80-year-old who has a compound fracture of the arm a 25-year-old with a sucking chest wound a 10-year-old with a laceration on his leg

a 25-year-old with a sucking chest wound During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

The nurse has just received the change of shift report on the clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first? a 30-year-old multiparous client who gave birth to a 6-lb, 5-oz (2,863-g) girl by cesarean 3 hours ago, has a firm fundus and scant lochia rubra, and is receiving morphine by patient-controlled analgesia a 24-year-old primiparous client who gave vaginal birth to a 7-lb, 3-oz (3,260-g) boy 1 hour ago, has a firm fundus and scant lochia rubra, and is attempting to breastfeed a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia an 18-year-old single primigravid client, in labor for 9 hours, with cervical dilation at 6 cm, 0 station, contractions occurring every 5 minutes, and receiving epidural anesthesia

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia The client who should be assessed first is the multigravid client who has been in labor for 8 hours and whose cervix is 8 cm dilated at 1+ station with contractions every 3 to 4 minutes. A multigravid client typically has a shorter labor than a primigravid, and this client's station is 1+, which means that birth of the fetus is imminent.

The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN? a 28-year-old client being evaluated for a bone marrow transplant a 65-year-old client diagnosed with endometrial cancer who underwent an abdominal hysterectomy 3 days ago a 52-year-old client with lung cancer admitted for acute dyspnea a 45-year-old client receiving tube feedings

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, the RN 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 LPN/VN and UAP.

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain a primigravida at 17 weeks' gestation who reports not feeling fetal movement at this point in her pregnancy a client at 13 weeks' gestation who is experiencing nausea and vomiting three times a day with + 1 ketones in her urine a client at 37 weeks' gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal movements per day

a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks' gestation with nausea and vomiting is a concern because the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin-dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need additional testing to further evaluate fetal well-being.) The client who is at 17 weeks' gestation may be too early in her pregnancy to experience fetal movement and would be the last person to be seen.

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply. a thorough explanation of the isolation procedures acknowledgement of the family's concerns discontinued isolation procedures at the family's request free access to the client for immediate family a communication plan for the family and client

a thorough explanation of the isolation procedures acknowledgement of the family's concerns a communication plan for the family and client To ensure that everyone complies with the isolation procedures, the nurse should develop a communication plan with the family and client, provide thorough explanations about the importance of complying with the isolation procedures, and address family and client concerns. Allowing free access or discontinuing isolation procedures at the family's request would be a safety violation.

When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face? selecting vocation, becoming financially independent, and managing a home developing leisure activities, preparing for retirement, and resolving empty-nest crises adjusting to retirement, deaths of family members, and decreased physical strength managing a home, developing leisure activities, and preparing for retirement

adjusting to retirement, deaths of family members, and decreased physical strength Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges faced in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty-nest crises.

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? evaluation assessment implementation diagnosis

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.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? toileting self-care deficit urinary retention electrolyte disturbance excess fluid volume

excess fluid volume A client with renal failure can't eliminate sufficient fluid. This issue increases the risk of fluid overload and consequent respiratory and electrolyte problems. This client shows signs of excess fluid volume and is acutely ill. Urine retention may cause renal failure but is a less urgent concern than fluid imbalance. Electrolyte disturbance and Toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they aren't life-threatening.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: inspiratory and expiratory wheezing. normal breath sounds. morning headaches. increased forced expiratory volume.

inspiratory and expiratory wheezing. The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

Which activities would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? obtaining a client's routine glucose reading using a glucometer taking a client's apical pulse before the nurse administers digoxin teaching a client how to change an ileostomy pouch performing a dressing change for a client whose incision is infected and requires irrigation

obtaining a client's routine glucose reading using a glucometer It is most appropriate for the nurse to delegate the activity of obtaining a client's routine glucose reading.The nurse is responsible for performing assessments and analyzing the data on which treatment decisions are based; the nurse should assess and evaluate the client's apical pulse before administering the digoxin.The dressing of an incision that is infected and requires irrigation should be changed by the nurse so that the nurse can perform the irrigation and evaluate tissue healing.It is the responsibility of the nurse, not the UAP, to teach the client.

The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed? 4 x 4 gauze petrolatum gauze adhesive strips No dressing is necessary.

petrolatum gauze Gauze saturated with petrolatum is placed over the site to make an airtight seal to prevent air leakage during the healing process. Dry dressings or adhesive strips are not used.

A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to: ask the nurse to read the policy book before administering the blood. give a thorough explanation of the procedure for blood administration to the nurse. ask the nurse to determine how confident he or she is to administer the blood safely. reassign the client to another nurse who is experienced in blood administration.

reassign the client to another nurse who is experienced in blood administration. The best option in this situation is to reassign the client to a nurse with experience in blood administration.The policy book and explanation are resources, but the nurse is a pediatric nurse who has never administered blood before, and therefore, an unsafe situation is created.An explanation is insufficient teaching for safe and proper blood administration, and reading policy book may be a resource, but having an experienced nurse administer the blood is a safer decision.Asking about the nurse's confidence is not sufficient evidence that the nurse can administer the blood. Asking an experienced nurse to administer the blood is a safer option.

A client who is blind is admitted for treatment of gastroenteritis. Which intervention takes highest priority for this client? improving physical mobility fall prevention maintaining activity status replacing fluid volume

replacing fluid volume Because the client has gastroenteritis and is probably dehydrated, replacing fluid volume takes highest priority. A sensory deficit, such as blindness, puts the client at risk for injury from the environment; however, a potential problem does not take highest priority. Although activity intolerance or Impaired physical mobility also may be relevant, these interventions do not take precedence over the client's dehydration.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: report this to the head nurse in the morning. report this to the nursing supervisor immediately. ask the nurse if she has been drinking. assess the nurse's behavior for signs of intoxication.

report this to the nursing supervisor immediately. This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action? reddened wound edges epithelizing tissue present small amount of creamy yellow drainage moderate pinkish to red watery drainage

small amount of creamy yellow drainage Yellow, creamy drainage describes purulent discharge and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered. Clear pink to red watery discharge describes serosanguinous discharge, which is evidence of some edema at the site; it does not warrant immediate intervention. Reddened wound edges are expected as healing occurs, and epithelizing tissue represent normal findings for a wound.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. next of kin identifying information when possible (such as name and age) presence of jewelry medications and treatments administered triage priority

triage priority identifying information when possible (such as name and age) medications and treatments administered Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.