Basic Care PrepU Questions

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine? serum potassium level lymphocyte count albumin level CBC differential

albumin level Explanation: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge their nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

The nurse is receiving a client in the operating room for an incision and drainage of the right thumb. What will the nurse do during the timeout procedure? Select all that apply. Review the surgical site marking of the right thumb. Obtain the client's medication history. Assess the client's dominant hand. Identify the correct surgical procedure. Confirm the client's name band.

Review the surgical site marking of the right thumb. Identify the correct surgical procedure. Confirm the client's name band. Explanation: The timeout procedure reviews client safety and includes reviewing surgical site markings, identifying correct surgical procedure, and confirming the client's name band. The nurse will obtain the client's medication history and assess the client's dominant hand prior to the surgery.

The client is ordered heparin IV and the nurse questions if the dose of heparin is safe according to the client's age and weight. What actions should the nurse implement? Select all that apply. -Administer the IV as ordered, but document concerns. -Administer the IV heparin as ordered. -Withhold the dose at this time. -Call the health care provider and discuss concerns. -Administer half the medication and document concerns

Correct response: Withhold the dose at this time. Call the health care provider and discuss concerns. Explanation: The nurse should withhold the dose until talking to the health care provider about any concerns they may have. It would be unsafe for the nurse to administer any part of the medication without investigating further, regardless of whether or not the nurse documented concern. The nurse should never change a medication order, as this is not within the nurses' line of practice.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. What should the nurse do? Reinforce the UAP's use of this intervention over the bony prominences. Explain that massage is effective because it improves blood flow to the area. Inform the UAP that massage is even more effective when combined with lotion during the massage. Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Explanation: Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? -"It is always a good idea to rest quietly after surgery, which will help minimize further pain." -"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." -"The physician will probably order you to lie flat for 24 hours." -"Why don't you decide about activity after you return from recovery?"

"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." Explanation: To prevent venous stasis and improve muscle tone, circulation, and respiratory function, the client should be encouraged to move around after surgery. Pain medication will be administered to permit movement. Early ambulation with associated pain management reduces postoperative risk, and all other answers do not reflect this.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care? Bending and twisting while providing care may cause injury. The center of gravity is located at the waist. A client's level of consciousness and ability to cooperate are not important factors during transfer. Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

Bending and twisting while providing care may cause injury. Explanation: Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client? -Measure NG tube length to confirm it is equal to the distance from the client's ear lobe to the nose plus the distance from the nose to the tip of the xiphoid process. -Obtain a chest X-ray and measure the pH of stomach contents. -Measure to the second or third black marking on the NG tube. -Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound.

Correct response: Obtain a chest X-ray and measure the pH of stomach contents. Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? Impaired urinary elimination Deficient fluid volume Imbalanced nutrition: Less than body requirements Excess fluid volume

Deficient fluid volume Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate? -Leave the drain open to the air to ensure maximum drainage. -Ensure that the drainage receptacles are kept compressed to maintain suction. -Attach the tube to straight drainage to monitor the output. -Irrigate the drain with normal saline to ensure patency.

Ensure that the drainage receptacles are kept compressed to maintain suction. Explanation: Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.

The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next? Explain the procedure in detail to the client, and assess the client's understanding. Continue to follow the preoperative procedures required to prepare the client for surgery. Notify the health care provider that the client cannot explain the scheduled surgery. Document the client's response in the electronic medical record.

Notify the health care provider that the client cannot explain the scheduled surgery. Explanation: The nurse should ask the health care provider to explain the surgery to the client again and ensure the client understands the procedure and the risks. If necessary, the nurse can call an interpreter. It is the role of the health care provider to explain the surgical procedure, not the nurse. The nurse cannot continue to prepare the client until the health care provider has explained the surgery and the client agrees to proceed. The nurse should then document the client's response and nurse's action after notifying the health care provider of the need to reexplain the procedure to the client.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied? Elevate the client's legs while out of bed. Remove elastic stockings once per day and observe lower extremities. Teach the client isotonic leg exercises. Order a second pair of stockings to be rotated each day.

Remove elastic stockings once per day and observe lower extremities. Explanation: Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stockings, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client? Stand at the head of the stretcher and push the device. Stand at the foot of the stretcher and pull with the arms. Stand at the side of the stretcher and push with the arms. Stand at the foot of the stretcher and pull the client's feet.

Stand at the head of the stretcher and push the device. Explanation: Equipment should be pushed rather than pulled whenever possible. When transporting a client on a stretcher, the nurse should stand at the head of the stretcher and push, using the weight of the entire body and not just the arms. Pulling the stretcher with the arms or entire body is not appropriate because it would be safer for the device to be pushed. Standing at the side of the stretcher and pulling with the arms could cause injuries to both the arms and back from twisting the spine.

A client had a cast applied to the left femur to stabilize a fracture. To promote early rehabilitation, what should the nurse do? -Call physical therapy to provide passive exercise of the affected limb. -Teach the client how to do isometric exercise of the quadriceps. -Show the family how to do active range-of-motion exercises of the unaffected limb. -Obtain weights so the client can exercise the upper extremities.

Teach the client how to do isometric exercise of the quadriceps. Explanation: The nurse should teach the client how to do isometric exercise, contraction of the quadriceps muscle without movement of joint, to maintain muscle strength. Physical therapy may assist the client later, and will then teach the client how to do active exercises and crutch walking if prescribed. The client will be able to move the unaffected limb; the family will not need to assist. If the client will be using crutches, building upper extremity strength will be helpful, but the immediate need is to maintain and develop strength in the quadriceps.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? -Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. -Review and revise the way client education is conducted in the surgeons' office. -Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. -Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? -a 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis -a 52-year-old with pneumonia and chronic back pain who is requesting pain medication -a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours -an 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours Explanation: Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advance directive. The client asks for an explanation of advance directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. a legal document, made by the client when the client is healthy, that directs others to follow the client's wishes if the client is incapacitated a legal document that is commonly referred to as a living will and recognized in North America. a legal document, also known as a health care proxy, where the client indicates a person to make health care decisions for the client if the client becomes incapacitated.

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. Explanation: A facility refers to an advance directive for guidance in providing care if the client cannot make health care decisions. The adult client writes or completes the advance directive when competent to do so. The living will and health care proxy are examples of advance directives. A living will is a document that provides direction regarding medical care if the client becomes incapacitated. A health care proxy is authorizes someone other than the client to exercise decision-making authority on the client's behalf under specific circumstances.

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort? assault battery negligence right to refuse care

assault Explanation: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow the client time to talk, and then determine if the client will take the medications. If the client still won't take the medications, the nurse should document this refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? at the top of the wound in the middle of the wound at the base of the wound over the total wound

at the base of the wound Explanation: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

Which nursing intervention is most important in preventing postoperative complications? progressive diet planning pain management bowel and elimination monitoring early ambulation

early ambulation Explanation: Early ambulation is the most significant general nursing measure to prevent postoperative complications and has been advocated for more than 40 years. Walking the client increases vital capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis, improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements. However, early ambulation is the most important intervention.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? -determining how planned absences, such as vacation time, will be -scheduled so that all staff are treated fairly -identifying who will be responsible for making client care decisions -deciding what type of dress code per nursing department will be implemented -identifying salary ranges for various types of staff

identifying who will be responsible for making client care decisions Explanation: Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations but they are not actually determined by the NCDS.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: turn on bright lights in the room so the client can see items in the room. instruct the client to rise slowly from a supine position. encourage the client to not use assistive devices because they reduce independence. instruct the client not to exercise painful joints.

instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury? -moving close to the object -leaning forward toward the object -using the arms and legs to lift the object -bringing the body close to the level of the object

leaning forward toward the object Explanation: Leaning forward causes the line of gravity to fall outside the base, encouraging the development of a back injury. Actions to reduce the development of a back injury include moving close to the object, using the large muscles of the arms and legs to lift the object, and bringing the body close to the level of the object.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? primary prevention secondary prevention tertiary prevention passive prevention

primary prevention Explanation: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything

Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? -gastrointestinal bleeding -myocardial infarction -emesis -rib fracture

rib fracture Explanation: Proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach.

The client has aching, weakness, and a cramping sensation in both of the lower extremities while walking. To promote health and maintain the client's level of activity, the nurse should suggest that the client try: -cross-country skiing. -jogging. -golfing. -riding a stationary bike.

riding a stationary bike. Explanation: In this case, the exercise prescription needs to be individualized because walking causes discomfort. To maintain the level of activity and decrease venous congestion, riding a stationary bike is another appropriate exercise behavior. Use of a stationary bike provides a non-weight-bearing exercise modality, which allows a longer duration of activity.Jogging and cross-country skiing are weight-bearing activities. In addition, cross-country skiing involves a cold environment, and maintaining warmth is essential in promoting arterial blood flow and preventing vasoconstriction.Golfing is a good activity, but it is not typically considered an exercise that causes aerobic changes in the body.

A nurse is conducting a nutrition class for a group of teenagers. Which food choices would a nurse encourage this group as best to consume to increase their dietary fiber content? carrots with dressing sandwiches on whole grain bread peeled apples with peanut butter a serving of cashew nuts

sandwiches on whole grain bread Explanation: While all selections are sources of dietary fiber, sandwiches on whole grain bread are the best source of fiber. One slice of whole grain bread contains 2 grams of fiber. Carrots offer 1.5 grams of fiber; broccoli would be a better choice. Most of the fiber of an apple is contained in the peel, so peeling decreases the fiber content. Cashews are rich in many vitamins and minerals, but are one of the lowest fiber nuts.

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder? to assist in collection of wound drainage products from the incision to maintain blood flow and circulation in the abdominal incision to reduce abdominal pain through pressure support to reduce stress on the abdominal incision

to reduce stress on the abdominal incision Explanation: Applying an abdominal binder will reduce further stress on the incision and prevent another dehiscence, thus allowing the skin and tissue to heal. The other choices are not accurate reasons to use a binder.

The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider? -unilateral swelling -dry, flaking skin -capillary refill less than 2 seconds -posterior tibial pulses +2 bilaterally

unilateral swelling Explanation: Despite the use of antiembolism stockings, a client may develop deep vein thrombosis. Unilateral swelling may be an indication of deep vein thrombosis development and would be reported immediately to the healthcare provider. Dry, flaking skin is not a priority and can be remedied with the use of lotion prior to applying the antiembolism stockings. Capillary refill less than 2 seconds and posterior tibial pulses +2 b

A nurse is working within the managed care delivery model. Which is true regarding managed care? All plans have the same values underlying the delivery of care. Their values are not reflected in the decision making. All systems reflect the values of efficiency and effectiveness. There are no conflicts between cost-effectiveness and respectful care.

All systems reflect the values of efficiency and effectiveness. Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen.

The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. What should the nurse do next? -Obtain a 12-lead ECG. -Administer pain medication. -Allow the client to rest for a few minutes, then re-assess. -Request new activity prescriptions from the health care provider.

Allow the client to rest for a few minutes, then re-assess. Explanation: The client is experiencing activity intolerance which is common following the first ambulation following surgery. The nurse should allow the client to rest and continue to monitor vital signs. Since the client is not dizzy or in pain, the nurse should wait to see if the client recovers from ambulating and reports having pain prior to administering pain medication. There is no need to request different activity prescriptions; it will still be important for the client to ambulate. The client is not having chest pain; it is not necessary to obtain a 12-lead ECG.

Which circumstance likely requires the most documentation and communication by the nurse? An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. A client is being discharged home following a laparoscopic appendectomy 2 days earlier. A client is being transferred from one medical unit of the hospital to another to accommodate another client on isolation precautions. A client is returning to an assisted-living facility following a colonoscopy earlier that day.

An older adult is being transferred from a subacute medical unit to a new long-term care facility following recovery from pneumonia. Explanation: Transfer from the hospital setting to a long-term care facility is likely to require significant documentation and communication from the nurses facilitating the transfer. This may include copying the chart or summarizing a large amount of relevant data. Transfers within a hospital typically require somewhat less documentation and communication, while discharges home or to an existing facility may not require a formal report of any type.

Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. Tell the client that a nurse will bring the hearing aid to the postanesthesia care unit as soon as the client wakes up. Explain to the client that the premedication that will cause sleepiness and it will not be necessary to hear anything. Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery.

Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery. Explanation: The nurse serves as a client advocate when helping the client addressing a client's concern. nurse should call the operating room and inform the intraoperative nurse about the client's request. A special container with correct identification can be prepared so that when the client is anesthetized and her hearing aid is removed, it will not be lost or broken. It is usual policy not to send personal belongings to surgery because they are easily broken or lost in the transfer of an anesthetized client with higher priority needs, but special needs do exist. In some instances, the nurse does bring a client's personal belongings to the postanesthesia care unit, but in this case the item involves the client's ability to communicate. Because the trend is to use little premedication, clients are more alert and may want to talk with their surgical team before going to sleep. Decreasing the client's anxieties preoperatively affects the amount of medication used to induce the client and her overall psychological and physiologic status. Telling the client that she will not need to hear is insensitive.

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse? Discontinue the graduated compression stockings and notify the healthcare provider. Apply antibiotic ointment to the blister and reapply the stockings. Cover the blister with a sterile dressing and reapply the stockings. Reapply the stockings and make a referral to the skin care team.

Discontinue the graduated compression stockings and notify the healthcare provider. Explanation: When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis. Applying antibiotic ointment or sterile dressings would require a healthcare provider's order, therefore the healthcare provider should be notified before proceeding with the reapplication of the stockings. Reapplying the stockings may cause further damage to the heel, therefore the healthcare provider should be notified before making a referral to the skin care team.

The nurse is caring for a terminally ill client whose family is sitting at the bedside. What nursing action(s) would best support the family at this time? Select all that apply. Decrease condition updates to minimize family sadness. Encourage the family to wipe the client's face with a cloth. Limit spiritual interactions as the client can no longer benefit. Prompt the family to go home and rest up for the next few days. Provide mouth swabs for family members to use to moisten the client's mouth.

Encourage the family to wipe the client's face with a cloth. Provide mouth swabs for family members to use to moisten the client's mouth. Explanation: Finding simple client care activities for the family to provide helps the family demonstrate caring and provides a feeling of usefulness. The nurse should continue to provide the family with condition updates as part of the communication process, and it is a key factor in acceptance of and planning for death. Family and the client can benefit from spiritual rituals and interactions during the dying process. Family should be supported, encouraged to stay with client, and provided with cots and refreshment to help them during this difficult time.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse? Contact the healthcare provider for a vitamin D supplement. Evaluate client protein levels. Massage the affected area to increase blood flow. Encourage the client to increase caloric intake.

Evaluate client protein levels. Explanation: Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. The nurse would evaluate the client's protein status by reviewing laboratory data. If protein stores are low, a dietician consult would be warranted. Increasing vitamin D and overall caloric intake will have little effect on a client's wound healing. A pressure ulcer should never be massaged.

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care? Good Samaritan laws are designed to protect the caregiver in emergency situations. Negligence is intentional failure to act responsibly or deliberate omission of a professional act. Malpractice is failure to perform professional duties that result in client injury. Scope of practice involves general guidelines that define nursing

Good Samaritan laws are designed to protect the caregiver in emergency situations. Explanation: Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the best response by the nurse? "I will get the furosemide from the floor stock right now and give it to the client." "I will find you a computer that is not being used so you can enter the order into the computerized order entry system." "I will need to let the charge nurse know about the order so it can be entered in the computerized order entry system." "I will call the pharmacy and have them send the furosemide right away." "I will put the order in the computer order entry system and give the furosemide once it arrives from the pharmacy."

I will find you a computer that is not being used so you can enter the order into the computerized order entry system." Explanation: The nurse cannot give the furosemide right away because the prescription needs to be put in the computerized order entry system first. This is not an emergency. The correct response is to have the health care provider put the prescription in the computerized order entry system because it is not an emergency. Verbal orders are for emergencies only. The charge nurse does not need to know about the prescription. The charge nurse does not need to put the order in the computerized order entry system. The nurse assigned to the client is responsible for the client's care. The nurse can call the pharmacy right away to have the furosemide sent, but the prescription needs to be entered first. The pharmacy will not send the medication, because it is not an emergency, without an order first. The nurse should not put the prescription in the computerized order entry system. The health care provider needs to put the prescription in the computerized order entry system. Verbal orders are for emergencies only.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? Administer the prescribed preanesthetic medication. Note this new allergy prominently on the medical record. Contact the scrub nurse in the operating room. Inform the anesthesiologist.

Inform the anesthesiologist. Explanation: The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply. Instill isotonic eyedrops as necessary. Provide several small, well-balanced meals. Provide regular rest periods. Keep the environment warm. Encourage frequent visitors. Weigh the client daily.

Instill isotonic eyedrops as necessary. Provide several small, well-balanced meals. Provide regular rest periods. Weigh the client daily. Explanation: Hyperthyroidism is a condition in which the thyroid is overactive and produces excessive amounts of thyroid hormone, which controls body metabolism. If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae would be moistened often with isotonic eyedrops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent, small, well-balanced meals. The nurse would provide the client with rest periods to reduce metabolic demands. The client would be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse would provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

When assessing a client's incision one day after surgery, the nurse sees redness and warmth around the incision site. What action by the nurse is best? Culture the wound. Apply a cool compress 3 times a day. Assess for blanching. Note the wound edges in the client's chart.

Note the wound edges in the client's chart. Explanation: Warmth and redness are normal signs of an inflammatory response and do not require interventions such as a cool compress. There are no infectious processes that would require a culture. Blanching does not demonstrate that there is wound infection.

The home health nurse is conducting a safety assessment in an older adult's home. On the bathroom floor, the nurse finds a throw rug that the client refuses to remove. What is the appropriate recommendation by the nurse? -Place nonslip backing on the underside of the rug. -Place the rug under a chair leg to keep it from slipping. -Remove all rugs from the home to control dust mites. -Replace the rug with a rubber mat.

Place nonslip backing on the underside of the rug. Explanation: The nurse should recommend that the client place nonslip backing on the underside of the rug to keep the rug from moving and causing a fall at home. Placing the rug under a chair leg will only keep one edge of the rug secure. While removing rugs to eliminate dust mites is an appropriate suggestion for clients with allergies and asthma, there is nothing in the stem of the question that indicates that the client has allergies and/or asthma. Replacing the rug with a rubber mat will not remove the fall risk as the mat can also slip and/or slide, leading to a fall.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings? Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. Apply an ice pack to the incision for 15 minutes prior to application. Cover the incision with a gauze bandage to provide cushion to the incision. Premedicate the client with prescribed acetaminophen 500 mg PO 15 minutes prior to application.

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. Explanation: The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Review medical record and medical orders for graduated compression stockings. 2Identify the client and explain procedure. 3Place the client in supine position. 4Apply powder or lotion to legs. 5Turn the stocking inside out and ease the stocking over the foot and heel. 6Smoothly pull the stocking over the ankle and

Review medical record and medical orders for graduated compression stockings. Identify the client and explain procedure. Place the client in supine position. Apply powder or lotion to legs. Turn the stocking inside out and ease the stocking over the foot and heel. Smoothly pull the stocking over the ankle and calf. Explanation: When applying graduated compression stockings, the nurse should first review the medical record and verify the medical order for application. The nurse should then identify the client and explain the procedure to alleviate anxiety and prepare the client for what to expect. The nurse then places the client in a supine position to reduce congestion of blood in vessels. The nurse then applies powder or lotion to the legs to reduce friction and ease the application. Next, the nurse turns the stocking inside out as this technique provides for easier application and with the heel pocket down, eases the stocking over the foot and heel. The nurse then smoothly pulls the stocking up over the heal and calf, making sure there are no wrinkles, as wrinkles may compromise circulation.

A client who has recently had a fractured hip repaired must be transferred from the bed to a wheelchair. Which information should the nurse consider while assisting the client? During a weight-bearing transfer, the client's knees should be slightly bent. Transfers to and from a wheelchair will be easier if the bed is higher than the wheelchair. The transfer can be accomplished by instructing the client to pivot while placing weight on both upper extremities rather than on the legs. The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained.

The appropriate proximity and visual relationship of the wheelchair to the bed must be maintained. Explanation: The wheelchair should be angled close to the bed so the client can pivot on the stronger leg. When the wheelchair is within the client's visual field, the client will be aware of the distance and direction the body must navigate to transfer safely and avoid falling. During a transfer, the knees need to be extended to support the weight, the bed needs to be in low position, and pivoting needs to be accomplished on the unaffected leg.

The nurse is caring for a client with thigh high antiembolism stockings. Which finding requires additional client teaching? -The client has rolled the stockings down to the knee. -The client is wearing nonskid slippers when ambulating. -The client washed the stockings in soap and water. -The client removed the stockings for 30 minutes in the morning.

The client has rolled the stockings down to the knee. Explanation: Rolling the thigh high antiembolism stockings to the knee requires additional teaching to the client because rolled stockings can cause excessive pressure and interfere with circulation. Stockings should be removed every shift for 20 to 30 minutes, so the client may remove the stockings for 30 minutes in the morning. Stockings should be washed in mild soap and water and allowed to air dry whenever soiled as per the manufacturer's instructions. Antiembolism stockings are slippery and a client should always wear nonskid socks or slippers when ambulating.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. The client rinses around the clean incision site, using gauze squares moistened with normal saline. The client rinses around the clean incision site, using gauze squares moistened with tap water. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.

The client rinses around the clean incision site, using gauze squares moistened with normal saline. Explanation: To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of non-raveling material instead of cotton-filled gauze squares.

The nurse is planning staffing assignments for a group of clients. Which client is most appropriate for the nurse to assign to a nurse who normally works on the maternity unit? a client in a halo traction brace following surgery for a cervical spine injury a client who had an open appendectomy yesterday a client with cancer who requires ventilator support a client with amyotrophic lateral sclerosis showing signs of progression

a client who had an open appendectomy yesterday Explanation: The nurse who usually works on a maternity unit has more experience with clients who have had abdominal surgery similar to a cesarean birth and should be assigned to a client who will closely match the nurse's experience level. The nurse should assign the client in halo traction to a nurse who has experience with the traction equipment. The client with cancer requiring ventilation and the client with progressing amyotrophic lateral sclerosis require care from a nurse who has more experience with clients with these needs.

A nurse should question an order for a heating pad for a client who has active bleeding. a reddened abscess. tight back muscles. purulent wound drainage.

active bleeding. Explanation: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A nurse-manager must include which items as part of the personnel budget? anticipated overtime payments for staff computers for staff use office supplies for secretarial use videos for staff education

anticipated overtime payments for staff Explanation: Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget.

Which nursing intervention for catheter care should have the highest priority? -cleaning the area around the urethral meatus -clamping the catheter periodically to maintain muscle tone -irrigating the catheter with several milliliters of normal saline solution -changing the location where the catheter is taped to the client's leg

cleaning the area around the urethral meatus Explanation: Good catheter care, including meticulous cleaning of the area around the urethral meatus, is the highest priority for the client with an indwelling catheter.Clamping an indwelling catheter is not a part of nursing care and would require a prescription.Irrigation of the catheter, which requires breaking the closed system, is not a part of nursing care for this client.Manipulation of the catheter taped to the client's leg causes trauma to the urethral meatus, which can predispose the client to an infection and is also not recommended.

A nurse is providing care for three clients on a medical unit, two of whom are significantly more acute than the third. The nurse is making a concerted effort to ensure that the less acute client still receives a reasonable amount of time, attention, and care during the course of the shift. Which is the nurse attempting to enact? -justice -beneficence -fidelity -nonmaleficence

justice Explanation: The ethical principle of justice includes an effort to fairly distribute benefits and to minimize discrimination, even when circumstances make this difficult to achieve. This is demonstrated by the nurse's efforts to fairly distribute the nurse's time and care.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care? documenting the situation and providing support for the victim protecting the client's safety by completing an incident or occurrence report counseling the person committing the abuse counseling the victim

documenting the situation and providing support for the victim Explanation: The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. The nurse should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for: disposal of emesis or other bodily secretions. handling of the dislodged radiation source. disposal of the client's eating utensils. storage of the radiation dose.

handling of the dislodged radiation source. Explanation: Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department.

Which nursing intervention is most important in preventing septic shock? administering IV fluid replacement therapy as ordered obtaining vital signs every 4 hours for all clients monitoring red blood cell counts for elevation maintaining asepsis of indwelling urinary cathete

maintaining asepsis of indwelling urinary catheters Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? dry sterile dressing sterile petroleum gauze moist sterile saline gauze povidone-iodine-soaked gauze

moist sterile saline gauze Explanation: Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? -rectal -oral -axillary -tympanic

rectal Explanation: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply. respiratory distress redness pain around the infusion site warmth edema above the insertion site

redness pain around the infusion site warmth edema above the insertion site Explanation: Redness, warmth, pain, and edema are all signs and symptoms of phlebitis. Respiratory distress is a sign of an air embolus.