EAQ's -Health Assessment
At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 am the healthcare provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the 8-hour shift? Record your answer using a whole number.
863 mL The client will have absorbed 313 mL of solution before the healthcare provider changes the prescription (2.5 hours × 125 mL/hour = 312.5, rounded up to 313); for the remaining 5.5 hours of the shift, the client will have received 550 mL (5.5 hours × 100 mL/hour), for a total of 863 mL.
A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate? Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessments Gastric tube feedings to increase fluid volume
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The client will be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gavage feedings are unnecessary.
Which intrinsic factor is associated with the fall of an older adult? Wet floors Poor lighting Deconditioning Inappropriate footwear
Deconditioning Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.
A primary nurse completes a nursing assessment of all assigned clients and develops a care plan for each client. Which element of decision-making does the nurse execute in this situation? Authority Autonomy Responsibility Accountability
Responsibility refers to duties and activities that an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given issue. Autonomy refers to freedom of choices and the responsibility for the choices. Accountability refers to individuals being answerable for their actions.
Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family
Determining the coping mechanisms of the client and the family The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.
A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? "Please do not worry, everything will be alright." "I am sorry; I do not have any information about the client." "You will have to wait for the primary healthcare provider." "Please wait; I will update you as soon as I have any information."
"Please wait; I will update you as soon as I have any information." The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. If the nurse does not have any information about the client, the nurse must find out details and inform the client's family. The nurse should not avoid the situation by asking the relatives to speak to the primary healthcare provider.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? Side-lying with head elevated 45 degrees Sims with head elevated 90 degrees Semi-Fowler with legs elevated High Fowler using the bedside table as an arm rest
High Fowler using the bedside table as an arm rest The high Fowler position elevates the clavicles and helps the lungs to expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.
What could be the reason for cataracts in a 36-year-old client? . Prolonged exposure to heat Prolonged exposure to pesticides Prolonged exposure to cement dust Prolonged exposure to metal powders Prolonged exposure to anesthetic gases
Prolonged exposure to heat Prolonged exposure to metal powders Glass workers are exposed to heat and metal powders for prolonged periods, which may increase their risk of developing cataracts. A prolonged exposure to pesticides may cause pesticide poisoning. Prolonged exposure to cement dust may cause bronchitis. Prolonged exposure to anesthetic gases may have reproductive effects.
A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? The dosage is kept at a minimum. Only a small part of the body is irradiated. The client's physical condition is not a risk factor. Nutritional environment of the affected cells is a risk factor.
Only a small part of the body is irradiated. Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the healthcare provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.
According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? (Choose all that apply) 1. Economic constraints 2. Continuity of care by the nursing staff 3. Fewer nurses in the healthcare facility 4. Collection of data about the client's clinical condition 5. Engagement in a caring relationship without assumptions
2. Continuity of care by the nursing staff 4. Collection of data about the client's clinical condition 5. Engagement in a caring relationship without assumptions
Which infant is likely to need iron supplementation throughout the first year? A full-term infant who is breast feeding. A full-term infant who is receiving formula. A breastfed infant who is four months old. A breastfed infant who is six months old.
A full-term infant who is receiving formula. Formula is fortified with iron; however, this iron is less readily absorbed than the iron in breast milk. Therefore, a full-term infant who is given formula must receive iron-fortified formula throughout the first year. If the infant is breast feeding, there is no need for iron supplements. A breastfed infant absorbs adequate iron from breast milk during the first four to six months of life.
A client calls out to all nursing staff members who pass by the door and asks them to do or get something. How can the nurse best manage this problem while meeting this client's needs? Assign one staff member to approach the client regularly and interact with the client. Close the door to the room so that the client cannot see the staff members as they pass by. Inform the client that one staff member will come in frequently and check whether the client has any requests. Arrange for a variety of staff members to take turns going into the room to see whether the client has any requests.
Assigning one staff member to approach the client regularly and interact with the client provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should reduce the client's need to call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for contact with staff. Telling the client is not the same as doing it; the client may not believe that staff will come in frequently. Arranging for a variety of staff members to take turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic relationship with a staff member.
After abdominal surgery a client reports pain. What action should the nurse take first? Reposition the client. Obtain the client's vital signs. Administer the prescribed analgesic. Determine the characteristics of the pain.
Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.
A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation? Discipline Confidence Responsibility Thinking independently
Discipline The nurse shows discipline in collecting a thorough assessment to find the source of the client's anxiety. Confidence involves completing a task or goal such as performing a procedure or making a diagnostic decision. Responsibility is applicable when performing a nursing skill by following standard care practices. Thinking independently involves reading the nursing literature, talking with other nurses, and sharing ideas about nursing interventions.
The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? Modifying the environment Limiting the client's choices of diet and clothing Encouraging fluid intake Discouraging social interaction to avoid the client's distraction from outside environment
Discouraging social interaction to avoid the client's distraction from outside environment The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement. Social interactions should be encouraged instead. Modifying the environment may help to provide better healthcare. The nurse should limit the client's choices of food and clothing to relieve any decision-making stress. The nurse should also encourage fluid intake.
Which critical thinking skill refers to the use of knowledge and experience to choose effective client care strategies? Evaluation Explanation Interpretation Self-regulation
Explanation involves using knowledge and experience to choose strategies to use to care for clients. Evaluation is applicable when using criteria to determine the results of nursing actions. Interpretation is involved in the orderly collection of data. Self-regulation is applicable when the nurse identifies ways to improve his or her own performance.
Which therapeutic communication technique is useful when the nurse and a client have a conversation and the client begins to repeat the conversation to himself or herself? Focusing Clarifying Paraphrasing Summarizing
Focusing is a therapeutic communication technique that is useful when clients begin to repeat themselves. Clarification helps to check whether the client's understanding is accurate by restating an unclear or ambiguous message. Paraphrasing involves restating a message more briefly using one's own words. Summarizing is a concise review of key aspects of an interaction.
The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection in which direction? To the client from outside sources From the client to others From the client by using special techniques to destroy infectious fluids and secretions To the client by using special sterilization techniques for linens and personal items
Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised (neutropenia). Protective environment isolation is also referred to as reverse isolation. "From the client to others," "From the client by using special techniques to destroy infectious fluids and secretions," and "To the client by using special sterilization techniques for linens and personal items" are incorrect concepts related to protective environment isolation.
The nurse assessing an adult understands that the client is experiencing a midlife crisis. Which factor should the nurse attribute to this condition? The client is seeking an occupational direction. The client is examining life goals and relationships. The client is directing energy towards achievements. The client is sharing responsibilities in a two-career family.
The client is examining life goals and relationships. Individuals between the age of 35 and 43 are vigorously examining their life goals and relationships. These individuals often experience stress or a midlife crisis during this reexamination, which may lead to changes in personal, social, and occupational areas. A young adult who is aware of his or her skills seeks to pursue a degree suitable to his or her desired occupation. A young adult between the ages of 29 to 34 directs enormous energy toward achievement and mastery of the surrounding world. A young adult must share all responsibilities in a two-career family to avoid stress.
While interacting with an older adult, the nurse leans towards the client. What does this posture convey? The nurse is relaxed and comfortable with the client. The nurse is involved and interested in the interaction. The nurse is there to listen and is interested in what the client is saying. The nurse is involved and has willingness to listen what the client is saying.
The nurse is involved and interested in the interaction. Leaning towards the client conveys that the nurse is involved and interested in the interaction. Sitting in a relaxed way conveys that the nurse is relaxed and comfortable with the client. If the nurse sits facing to the client, this posture conveys that the nurse is there to listen and is interested in what the client is saying. If the nurse maintains intermittent eye contact, this posture conveys the nurse's involvement in and willingness to listen to what the client is saying.
The registered nurse is teaching a nursing student about caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client? "I will give the client a call bell." "I will involve the client's family members as interpreters." "I will provide a dictionary to the client if the client can read." "I will use boards and pictures to communication with the client."
The nurse should not involve the client's family, especially children, as interpreters because they may misinterpret the client's feelings. The nurse should provide a call bell to the client to help the client ask for assistance. The nurse should provide a dictionary to the client if the client can read to help the client to easily interpret his or her feelings. The nurse should use communication boards and pictures aid in clear and effective communication with a client.
The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to? Behavioral Community Physiological Health system
The nursing care that supports effective use of the healthcare delivery system is classified under the health system domain according to the NIC taxonomy [1] [2] provided. Interventions that support services for delivery care belong to health system. Nursing care that supports psychosocial functioning and facilitate lifestyle change belongs to behavioral nursing intervention. The nursing care that supports the health of the community falls under the community domain. The nursing care that supports physical functioning belongs to physiological nursing intervention.
A staff nurse on a medical-surgical unit has been assigned to care for a number of clients. The nurse decides to review their individual records before client contact. Which phase of the nurse-client relationship does this represent? Working phase Orientation phase Termination phase Preinteraction phase
The preinteraction phase is a preparatory phase of the planned therapeutic relationship. The working phase is the period in the relationship when individuals are occupied with achieving goals and sharing facts and feelings. The orientation phase is the initial period of the interaction; it is an introductory or exploratory phase. The termination phase is the period in the relationship when individuals are beginning to separate and move toward independent paths.
A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. What is this nursing care delivery system called? Team nursing Modular nursing Functional nursing Primary care nursing
This is the definition of primary care nursing. In team nursing there is a mix of staff members who provide care along with a team leader who usually is a registered nurse. In modular nursing clients are assigned according to geographic location and a variety of professionals are involved; this is similar to team nursing, but the teams are smaller. In functional nursing the nurse manager makes work assignments with specific tasks for each nurse.
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? Whether the client is allowed to give consent That the client cannot make informed decisions about healthcare Whether the client is permitted to give voluntary consent when parents are not available That the client probably will be unable to choose between alternatives when asked to consent
Whether the client is allowed to give consent A person is legally unable to sign a consent until the age of 18 or 19 years (depending upon individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.)
Whole grains Cooked fruit and vegetables Milk and eggs With diverticular disease, the client should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. For clients with diverticular disease, nuts and seeds are contraindicated, because they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.
A client has been diagnosed as brain dead. The nurse understands that this means that the client has what? No spontaneous reflexes Shallow and slow breathing No cortical functioning with some reflex breathing Deep tendon reflexes only and no independent breathing
client who is declared as being brain dead has no function of the cerebral cortex and a flat electroencephalogram (EEG). The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. No spontaneous reflexes, shallow and slow breathing, and deep tendon reflexes only and no independent breathing do not fit the definition of brain dead.
Which developmental changes should be evaluated in girls around 12 years of age? Motor skills Visual acuity Skeletal growth Hormonal changes
skeletal Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated. Motor skills should be evaluated in preschool children. Visual acuity should be evaluated in school-age children. Hormonal changes should be evaluated in adolescents.
A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? Prejudice Stereotyping Assimilation Ethnocentrism
Assimilation Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.
When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands what about this finding? It is a normal occurrence. It may indicate atherosclerosis. It can be attributed to aortic disease. It indicates lymphedema.
It is a normal occurrence. When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result of impaired flow of the lymphatic system.
Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? Knowing Enabling Doing for Being with
The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.
A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? Inform the client of the results. Ensure that the results are placed in the client's medical record. Notify the client's primary healthcare provider of the results. Obtain results of the other lab tests that were performed.
The nurse is most ethically and legally accountable for reporting diagnostic testing results to the client's primary healthcare provider, whether the results are normal or, more important, abnormal. Informing the client of the results is an incorrect action in this situation. Placing the results in the client's record and obtaining normal values of the results from the lab are acceptable actions for the nurse after notifying the primary healthcare provider of the abnormal results.
A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? Asking about what type of foods the client usually eats Telling the client that the diet must be followed exactly as written Telling the client that the intake of foods on the list must be limited Asking about what the client knows about the diet that was prescribed
4 Asking about what the client knows about the prescribed diet may validate the client's understanding; the response may indicate the need for further teaching or that the client understands; understanding and accepting the need for restrictions will increase adherence to the diet. Assessing the client's food preferences and teaching about diets follow an assessment of the client's understanding about the need for a specific diet; the client must understand the need for and the benefits of the diet before there is a readiness for learning. Telling the client that the diet must be followed exactly as written and telling the client that the intake of foods on the list must be limited are authoritarian and should be avoided.
The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader? Charge nurse Registered nurse Licensed practical nurse Unlicensed assistive personnel
The registered nurse acts as a team member by creating a care plan for the client and coordinating the care among the team members. The registered nurse works directly with the client, family, and healthcare team members. The charge nurse assigns tasks to the other healthcare professionals if the registered nurse is absent. The licensed practical nurse provides care to the client under the supervision of registered nurse. The unlicensed assistive personnel are team members who provide care to the client under the supervision of the registered nurse.
The chief operational officer (COO) interviews a nurse and asks, "Tell me about your practical experiences in clinical decision making." Which example would the nurse give? "I palpated the right hip of the client, which appeared red, and noted the warm feeling." "I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip." "I quickly offered a salt recipe to a client with a history hypotension history who suffered from light-headedness and dizziness." "I assessed weakness and hunger in a client with a history of diabetes history who suffers with light-headedness and blurred vision."
"I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip." Clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. So as a part of clinical decision making, the nurse identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip. Diagnostic reasoning and inference is an analytical process that involves determining the client's health problems. An example is the nurse palpating and observing a warm sensation in the client's right hip that has turned red. Another example is a nurse who finds that a client who has hypotension history now feels light-headedness and dizziness. A further example is a nurse who assesses symptoms of diabetes in a client who has a history of the disease and now suffers blurred vision.
A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction? "I should practice respiratory hygiene/cough etiquette." "I should avoid contact with the elderly or children." "I should obtain a pneumococcal vaccination each year." "I should allow visitors for short periods of time only."
"I should obtain a pneumococcal vaccination each year." The client should be encouraged to receive an influenza vaccine each year. Pneumococcal vaccines will not prevent influenza. The nurse should stress the importance of practicing respiratory hygiene/cough etiquette. The client should avoid contact with vulnerable populations such as the elderly and children. Visitors for clients in isolation for influenza should be limited to persons who are necessary for the client's emotional well-being and care. Visitors who have been in contact with the client before and during hospitalization are a possible source of influenza for other clients, visitors, and staff.
While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."
"You seem upset." The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negates the client's feelings and presents a negative connotation.
A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? 7.20 7.35 7.45 7.48
7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.
The nurse who is working during the 8:00 am to 4:00 pm shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of orange juice and 6 oz of tea at 8:30 am and vomits 200 mL at 9:00 am. At 10:00 am the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11:00 am. At 12:30 pm, 3 oz of soup and 4 oz of ice cream are ingested. The client voids 450 mL at 2:00 pm. Calculate the total intake for the 8:00 am to 4:00 pm shift. Record your answer using a whole number. 970 mL
970 1 ounce = 30 mL; therefore the client ingested 120 mL of orange juice at 8:30 am, 180 mL of tea at 8:30 am, 60 mL of water with medications at 10:00 am, 90 mL of soup at 12:30 am, and 120 mL of ice cream at 12:30 pm (counted as a liquid because it melts at room temperature). The client received 400 mL of IV fluid (50 mL × 8 hours = 400). Total intake is 970 mL. Vomit and urine output should not be included in the patient's intake.
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? Ensuring the client's skin integrity Reviewing the preoperative instructions Administering general anesthetic to the client Placing the client in the correct position on the operating table
Administering general anesthetic to the client Only anesthesiologists who are specially trained can administer anesthesia. Therefore, the nurse should exclude this intervention from the nursing care plan. In the operating room, the nurse should ensure the client's skin integrity to prevent complications such as pressure sores. The nurse should review the preoperative care plan to establish or amend the plan if changes are required. The nurse should place the client in the correct position to prevent the client from injury during the operation.
Which professional standard does the nurse feel is most important for critical thinking? Logical thinking Evaluation criteria Accurate knowledge Relevant information
An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.
A client is receiving an intravenous infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? Excessive carbohydrate intake Lack of protein supplementation Insufficient intake of water-soluble vitamins Increased concentration of electrolytes in cells
An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.
The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine? Protein Glucose Ketones Uric acid
As a result of fat metabolism, ketone bodies are formed, and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low-carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.
A nurse is taking care of a client who has chronic back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Ask the client about the acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes.
Ask the client about the acceptable level of pain. Administer the pain medications regularly around the clock. The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires the pain assessment at frequent intervals.
A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? Get a full report from the first nurse and adjust the plan accordingly. Ask the primary healthcare provider for a report on the client's condition and plan appropriately. Tell the client about the change in staff responsibilities and assess the client's reaction. Assess the client's present status and include the client in a discussion of revisions to the plan of care
Assess the client's present status and include the client in a discussion of revisions to the plan of care. Because the client is feeling a loss of control, it is most important to include the client in revision of the plan of care. Getting a full report from the first nurse does not consider changes in the client or obtain the client's input. Planning nursing care is within the nurse's function and judgment, not the primary healthcare provider's; also, the client should be included. Telling the client of the change in staff responsibilities is an authoritarian approach and does not include the client in planning future care.
The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant? Cognitive age Basic personality Financial resources General physical health
Basic Personality Lifelong coping styles are most important in how a person will deal with stress. Age may influence defense mechanisms, but lifelong coping styles will most significantly affect a person's behavior. Financial resources are a factor to be considered, but past coping ability is the most significant factor to predict future coping. General physical health is a factor to be considered, but past coping ability is the most significant factor to predict future coping.
A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? . Assessing vital signs Administering injections Assessing wound drainage Bringing equipment to the client's room Transporting the client to a diagnostic test
Bringing equipment to the client's room Transporting the client to a diagnostic test The nursing assistive personnel can bring equipment to a client's room and transport the client from one place to another. Because the client is on isolation precautions, the registered nurse should assess vital signs, administer injections, and assess wound drainage.
A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child's gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother? Can your child hold on to furniture? Can your child show hand preference? Does your child move on his or her hands and knees? Can your child place objects in containers?
Can your child hold on to furniture? Gross-motor skill development features in a seven-month-old include sitting alone without any support. Another sign is the infant's ability to hold on to furniture. An infant between 8 and 10 months may show hand preference as a part of fine-motor skill development. Moving on hands and knees may represent gross-motor skill development in an 8 to 10 month old. A 10 to 12 months infant may have the ability to place objects in containers; this action is a part of fine-motor skill development.
A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber 75 mL of bright red blood in the drainage collection chamber An intact occlusive dressing at the insertion site Constant bubbling in the water seal chamber
Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and therefore the healthcare provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.
A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client? Delirium Dementia Depression Alzheimer's disease
Delirium is an acute confusion state where the client has reduced or disturbed consciousness, fatigue, and distorted perceptions accompanied by delusions, hallucinations, and misperceptions. Clear consciousness exists and misconceptions are usually absent in clients with dementia. Clear consciousness exists and distortions and hallucinations are only observed in severe cases of depression. Alzheimer's disease is a progressive cerebral deterioration that can occur in middle-aged or advanced age adults.
While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her needs. Which phase of the helping relationship is observed? Working phase Orientation phase Termination phase Preinteraction phase
During the orientation phase, the nurse assesses the health status of the client and prioritizes his or her needs. During the working phase, the nurse encourages and helps the client to set treatment goals. In the termination phase, the nurse evaluates the achievement of treatment goals with the client. In the preinteraction phase, the nurse reviews the client's medical and nursing history and talks to the caregivers.
An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? Use the client's first name. Visit with the client frequently. Explain what the client can expect. Listen to what the client has to say.
Explain what the client can expect. Explaining procedures and routines should decrease the client's anxiety about the unknown. The nurse should not confuse roles of professional and friend; the client should be called by an appropriate title (Mr., Miss, Ms., Mrs., etc.) unless the client requests otherwise. The nurse should not confuse the role of professional with that of being a friend; "visiting" has a social connotation. Although listening to the client is therapeutic, this does not change the fact that the hospital environment is strange to the client and the client needs information.
An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? Industry versus inferiority Identity versus role confusion Generativity versus stagnation Autonomy versus shame/doubt
Generativity versus stagnation The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? Institute the prescribed blood transfusion because the client's survival depends on volume replacement. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.
Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a healthcare proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary healthcare provider for an administrative prescription are without legal basis, and the nurse may be held liable.
While reviewing a client's prescriptions, the nurse finds that one of the prescribed drugs is redundant and notifies the primary healthcare provider. Which attitude of critical thinking does the nurse exhibit? Curiosity Risk taking Thinking independently Responsibility and authority
If the nurse questions a healthcare provider's order by applying his or her knowledge, then this attitude is considered risk taking. If a nurse explores and learns more about a client to make appropriate judgments, then the attitude is curiosity. Thinking independently is indicated when a nurse reads nursing literature that provides multiple viewpoints on the same subject. The responsibility and authority of a nurse is shown by asking for help, reporting problems immediately, and following proper procedures.
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? Rehabilitation needs are met best by the client's family and community resources. Rehabilitation is a specialty area with unique methods for meeting clients' needs. Immediate or potential rehabilitation needs are exhibited by clients with health problems. Clients who are returning to their usual activities after hospitalization do not require rehabilitation.
Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to prevent complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the primary healthcare provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.
Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months? Turning from side to back Sitting erect using support Showing good head control Bringing objects from hand to mouth
Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. There is no need to check with the healthcare provider before administration. The seasonal flu shot has been given safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies. Flu shots are not contraindicated; however, the nasal vaccine is. There is no indication that dosages should be altered.
A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? Suddenness of the change Obviousness of the change Extent of the change Perception of the change
It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.
client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others? Insert a urinary catheter. Initiate droplet precautions. Move the client to a private room. Use a high-efficiency particulate air (HEPA) respirator during care.
Move the client to a private room. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? Sodium Potassium Chloride Calcium
Na Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.
The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. What should the nurse be aware of when using the problem-etiology-signs and symptoms (PES) format? Signs and symptoms come last in the diagnostic process. Nursing interventions are derived from the etiology statement. The only allowable diagnoses are nursing diagnoses. Nursing diagnoses deal only with actual or potential illness problems.
Nursing interventions are derived from the etiology statement. The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the signs and symptoms, or "S" in the acronym, comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses handle most commonly with other healthcare providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.
Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? Instruct the client to position one arm on each shoulder of the nurses. Direct the client to extend the legs and remain still during the procedure. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Eugene on target
Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Eugene on target Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.
The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? Chemically stimulate the loop of Henle Diminish the thirst response of the client Prevent reabsorption of water in the distal tubules Cause fluid to move toward the interstitial compartment
Prevent reabsorption of water in the distal tubules Sodium absorbs water in the kidneys' renal tubules. When dietary intake of sodium is decreased, water is not reabsorbed and edema is reduced. A decrease in sodium will prevent the reabsorption of water. Furosemide stimulates the loop of Henle to inhibit the reabsorption of sodium and chloride at the proximal and distal tubules. Adequate hydration is the major factor that diminishes the thirst response. A low-sodium diet will help move fluid from the interstitial compartment to the intravascular compartment.
An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? Provide nutritional support Provide voiding opportunities Avoid indwelling catheterization Provide beverages and snacks frequently Promote measures to prevent skin breakdown
Provide voiding opportunities Avoid indwelling catheterization Promote measures to prevent skin breakdown An older adult should be provided voiding opportunities to minimize urinary incontinence. Indwelling catheterization should be avoided because this action increases the risk of infection and may cause discomfort. Measures to prevent skin breakdown should be taken because the client may develop skin problems due to incontinence. Nutritional support and frequent beverages and snacks should be provided to a client with malnutrition.
The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? Care that supports physical functioning Care that supports homeostatic regulation Care that supports psychosocial functioning Care that provides immediate short-term help in physiological crises
Providing perioperative care (care before, during, and immediately after surgery) involves care that supports homeostatic regulation. If interventions are provided to support the client in doing daily activities, they are considered a physiological basic domain that supports physical functioning. Providing behavioral and cognitive therapies helps to support psychosocial functioning and facilitates lifestyle changes. Providing immediate short-term help in physiological crises helps to support protection against harm.
Question 3 During a peer review, the chief operational officer of a healthcare unit understands that the newly appointed nurse excels in reminiscence theory. What statement of the nurse confirms this understanding? The nurse restores the client's sense of reality. The nurse builds self-esteem by asking about a client's previous achievements. The nurse agrees to a confused client's incorrect statement.
Reminiscence theory involves helping the client to recall past experiences to help resolve current conflicts. A nurse who builds a client's self-esteem by asking about his or her previous achievements is using the theory. Reality orientation is associated with the restoration about the sense of reality. Validation therapy is associated with agreeing with a confused older client's incorrect statement. The nurse may use therapeutic communication to address the expressed and unexpressed needs of the client.
Which nursing action would be considered a part of self-regulation in the decision-making process? Reflecting on one's own experiences Looking at all the situations objectively Supporting findings and conclusions Making careful assumptions about a client's information
Self-regulation requires the nurse to reflect on his or her own experiences. Explanation requires looking at all situations objectively. Findings and conclusions are supported by explanation. Analysis requires the nurse to not make any careless assumptions.
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? Sharing hope Sharing humor Sharing empathy Sharing observations
Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress. Nurses should recognize that hope is essential for healing and communicate a sense of possibility. Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.
Which nursing actions reflect the carative factor of 'promoting and expressing positive and negative feelings' according to the Watson's transpersonal caring? Supporting and accepting the client's feelings Learning together while educating the client to acquire self-care skills Creating a healing environment at the physical and nonphysical levels Applying the nursing process in systematic, scientific problem-solving decision-making Showing a willingness to take risks in sharing in the relationships when connecting with clients
Supporting and accepting the client's feelings Showing a willingness to take risks in sharing in the relationships when connecting with clients According to the Watson's transpersonal caring, there are ten carative factors that should be incorporated into the nursing practice. The nurse can include the carative factor "promoting and expressing positive and negative feelings" by supporting and accepting the client's opinions and feelings. It also includes showing a willingness to take risks in sharing in the relationship. Transpersonal teaching-learning is promoted by learning together while educating the client. This learning together session helps in acquiring self-care skills. A healing environment is created by providing supportive, protective, and corrective mental, physical, and spiritual environment. According to Watson's theory, the nursing process should be used as the creative, problem-solving caring process. It involves applying systematic, scientific problem-solving and decision-making in providing client-centered care.
A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include? Foster self-activity whenever possible. Plan care to be completed at one time followed by a long rest. Teach family members how to assist with the client's basic care. Limit visiting to evening hours before the client goes to sleep.
Teach family members how to assist with the client's basic care. Because the family members are old enough to understand the client's needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system.
A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? Limit the client's fluid intake. Teach the client how to exercise the legs. Encourage use of the incentive spirometer. Maintain the knee gatch position at an angle.
Teach the client how to exercise the legs. The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function, but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.
While assessing an elderly client, a nurse infers cognitive impairment. Which statements made by the client confirm the nurse's conclusion? "I have difficulty judging things." "I forget to take medicines." "I am unable to do financial calculations." "I get confused about the proper date and time." "I am unable to recall words during conversations with my family."
That's right! Poor judgment, loss of the ability to calculate, and loss of language skills are related to cognitive impairment. These changes may develop due to an imbalance of neurotransmitters in brain. Forgetfulness and getting confused are symptoms that may be associated with normal aging changes.
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what? Restore function and/or appearance Replace an organ or tissue Relieve or reduce symptoms Remove or excise an organ or tissue
The main function of reconstructive surgery is to restore function and/or appearance. This type of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In reconstructive surgery, repairs are made and malformations corrected that are congenital, a result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known as transplant; surgery to relieve or reduce symptoms is known as palliative; and surgery to remove or excise an organ or tissue is known as resection.
Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss? Smiling while seeing the client Nodding head in front of the client Making eye contact with the client Leaning forward towards the client
The nurse should make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help to build a positive relationship. Nodding in front of the client helps to regulate the conversation. Leaning forward towards the client shows attention and awareness.
A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? Tubing injection port Distal end of the tubing Urinary drainage bag Catheter insertion site
Tubing Injecting point The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.
An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is always angry at me." What is the nurse's best initial response? "Your parent is frightened by impending death." "Your parent is working through acceptance of the situation." "Your parent is attempting to reduce your need for dependency." "Your parent is hurt that you will not provide physical care at home."
Understanding the stages leading to the acceptance of death may help the family member understand the client's moods and anger. The parent may not be frightened unless stated by the client; some clients welcome death as a release from pain. It is unlikely that the parent is attempting to reduce the family member's need for dependency; anger is one of the stages of accepting death. It is an assumption by the nurse that the parent is hurt that the family member will not provide physical care at home unless stated by the client.
A 2 g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? Discuss the diet with the client and family. Tell the client why salty foods should not be eaten. Explain the dietary restriction to the client's visitors. Ask the dietitian to teach the client and family about sodium restrictions.
discuss diet w/ client and family The client and significant family members should be included in dietary teaching; families provide support that promotes adherence. The client already has received information about why salty foods should not be eaten. Explaining the dietary restriction to the client's visitors could violate confidentiality. The client should be involved in his or her own care; the client ultimately will assume the responsibility. The dietitian is a resource person who can give specific, practical information about diet and food preparation once there is a basic understanding of the reasons for the diet.
