Basic Physical Care

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes.

The nurse is teaching a client how to manage a nosebleed. What instruction should the nurse give the client?

Sit down, lean forward, and pinch the soft portion of your nose."

The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torso indicating the location for leveling the transducer.

The zero point on the CVP transducer needs to be at the level of the right atrium. The right atrium is located at the midaxillary line at the fourth intercostal space. The phlebostatic axis is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal border to the right side of the chest (A). A secondary imaginary line is drawn horizontally at the level of the midpoint between the anterior and posterior surfaces of the chest (B). The phlebostatic axis is located at the intersection of points A and B.

Which item must the nurse consider when positioning a client for tracheal suctioning?

Position in a semi-Fowler's position.

In evaluating a client's response to nutrition therapy which laboratory test would be of highest priority to examine?

albumin level -rationale: 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 children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse best demonstrates the role of the nurse as a client advocate?

Communicate the client's wishes to the healthcare provider.

A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply.

-correct response: the student nurse, the nursing instructor, the assigned nurse -rationale: The student nurse, nursing instructor, and staff nurse are held to the same standard of care. The tube placement should be confirmed by radiology. The physician and dietician were not involved with the tube placement and following the standard of care with a radiology placement confirmation.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an assessment. The nurse then informs the physician and the nursing supervisor about this incident and also completes an incident report. Which actions by the nurse indicates correct knowledge of handling an incident report?

-you answered: makes a copy of the incident report and places it in the client's records -correct answer: documents a complete description of the happenings in the client's records -rationale: An incident report is a written account of an unusual, potentially injurious event involving a client, employee, or visitor. It is kept separate from the medical record. The incident report is a legal document and making a copy of it is not advisable. It should not be placed in the client's records; however, the nurse can mention the incident in the client's records without mentioning the incident report.

Which task would a nurse choose to delegate to a nursing assistant? Select all that apply.

-your answer: Performing a blood glucose check, Planning bathing techniques, Taking a client's vital signs -correct answer: Taking a client's vital signs Documenting a client's oral intake Performing a blood glucose check Assisting with IV insertion -rationale:Registered nurses are responsible for all phases of the nursing process. These responsibilities include planning bathing techniques. A nurse may delegate tasks such as taking vital signs, documenting intake and output, assisting with IV insertion, and performing blood glucose checks if the nurse follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed).

A nurse has recently had multiple clients who were admitted to the intensive care unit (ICU) without advance directives. The nurse wants to improve the number of clients with advance directives on the unit. Place the steps the nurse would use to implement a performance improvement for advance directives in the correct order. All options must be used.

1. Discussions on advance directives are not being consistently obtained. 2.Decide all nurses will be responsible for helping clients with advance directives. 3.Appoint a small group to monitor the progress at monthly intervals. 4.Evaluate whether the new plan improved the number of advance directives obtained. 5.Plan a new strategy with a smaller group being responsible for advance directives.

A nurse sends a group text message to coworkers describing a coworker dating a former client. The message includes sexual behaviors, times, and places that the two people were seen together. The nurse is at risk of what act of wrongdoing? Select all that apply.

you answered: libel, slander of the client,and intentional tort correct answer: libel and intentional tort rationale: The texting nurse is at risk of libel and the texting is considered an intentional tort. Slander is the spoken word of defamation of character so the texting is not spoken. An unintentional tort is negligence or malpractice and the nurse is texting information willingly. False imprisonment is restricting movement without proper consent so this does not describe texting.

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should

your response: open the drainage bag and pour out some urine. correct response: aspirate urine from the tubing port, using a sterile syringe and needle. rationale: To collect urine properly, the nurse should aspirate it from a port, using a sterile syringe and needle after cleaning the port. Opening a closed urine-drainage system, which would occur if the nurse disconnected the catheter from the tubing or opened the drainage bag, would increase the risk of urinary tract infection. Although standard precautions specify wearing gloves during contact with body fluids, the nurse need not wear sterile gloves for this procedure.