(HESI PREP) Basic Physical Care
The nurse is caring for a child with a newly diagnosed allergy to latex. List, in order of priority, the nursing interventions for this client. All options must be used.
1. assessment of respiratory effort 2. assessment of heart rate and blood pressure 3. assessment of skin 4. education of the family According to Maslow's hierarchy, physiological needs must be met first and a basic need for oxygenation and perfusion comes first. Oxygenation has a higher priority than perfusion. Skin integrity would be next, and then, knowledge deficit.
In anticipation of discharge, a nurse is teaching the caregiver of an elderly client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?
Demonstrate and explain the procedure and then have the caregiver perform it. All steps of a procedure such as a dressing change should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure or treatment in the presence of the nurse to demonstrate understanding and ability to carry out the procedure. This is more likely to facilitate success than providing a passive multimedia resource, explaining, or providing written instructions alone without reciprocal demonstration.
A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which action would the nurse employ to be a leader?
Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. A leader does not have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager's formal power and authority within the organization are detailed in the job description. An autocrat is not interested in guiding or encouraging staff or in being an effective role model. A manager derives authority by virtue of the position within an organization.
The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?
Measure the client's legs. After receiving orders for graduated compression stockings, the nurse would explain the procedure to the client and then measure the client's legs to determine the appropriate sized stocking. Improperly fitting stockings are uncomfortable and may be harmful to the client. Compression stockings should be placed in the morning, before the client is out of bed for the day to prevent blood vessels from being congested with blood, therefore, the nurse should place the compression stockings prior to having the client use the restroom. The nurse would not want to massage the legs. If a blood clot is present, this may cause the clot to break away from vessel and circulate in the bloodstream. Applying graduated compression stockings may be delegated to unlicensed assistive personnel, but only after the nurse has determined the correct size stocking by measuring the client's legs.
A nurse is caring for an Asian-American client after arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened by physical closeness. What would be the most appropriate nursing action?
Explain the purpose and need for assistance during ambulation. The nurse would explain the purpose of ambulation, and the need for assistance while ambulating, to the client. This would relieve his anxiety associated with physical closeness. However, the client won't be able to ambulate without assistance. Even though the nurse can instruct a family member to ambulate the client, this is not an appropriate action. Ambulating the client without answering the client's question is non-therapeutic, as the nurse would be performing a procedure without giving adequate explanation.
A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 250 mg (10 ml) phenytoin oral suspension to be given via the feeding tube twice daily. How should the nurse give this medication?
Flush the feeding tube with 30 ml water, infuse the liquid, followed by a 30 ml water flush The nurse would infuse this medication through the feeding tube, giving a 30 ml flush of water before and after the medication. Oral suspensions are a liquid form of the medication, and are appropriately formulated to be given via a feeding tube. Giving the medication orally would be a medication error, because it is prescribed to be given through the feeding tube, and the client may be NPO or it could be unsafe for the client to take PO medications. Requesting the dose be given intravenous is not indicated. Not giving the medication would put this client at risk for a seizure, due to the nurse withholding an antiepileptic medication.
A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?
IV catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an IV catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.
A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy?
Monitor the appearance, size, and number of stools. A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, reviewing blood urea nitrogen and serum creatinine levels, and recording intake and output don't indicate the effectiveness of nutritional therapy.
The standards of professional performance within the Nurse Practice Act are numerous. Which are examples of the professional performance of a registered nurse? Select all that apply.
practicing in a safe environment communicating with the physical therapist collaborating with the pharmacist about medication dosing The standards of professional performance in the Nurse Practice Act include the nurse practices in safe environment, communicates to the physical therapist, and collaborates with the pharmacist about medication dosing. The nurse refusing a charge nurse assignment is a break in leading the profession. The nurse notifying the local newspaper about a meningitis outbreak is not an ethical practice.
A nurse manager is auditing the nursing unit's adherence to infection control practices. Which observation causes the nurse manager to be most concerned that the clients on the unit are at risk for infection?
Several nurses fail to perform hand hygiene between clients. Hand hygiene is the single most important infection prevention and control practice. A mask is not necessary for clients on contact precautions, and tape does not have to be cut with sterile scissors. Although administering the antibiotic late is cause for concern, it does not present as big a risk as failure to perform hand hygiene.
The nurse is planning to move a box of dialysis solution in a client's room. Which action should the nurse take to reduce the risk of a back injury?
Stand close to the box. The nurse should work as closely as possible to the object that needs to be lifted or moved. This closeness brings the body's center of gravity close to the object being moved, permitting most of the burden to be on the leg and arm muscles and not the back muscles. Twisting should be avoided because this strains back muscles. The weight of the body, and not the arms, should be used to push the object. This reduces the amount of strain on the arms and back. The direction of the move should be faced when moving an object.
A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately?
The LPN pours the urine into a graduated measuring container. The only means to measure urine output accurately is to use a container that has specific markings for measuring liquid. The other options would not provide an accurate measure of urine output.
The quality assurance nurse is reviewing orders on a client's chart. Which order transcribed by the nurse would require the quality assurance nurse to speak with the nurse manager?
Tom B. Smith 12/28 sertraline hydrochloride 25 mg oral twice Frank Bill, MD The orders by Greg Davis, MD; Missy Smith, APN; and Scott Miller, APN contain all the parts of a medication order: client's name, date, and time the order is written, name of drug to be administered, dosage of the drug, route by which the drug is to be administered, frequency of administration of drug, and the signature of the person writing the order. The order written by Frank Bill, MD is incorrectly written. The frequency and time are missing.
A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?
asking the physician to write an order for home skilled nursing assessments and interventions Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home healthcare. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home healthcare. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.
After suctioning a client, a nurse should expect to find
clear breath sounds. Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.
Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?
completion of range of motion on limbs restrained Any client assessment and subsequent decision making/judgment is in the scope of practice of the nurse. The unlicensed healthcare worker (UHW)/nursing assistant (NA) is able to complete the task of range of motion.
The nurse finds a hospitalized client unconscious with spontaneous breathing sitting in a chair in the unit's visiting room. What initial actions will the nurse implement? Select all that apply.
identify the client call a rapid response team prepare an incident report after client is stable The nurse will need to identify the client, call a rapid response team, and prepare an incident report after client is stable. The client is breathing sitting in chair so the team will change positions with care. The supervisor will be notified through the call of the rapid response team.
A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction?
in a widening circle around the drain, outward from the center When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection.
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action?
wearing of sterile gloves to bathe a neonate at 2 hours of age One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.
A client has left-sided paralysis. The nurse should document this condition as left-sided
hemiplegia. Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.
