chapter 14
The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. a) The client denies the need for education. b) The client is married. c) The client is an architect. d) The client is blind. e) The client is male.
a d
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? a) Physician b) Nurse manager c) Insurance company d) Nurse case manager
b
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? a) Discontinue the education and ask the client for permission to teach a family member. b) Discontinue the education and attempt at another time. c) Continue the education and remind the client that it is essential to learn self-care. d) Medicate the client for anxiety and continue the education later.
b
The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority? a) Discuss discharge plans with the client. b) Teach the client about dietary restrictions during recovery. c) Instruct the client and family in wound care. d) Inform the client what to expect after the surgery.
d
A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? a) The nurse should recognize the necessity of the assignment and provide care to the best of her ability. b) The nurse should request that the blood transfusions be delayed until the next shift. c) The nurse should ask another nurse who was previously assigned to the client for instruction. d) The nurse should inform the charge nurse that she does not have the experience to properly care for this client.
d
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action? a) Discuss the frequency of pain medication administration with the client. b) Consult with the physician for additional pain medication. c) Assist the client to reposition and splint the incision. d) Assess the client to determine the cause of the pain.
d
The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond? a) Ask the client to discuss the decision with family members. b) Discuss with the client the reasons for declining surgery. c) Review with the client the risks and benefits of surgery. d) Notify the physician of the client's refusal.
b
Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order? a) Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment b) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners c) Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose d) Changing a client's advance directive after his prognosis has significantly worsened
b
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? a) Document the interventions and the result. b) Determine the client's code status in case of an emergency. c) Communicate with the physician for additional orders. d) Reassess the client for improvement in 30 minutes.
c
When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a) "It is a hospital policy to reduce the potential for errors." b) "It is a habit that nurses develop in school." c) "We ask your name to show that we respect your rights." d) "We ask your name to ensure that we are treating the right client."
c
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a) Encourage the client to provide as much self-care as possible. b) Teach the family to anticipate the client's needs to care for the client. c) Arrange with the nurse case manager for an early discharge. d) Perform all care activities for the client to facilitate rest.
a
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action? a) Standing orders b) Order set c) Protocol d) Algorithm
a
The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP? a) Provide client assistance to the bedside commode. b) Request the UAP to get the unit of blood from the blood bank. c) Reassess the client's sacrum for redness when doing bed bath. d) Secure the client's jewelry before surgery.
a
The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? a) Medicate the client and wait to ambulate later. b) Emphasize to the client the importance of following the treatment plan. c) Ambulate the client and medicate later. d) Explain to the client the benefits of ambulation.
a
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? a) The client with continuous pulse oximetry who requires pharyngeal suctioning. b) The client who needs vital signs taken following infusion of packed red blood cells. c) The client who is pleasantly confused and requires assistance to the bathroom. d) The client who requires assistance dressing in preparation for discharge.
a
The student nurse is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action? a) Tell the student that the RN will assist the student with the client's ambulation. b) Tell the student to ask the client if the client is comfortable with the student assisting ambulation. c) Tell the student not to ambulate the client at this time. d) Tell the student that the nursing assistant should ambulate the client.
a
The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first? a) Force fluids by mouth. b) Assess for bladder distention. c) Diet as tolerated. d) Strain urine after each void.
b
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a) ambulation of the client with a history of falls for the first time after surgery b) preparation of insulin for the diabetic client with elevated blood glucose c) bed bath for the newly-admitted client who has multiple skin lesions d) insertion of a urinary catheter in a client with benign prostatic hypertrophy
c
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? a) Leave written information for the client to read later. b) Ask the client if the client has any questions. c) Give the visitors instructions to leave in 10 minutes. d) Delay the instruction until the visitors leave.
d
The nursing is caring for several clients. Which client can the nurse delegate to the unlicensed assistive personnel? a) Feed a client who is eating for the first time following an ischemic stroke. b) Take the vital signs of the client who just returned from surgery. c) Assist the client who is ambulating the first time since hip replacement surgery. d) Bathe a client with stable angina who has a continuous IV infusing.
d
