EVOLVE FUNDAMENTALS CASE STUDIES PRACTICE
Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing?
ANSWER = MECHANICALLY DEBRIDE THE TISSUE RATIONALE = Moistened gauze is placed on the wound and allowed to dry. It then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed. EXTRA RATIONALES: impedes healing due to tissue cooling. increase the risk of infection due to frequency of dressing change. may destroy granulation tissue.
When the medication bottle is properly relabeled, the nurse mixes the suspension prior to pouring it. Which technique should the nurse use to mix the linezolid?
ANSWER = MIX ACCORDING TO DIRECTIONS RATIONALES = Instructions should be to turn 2-3 times, AVOID SHAKING, according to manufacturer's specifications. Linezolid should never be shaken.
When the client is calm, the nurse assigns the UAP to help the client into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing the client's clothes. The nurse enters the room and assesses the situation. Which aspect of the situation requires the nurse's MOST immediate intervention?
ANSWER = THE CLIENT'S ROOM DOOR IS OPEN TO THE HALLWAY. RATIONALE = This is disrespectful, demeaning, and an invasion of the client's privacy. It should be corrected immediately.
After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal should the nurses include in the client's plan of care?
ANSWER = THE CLIENT'S SKIN WILL REMAIN INTACT WITHOUT DETERIORATION RATIONALE = A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.
The client returns from the Post Anesthesia Care Unit (PACU) after the surgical procedure. The client has an IV of LR infusing at 125 mL/hr, O2 at 2 L/min per nasal cannula, and an indwelling catheter attached to a drainage bag.Four hours later, the nurse documents the client's intake/output. The LR solution has been running for 4 hours, and the nurse administers an IV antibiotic that runs in 150 mL of normal saline. The client is still NPO after the procedure.How does the nurse document the client's intake in mL? (Enter numerical value only. If rounding is necessary, round to the whole number.)
150 mL x 4(hours) = 500 mL LR solutio 500 mL + 150mL(antibiotic)= 650 mL
The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." The nurse is scheduled to administer 20 mL per their calculation. The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200 mg. What is the total daily dosage (in mg) that the client will be receiving?
400 MG x 2 daily doses (q12h)= 800 mg/24 hrs
The nurse plans to administer an ordered dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." How many mL of medication will the nurse administer?
400MG/100 MG * 5 ML = 20 ML
A client with paraplegia as the result of a spinal cord injury received in a motorcycle accident lives at home with their parents who assist with care. The client is attending college and has a strong social support system. The client visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on their sacrum.
SKIN INTEGRITY
The nurse interprets the client's angry outburst as an indication that he is afraid that he may become dependent upon others if his sensory deficits continue. Which nursing problem should be added to the plan of care?
ANSWER = SELF CARE DEFICIT RATIONALE = The nurse's analysis of the client's behavior reflects the fear that they he become dependent on others, creating feelings of diminished self-esteem, which may lead to impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, or toileting.
The client becomes angry after the nurse provides the list of home safety checks that should be performed and suggests removing the throw rugs. The client yells, "You think I am helpless, old, and can't take care of myself anymore!" Which action should the nurse implement?
ANSWER = STAY IN THE ROOM, SITTING WITH CLIENT RATIONALE = The nurse needs to recognize the reasons behind the client's angry outburst and provide a therapeutic response, such as presence and silence.
The nurse suspects that the client's wound has developed a sinus tract, or tunneling. Which equipment should the nurse utilize to assess the length of the tract?
ANSWER = STERILE COTTON TIPPED APPLICATOR RATIONALE = A sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling. Once length is noted with applicator, then use tape measure to document exact length.
What additional teaching can the nurse provide to reduce the problems related to the client's sense of smell?
ANSWER = Suggest that the meals be prepared at the friends' homes and then delivered to the client ready to eat. RATIONALE = Removing the aroma of cooking food eliminates a major trigger for the client with a heightened sense of smell. EXTRA RATIONALES: Aromatherapy may worsen the symptoms of a client with a heightened sense of smell. PT SNIFFS FOODS BEFORE EATING:useful technique for a client with a diminished sense of smell rather than a heightened sense of smell
The client reports, prior to the stroke, getting up five or six times to urinate nightly but controlled the urge long enough to make it to the bathroom. How should the nurse describe the urinary pattern that the client is describing?
ANSWER = NOCTURIA voiding frequently at night. ANSWER RATIONALE = The incidence of nocturia increases greatly in the older male client who has an enlarged prostate & can indicate inability to concentrate urine b/c of poor blood flow to the kidneys. EXTRA RATIONALES DYSURIA - pain/burning with urination FREQUENCY = voiding at more frequent intervals than normal DIURESIS = increased urination that would occur from taking diuretic meds.
During the follow-up visit, the client states, "I'm a little worried about my older son. He is 16 and seems to be sleeping too much. If this keeps up, I'm afraid that I may have trouble sleeping due to the stress again!" Which initial response by the nurse is best?
ANSWER = PLEASE TELL ME AOBUT YOUR SON'S SLEEP HABITS RATIONALE = This information is needed to determine what is "too much." The response also invites the client to continue expressing concerns. EXTRA RATIONALE: Teens usually need as much or more sleep than adults need nurse is making a judgment that the client is overly concerned, and this statement blocks further communication.
After further examination and testing by the HCP, the client is referred to a surgeon and is scheduled for a uvulopalatopharyngoplasty (UPPP), the removal of tissue in the throat to treat the obstructive sleep apnea. The client is admitted to the hospital, and an apnea monitor is prescribed. The charge nurse should assign the client to which room?
ANSWER = PRIVATE ROOM NEAR THE NURSING STATIONS & REPORT ROOM RATIONALE = Due to the increased monitoring necessitated by the client's sleep apnea, the client's room should be near the nursing station.
To reduce the effects of moisture on the client's skin, which intervention should be implemented?
ANSWER = APPLY A MOISTURE REPELLENT OINTMENT TO INTACT SKIN AREAS RATIONALE = After the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage. EXTRA RATIONALES: Alcohol is drying and damaging to tissue. Plastic-lined underpads are designed to protect bed linens by retaining the moisture. They are not designed to wick the moisture away from the client's skin. Heat and excessive moisture are damaging to the skin.
The nurse notifies the HCP of sinus tracts discovered during the assessment and receives an order to irrigate the wound with sodium chloride (NS). Which irrigation technique is best?
ANSWER = APPLY STEADY PRESSURE USING A 35 ML SYRINGE AND 19- GAUGE NEEDLE RATIONALE = Using a 35 mL syringe and 19-gauge needle provides 8 pounds per square inch (PSI), which applies adequate pressure to ensure effective irrigation. Safe, effective pressure is between 4 and 15 PSI. More than 15 PSI will drive bacteria into the wound and destroy healthy tissue.
How would the nurse assess for the presence of tinnitus?
ANSWER = ASK THE CLIENT IF HE EVER HEARS RINGING IN HIS EARS RATIONALE = Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss. EXTRA RATIONALES: Discrimination testing does not provide data on tinnitus. TYMPANOMETRY TO ASSESS MIDDLE EAR:does not provide data about the presence of tinnitus HOLD AURICLE UP AND BACK AND OBSERVE THE EAR CANAL:This is the correct technique to examine the ear canal in the adult, but it will not provide data about tinnitus.
The client is seen in the surgeon's office for a follow-up evaluation 2 weeks after surgery. Which is the most effective method to evaluate improvement of the client's OSA?
ANSWER = ASK THE PT SPS ABOUT THE CLIENT'S SNORING AND RESPIRATORY PATTERN AT NIGHT RATIONALE = Speaking with the client's spouse about her observations regarding snoring, respiratory rate, and sleep pattern corroborates the nursing problem of ineffective respiratory patterns. EXTRA RATIONALES: ASK PT HOW HE'S BEEN SLEEPING THE LAST 2 WKS:this may assess the client's overall level of sleep, it does not specifically address their respiratory pattern.
Which interventions should the nurse add to the client's plan of care? SATA
ANSWER 1.) MONITOR BEDTIME FOOD/BEVERAGE INTAKE WHICH MIGHT INTERFERE W/SLEEP:Foods and drinks containing caffeine, stimulants, or alcohol can interfere with sleep patterns. 2.) INSTRUCT THE PT TO GET OUT OF BED IF UNABLE TO FALL BACK TO SLEEP W/IN 30 MIN & TO DO A QUIET ACTIVITY UNTIL BECOMING SLEEPY:Lying in bed awake for more than 30 minutes may increase anxiety and inhibit the onset of sleep. A quiet activity such as reading or muscle relaxation can be helpful. EXTRA RATIONALES: A carbohydrate snack is associated with inducing sleep, but meals should be avoided for 3 to 4 hours before bedtime. Activities associated with work may increase the client's stress and inhibit sleep. SUGGEST USE OF SOFT MATTRESS: The client has not expressed any physical discomforts related to his bed.
The nurse performs a focused assessment on the client, before he sees the healthcare provider (HCP). As part of the assessment, the nurse evaluates the client for which additional symptoms that are commonly associated with sleep deprivation? SATA
ANSWER 1.) NOCTURIA 2.) SLEEP APNEA RATIONALE = 1.)Urination during the night disrupts the sleep cycle and contributes to sleep deprivation. 2.)Sleep apnea occurs when there is a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep, resulting in sleep deprivation. EXTRA RATIONALES: NOT ASSOCIATED PARESTHESIA = burning/tingling sensation in hands, feet EUPHORIA = feeling of wellbeing or good health TACHYCARDIA is not associated
Which statements reflect potential expected outcomes for the nursing problem "disturbed sleep pattern related to stress from new job"? SATA
ANSWER 1.) PT IDENTIFY WAYS TO RELIEVE STRESS DURING THE DAT/BEFORE BEDTIME: important for the client to be able to identify ways to relieve stress before going to bed at night. 2.) PT WILL REPORT 50% DECREASE IN NIGHT AWAKENINGS W/IN 1 WEEK: outcome is directly related to the nursing problem, is specific and measurable, and is realistically timed. 3.) PT REPORTS FEWER INCIDENCES OF DOZING OFF DURING THE DAY: It is important for the client to report less daytime sleepiness. This outcome is directly related to the nursing problem.
The nurse plans to assess subjective data about the client's hearing loss. To follow up with this type of data collection, which questions will provide the most useful subjective information?
ANSWER 1.)HAVE TOU HAD GRADUAL HEARING LOSS OR DID IT HAPPEN ALL AT ONCE?The nurse wants to know the ONSET of the hearing loss. PRESBYCUSIS = gradual onset hearing loss, which is usually worse in noisy environments. 2.)WHAT CHANGES DID YOU NOTICE?The nurse is assessing the CHARACTER of the hearing loss with this question. A marked loss is at low intensity but sound actually becomes painful when a speaker repeats in a loud voice. 3.)ARE THERE ANY SOUNDS THAT YOU CAN NO LONGER HEAR?The nurse is assessing the character of hearing loss. Asking if the client has recently traveled by airplane or had an upper respiratory infection would also be useful information to obtain. 4.)WHAT EFFECTS HAS YOUR HEARING LOSS MADE ON YOUR DAILY ACTIVITIES?By asking the client about the impacts that hearing loss has had on daily life, the nurse is collecting subjective data. Hearing loss can cause social isolation and decreased quality of life and lead to functional and cognitive decline and depression.
In managing the client's postoperative care, which task should the nurse delegate to the unlicensed assistive personnel (UAP)? SATA
ANSWER = 1.) OBTAIN PULSE OXIMETRY & RESPIRATORY RATE EVERY 2 HRS 2.) SERVE THE PRESCRIBED BREAKFAST TRAY TO THE CLIENT
The client returns to the clinic after using the CPAP machine at home for 3 months. He reports no improvement in symptoms and appears disheveled and irritable. He describes sleeping only 3 or 4 hours each night and blames it on discomfort caused by the CPAP machine. The nurse records the client's appearance and complaints in the chart. The nurse considers which information to be subjective data? (Select all that apply.)
ANSWER = 1.) PT STATES HE SLEEPS 3-4 HRS/NIGHT 2.) PT REPORTS CPAP APPARATUS IS UNCOMFORTABLE 3.) PT WIFE STATES HE'S BEEN YAWNING ALOT AT HOME: info reported by the wife is subjective data
The nurse notifies the HCP and obtains a prescription for wrist restraints. The nurse applies the restraints and plans to monitor the client every 30 minutes. Which assessments are most important for the nurse to perform at each of these times? SATA
ANSWER = 1.) SKIN INTEGRITY OF THE RESTRAINED EXTREMITIES 2.) PULSE RATE & VOLUME IN THE WRISTS RATIONALES= 1.)Wrist restraints can impede circulation, causing tissue damage under the restraint and distal to the restraint. Skin integrity and assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints must be REMOVED EVERY 2 HOURS to allow for range of motion. 2.)Assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints must be removed at least every 2 hours to allow for range of motion.
The nurse observes that the reddish area is round and is directly over the client's sacrum. The skin is intact In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform?
ANSWER = 1.)APPLY LIGHT PRESSURE TO THE AREA WITH THE FINGERTIPS:nurse applies light pressure with the fingertips to assess for blanching. Blanching is a normal response that indicates there is no tissue perfusion impairment. 2.)MEASURE THE DIAMETER OF THE REDNESS:area of redness should be measured to evaluate progression or healing.
The nurse monitors the client's postoperative lab values. The nurse notes that his white blood cell count (WBC) is 15,000 mm3 (15 × 109/L). Which observation should be documented in the nurse's assessment? (Select all that apply.)
ANSWER = 1.)OBSERVE FOR EXCESSIVE DRAINAGE: Abnormal drainage could indicate the presence of infection. The nurse should evaluate the surgical wound as well. 2.) MEASURE TYMPANIC TEMPERATURE: client's WBC count is elevated, indicating a possible infection. The client should be assessed for fever.
The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine. The catheter is secured and the client is resting comfortably. In documenting the catheter insertion procedure, which statement should be included?
ANSWER = 16 FRENCH FOLEY CATH INSERTED W/RETURN OF CLEAR YELLOW URINE RATIONALE = This statement includes the best objective data, including the size of the catheter and the outcome of the procedure. In addition, the nurse should also document how the client tolerated the procedure and the client's condition following completion of the procedure.
The student nurse instills a total of 60 mL of the correct solution and withdraws 40 mL of fluid containing several small blood clots. The student nurse then empties 200 mL from the urinary drainage bag.What urinary output should be recorded? (Enter the numerical value only. If rounding is required, round to the whole number.)
ANSWER = 180 RATIONALE = The student instilled 20 mL more than was withdrawn, so that amount must be subtracted from the volume emptied from the drainage bag. 200 mL - 20 mL = 180 mL The nurse may instill the irrigant without withdrawing any fluid. In that circumstance, the entire amount of the irrigant must be subtracted from the amount of fluid emptied from the drainage bag to obtain an accurate measurement of the client's urinary output.
The client has been prescribed levoflloxacin 750 mg PO daily. The nurse has received 250 mg tablets from the pharmacy. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the whole number.)
ANSWER = 750/250 = 3 tabs
The client's incontinence continues. Use of the condom catheter is resumed until the client develops localized dermatitis. The condom catheter is removed temporarily to promote healing. Although the nursing staff takes the client to the bathroom every 2 hours, episodes of incontinence occurs occasionally. The nurse enters the client's room and finds him crying. What is the best initial response by the nurse to this behavior?
ANSWER = ACKNOWLEDGE THE CLIENT'S DISTRESS RATIONALE = Acknowledgment of a client's distress is a therapeutic and caring response. This should be the first action implemented by the nurse.
Music is playing loudly through the exam room's intercom system. Another nurse enters the room and turns the music off before speaking with the client Which action should the nurse assessing the client implement?
ANSWER = AFFIRM THAT THE OTHER NURSE'S ACTION MAY ASSIST THE CLIENT'S ABILITY TO HEAR BY ELIMINATING BACKGROUND NOISE RATIONALE = Clients with a hearing impairment have difficulty hearing conversation when there is background noise, such as music or other conversations
Which statement is the best description of the sleep pattern for a normal adult?
ANSWER = AN ADULT HAS 4-6 SLEEP CYCLES, EACH WITH NREM AND REM SLEEP DURING A NORMAL NIGHTS SLEEP RATIONALE = Every 90 minutes REM sleep recurs. When a sleeper awakens at any stage of the sleep cycle it must start again at N1. EXTRA RATIONALES: Middle-aged and older adults tend to have more problems with sleep, including insomnia and waking up multiple times at night. The sleep cycle primarily consists of non-rapid eye movement (NREM) sleep. There are three stages of NREM or slow wave sleep: N1, very light sleep, to N3, very deep sleep. Although sleep patterns vary for each developmental age group, middle-aged adults usually require about 7 hours of sleep while the elderly require about 6 hours of sleep. Stage IV sleep is sometimes markedly decreased or absent in the elderly.
Prior to administering the first dose of the antibiotic, the nurse asks the client about any drug ALLERGIES. The nurse explains to the client that this precaution reduces the risk for what potential problem?
ANSWER = ANAPHYLACTIC REACTION RATIONALE = anaphylactic reaction is a severe allergic response that can be life threatening. EXTRA RATIONALES: IDIOSYNCRATIC RESPONSE: individually unique response to a medication is not predictable or related to allergies. SYNERGISITIC EFFECT:occurs when the combined effect of two drugs is greater than the effect of either substance. It is not related to allergies DRUG COMPATIBILITY:mixing medications in a solution that causes precipitation or adverse chemical reaction. It is not related to medication allergies.
After the client receives the first dose of linezolid, the nurse reports to the HCP that a rash and itching develop on his thorax, but he has no respiratory symptoms Which class of medication should the nurse expect to administer?
ANSWER = ANTIHISTAMINE SUCH AS DIPHENHYDRAMINE RATIONALE = antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid. The nurse should, however, continue to monitor for a more severe allergic response. EXTRA RATIONALES: NOT NEEDED ADRENERGIC MED (EPINEPHRINE):for severe allergic reactions TOCOLYTIC (TERBUTALINE) 5HT3 RECEPTOR ANTAGONIST (PALONOSETRON)
The nursing staff continues with bladder-training, but the client's incontinence shows little improvement. Since bladder training has not been successful, the nurse obtains a prescription to apply an external male catheter. Which intervention is most important for the nurse to include in the client's plan of care?
ANSWER = ASSESS FOR SIGNS OF SKIN BREAKDOWN RATIONALE = Catheters can cause skin breakdown and lead to external infections. Even with these preventative measures, skin breakdown can occur and should be assessed frequenly to prevent external infection or injury. EXTRA RATIONALES = It is important to use good hygiene HOWEVER, external cath are NOT sterile. Replace catheter daily = should be done AS NEEDED which may NOT be daily Silicone catheters will allow for better visualization of penis while catheter is in place = UNLESS pt is allergic, this is NOT a factor.
During the initial interview, the nurse inspects the external anatomy of the eye. The nurse notes that the cornea looks cloudy and an arcus senilis is seen around the cornea.
ANSWER = ASSESS WHETHER THE CORNEA LOOKS THICKENED AND RAISED AND DOCUMENT THE FINDING RATIONALE = As the lipid deposits accumulate, the cornea may look thickened and raised. The assessment finding should be documented in the electronic medical record. EXTRA RATIONALES: DOC ANY REPORT OF TEARING OR A BURNING SENSATION: The lacrimal apparatus may decrease tear production, causing the eyes to look dry and lusterless. A person may report a burning sensation. This is NOT RELATED to the arcus senilis. ASSESS RETINAL STRUCTURE:This action is done during an internal, not external, examination of the eye. PREPARE ASSIST HCP IN OBTAINING OCULAR PRESSURES:Elevated eye pressure is related to glaucoma.
The nurse prepares a written positioning schedule and places it in the client's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with the client's care. The charge nurse removes the schedule and states that it violates the client's privacy. What action should the nurse take?
ANSWER = ASSURE THE CHARGE NURSE THAT WRITTEN INSTRUCTIONS IN THE CLIENT'S ROOM ARE EFFECTIVE AND DO NOT VIOLATE ANY CLIENT RIGHTS. RATIONALE = A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality.
During the preoperative evaluation for the client's cataract surgery, a chest x-ray reveals a small mass in the client's left lung. A biopsy reveals that the mass is cancerous. The client's cataract surgery is postponed, and chemotherapy is started.After the second round of chemotherapy, the nurse's assessment reveals that the client has lost 10 pounds. The client states that smells make him feel sick to the stomach and that food has no taste. To improve the client's appetite, friends often cook meals for him, keeping the foods soft and bland. What client teaching should the nurse provide?
ANSWER = Add seasonings to the bland food to stimulate the taste buds. RATIONALE = The addition of seasonings, such as lemon juice, enhances food flavor and stimulates taste sensation. EXTRA RATIONALES: Clients with a diminished taste sensation should be encouraged to chew food longer to increase the ability to taste the food. Maintaining moist mucus membranes through regular oral hygiene promotes taste sensation. The taste sensation is not improved by mixing foods together
The client is responsive but confused and frequently pulls on the urinary catheter. The nurse observes obvious hematuria in the drainage bag and notes the presence of several blood clots in the tubing. How should the nurse document this situation?
ANSWER = CLIENT IS CONFUSED AND PULLS ON THE FOLEY CATH. URINE IS PINKISH-RED W/BLOOD CLOTS. RATIONALE = This recording is concise but complete, providing objective data that describes the current situation.
To promote sleep for a hospitalized client, which intervention should the nurse implement?
ANSWER = CLOSE THE DOOR TO THE CLIENT'S ROOM WHENEVER POSSIBILE TO DECREASE THE NOISE LEVEL AND LIGHT COMING INTO THE ROOM RATIONALE = Reducing the amount of light and the noise of call lights, hallway traffic, and overhead paging are important nursing interventions to facilitate sleep for a hospitalized client. EXTRA RATIONALE: The hospital is an unfamiliar environment for the client. Therefore, a small nightlight or bathroom light should be used to prevent falls during the night. Comfort is still a priority in the client's plan of care, and pain medication should not be withheld even if daytime sleeping or napping is increased The client with a sleep disorder must still be assessed and monitored during the night.
A wound culture indicates that the client's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?
ANSWER = CONTACT PRECAUTIONS RATIONALE = The client should be cared for using contact precautions when there is potential for wound drainage and debris to splatter during care. The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces. EXTRA RATIONALES: DROPLET: used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. AIRBORNE: used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods of time. STANDARD: used for ALL patients when contact with potentially infectious bodily materials is possible.
After learning to self-administer eye drops, the client is preparing to go home. The nurse has identified that the client is at risk for injury because of his visual and auditory sensory deficits. Which action should the nurse implement?
ANSWER = Consult with the case manager to help the client assess his home for safety hazards. RATIONALE =The nurse can provide a home safety checklist as a reference to ensure that the client's home is safe for a person with sensory deficits.
In identifying this problem, the nurse clusters the subjective and objective assessment data and compares them with which information?
ANSWER = DEFINING CHARACTERISTICS OF THE PROBLEM RATIONALE = The assessment data are compared with the defining characteristics of the problem to ENSURE THE CORRECT PROBLEM IS IDENTIFIED. EXTRA RATIONALES: MED DIAGNOSIS:The medical diagnosis may support the selected problem, but it is NOT USED TO IDENTIFY THE PROBLEM. It is outside the scope of practice for a nurse to determine a medical diagnosis.
Since the client now voids spontaneously without recognizing the need to void, how should the nurse document the client's current urinary pattern in the medical chart?
ANSWER = INCONTINENCE involuntary loss of urine. ANSWER RATION = In the case of this client, it may be the result of neurologic impairment secondary to the stroke EXTRA RATIONALES: POLYURIA = voiding large amounts of urine RETENTION = inability to empty the bladder completely OLIGURIA = decreased urinary output
The student obtains a 16 French Foley catheter from the supply room. The student nurse explains the procedure to the client, who gives permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches. While inflating the balloon, the client cries out in obvious pain. What action should the student nurse take?
ANSWER = DEFLATE THE BALLOON AND INSERT THE CATH FARTHER RATIONALE = The catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student nurse has maintained aseptic technique, the balloon can be deflated and the catheter inserted farther. Typically, the catheter should be inserted 7 to 9 inches to ensure proper placement in the adult male. EXTRA RATIONALE: REASSURE PT PAIN IS TEMP:Inserting a urinary catheter may cause some discomfort, but not pain. Corrective action is needed. TAPE THE CATH TO ABD TO PREVENT MVMT: the pt pain isnt the result of cath mvmt REMOVE THE CATH FROM URETHRA IMMEDIATELY: There is something else that the student nurse can try first, before removing the catheter.
The client voids after the catheter is removed and is discharged from the acute care facility and transferred to the long-term care facility. Since the client no longer has an IV, the prescription for the antibiotic is changed to an oral medication. The client has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help the client swallow the medication. Before deciding to open the capsule and mix it with food, what will the nurse need to determine?
ANSWER = DETERMINE IF THE MEDICATION IS AN EXTENDED RELEASE FORM RATIONALE = An extended-release medication is formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action. EXTRA RATIONALES: capsule is not scored dysphagia is a current problem, the client's ability to swallow capsules before the stroke is not pertinent. Individual, or unit dose, packaging is not information that is needed to determine if a capsule can be opened and mixed with food.
As the interview continues, the nurse notes that the client is very pleasant and nods his head in agreement with all of the nurse's statements, but does not respond to simple requests during the assessment. Which nursing problem is best supported by the data available?
ANSWER = DISTURBED SENSORY ALTERATION (AUDITORY) RATIONALE = Clients with impaired hearing often SMILE AND NOD IN AGREEMENT with the person conversing even though they are UNABLE TO CLEARLY HEAR the conversation. Appearing to be inattentive, speaking loudly, and difficulty following directions are other indications of a disturbance in auditory sensory function.
The client's surgery is completed without complications. After a 2-hour stay in the postanesthesia unit, he returns to his room. The next day, the nurse observes the following vital signs: The client's heart rate drops from 80 bpm to 65 bpm while alseep. Oxygen saturation remains greater than 95% with regular respirations of 16 to 20 per minute. Which action should the nurse implement?
ANSWER = DOCUMENT THIS EXPECTED FINDING RATIONALE = A decrease of up to 20 bpm during NREM sleep is considered a normal finding and a part of the body's circadian rhythm. EXTRA RATIONALES: finding does not warrant contacting the HCP unless the client does not tolerate the decrease. finding does not necessitate use of a cardiac monitor Increasing the frequency of vital sign monitoring is not needed unless the client does not tolerate the decrease in heart rate
After reviewing the client's diagnostic test results, the nurse consults with the HCP and receives a prescription for a new antibiotic. Since the client's creatinine level is elevated, the nurse is concerned about which problem in administering the medication?
ANSWER = DRUG TOXICITY DUE TO REDUCED DRUG EXCRETION RATIONALE = An elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time, which may RESULT IN DRUG TOXICITY
The nurse encourages the client to select which breakfast items to provide a good source of protein?
ANSWER = EGGS AND ORANGE JUICE RATIONALE = Eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice, are a good source of vitamin C, which is also important for wound healing.
The RN encourages the student nurse to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. What action should the nurse take?
ANSWER = ENCOURAGE STUDENT TO CONTINUE MAINTAINING ASCEPTIC TECHNIQUE RATIONALE = The student nurse is performing the procedure correctly. Irrigation may also be performed by opening the connection between the catheter and the drainage tubing, but opening that connection increases the risk of contamination. EXTRA RATIONALES: The student should avoid instilling air into the bladder. There is no need to keep the distal clamp in place before proceeding with irrigation. The distal clamp should be released after the normal saline is instilled so that the catheter can drain. Emptying the drainage bag before instilling the solution is not a necessary step in this procedure.
Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take?
ANSWER = ENCOURAGE THEM TO CONTINUE TO USE THIS DEVICE IN THEIR WHEELCHAIR AT ALL TIMES RATIONALE = These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently. EXTRA RATIONALES: Donut-shaped cushions are no longer recommended, because they are likely to reduce blood supply to the area, worsening the ischemia. ADVISE TO AVOID ANY FORM OF PRESSURE CUSSION: will increase the risk of tissue destruction.
The nurse identifies that the client has developed a Stage 1 pressure injury and is concerned that the client may have other pressure injuries Which areas are most important for the nurse to observe for additional pressure injuries (PI)?
ANSWER = ISCHIAL TUBEROSITIES RATIONALE = PI typically occur over bony prominences, such as the heels, ankles, ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial tuberosities at greater risk for breakdown. While bony prominences are the most common sites for PI development, the nurse should perform a complete skin assessment. EXTRA RATIONALES: DISTAL TIPS OF TOES:Ulcers occur on the tips of the toes when there is diminished arterial circulation. That is not the client's primary problem. LOWER ABD FOLDS:This is not an area where PI typically occur. More typical skin breakdown here is escoriation. THIGHS/CALVES: PI don't occur here
The client's hematuria continues. Two hours later, the client becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last 2 hours. Which assessment should the nurse complete first?
ANSWER = EVALUATE THE URINARY DRAINAGE TUBING RATIONALE = The client has had no urine output in 2 hrs/ has blood clots in urine/in obvious discomfort. FIRST consider the cath tubing is obstructed ASSESS for kinks or pressure on the tubing that might cause an obstruction. The nurse should also note the presence of any observable blood clots, which can also obstruct urine flow. This simple, noninvasive measure could easily identify and immediately resolve the client's discomfort. EXTRA RATIONALES: MEASURE THE O2 SAT: O2 Sat measure will provide useful info IF the client's restlessness/ lack of urine output are RELATED TO HYPOVOLEMIC SHOCK considering the available data, ANOTHER ASSESS more relevant to the client's IMMEDIATE SITUATION & should be performed first. OBTAIN BP: Vital sign measure will provide useful info IF the client's restlessness/lack of urine output are RELATED TO HYPOVOLEMIC SHOCK considering the available data, another assessment is more relevant to the client's immediate situation and should be performed first. PALPATE FOR BLADDER DISTENTION: This action should be completed, but it is NOT BEST ACTION TO TAKE FIRST
At 0300 the client awakes and requests a sleeping pill, stating he needs to make sure to get some sleep the night before surgery. His prescriptions include zolpidem tartrate 5 mg PO at bedtime PRN for sleep. His last respiratory rate while sleeping was 12 with an oxygen saturation level of 89%. Current vital signs are P 80 beats/min, BP 120/70 mmHg, R 22 breaths/min, T 98.9° F, and oxygen saturation 95%. How should the nurse proceed?
ANSWER = EXPLAIN THE O2 SAT LEVEL IS TOO LOW AND THAT IT WOULDN'T BE SAFE RATIONALE = The client's saturation level is too low in order to tolerate the hypnotic drug, which will likely drop the oxygen saturation level further. EXTRA RATIONALES: ADMIN 1/2 OF THE DOSE:It is not safe to administer a dose other than what has been prescribed. ADMIN O2 VIA FACEMASK:client has obstructive sleep apnea. Administering oxygen will not reverse the low oxygen saturation level. ADMIN PRN MED:client's oxygen saturation while sleeping is too low to administer the zolpidem
The client demonstrates the eye drop procedure by holding the outer canthus up and back, inserting the drops without touching the eye with the dropper, and applying light pressure over the inner canthus. Which action should the nurse take?
ANSWER = Educate the client by demonstrating to pull the conjunctival sac down while administering the medication.
The client refuses to wear the CPAP mask while hospitalized. The night before their surgical procedure, the pulse oximeter alarms. The nurse enters the client's room and observes that the client is sleeping and that his oxygen saturation has decreased to 84%. Which priority action should the nurse implement?
ANSWER = GENTLY SHAKE THE CLIENT TO AWAKEN HIM RATIONALE = Although the nurse wants to promote sleep, the client must be awakened to relieve the obstruction and increase oxygen saturation. EXTRA RATIONALE: This client's type of apnea is obstructive. Placing the client on oxygen will do little to increase oxygen saturation. Although this is an expected finding due to the client's obstructive sleep apnea, the nurse must take action to increase the oxygen saturation before documenting. REQ HCP TO REEVAL:This is not necessary because the nurse can take action to increase the oxygen saturation.
The nurse recognizes that the client is fearful and angry. How should the nurse demonstrate a caring response to the client?
ANSWER = GIVE FULL ATTENTION TO WHAT THE CLIENT IS SAYING RATIONALE =Active listening includes giving full attention to what the client is saying and provides a caring presence.
The nurse notes that the medication dosage is in the safe range for older clients, which is to be administered by IV every 12 hours. The nurse recognizes that the frequency of drug administration is based on which characteristic of the medication?
ANSWER = HALF LIFE RATIONALE = Half-life describes the LENGTH OF TIME required to REDUCE a drug level to 1/2 of its initial value. Drugs with SHORTER half-lives will have to be GIVEN MORE FREQ those with longer half-lives. EXTRA RATIONALES: BIOAVAILABILITY:the rate and extent to which a drug enters the systemic circulation. PROTEIN BINDING:the reversible (binding and release can occur in milliseconds) interaction of drugs with proteins in plasma. THERAPEUTIC INDEX:the ratio of a drug dose that produces an undesired effect to the dose that causes the desired effects.
The client apologizes to the nurse and expresses how discouraged they are about the bed sore and the infection. Which nursing response best promotes effective communication?
ANSWER = HELP THE CLIENT IDENTIFY THE CONCERNS HE IS TRYING TO COPE WITH AT THIS TIME RATIONALE = This response acknowledges the client's experience and encourages further insight and verbalization by the client.
The home care nurse observes that the client's PI is red, with obvious granulation tissue filling in the wound crater
ANSWER = HYDROCOLLOID DRESSINGS SHOULD BE CONTINUED OVER THE ULCER RATIONALE = The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid dressing. EXTRA RATIONALES: ANOTHER ROUND OF ANTIBIO THERAPY: no evidence of further infection DEBRIDE PRESSUE ULCE RESTART: debridement will destroy granulation tissue PRESSUE ULCER KEPT OPEN TO AIR: doesnt promote safe healing of the wound.
During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy What action should the nurse implement?
ANSWER = IDENTIFY THESE AREAS AS SITES WHERE PRESSURE DMG HAS OCCURRED RATIONALE = Palpable changes in the consistency of the tissue underlying a bony prominence, often described as "spongy," is an indication that pressure damage has occurred. Additional manifestations may INCLUDE change in skin temperature and induration. EXTRA RATIONALES: Heat may be damaging to the tissues with impaired perfusion Excess fluid, if present, is most likely related to a different problem This finding is significant and is related to pressure damage; therefore, this would be false reassurance.
The PN and RN team leader identify a priority problem for the client's plan of care as "impaired skin integrity. Which etiology identified by the nurse is accurate?
ANSWER = IMPAIRED PHYSICAL MOBILITY RATIONALE = the client is paraplegic, they have impaired physical mobility, a major factor that contributes to PI development.
The client reports that his son sleeps sometimes until noon in the summer. He often stays up very late at night. Which response by the nurse is accurate?
ANSWER = MANY ADOLESCENTS START DEVELOPING THIS TYPE OF PATTERN AS THEY DEVELOP INDEPENDENCE RATIONALE = This is particularly common during the summer months, if there are no school obligations to make them rise earlier.
The nurse is unable to resolve the catheter obstruction using noninvasive measures and notifies the healthcare provider (HCP), who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow.The nurse anticipates that the prescription will include the use of which sterile solution to irrigate the catheter?
ANSWER = NORMAL SALINE RATIONALE = An isotonic saline is a sterile normal solution that can be used for bladder irrigation EXTRA RATIONALES: HYDROGEN PEROXIDE: may be diluted and used as an external cleansing agent, but it is NOT USED for urinary catheter irrigation HEPARIN: is an anticoagulant, which would likely INCREASE the client's BLEEDING problem. CLORHEXIDINE ANTIMICROBIAL SOLUTION:This effective antimicrobial solution is used EXTERNALLY to CLEANSE the SKIN, but it is NOT USED for urinary catheter irrigation.
The client's confusion decreases, and 12 hours later the nurse is able to remove the wrist restraints. By the third postoperative day, no further hematuria or blood clots are observed in the urine. However, the nurse does observe that the urine has developed a cloudy appearance. Which action should the nurse implement?
ANSWER = OBTAIN A STERILE URINE SPECIMEN RATIONALE = Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect an infection and identify microorganisms. EXTRA RATIONALES: DONT REMOVE Foley catheter UNLESS prescribed by the doctor. There is also no urgent or emergent indication for removing the catheter CONTINUE CATH IRRIGATION:If the catheter is draining well and there is no further hematuria, this action is not indicated. PALPATE BLADDER FOR DISTENTION: no indication of further urinary retention
No evidence of drug toxicity is found. The client's next BP is within normal limits, and experiences no further episodes of diarrhea. The wound eschar has been removed (debrided), and there is no further drainage. A hydrocolloid dressing is placed over the wound, and the client is discharged. The client will complete the 2-week antibiotic treatment at home. The home care nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure injuries as well as preventative measures, with the client, and when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals. What initial action should the nurse take?
ANSWER = OFFER THE CLIENT THE OPPORTUNITY TO DISCUSS THEIR FEELINGS OF ANGER RATIONALE = Using therapeutic communication techniques, the nurse can provide the opportunity for the client to deal with his concerns.
The nurse consults with the pharmacist, who determines that the capsule can be opened and mixed with a food that the client likes. Which technique should the nurse use?
ANSWER = OPEN THE CAPSULE AND MIX WITH PUDDING RATIONALE = Opening the capsule allows the client to receive the medication enclosed. Pudding is a safe consistency for most clients with dysphagia, who typically have more difficulty swallowing liquids than semi-soft foods. EXTRA RATIONALES: client with dysphagia typically has difficulty swallowing liquids. Crushing the capsule will leave large pieces of the capsule's outer coating, which would be difficult to swallow.
The client has been receiving antibiotic therapy for several days. The client has a mild elevation in blood pressure and a 2 × 2 cm bruise in the antecubital space, where blood was obtained earlier that day and has had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use. Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity?
ANSWER = PEAK AND TROUGH RATIONALE = Serum drug levels are obtained at the highest (peak) and lowest (trough) levels, provides info regarding the amount of drug the individual client has in the bloodstream. If the trough is greater than the acceptable limit for the drug, the next dose should be withheld and the blood level rechecked 6 hours later. EXTRA RATIONALES: CULTURE/SENSITIVITY: determine what microorganism is present and which antibiotic will be effective. This test should be performed prior to the initiation of antibiotic therapy. THERAPEUTIC INDEX: calculated value that identifies the range between the therapeutic level and the toxic level of a medication. It is a useful reference for the nurse to identify which medications are likely to lead to toxicity, but it is not a diagnostic test performed for an individual client. HALF LIFE: information related to medication dosing, but it is not a diagnostic test performed for an individual client.
Before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?
ANSWER = PHARMACIST RATIONALE = Incorrectly labeled medications are the responsibility of the pharmacist. EXTRA RATIONALES: HCP does not have responsibility for the resolution of this problem. charge nurse can provide the nurse with guidance, but this person is not the professional with responsibility for medication labeling.
The client is referred to vision and hearing specialists for more in-depth evaluation and treatment. A medical diagnosis of cataracts is identified as the cause of the client's visual deficit. Noise-induced hearing loss and changes related to aging are identified as the causes of the client's auditory deficit. The client is scheduled for eye surgery in three weeks. The nurse teaches the client about the administration of the eye drops he will need to use. The healthcare provider (HCP) prescribes 2 gtts in right eye twice a day. Which direction should the nurse provide the client?
ANSWER = PLACE 2 DROPS IN THE RIGHT EYE E VERY 12 HOURS
The nurse correctly uses which technique when pouring the suspension?
ANSWER = PLACE THE MEDICATION CUP ON A FLAT SURFACE AT EYE LEVEL RATIONALE = To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.
The nurse monitors lab values and assesses for adverse effects during the course of the client's treatment with linezolid. During the course of antibiotic treatment with linezolid, which of the client's serum laboratory values requires intervention by the nurse?
ANSWER = PLATELET COUNT (100 x 10^3/mcL (100 X 10^9/L) RATIONALE = This medication has been shown to decrease platelet count (thrombocytopenia). Normal platelet count is 130-400 x 103/mcL (130-400 X 109 /L). EXTRA RATIONALES: This medication does not affect magnesium level. Normal is 1.82 - 2.31 mg/dL (0.75-0.95 mmol/L). This medication may increase BUN, not creatinine. Normal creatinine is 0.84 to 1.21 mg/dL (64.05 - 92.26 mcmol/L). This medication does not affect potassium. Normal is 3.5 - 5.0 mEq/L (3.5-5.0 mmol/L).
The nurse reviews factors that may impact catheter insertion with the student nurse. Which physiologic change that commonly occurs in adult males may affect insertion of the catheter?
ANSWER = PROSTATE GLAND ENLARGEMENT RATIONALE = The prostate gland often begins to enlarge after a male client reaches the age of 40, making urethral catheterization more difficult if the gland compresses the urethra. EXTRA RATIONALES: Urethral stricture, or narrowing, does not occur as the result of the aging process. Stricture can be caused by TRAUMA due to catheterization or as the result of SEXUALLY infections. Diminished bladder capacity often occurs due to aging, but it DOES NOT affect catheter insertion. A weakened detrusor muscle may result in incomplete bladder emptying, but it DOES NOT affect catheter insertion.
Urinalysis results are as follows: pH 8.5 Specific gravity 1.015 Protein 0 g/day Glucose 0 mmol/L WBC 8/hpf RBC 2/hpf Based on the urinalysis results, the HCP prescribes a broad-spectrum antibiotic. After 24 hours of receiving the antibiotic, the client's condition has not improved. What additional nursing intervention should the nurse implement?
ANSWER = PROVIDE A GLASS OF CRANBERRY JUICE DAILY RATIONALE = The pH of the client's urine is elevated, indicating alkaline urine. Cranberry juice is believed to increase the acidity of urine, providing a less desirable environment for bacterial growth. EXTRA RATIONALES: ENCOURAGE THE INTAKE OF HIGH PROTEIN FOOD: The lack of protein in the client's urine is normal OFFER ADD HIGH CARBOHYDRATE SNACKS = The lack of glucose in the client's urine is normal REDUCE PT WATER INTAKE:The specific gravity of the client's urine is normal, with no indication of excessive water intake or altered fluid balance
A month later, the client arrives in the emergency department at the local hospital and reports having had the flu and has spent most of their time in bed for the last several days. The client has been experiencing vomiting and diarrhea. The nurse observes that the sacral PI is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. The client is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. How should the nurse describe the drainage in documenting the wound?
ANSWER = PURULENT RATIONALE = refers to something that contains or produces pus. Pus is an indication that an infection is likely. EXTRA RATIONALES: SEROUS = a thin, watery substance. SANGUINEOUS = a bright red substance.
The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document?
ANSWER = REACTIVE HYPEREMIA RATIONALE = occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch EXTRA RATIONALES: UNUSUAL SKIN MOTTLING: irregular or patchy discoloration of the skin. DEPENDENT SACRAL RUBOR: redness that occurs when an area is lower than the heart. It is most commonly seen in the legs.
To help manage the client's incontinence, the nurse initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for the client?
ANSWER = REMIND THE PT TO VOID EVERY 2 HOURS WHILE AWAKE AND TO CALL FOR ASSISTANCE TO THE BATHROOM RATIONALE = A toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every 2 hours in the daytime and every 4 hours at night and then be adapted to the individual needs. The call bell should be near the client so that he can ring the bell for assistance to prevent the risk of falling. EXTRA RATIONALES: the client should try to drink 1,200 to 2,000 mL of fluid daily to maintain optimal renal function and prevent problems such as urinary tract infections. Drinks containing caffeine, such as coffee, cocoa, and tea have a diuretic effect, increasing episodes of incontinence. Socialization is important for the client and should not be restricted because of incontinence
The client's visual acuity is measured using a Snellen chart. The reading obtained is 20/200 in the right eye and 20/80 in the left eye. How should the nurse explain these findings to the client?
ANSWER = RESULTS REFLECT NEARSIGHTEDNESS (MYOPIA) ESP IN THE RIGHT EYE RATIONALE = The larger the denominator (bottom number), the poorer the visual acuity. This is commonly referred to as being near-sighted. Standing at 20 feet, the client can read what the person with normal vision can read at further distances, such as 80 feet (left eye) or 200 feet (right eye). Nearsightedness (myopia) occurs when the eye overbends the light and images converge in front of the retina where near vision is normal, but distance vision is poor. EXTRA RATIONALES: FAR SIGHTEDNESS ESP IN LFT EYE:Far-sightedness (presbyopia) is characterized by a loss of lens elasticity and the ability of the eye to accommodate. The near point of vision increases, and near objects must be placed farther from the eye to be seen clearly. Macular degeneration is when central vision declines, and clients will describe it as mild blurring and distortion at first. There is no evidence to indicate an issue with the cornea.
It is most important to include this group in which aspect of the client's overall care?
ANSWER = REVIEWING CLASS NOTES AND STUDYING FOR EXAMS RATIONALE = The young adult is developmentally involved in establishing intimacy and working toward future goals. In addition, studying with his peers will help maintain a sense of normalcy for the client. Other tasks can easily be performed by other groups, such as family members. This task can best be performed by his peers.
The client reports to the nurse that he feels the home is free of hazards. The client states that he has some decorative throw rugs on top of hardwood floors, but they can't slide because there is padding underneath them that prevents sliding. When teaching the client about home safety, which instruction is most important for the nurse to include?
ANSWER = Removal of the rugs prevents accidental tripping and falling. RATIONALE = The client with a visual deficit may trip on loose edges, cords, wet spots, or unexpected items left on the floor. Explaining the rationale for desired actions, such as the removal of throw rugs, increases client compliance.
Realizing that indwelling urinary catheters increase the risk of developing a urinary tract infection, which intervention should the nurse implement?
ANSWER = SECURE THE CATH BAG TO THE BED FRAME WHEN THE CLIENT IS REPOSITIONED ON HIS SIDE RATIONALE = Securing the catheter to the bed frame will keep the urine draining with gravity and will avoid backflow. It is also safer to connect to a part of the bed that is not adjustable. EXTRA RATIONALES: Clamping the catheter will not prevent urine from above the clamp from backflowing. Catheter care will not decrease the risk of infection related to urine backflow. Catheter bag should be empty when 2/3 full NOT AT THE FULL MARK to prevent urine from backing up into bladder.
The client's indwelling catheter is removed by the nurse on the morning of the client's anticipated discharge. Which assessment finding warrants intervention by the nurse?
ANSWER = THE CLIENT HAS NOT VOIDED IN 8 HOURS AFTER CATH REMOVED RATIONALE = report if the client is unable to void within 6 to 8 hours after catheter removal, has sensation of not emptying, strains to void, or experiences small voiding amounts with increasing frequency. EXTRA RATIONALES: Burning may be a normal finding due to tissue sensitivity related to insertion. Should be monitored but not urgent matter. Often urine comes out as catheter is removed. sensation of a need to void is common with the removal of the catheter.
During the catheter irrigation, the nurse observes that the client is still confused and attempts to pull at the urinary catheter, IV, and nasal cannula. The nurse considers the use of wrist restraints on the basis of which rationale?
ANSWER = THE CLIENT IS AT RISK FOR SELF INJURY RATIONALE = Risk of self-injury is a reasonable rationale for the use of physical restraints. However, all other safety measures should be attempted before physically restraining a client. EXTRA RATIONALES: Confusion alone is not sufficient reason for the use of physical restraints. Postoperative status is not a sufficient reason for the use of physical restraints and there is no evidence that the client is at risk for falling at this time. Lack of family presence is not sufficient reason for the use of physical restraints
Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group?
ANSWER = THE CLIENT'S GF AND 2 BEST FRIENDS FROM COLLEGE RATIONALE = As a young adult, the clients primary developmental task, according to the theorist Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support this developmental task.
A polysomnogram (sleep study) reveals more than 200 episodes of sleep apnea during the night. A pulse oximeter is used during the testing, and the client's oxygen saturation level drops to 82% periodically. The client is diagnosed with obstructive sleep apnea (OSA) and is prescribed a nasal continuous positive airway pressure (CPAP) device to be used at night. Which is the best explanation by the nurse for educating the client about OSA?
ANSWER = THERE IS A LACK OF AIRFLOW THROUGH THE NOSE/MOUTH FOR PERIODS OF 10 SEC OR LONGER DURING SLEEP RATIONALE = This describes obstructive sleep apnea. Efforts by the brain and respiratory muscles continue, but airflow is obstructed. EXTRA RATIONALES: NARCOLEPSY: dysfunction of mechanisms that regulate the sleep and wake states, causing excessive sleepiness during the day. CENTRAL SLEEP APNEA: The airway remains open, but the brain fails to send messages to the diaphragm and chest muscles to initiate respirations. INSOMNIA: syndrome characterized by chronic difficulty falling asleep with frequent awakenings at night.
To provide pressure relief at night, the nurse teaches the client to sleep in which position?
ANSWER = THIRTY DEGREE LATERAL INCLINED POSITION RATIONALE = This position best reduces pressure on bony prominences where PI frequently develop. Pillows and foam wedges may be used for support and protection in this position. EXTRA RATIONALES: SUPINE W/HEAD OF BED ELEVATED: Elevating the head of the bed increases the potential for shearing forces to worsen skin integrity. SUPINE W/A FOAM WEDGE BETWEEN THE KNEES: While a wedge reduces the contact between the knees, lying supine leaves direct pressure on the sacral area and on the heels. FULL SIDE LYING POSITION SUPPORTED W/PILLOWS: A full side-lying position results in prolonged pressure on the trochanter, another bony prominence where PI frequently develop.
The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI?
ANSWER = TRANSPARENT FILM DRESSING RATIONALE = This type of dressing allows for visualization of the area and protects it from shear. EXTRA RATIONALES: ADHERENT = used to facilitate softening of eschar. The client's PI is a stage 1 and thus has no eschar. GAUZE = used in combination with sodium chloride 0.9% or other prescribed medications when treating the more advanced stages of PI. HYDROGEL COVERED WITH A FOAM DRESSING = used with stage lll or lV PI to protect the area and absorb moisture.
To encourage voiding, the nurse instructs the UAP to perform which intervention?
ANSWER = TURN ON THE TAP SO WATER IS RUNNING WHEN THE CLIENT ATTEMPTS TO VOID RATIONALE = Running water often stimulates the urge to void, as does placing the client's hands in WARM WATER EXTRA RATIONALES: This semiprone, side-lying position is not useful to stimulate voiding. Lateral recumbent position is used when a nurse is administering an enema or suppository to a client. APPLY FIRM PRESSURE TO BLADDER:may be painful to the client, and it is unlikely to stimulate the urge to void.
Which diagnostic test result would make the nurse concerned that the client is at risk for sepsis?
ANSWER = URINE CULTURE SHOWS RESISTANCE TO THE PRESCRIBED ANTIBIOTIC RATIONALE = If the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic, the antibiotic is ineffective, and the client is at risk for sepsis, or generalized infection. EXTRA RATIONALE: SERUM CREATININE/BUN ELEVATE: Creatinine relates to renal function, and BUN relates to renal function or hydration status. PARTIAL THROMBOPLASTIN TIME (PTT) IS EXCESS PROLONGED: indicates a bleeding problem may have contributed to client's earlier hematuria. CBC SHOWS LOW H/H LVL: relate to previous hematuria that the client experienced, but DOES NOT substantially INCREASE the client's RISK for SEPSIS
The client seems nervous and asks for a glass of water. After taking a drink, the client attempts to set the glass down, but places the glass on the edge of the counter, causing it to crash to the floor. To follow up on this situation, which assessment would provide the most useful data?
ANSWER = VISUAL FIELD AND DEPTH PERCEPTION RATIONALE = Under- or over-reaching for objects is an indication of a visual deficit. Assessment of visual field and depth perception will provide the most useful data related to this situation.
The nurse notifies the healthcare provider of the elevation in WBCs and receives a prescription for an oral antibiotic. The client is to receive the first dose prior to discharge. Upon entering the client's room with the medication, the nurse observes the client is asleep. The spouse asks the nurse to leave the medication at the bedside for self-administration when he awakens. Which is the most important action for the nurse to implement?
ANSWER = WAKE THE PT AND ADMIN THE FIRST DOSE OF ANTIBIOTIC RATIONALE: Although the client may need sleep, his need for the antibiotic is greater.
The client is admitted to the acute care facility for minor surgery. Preoperative prescriptions include the insertion of an indwelling urinary catheter. A student nurse is assigned to care for the client. The nursing instructor asks the student nurse to prepare to insert the indwelling catheter under supervision. What is the first step in the proper placement of an indwelling urinary catheter for a male client?
ANSWER = WASH PERINEAL WITH SOAP AND WATER RATIONALE = student nurse should first wash the entire perineal area with soap and water before applying antiseptic or lubricant. EXTRA RATIONALES: ASSEMBLE THE CATH, LUBRICANT, DRAINAGE RECEPTACLE: This is done after the student nurse washes his or her hands, and washes the perineal area. GENTLY INSERT & ADVANCE THE CATH:Before the catheter is inserted, ask the client to try to void. If the catheter is difficult to insert, it may be because of an enlarged prostate. A smaller catheter or a urology consultation may be necessary in this case. ADVANCE THE CATH ONE MORE INCH (2.5 CM): This occurs after the urine starts to flow.
Following an episode of incontinence, the nurse washes the client's perineal area with mild soap and water and applies a water-repellent ointment to the skin. The client's spouse is present and the nurse uses this opportunity to educate them about proper skin care to prevent breakdown. Which statement by the client's spouse indicates that teaching provided was effective?
ANSWER = WASH THE AREA W/MILD SOAP AND WATER FOLLOWED BY OINTMENT RATIONALE = Mild soap and warm water should be used to cleanse the skin followed by a protective ointment. These water-repellent ointments help protect the skin from the acidic effects of urine. EXTRA RATIONALES: Mild, pH-balanced soap is beneficial in cleansing the skin. Harsh soaps should be avoided because they can cause excessive drying and leave an alkaline residue on the skin. Lotions and ointments provide moisture and protection to irritated skin. Massaging reddened areas causes damage to the capillary beds, increasing the risk for skin breakdown.
While reviewing discharge paperwork with the client, he states, "I really need to get back to work. All of this has caused a great strain on my job." How should the nurse respond to the client's statement?
ANSWER = YOU SEEMED CONCERNED ABOUT MISSING WORK AND THE PRESSURES OF YOUR JOB RATIONALE = nurse is therapeutically restating the client's feelings, which is likely to encourage the client to continue the conversation.
The client reports that a few years ago he took temazepam for sleep and it worked for a while. He asks if he can have a new prescription. Which response by the nurse is most appropriate?
ANSWER = YOU SHOULD BE RE-EVALUATED BY A HCP BEFORE RESUMING THIS MEDICATION RATIONALE = The client should always be reevaluated before resuming any medication. A new prescription needs to be filled if indicated. Continued evaluation is also needed if temazepam is used for more than 2 weeks or in high doses, both of which put the client at risk for tolerance and/or physical dependence.
The nurse obtains a health history that reveals the client is worried about the pressures of a growing family and a new job. The client has been unable to maintain his normal exercise routine and has gained 15 lbs. (6.8 kg) in the last 6 months. The client admits he frequently smokes when he cannot sleep. His spouse, who has accompanied on the visit to the clinic, states that her husband's snoring has worsened in both frequency and noise level over the last 3 months. The client has even resorted to taking one of his spouse's diazepam tablets before bedtime. How does the nurse respond to the client's disclosure that he used his spouse's diazepam tablets to help him sleep?
ANSWER = YOU SHOULD NOT TAKE SOMEONE ELSE'S PRESCRIPTION RATIONALE = This response directly addresses the issue without being condemning. It can be dangerous for clients to take someone else's prescription, due to the risk of contraindications or drug interactions.
After several weeks, the bladder training program is unsuccessful in stopping the client's incontinence. The client appears withdrawn and states that they are frustrated at the number of episodes that continue to occur. Which interventions should the nurse include in the client's plan of care? SATA
ANSWER: 1.) REPORT SIGNS OF INSOMNIA DUE TO ANXIETY 2.) DISCUSS POSSIBLE COPING STRATEGIES RATIONALES: 1.) Reports of fatigue, lack of sleep, and anxiety are signs of inability to cope 2.) .Coping skills are needed to deal with stressors that threaten physical and mental well-being. EXTRA RATIONALES: The client is already withdrawn and needs encouragement. Sitters do not address the underlying issue of inability to cope The client is withdrawn and should not be ignored.
