Management of Care

The nurse is caring for a client with pancreatitis. What assessment finding would the nurse expect?

lower abdominal pain

Which activities would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

obtaining a client's routine glucose reading using a glucometer

The nurse has just received the change of shift report on the clients on the labor, birth, recovery, and postpartum unit. Which of these clients should the nurse assess first?

a 26-year-old multigravid client, in labor for 8 hours, with cervical dilation at 8 cm, 1+ station, contractions every 3 to 4 minutes, and receiving no anesthesia

The emergency room nurse is providing care to a client who admits to being a victim of domestic violence. Which statement by the client indicates to the nurse that the client will accept safe shelter living? Select all that apply.

"A social worker can help me set up a place to stay." "I would like to get a restraining order from my partner." The two client statements, "A social worker can help me set up a place to stay" and "I would like to get a restraining order from my partner," indicate that the client is ready to change living conditions. If the client tells the partner the client is not coming home or accepts a house from the family then the client is not gaining independence. The statement that the client still needs a plan for the children does not indicate that the client is ready for a change in living conditions and independence.

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse?

"I'm grateful that you're satisfied with the care you're recieving, but I can't accept any form of gift."

The nurse is teaching a client about the symptoms of anaphylaxis. Which client statements indicate no further teaching is needed? Select all that apply.

"If I start having difficulty breathing, I need to get help right away." "Peripheral tingling is a symptom of anaphylaxis reaction."

A coworker asks another nurse if a client received their pathology report. The coworker is not directly involved in the care of the client. How should the nurse respond? Select all that apply.

"You need to review the hospital policy related to client privacy." "I'm sorry, but I'm not at liberty to give you that information." "Information can only be shared if you're involved in the client's care."

Which nursing action would be most beneficial to a client and her spouse who state they wish to go through labor without the use of analgesics or anesthetic agents?

Act as an advocate for the couple and verbalize their wishes to nurses and physicians.

A nurse preceptor is reviewing documentation by a new nurse. Which chart entry would require the preceptor to provide instruction about appropriate notation?

Angrily stated, "My doctor is rude." Offered the name of another personal healthcare provider.

A child with a nut allergy presents with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." What should the nurse do first?

Assess the parent's ability to read.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?

Assess the patient for the medications' effects.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first?

Call the health care provider (HCP).

A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that the client's children work and no one has time to assist the client with self-care activities. The nurse should

Contact the nursing supervisor.

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the next action by the nurse?

Contact the surgeon to answer the client's question.

Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

Evaluate the client for voluntary admission to a mental health facility.

A nurse manager in a pediatric intensive care unit notices an increase in healthcare-associated infections. What should the nurse manager do next?

Gather data on possible reasons for this increase.

The nurse is reviewing laboratory values on a client with heart failure. The client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The client is scheduled to receive the 0900 dose of furosemide. What should the nurse do next?

Give the furosemide dose to the client.

The nurse develops the plan of care for a child with early Duchenne's muscular dystrophy. What is the priority goal for this client?

Maintain function of unaffected muscles.

The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first?

Mother: fundus is firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute.

A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first?

Notify the physician.

Three victims with gunshot wounds are brought to the emergency department. The nurse should take which action to preserve forensic evidence on the clients' clothing?

Place each item of clothing in a separate paper bag.

A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option?

Refuse treatment.

The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate?

Remove the clients to separate areas and set limits

Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next?

Remove the infant from the room.

The client and her partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence?

The national standards of practice were met when providing care.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse?

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization.

A nurse manager of the pediatric unit discovers that she is overbudget on supplies. How could each nurse assigned to the unit help with cost containment?

Use care pathways to specify care and identify daily outcomes.

The nurse has received the change-of-shift report on the clients. Who should the nurse assess first?

a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to their back. Which intervention takes priority for this client?

administering morphine I.V. as ordered

A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to:

assess for and maintain adequate nutrition and hydration.

A nurse is counseling a client at a crisis center after the client's house burned down and the client's daughter was killed. Which action by the nurse is a priority?

assisting in psychological resolution of the immediate crisis

A nurse is considering employment at a hospital where nurses belong to a collective bargaining unit. How will the potential employee benefit from the collective bargaining unit? Select all that apply.

negotiation for wages negotiation for improved work environment organization of social activities

A registered nurse on the neonatal unit appropriately uses the chain of command when

notifiing the unit manager of unresolved issues between the nursing unit and housekeeping personnel.

A client who is blind is admitted for treatment of gastroenteritis. Which intervention takes highest priority for this client?

replacing fluid volume

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should:

report this to the nursing supervisor immediately.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. What best protects the client's right to self-determination?

respecting the client's desire to have the uncle make choices on her behalf

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship?

"I'm curious about your question but I want to know how you are feeling today."

The nurse is making assignments for the next shift. Which client can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply.

A client who is receiving glargine subcutaneously A client who needs assistance with colostomy irrigation

Which client is the most appropriate candidate for outpatient care?

A client whose reports of irregular bowel movements have necessitated a colonoscopy.

A client in a long-term care facility has signed a form stating that they do not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?

Notify the physician that the client has no vital signs.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply.

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies.

A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply.

Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation. Explore the possibility of a female nurse being willing to swap clients.

The nurse overhears two nursing assistants saying that they think it is ridiculous that a female client of the Islamic culture insists that only female nurses care for her. What should the nurse do? Select all that apply.

Speak to the nursing assistants about the importance of culturally competent care on the unit. Explain to the nursing assistants that it is wrong in the client's culture for a male to touch a female that is not their wife. Remind the nursing assistants that it is inappropriate to talk about clients in any way that does not involve them providing care.

he nurse can be an important advocate for the client who is considering an alternative method of cancer treatment. Which statement best demonstrates the nurse as client advocate?

allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

standing order

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. What should the nurse manager of the operating room do?

Change the assignment without comment.

The client with benign prostatic hypertrophy is being transferred from the emergency department to a surgery unit. Which information should be included in the report from the nurse in the emergency department to the nurse responsible for admitting the client?

"The client was catheterized, and 1,100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory."

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond?

"You seem worried about this assignment."

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation?

"Your verbal threats to the client are legally considered assault."

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

Administer bronchodilators as prescribed.

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit?

Administer zolpidem 5 mg as needed for sleep.

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today but had to cancel the appointment when the child became ill. Which action should the nurse take?

Arrange for the pump to be refilled in the hospital.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics.

A nurse is caring for a client with bruises on her face and arms. Her partner refuses to leave the client's bedside and answers all of the questions for the client. Which intervention by the nurse would be most appropriate?

Collaborate with the physician to make a referral to social services.

The nurse meets with the family of a 3-year-old child who is seriously ill. What is the most important role of the nurse as collaborator?

Coordinates the multidisciplinary services and provides information about them.

A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next?

Reposition the client and continue to evaluate the tracing.

The nurse assesses a client's outflow is less than the inflow during a peritoneal dialysis exchange. What actions will the nurse use to increase peritoneal dialysis outflow? Select all that apply.

Reposition the client to a side lying. Check the level of the drainage bag. Check the peritoneal dialysis system for kinks.

The nurse provides care to a client with chemical dependency. What are the primary nursing considerations for this client? Select all that apply.

Teach the client to deal with life stressors through coping skills. Support the client's decision to stop substance use. Promote family interaction and involvement in the rehabilitation process.

The nurse is providing cost-effective, evidence-based care health education to a client. Which choices are examples of cost-effective, evidence-based care? Select all that apply.

education on healthy dietary choices education on beginning an exercise regime

The nurse is planning staffing assignments for a group of clients. Which client is most appropriate for the nurse to assign to a nurse who normally works on the maternity unit?

a client who had an open appendectomy yesterday

A nurse documents a fraudulent wound assessment with the intent to increase the client's length of stay. What type of legal action is the nurse at risk for with fraudlent documentation? Select all that apply.

a fine loss of nursing license job termination a jail sentence

The nurse is beginning the shift and is planning care for six clients on the postpartum unit. Three of the clients have immediate needs, and three of the clients are listed as "stable." For the best utilization of time and client safety, the nurse should make rounds on which client first?

a mother who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that they will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must

ensure that health education is begun as early as possible.

A scrub nurse in the operating room has which responsibility?

handing surgical instruments to the surgeon

Which strategy can help make the nurse a more effective teacher?

including the client in the discussion

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention?

monitoring temperature and blood cell count

A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?

on admission to the facility

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to

review the capillary glucose monitoring calibration log book.

Which client will the community health nurse visit first?

the client with type 1 diabetes mellitus with acute visual changes

The emergency department (ED) nurse should assess which client first?

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain

The charge nurse on a pediatric unit is making clientn assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent

After receiving a change-of-shift report at 0700, the nurse should assess which client first?

a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain

The emergency room nurse is caring for a Hispanic client following an anaphylactic reaction to a bee sting. The client needs education on self-administering an EpiPen for future use. Spanish is the client's primary language. Identify the proper steps the nurse needs to follow in order to correctly teach the client to use an EpiPen. All options must be used.

Request a Spanish-speaking interpreter. Have the client take the EpiPen out of the carrying tube. Tell the interpreter to tell the client to remove the outer safety release cap. Demonstrate how to swing and inject firmly into the outer thigh region. Show the client how to press firmly against thigh for 10 seconds and then massage. Reinforce to the client to seek emergency medical attention if stung again.