Performance by Client Needs

The nurse is assisting a healthcare provider with suturing an arm laceration on a school-age client. What relaxation strategy will the nurse instruct the client to use during this painful procedure?

"Take a deep breath, and blow out until I say to stop." Explanation: Having the child take a deep breath and blow it out is a form of distraction and will help the child cope better with the procedure. A child may prefer to keep the eyes open, not shut, during a procedure to see what is happening and anticipate what will happen next. Letting a child scream into a pillow can interfere with breathing, so it is not safe practice. When preparing a child for a procedure, the nurse should avoid using descriptors that mention or suggest pain. For example, the nurse might say, "Sometimes this feels like pushing or sticking, and sometimes it doesn't bother children at all."

The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best response?

"Your cervix is not fully dilated. Let's keep breathing through the pressure." Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue damage and may impede fetal descent. This feeling is natural at this stage of labor. Giving the client IV pain medication at 8 cm can cause fetal respiratory distress. Although it is true that the client should not push yet, simply stating that fact will not help the client with the pain or anxiety. Breathing through the pressure is a nonpharmacologic comfort measure.

A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply. 1.The client with pyelonephritis cannot use analgesics. 2.Ask the client which migraine treatments are helpful when at home. 3.Alternative therapies such as relaxation or music can help. 4.Short-term use of opioids has a high addiction risk. 5.Using opioids will prolong the inpatient hospital stay.

2,3 The nurse should respect the client's opposition to analgesics, but this should be explored. A discussion will likely reveal a variety of alternative options, many of which may be known to the client already. Opioids are not the best drug of choice for migraines. Short-term use of opioids will not independently prolong the hospital stay and do not carry a higher risk of addiction.

A nurse is caring for a pediatric client wearing diapers. The nurse must calculate the urine output for the client. The dry diaper weighs 35 g. The wet diaper weighs 250 g. How much urine output has the client had? Record your answer using a whole number.

215 Explanation: One gram of urine is equivalent to 1 mL of urine. Output = (wet diaper weight) - (dry diaper weight) = 250 - 35 = 215 mL.

When the nurse is developing a plan of care to manage a client's pain from cancer, what should the nurse plan to do?

Individualize the pain medication regimen for the client. Explanation: The nurse should work with the client to individualize the plan of care for managing pain. Cancer pain is best managed with a combination of medications, and each client needs to be worked with individually to find the treatment regimen that works best. Cancer pain is commonly undertreated because of fear of addiction. The client who is in pain needs the appropriate level of analgesic and needs to be reassured that addiction is unlikely. Cancer pain is best treated with regularly scheduled doses of medication. Administering the medication only when the client asks for it will not lead to adequate pain control. As drug tolerance develops, the dosage of the medication can be increased.

The family of a client is considering end-of-life care for their parent. When explaining hospice care, the nurse should give the family which information? "Hospice care:

offers end-of-life care that includes palliative care and focuses on the client's physical, emotional, and spiritual needs." Explanation: Hospice care services provide palliative care and also address the client's physical, emotional, and spiritual needs. The focus of the care is on the care of the client and family. Hospice care services can begin 6 months before the illness is terminal and can be renewed, depending on the course of the disease. Hospice care collaborates with the client's HCP, but the HCP does not direct the care. Not all hospice clients want to die at home, nor is it a requirement to be at home to receive hospice care.

Which action is most important for the nurse to perform post procedure in a client with impaired renal function who is scheduled for a multidetector-computed tomography (MDCT) to evaluate peripheral circulation?

strictly monitoring intake and output Explanation: After an MDCT procedure, clients with impaired renal function should be monitored closely for urine output of at least 0.5 mL/kg/hr because they are at risk for contrast-induced nephropathy. Before the procedure, there may be an indication for IV fluids and sodium bicarbonate to alkalinize urine and protect against free radical damage. Allergies should also be assessed prior to the procedure and treated with steroids and/or histamine blockers if necessary.

What dietary recommendations should the nurse provide for a client with intermittent claudication to assist in the prevention of disease? Select all that apply. 1. reduce fat 2. substitute saturated fats for unsaturated fats 3. decrease cholesterol 4.limit calorie intake to 1500 calories per day 5. refrain from eating processed foods

1,2 Explanation: Intermittent claudication is a symptom of atherosclerosis. Association guidelines recommend a diet with decreased fat, decreased cholesterol, and unsaturated fats instead of saturated fats to prevent disease. Guidelines do not recommend limiting the number of calories to 1500, nor do they specifically recommend refraining from processed foods.

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. What is the nurse's best response?

"Let us try this until you can have acupuncture." Explanation: The nurse should respect the client's choice of alternative treatments. It is respectful to offer choices until the client can again access acupuncture treatment. Acupuncture is not experimental. The nurse should not ignore the client's right to choose any treatment, but at the same time an attempt should be made to get the client to accept treatment that will be immediately beneficial.

A client is exclusively breastfeeding her 1-week-old infant and is concerned about the baby taking enough milk per day. The client tells the nurse that the infant has six wet diapers per day. Which response by the nurse is most appropriate?

"That many wet diapers indicates your infant is adequately hydrated." Explanation: The best indicator for adequate hydration with breastfed babies is if the baby is having six to eight heavy, wet diapers per day from day four onwards. The infant's sleeping pattern and the feeling of the breasts are not good indicators of the infant's nutritional intake.

The nurse is caring for a client receiving narcotics for pain control. The client reports no bowel movement since admission. What interventions should the nurse consider? Select all that apply. Offer hot drinks with meals. Encourage doubling hall walking. Suggest drinking more fluids like water. Order high-fiber foods to be added to the diet. Suggest a reduction in the amount of narcotics taken.

1,2,3,4 Constipation can be minimized with the initiation of some simple measures. Hot liquids, increasing activity, increasing fluid intake, and eating high fiber foods can all help. Suggesting a client cut back on narcotics is not recommended if they are needed for pain control.

A client has a risk for skin breakdown due to incontinence. Which nursing actions for the client will help with decreasing this risk? Select all that apply. 1. Have scheduled toileting every 2 hours. 2. Cleanse the perineal area daily and after each incontinent episode. 3. Encourage the client to decrease fluid intake. 4. Apply adult briefs for the client and change every 8 hours. 5. Maintain a voiding record to determine any patterns of incontinence.

1,2,5 The client should have scheduled toileting to prevent incontinence and needs perineal care daily and after every incontinent episode to maintain clean and dry skin. A voiding record may help determine any patterns of incontinence with medications, fluid intake, or other reasons. The client should not be encouraged to decrease fluid intake as there is no evidence this is contributing to incontinence and, while adult briefs can be used, they should be changed more frequently to ensure that skin stays dry.

A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate?

Administer pain medication as ordered. Explanation: A pain rating of 7 out of 10 indicates significant pain. Therefore, the most appropriate action would be to administer pain medication as ordered. The nurse can ask the client what makes the pain better after medication has been given. Providing diversional activities is appropriate only after administration of pain medication. It isn't appropriate to not treat the client's pain.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often. Explanation: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours. A rectal tube also may be used. A gastric or intestinal tube is sometimes used when other measures fail.Simethicone tablets may provide some relief, but the nurse, not the client, should ask the primary care provider for this medication.Chewing on ice chips or using a straw may actually increase gas accumulation.Drinking hot coffee should be avoided because very hot or cold beverages increase gas accumulation.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed. Explanation: A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. Lambs' wool may trap heat and exacerbate skin breakdown. Turning should be at a minimum of every 2 hours. Egg crate has not been proven to be effective to prevent the development of pressure injuries and should not be used.

The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take?

Have the client breathe into a paper bag. Explanation: The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise their carbon dioxide level, which encourages deeper, slower breathing.The symptoms of hyperventilation will not be alleviated by having the client put their head between their knees; giving the client low concentrations of oxygen; or having the client take deep, slow breaths and exhale normally.

The nurse is preparing to administer a preoperative medication that includes a sedative to a client who is having abdominal surgery. What should the nurse do first?

Have the client empty the bladder. Explanation: The nurse should have the client empty the bladder before the premedication is administered. This will be more comfortable and safer for the client. The purpose of the premedication is to decrease anxiety and promote a relaxed state. The client must have an empty bladder before being transferred to the operating room, where the client will be immobilized and receive intravenous fluids. The family does not have to be present, but it is usually desired. Shaving the operative area is not generally recommended because it can cause small nicks that harbor bacteria. If the client must be shaved, it is usually done in the operating room holding area. The client should be comfortable at all times and offered a warm blanket before or after the premedication.

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best for the nurse to take?

Offer the child small feedings several times a day. A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm, resulting in decreased chest expansion and subsequent possible respiratory distress. The child's problems are associated with meals, so offering small, frequent meals provides nutritional support while minimizing distention. Encouraging increased drinking would increase abdominal distention, thus increasing the child's respiratory distress. Pursed-lip breathing would prevent air trapping, not decreased chest expansion. Administering a laxative with meals would not relieve the decreased chest expansion.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis. Explanation: Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?

Promote arterial and venous circulation. Explanation: Maslow's hierarchy defines priorities with physiological needs as the highest priority. In the case of a client with peripheral vascular disease, the highest priority would be tissue perfusion. Once this is established, the nurse can address the problems of pain and skin integrity. It is also important to educate the client and provide a self-care program. However, the client's physiological needs must be met first.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?

Remove elastic stockings once per day and observe lower extremities. Explanation: Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stockings, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.

A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important?

Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal. Explanation: Allowing the client to select food from the menu will help the client feel some sense of control. The client must eat 100% of what is selected. Remaining with the client for at least 1 hour after eating will prevent the client from purging. Bulimic clients should be allowed to eat only food provided by the dietary department.

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time?

a peanut butter sandwich Explanation: Giving the client finger foods that have protein, carbohydrates, and calories supplies energy and allows the client to eat while on the move. A salad or soup is very difficult for the client to eat while moving and may not supply the nutrients needed. Favorite foods from home may or may not be appropriate to eat while walking.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

a small amount of yellow drainage at the left pin insertion site Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A postpartum client has unrelenting pain in their rectum after vaginal birth despite the administration of pain medications. Which action is most indicated?

assessing the perineum Explanation: Pain after birth is generally well managed with pain-control medications; since they did not help this client, further assessment is necessary. The first nursing action would be to assess the source of the pain; the client may have sustained a laceration or a hematoma as a result of birth. Assessing the perineum may help the nurse to determine the source of the pain and may require follow-up by the health care provider. Subsequent nursing interventions may include pain medication, sitz bath, or education regarding the healing process.

A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching?

herbal remedies Explanation: A pregnant woman should avoid all medication unless instructed by the physician. This includes herbal remedies, because their effects on the fetus have not been identified. Meditation, music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or baby.

When assessing a child for impetigo, the nurse expects which assessment findings?

honey-colored, crusted lesions Explanation: In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.

An adolescent is being seen in the clinic for abdominal pain with a fever. In what order should the nurse assess the abdomen? All options must be used.

inspect auscultate percuss palpate Explanation: The nurse should first inspect the abdomen for abnormalities. Auscultation should be done before percussion and palpation as vigorous touching may disturb the intestines. Percussion is next. Palpation is the last step as it is most likely to cause pain.

Which goal is a priority for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?

obtaining adequate food intake Explanation: The priority goal for the client with diabetes mellitus who is experiencing vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 calories every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider (HCP) should be called, or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to:

offer finger foods and sandwiches. Explanation: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose some favorite foods is inappropriate because the client has a short attention span and has trouble making choices.

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of

organ meats. Explanation: Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

A client is drinking 3000 mL of fluid a day during the acute phase of kidney failure. Which assessment finding would be expected?

straw-colored urine Explanation: The more fluid the person drinks, the lighter the color of the urine. The other choices demonstrate low fluid volume returns.

A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:

tea and gelatin dessert. Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?

weighing the diaper before and after micturition Explanation: Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.