Client Needs/Management of Care
A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority? a. offering frequent rest periods b. removing pulmonary secretions c. allowing the client to express concerns d. improving nutritional status
b. removing pulmonary secretions Explanation: Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, adequate removal of pulmonary secretions is a priority. Although clients may exhibit fatigue, anxiety, or appetite loss, these need to be addressed, but are not the priority.
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up? a. twice-weekly clinic appointments b. weekly visits by a community health nurse c. daily phone calls from the hospital nurse d. enrollment in community parenting classes
b. weekly visits by a community health nurse The most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant's progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.
The nurse-manager of a home health facility includes which item in the capital budget? a. office supplies b. salaries and benefits for the staff c. client-education materials costing $300 d. a $1,200 computer upgrade
d. a $1,200 computer upgrade Explanation: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.
A nurse is caring for an alert and oriented client with end-stage breast cancer who has been unable to eat for 4 days due to intractable nausea. The nurse calls the health care provider (HCP) and obtains an order for an NG tube placement per the spouse's request. When the nurse brings the equipment to the room, the client turns to the spouse and states "I just told you that I don't want any tubes or feedings!" Using the ANA Code of Ethics for Nurses, place the nursing actions in sequential order (rank actions from first to last). All options must be used. - Notify the HCP of the client's wishes and decision. - Apologize for not asking the client prior to calling the HCP. - Explore other options that would be acceptable to the client. - Verify that the client understands the purpose of the NG tube. - Educate the husband on the wife's right to refusal of care. - Document the client's wishes in the medical record.
- Apologize for not asking the client prior to calling the HCP. - Verify that the client understands the purpose of the NG tube. - Explore other options that would be acceptable to the client. - Educate the husband on the wife's right to refusal of care. - Document the client's wishes in the medical record. - Notify the HCP of the client's wishes and decision. Explanation: The ANA Code of Ethics for Nurses directs that a nurse promote, advocate for, and strive to protect the health, safety, and rights of the patient. The client has the right to refusal and is able to make an informed decision. The nurse should first apologize, then make sure the client has enough information to make an informed decision, including exploring other options, then educate the husband about the wife's right to refuse treatment. This should be followed by documentation of the client's wishes and notification of the HCP.
The nurse is collecting supplies to apply a vacuum assisted wound closure dressing. In which order would the nurse apply the dressing to a client's sacral wound? All options must be used. - Ensure the correct pressure settings are as prescribed. - Assess and measure the wound bed. - Insert black foam into the wound. - Explain the procedure to the client. - Connect the tubing to machine. - Apply the transparent film with vacuum tubing.
- Explain the procedure to the client. - Assess and measure the wound bed. - Insert black foam into the wound. - Apply the transparent film with vacuum tubing. - Connect the tubing to machine. - Ensure the correct pressure settings are as prescribed. Explanation: First explain the procedure to the client. The nurse will assess the wound bed, then insert black foam into the wound bed. The next step is to apply the transparent film with vacuum tubing and connect the tubing to machine. Finally the nurse will ensure the prescribed settings are set.
A Jewish client requests an orthodox diet while hospitalized. The nurse should refer this request to which team member? a. dietitian b. health care provider (HCP) c. unit case manager d. rabbi in pastoral care
a. dietitian Explanation: The dietary department should meet with the client to ensure that the foods are available and prepared according to religious beliefs. On admission, the client should be asked whether there are special dietary needs. The dietary department should be notified of these special needs, and a dietary representative should meet with the client and family when possible. The HCP should be consulted if a requested food is contrary to a prescribed diet restriction. The unit case manager does not need to be contacted regarding a dietary request. The rabbi is not involved in dietary requests.
Which description best matches the role of a parish nurse? a. A nurse who works to reintegrate the healing tradition into the life of a faith community. b. A trained layperson who provides for the spiritual needs of a congregation or parish. c. A nurse who provides home health services similar to a visiting nurse. d. A spiritual leader, such as a minister, who is also a registered nurse.
a. A nurse who works to reintegrate the healing tradition into the life of a faith community. Explanation: Parish nurses and health ministry teams work to reintegrate the healing tradition into the life of faith communities. The key roles of the parish nurse are health educator, personal health counselor, referral agent, trainer of volunteers, developer of support groups, integrator of faith and health, and health advocate. Parish nurses are not visiting nurses or home health nurses.
Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when the nurse reflects on the decision-making process and the role it will play in making future decisions? a. evaluating b. diagnosing c. planning d. implementing
a. evaluating Explanation: Evaluating an ethical decision involves reflecting on the process and considering those elements that will be helpful in the future. The nurse may also question how this experience can improve reasoning and decision making in the future. Diagnosing the ethical problem involves stating the problem clearly. Planning includes identifying the options and exploring the probable short-term and long-term consequences. Implementing includes the implementation of the decision and comparing the outcomes of the action with what was considered and hoped for in advance.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which is the mostappropriate principle behind informed consent? a. protects the client's right to self-determination in health care decision making b. helps the client refuse treatment that he or she does not wish to undergo c. helps the client to make a living will regarding future health care required d. provides the client with in-depth knowledge about the treatment options available
a. protects the client's right to self-determination in health care decision making Explanation: Informed consent protects the client's right to self-determination in healthcare decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.
A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? a. the client's partner b. the client's best friend, who's the sperm donor c. the client's parents, because they're blood relatives d. the court system, because the client isn't married and is legally responsible for the neonate
a. the client's partner Explanation: A legal document stating that the client's partner is the healthcare surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client isn't able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make healthcare decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents don't have rights to make healthcare decisions for pregnant adolescents. The court system wouldn't make the decision if the client has designated a legal healthcare surrogate.
A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required? a. intradependent b. interdependent c. dependent d. independent
d. independent Explanation: Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.
The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. - Obtain vital signs. - Initiate oxygen therapy as needed. - Apply antiembolic stockings. - Assess the client's breath sounds. - Keep the client oriented.
- Obtain vital signs. - Apply antiembolic stockings. - Keep the client oriented. Explanation: It is appropriate for the nurse to delegate obtaining vital signs and applying antiembolic stockings to the UAP. The UAP can also help keep the client oriented to time, person, and place by talking with the client. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with the health care provider's prescriptions. It is also the registered nurse's responsibility to perform the nursing history and assess the client's breath sounds.
A registered nurse (RN) suspects that a licensed practical/vocational nurse (LPN/VN) on the unit is using controlled substances. The LPN/VN is often late, recently appears unkempt, frequently nervous, and is often behind in client care duties. According to the ANA Code of Ethics for Nurses, what should the RN do to address her concerns? Select all that apply. - Continue to document the behaviors, but wait until something happens to report. - Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. - Report the behaviors to the unit manager for further investigation. - Do nothing as the RN does not have proof of controlled substance abuse. - Discuss the RN's concerns with another nurse on the unit to see what they think.
- Talk compassionately to the LPN/VN and discuss the RN's concerns and observations. - Report the behaviors to the unit manager for further investigation. Explanation: ANA Code of Ethics for Nurses provision 3 states that nurses have a duty to protect the patient, the public, and the integrity of the nursing profession when they observe physical or mental impairment in a nurse or other healthcare professional. Substance abuse is treatable and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; she is still liable for her actions. The nurse should talk to the suspected nurse and report to management. It should not be discussed with others on the unit. It is not appropriate to wait until something happens.
The home health nurse is completing a screening for elder abuse during a client visit. Which findings would require action by the nurse? Select all that apply. - The client who lives with family who is assuming more of their care responsibilities. - The client who is frequently scheduling appointments with their primary care provider. - A client on apixaban with multiple small bruises on their bilateral arms and legs. - A client who reports having excessive sleepiness after their evening medications. - A client who is less talkative recently and avoiding eye contact with the nurse.
- The client who is frequently scheduling appointments with their primary care provider. - A client who reports having excessive sleepiness after their evening medications. - A client who is less talkative recently and avoiding eye contact with the nurse. Explanation: The nurse responsible for knowing, screening, recognizing, and reporting elder abuse which can stem from negligent or intentional acts performed by a caregiver or other trusted individual that results in harm to a vulnerable elderly person. Clients making frequent appointments or trips to the ER, who reports having excessive sleepiness after their evening medications may be being abused and over-medicated, and who have become less talkative or avoid eye contact with you are often being abused. The client who lives with family who is assuming more of their care responsibilities is showing signs of improvement and independence. A client on apixaban which is an anticoagulant would be expected to have some small bruises on their body.
The nurse is caring for a client admitted with seizures. Which nursing action is important when caring for a client during a postictal state? Select all that apply. - keeping the client side lying - restraining the client - keeping a bite block close - padding the side rails - setting up suction
- keeping the client side lying - padding the side rails - setting up suction Explanation: The nurse will keep the client side lying, pad the side rails and set up suction for a client in a postictal state. Restraining the client and inserting anything into the mouth is contraindicated during a seizure.
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? a. Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. b. Advise the client that the appointment will have to be rescheduled due to the fact that the medical record cannot be located. c. 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. d. Document the information about the visit on paper, and transcribe these notes into the client's medical record once it is located.
a. Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Explanation: 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.
The charge nurse is unable to replace a registered nurse for a shift on an acute medical unit. The staffing department states they are able to send an additional unlicensed assistive personnel (UAP) to assist. What priority action would the charge nurse take in this situation? a. Create the client assignment by considering available staff's skill level and client needs. b. Refuse to create the client assignment and tell management that a nurse must be found. c. Call charge nurses on other units to request a registered nurse come assist on the unit. d. Notify the local nursing regulating body about the unsafe working conditions at the facility.
a. Create the client assignment by considering available staff's skill level and client needs. Explanation: When working with less than an ideal number of registered nurses for a given number of clients, the charge nurse's first priority is to ensure safe distribution of client needs among the available staff members. The charge nurse's primary duty is to the safety of the clients. If there were serious impediments to safely adjusting the workload, it may be reasonable to voice this concern to the management, but the priority is to attempt to create the safe client assignment within the current staffing realities. The nurse should not attempt to arrange for staffing independently by calling other charge nurses as this is outside the role and responsibilities and may create safety concerns on other units. If the working conditions are considered unsafe, this could be a matter to be brought forward to a regulating body. However, in the moment, the charge nurse's priority is to attempt to distribute the clients' care in a safe manner.
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next? a. Promptly assess the client for potential perforation. b. Tell the assistant to change thermometers and retake the temperature. c. Plan to give the client acetaminophen to lower the temperature. d. Ask the assistant to bathe the client with tepid water.
a. Promptly assess the client for potential perforation. Explanation: A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without ahealth care provider's (HCP's) prescription; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.
The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? a. The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. b. The LPN/VN places an infant having a cyanotic episode in a knee-chest position. c. The LPN/VN checks a child's apical heart rate prior to administering digoxin. d. The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram
a. The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Explanation: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.
A client with severe and persistent depression is debating undergoing electroconvulsive therapy (ECT). The client's family asks a nurse to convince the client that this treatment would be beneficial. In educating the family about the client's situation, what statement about client rights should the nurse make? a. "In a situation like this, I recommend family obtain legal counsel for the client." b. "The client, treatment team, and family can meet to discuss this treatment option." c. "If the client declines treatment after learning the pros and cons, there is a form to sign." d. "You must make the client aware of the moral aspects of refusing treatment."
b. "The client, treatment team, and family can meet to discuss this treatment option." Explanation: When a client is undecided about treatment, the best approach is to assemble the client, family, and appropriate healthcare providers to discuss what option serves the client's best interests while acknowledging the client's right to refuse treatment. Because the client has the right to refuse treatment, there's no need for the family to obtain legal counsel or for the client to sign any refusal-of-treatment forms. Neither family members nor healthcare providers should coerce the client to reconsider the decision under the guise of addressing the ethical aspects of treatment.
A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? a. Tell the ICU they have to wait to transfer the client because everyone is too busy to accept the client. b. Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. c. Administer the medications quickly and ask the nursing assistant and LPN to finish providing care for the clients. d. Notify the supervisor that the client care assignment is unsafe with the addition of the new client, and insist the supervisor assist with the assignment.
b. Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. Explanation: The registered nurse should use the ancillary staff to help effectively manage the group of clients. While the registered nurse accepts the client from the ICU, the nursing assistant can provide care for the clients, and the LPN can administer the remaining medications. Telling the ICU to wait or notifying the supervisor that they must assist are incorrect options because the nurse should assess the situation and use the ancillary staff appropriately. The nurse has adequate staff to safely provide care for this group of clients. The nurse shouldn't administer medications quickly because haste is an unsafe practice that could lead to a medication error. Instead of rushing, the nurse should delegate the responsibility to the LPN.
The nurse is working as charge on a medical-surgical unit and is working with a graduate nurse who has been on orientation for the past 4 weeks. Which client should the charge nurse assign to the new nurse? a. a client who needs teaching before a biopsy of a facial lesion b. a client who requires a dressing change of a pressure ulcer c. a client who needs discharge instructions after a skin graft d. a client who was just admitted with periorbital cellulitis
b. a client who requires a dressing change of a pressure ulcer Explanation: The new graduate would be competent to perform skills such as sterile dressing change taught in school. Clients whose care requires more experience, such as complex skills, and education, such as admission assessments, pre-procedure teaching, and discharge teaching, should be assigned to more experienced RN staff members because these nurses are aware of the organizational procedures and have completed them routinely.
A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first? a. an infant whose pulse is 140 bpm b. a restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening c. An infant with an axillary temperature of 100.4°F (38°C) on the third postoperative day d. an infant whose respirations are between 38 and 50 breaths per minute
b. a restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening Explanation: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from the ICU the previous night, assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Decreased respirations are indicative of increased intracranial pressure, but this infant's respirations of 38 breaths per minute would not be a priority concern.
A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when a. e-mailing information about a client to a friend at home. b. documenting medications after administration. c. documenting medications before administration. d. determining a client's identity from a computer chart.
b. documenting medications after administration. Explanation: A nurse should document medications after administering them, not before. E-mailing information regarding a client to a friend at home is a violation of the Canadian Privacy Act, the Personal Information Protection and Electronic Documents Act, and the Health Insurance Portability and Accountability Act (HIPAA). When administering medication, a nurse should rely on more than one identifier to confirm a client's name.
The nurse makes initial rounds for the clients. Five medications are scheduled for administration at the same time to five different clients. Which medication should the nurse administer first after initial rounds? a. a maintenance dose of digoxin to the client with congestive heart failure b. morphine sulfate to a client with a myocardial infarction reporting chest pain c. naproxen to the client with rheumatoid arthritis d. ondansetron to a diabetic client reporting nausea
b. morphine sulfate to a client with a myocardial infarction reporting chest pain Explanation: Morphine sulfate relieves pain which immediately decreases myocardial oxygen demand and decreases preload and afterload pressure. The digoxin is a maintenance dose and does not elicit an immediate reaction. Though administration of naproxen and ondansetron are next in the order of urgency, they are not the priority.
A nurse is caring for a client who is receiving hospice care at home. The client's neighbors have been calling the nurse to inquire about the client's condition. What should the nurse tell the neighbors? a. "Please call the oncologist." b. "The client is in a coma now." c. "Please call the client's sister" d. "The client is not expected to live much longer."
c. "Please call the client's sister" Explanation: The family is in the best position to give the information they elect to disclose to friends and community members. The hospice nurse and the oncologist must maintain client confidentiality and follow privacy guidelines for release of confidential information. Therefore, disclosing any information about the client's condition would be inappropriate.
A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best? a. "You'll need help with your bath and meals for quite some time, which can be difficult for family members." b. "The rehabilitation staff can provide you with better, safer care than untrained family members." c. "The rehabilitation staff can evaluate your progress and help you recover without risking injury." d. "The healthcare provider advises care at a rehabilitation center until you can care for yourself."
c. "The rehabilitation staff can evaluate your progress and help you recover without risking injury." Explanation: The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility and not providing total care. Stating that the client will need help with bathing and meals for a long period does not provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to provide self-care. Telling the client that the rehabilitation staff can provide better care than family is judgmental about care the family might provide and does not adequately explain the role of a rehabilitation center. Telling the client that the health care provider wants the client to go does not explain the importance of a rehabilitation center.
A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? a. Ask the client to get out of bed and try to urinate. b. Call the physician for a methylergonovine order. c. Assess the fundus and massage it if it's boggy. d. Give the client a new pad and check her in 30 minutes.
c. Assess the fundus and massage it if it's boggy. Explanation: The nurse should first asses the fundus to determine if clots are present or if uterine involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30 minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a firm fundus, the nurse should next assess for a full bladder and then ask the client to try to urinate. If the uterus remains boggy after massage, the nurse should obtain an order from the physician for methylergonovine. Waiting 30 minutes without intervening could contribute to uterine hemorrhage.
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month, five clients were diagnosed with pressure ulcers. What should the nurse manager do? a. Use benchmarking procedures to compare the findings with other nursing units in the hospital. b. Ask the staff education department to conduct an educational session about preventing pressure ulcers. c. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. d. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
c. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. Explanation: The problem of pressure ulcers in hospitalized clients is best addressed by using quality improvement techniques to identify the problem, determining strategies for improvement, and setting goals for outcomes. Benchmarking for comparison will indicate where this nursing unit compares with other units, but does not address the problem for this unit; having clients with pressure ulcers on any unit is not acceptable. Educational programs are more effective after there is an understanding of the problem. Chart audits and blaming do not solve the problem or address quality improvement measures.
A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks? a. The RN must directly supervise all delegated tasks. b. After a task is delegated, it's no longer the RN's responsibility. c. The RN delegates a task based on the UAP's skill set. d. Follow-up with a delegated task is only necessary if the UAP is untrustworthy.
c. The RN delegates a task based on the UAP's skill set. Explanation: The RN must delegate tasks that are within the scope of practice of the unlicensed personnel. The RN need not directly supervise all delegated tasks, as this would negate the benefits of delegation. When a task is delegated, the RN retains responsibility for the successful completion of the task. The RN must always follow up with the UAP to ensure the task was completed appropriately.
A nurse is caring for a 16-year-old male client who needs an appendectomy. His parents are not present at the hospital. Prior to the surgery, the nurse needs to ensure that informed consent is obtained. Which situations allows the healthcare provider to obtain an informed consent from an adolescent? a. The adolescent is the appropriate age to sign an informed consent. b. The adolescent has a power-of-attorney document. c. The adolescent has declared himself emancipated. d. The adolescent is under the protection of a court guardian.
c. The adolescent has declared himself emancipated. Explanation: Individuals under the age of 18 need a parent or guardian to provide an informed consent, unless the individual is an "emancipated minor," an adolescent who is legally recognized as an adult. Otherwise, an adolescent is considered a minor until his 18th birthday. The power-of-attorney document allows another individual who is over the age of 18 to make decisions.
A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which client goal would be most appropriate? a. The client will identify two trusted staff members to help the client choose appropriate dress. b. The client will record the number of clothing changes per day. c. The client will refrain from hugging other clients and change clothing only twice per day. d. The client will verbalize feelings of low self-esteem with nursing staff.
c. The client will refrain from hugging other clients and change clothing only twice per day. Explanation: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small changes in hugging and wardrobe change behavior will be realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem.
A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority? a. impaired physical mobility b. decreased gastrointestinal motility c. impaired swallowing d. risk for isolation
c. impaired swallowing Explanation: Impaired swallowing is the priority nursing diagnosis for this client because there is a risk for aspiration. The other choices are appropriate, but not the priority.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? a. sequestering free hydrogen ions in the nephrons b. returning acid to the body's circulation c. returning bicarbonate to the body's circulation d. excreting bicarbonate in the urine
c. returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.
The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's: a. sincere desire to help others. b. acceptance of others. c. self-awareness and understanding. d. sound knowledge of psychiatric nursing.
c. self-awareness and understanding. The nurse must be self-aware and understand personal feelings before understanding and helping others. Although wanting to help others, accepting others, and being knowledgeable of psychiatric nursing are desirable traits, self-awareness and understanding are the basis of a therapeutic nurse-client relationship.
The nurse is prioritizing care for several clients. Which client should the nurse assess first? a. the client with chest pain improving after medication b. the client with a blood pressure of 150/90 mmHg c. the client with stridor who just received the first dose of an antibiotic d. the client with bilateral wheezing receiving a breathing treatment
c. the client with stridor who just received the first dose of an antibiotic Explanation: The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. This may indicate an anaphylactic reaction to the antibiotic. The nurse must intervene to prevent anaphylactic shock. The airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the clients with improving chest pain and elevated blood pressure should be assessed.
A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. The client has decided against further curative treatment and wishes to return home. Before discharge, the client develops ocular cytomegalovirus (CMV). The physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy? a. "The implant may cure the virus. But if you decide against it, I'll tell the physician that you don't want your partner to have the procedure." b. "The implant won't cure the virus, but it may protect your partner's sight. Just because your partner has dementia doesn't mean your partner shouldn't be given the opportunity to see." c. "The implant may cure the virus in your partner's eye. The dementia doesn't predict how long your partner has to live. However, you are well within your rights to refuse further treatments because nothing more will help your partner." d. "The implant won't cure the virus, but it may help preserve your partner's vision. Not being able to see you or the surroundings may worsen your partner's dementia and make caring for your partner at home more difficult."
d. "The implant won't cure the virus, but it may help preserve your partner's vision. Not being able to see you or the surroundings may worsen your partner's dementia and make caring for your partner at home more difficult." Explanation: The nurse is advocating for the client's wishes when explaining the client's wishes for no further curative treatment, yet promoting an improved quality of life and safety while the client is being cared for at home. There is no cure for CMV unless the surgical procedure is done. "Nothing more will help your partner" provides factual information, but it's delivered in a confrontational manner.
As part of a quality improvement team, the nurse uses the plan-do-study-act method to address unit-based alarm fatigue. The team has interviewed stakeholders to identity opportunities for reducing alarms and collaborated with the equipment vendors to gather alarm data. What should the nurse do next? a. Revise default alarm parameters for the unit's client population. b. Prioritize which alarm parameters need visual, audio, or secondary alerts. c. Conduct a staff training on ways to reduce wave artifact alarms. d. Analyze the patterns to identify which devices account for the most alarms.
d. Analyze the patterns to identify which devices account for the most alarms. Explanation: After gathering alarm data, the nurse should "study" or analyze the data to identify which devices account for the most alarms. Once the data has been analyzed the nurse can "act" and make specific recommendations to reduce alarms. Conducting training on ways to reduce wave artifact, prioritizing how alarm limits are displayed, and revising default limits are all valid methods for reducing alarms. However, understanding the unit-specific data helps the nurse design interventions that will have the most impact.
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? a. 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. b. Review and revise the way client education is conducted in the surgeons' office. c. Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. d. 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.
d. 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 is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention? a. teaching a newly admitted burn client about the use of pressure garments b. obtaining an anaerobic culture specimen from a superficial burn wound c. discussing the use of herpes zoster vaccine with a young adult d. administering oral tetracycline with milk to a client with cellulitis
d. administering oral tetracycline with milk to a client with cellulitis Explanation: Dairy products inhibit the absorption of tetracycline, decreasing the effectiveness of the antibiotic. All the other activities are not appropriate, but would not cause as much potential harm as the administration of tetracycline with milk. Anaerobic bacteria would not likely grow in a superficial wound. Herpes zoster vaccine is recommended for clients who are older adults (60 years or older). Pressure garments are used after graft wounds heal and during the rehabilitation phase after a burn injury, and should be discussed when the client is ready for rehabilitation, not when the client is admitted.