Fundamental 1
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? 1. Obtaining cotton balls for the tracheostomy care 2. Obtaining hydrogen peroxide for the tracheostomy care 3. Obtaining sterile gloves for the tracheostomy care 4. Obtaining a sterile brush for the tracheostomy care
Obtaining cotton balls for the tracheostomy care (Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess.) **Half-strength peroxide solution is used to clean the inner cannula. **Tracheostomy care is a sterile procedure requiring the use of sterile gloves. **Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? 1. Tie the restraints to the side rails. 2. Perform range-of-motion exercises to the wrists every 3 hr. 3.Remove the restraints one at a time. 4.Obtain a PRN prescription for the restaints.
Remove the restraints one at a time. (The nurse should remove one restraint at a time for a client who is violent or noncompliant *restraints are removed and range-of-motion exercises are performed every 2 hr. **The nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered. **Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? 1. Offer to call the client's minister. 2. Sit and hold the client's hand. 3. Contact the family and ask them to stay with the client. 4. Leave the room and allow the client to cry privately.
Sit and hold the client's hand. With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? 1. Absent bowel sounds with distention 2. Hyperactive bowel sounds with diarrhea 3. Normal bowel sounds with increased peristalsis 4. Frequent bowel sounds with flatus
Absent bowel sounds with distention Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.
A nurse is receiving a client from the PACU who is postoperative following abdominla surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? 1. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. 2. Instruct the client to raise his arms above his head. 3. Lock the wheels on the bed and stretcher. 4. Log roll the client.
Lock the wheels on the bed and stretcher. (Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. ) **The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. ** the client to cross his arms across his chest **Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.
A nurse is planning care for a client who reported abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? 1. Temperature 2. Soft, nontender abdomen 3. Heart rate 105/min (**This is an important assessment finding because the client's heart rate is elevated. However, fever and pain can contribute to tachycardia. This is not the priority finding.) 4. Overdue menses
Temperature (Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? 1. The nurse witnessed the provider's explanation of the procedure. 2. The client fully understands the provider's explanation of the procedure 3. The signature on the preoperative consent form is the client's. 4. The client has been informed about the risks and benefits of the procedure.
The signature on the preoperative consent form is the client's. (The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.)
A nurse is caring for an older adult who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? 1. "It's for your safety. Dentures can slip and block your airway during surgery." 2. The anesthesiologist requires everyone to remove their dentures." 3. "What worries you about being without your teeth?" 4. "You wouldn't want your teeth to be lost or broken during surgery, would you?"
What worries you about being without your teeth?" (This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.)