PN Live Review Management 2020
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about safe home disposal of insulin syringes and needles. Which of the following statements by the client indicates an understanding of the teaching? A) "I'll recap the needles and discard them in their original wrappers in a metal trash can." B) "I'll collect the needles in a rigid plastic laundry detergent container and take them to a hazardous waste facility." C) "I'll put the needles in a sealed red bag and bring them to the hospital for disposal." D) "I'll collect the needles in a disposable aluminum pie plate and fold it in half before I put it in the trash."
"I'll collect the needles in a rigid plastic laundry detergent container and take them to a hazardous waste facility." Rationale: The client should use an impervious container made of heavy plastic, such as a laundry detergent container, to prevent self-injury. The client can take the container to a community drop-off program or a hazardous waste facility for disposal. ------------------- "I'll recap the needles and discard them in their original wrappers in a metal trash can." The client risks injury to themself and others by recapping the needles and discarding them in a trash can. -------------------------- "I'll put the needles in a sealed red bag and bring them to the hospital for disposal." Used needles can puncture a plastic bag and cause injury to the client and others. A hospital does not provide disposal services for clients. ---------------------------- "I'll collect the needles in a disposable aluminum pie plate and fold it in half before I put it in the trash." A folded pie plate could allow needles and syringes to slip out and cause injury to the client and others. Furthermore, discarded needles cannot be placed in the trash. They must be taken to a hazardous waste facility and incinerated.
A nurse is reinforcing teaching about a provider's treatment plan with a client. The client refuses the plan. Which of the following statements should the nurse make? A) "Tell me about your personal treatment wishes." B) "Tell me why you're refusing treatment that can improve your health." C) "Your provider's treatment decision is what is best for you." D) "If I were you, I would accept this treatment plan."The nurse is avoiding the client's concern and offering personal advice.
A) "Tell me about your personal treatment wishes." Rationale: The nurse should ensure that the client has the right to state their personal wishes regarding treatment decisions, including the refusal of treatment. -------------- "Tell me why you're refusing treatment that can improve your health." The nurse should not ask a client to explain why they think or act a certain way because it causes resentment, insecurity, and mistrust. ---------------- "Your provider's treatment decision is what is best for you." The nurse should not impose personal values, beliefs, and attitudes on the client because they have the right to make their own informed decisions. ------------ "If I were you, I would accept this treatment plan." The nurse is avoiding the client's concern and offering personal advice.
A nurse is reinforcing teaching with a client who has a new diagnosis of celiac disease. Which of the following statements should the nurse make first? A) "Tell me some foods that you like to eat." B) "Many uncooked foods are gluten-free." C) "You can only eat certain types of grain." D) "You might need to eliminate dairy temporarily."
A) "Tell me some foods that you like to eat." Rationale: The first action the nurse should take using the nursing process is to collect data from the client. Therefore, the nurse should ask the client about food preferences to help plan appropriate food choices. It also involves the client in decision-making, which promotes effective teaching and adherence to new dietary requirements. "Many uncooked foods are gluten-free." The nurse should teach the client about food choices that are naturally gluten-free, such as milk, cheese, fruits, and vegetables. However, there is another statement the nurse should make first. ------ "You can only eat certain types of grain." The nurse should tell the client that gluten is mainly found in grains and provide the client with information on selection of appropriate grain sources. Providing the client with a handout can help promote understanding. However, there is another statement the nurse should make first. "You might need to eliminate dairy temporarily." The nurse should inform the client that acute celiac disease can cause lactose intolerance. Lactose restriction might be required until the intestinal tract heals. However, there is another statement the nurse should make first.
A nurse is assisting in planning care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional client care conference? A) A client who has cystic fibrosis B) A client who has appendicitis C) A client who has pyelonephritis D) A client who has a kidney stone
A) A client who has cystic fibrosis Rationale: The nurse should recommend interprofessional care for a client who has a chronic disease, such as cystic fibrosis (CF). CF is a genetic disease that affects many organs, including the lungs, pancreas, liver, salivary glands, and reproductive system. Potential complications of CF include respiratory infections, intestinal obstruction, poor growth, malnourishment, cirrhosis, osteoporosis, and diabetes mellitus. Management of CF is complex and requires a lifelong multidisciplinary approach. --------------------------- A client who has appendicitis Appendicitis is an acute inflammation of the appendix. Manifestations include pain in the lower right quadrant of the abdomen, fever, nausea, and vomiting. This client has an acute illness and does not require an interprofessional client care conference. ------------- A client who has pyelonephritis Acute pyelonephritis is an infection in the kidneys. Manifestations include fever, flank pain, chills, nausea, vomiting, and fatigue. This client has an acute illness and does not require an interprofessional client care conference. ------------------ A client who has a kidney stone Manifestations of a kidney stone can include flank pain, nausea, and vomiting. Treatment includes increased fluid intake, analgesics, insertion of a urinary stent, and extracorporeal shock waves to break up the stone. This client has an acute illness and does not require an interprofessional client care conference.
A nurse is preparing to apply a belt restraint for a client. Which of the following actions should the nurse plan to take? A) Apply the restraint over the client's clothing. B) Attach the restraint to the side rails of the bed. C) Allow three fingerbreadths between the restraint and the client. D) Position the restraint across the chest at the client's nipple line.
A) Apply the restraint over the client's clothing. Rationale: The nurse should apply the restraint over the client's clothing. This helps to decrease the client's risk of skin irritation. The nurse should also ensure that wrinkles in the client's clothing are smoothed out. ------------------------ Attach the restraint to the side rails of the bed. The nurse should attach the restraint to a moveable part of the frame of the client's bed. Securing a restraint to a side rail of the bed increases the risk for injury if the head of the bed is adjusted. ------------------------ Allow three fingerbreadths between the restraint and the client. The nurse should allow no more than two fingerbreadths of space between the restraint and the client to allow for adequate restraint while not compromising circulation. The nurse should monitor a client in restraints for manifestations of compromised circulation, including pallor, cool skin, or client report of pain or numbness. ------------------ Position the restraint across the chest at the client's nipple line. The nurse should place the belt restraint across the client's waist, not across the chest or abdomen. The nurse should apply the restraint while the client is in a sitting position and place it over the client's clothing.
A nurse in an outpatient clinic is reviewing the medical record of a school-age child who had a negative rapid strep test 2 days ago. The nurse notes a positive throat culture result for a group A streptococcus B- hemolytic. Which of the following actions is the nurse's priority? A) Notify the guardian of the need to start antibiotic therapy. B) Instruct the guardian to replace the child's toothbrush. C) Tell the guardian to have the child gargle with warm saline several times daily. D) Instruct the guardian to increase the child's daily fluid intake.
A) Notify the guardian of the need to start antibiotic therapy. The greatest risk to this client is injury due to complications from a streptococcal infection, including rheumatic fever and glomerulonephritis. Therefore, the priority action is to initiate antibiotic therapy. The nurse should also reinforce the importance of completing the entire course of antibiotic therapy, even if manifestations subside. The child is no longer infectious to others 24 hr after initiating antibiotic therapy. Manifestations of group A streptococcus ß-hemolytic infection include swollen and red tonsils, exudate on the pharynx, nasal discharge, fever, arthralgia, and an enlarged local lymph node.
A nurse is assisting in planning an in-service about time-management strategies with a group of newly licensed nurses. Which of the following information should the nurse plan to include? A) Organize client care tasks based on data from change-of-shift report. B) Perform simple tasks before performing more complex tasks. C) Fulfill client requests as soon as they are made. D) Plan to multitask several client care activities.
A) Organize client care tasks based on data from change-of-shift report. Rationale: The nurse should use data from change-of-shift report to help determine priorities of care. The nurse should delegate tasks to assistive personnel to allow more time for tasks that cannot be delegated. ----------- Perform simple tasks before performing more complex tasks. The nurse should prioritize tasks according to the needs of the clients. -------------- Fulfill client requests as soon as they are made. The nurse should use client goals to guide care delivery. Meeting requests as they are made can waste the nurse's time and can prevent the nurse from meeting needs that relate to risks or urgent issues. ---------------- Plan to multitask several client care activities. The nurse should plan to complete one client care activity at a time. Multitasking divides the nurse's attention and increases the risk for errors.
A nurse is caring for a client who is receiving internal radiation therapy and discovers a radioactive pellet on the client's bed. Which of the following actions should the nurse take? A) Place the pellet in a lead container. B) Remove the pellet with a gloved hand. C) Contact environmental services. D) Notify the infection control officer.
A) Place the pellet in a lead container. Rationale: The nurse should use tongs and place the pellet in a lead container due to radioactive elements the pellet contains. This action protects the nurse and other clients from radiation exposure. When caring for a client receiving internal radiation, the nurse should limit time spent in the room and maintain distance from the client when possible. The nurse should also wear a lead apron and a dosimeter badge during client care. ------------------- Remove the pellet with a gloved hand. The pellets are radioactive and require specific safety measures for removal. The nurse should use tongs, rather than gloves, to remove the pellet and place it in a lead container. ------------------- Contact environmental services. he nurse should contact the radiology department to replace or dispose of the radioactive pellet. There is no need to contact environmental services. For a client receiving internal radiation therapy, the nurse should ensure a sign is on the door warning other staff of possible exposure to radiation when in the room. --------------- Notify the infection control officer. There is no need for the nurse to notify the infection control department. The radioactive pellet is not a source of infectious disease. However, the nurse should use special precautions to dispose of client secretions and when handling dressings and linens that contain secretions, because they are radioactive.
A nurse is demonstrating actions to take when using a fire extinguisher to contain a small fire to a group of staff. Which of the following actions should the nurse take first? A) Pull the pin out of the extinguisher. B) Rotate the handles a quarter turn until they click into place. C) Aim the hose of the extinguisher at the top of the fire. D) Keep the hose steady while dousing the central portion of the fire.
A) Pull the pin out of the extinguisher. Rationale: When in place, the pin locks the handles. The nurse must remove the pin to use the extinguisher. ----------------- Rotate the handles a quarter turn until they click into place. The nurse should squeeze the handles together to discharge the extinguishing material onto the fire. ---------- Aim the hose of the extinguisher at the top of the fire. The nurse should aim the hose at the base of the fire. -------------- Keep the hose steady while dousing the central portion of the fire. The nurse should sweep the hose from side-to-side while attempting to douse the fire.
A nurse is obtaining informed consent from a client who is scheduled for a procedure. Which of the following actions should the nurse take? A) The nurse should witness the client signing the informed consent document. B) The nurse should ensure that the client understands the benefits of the procedure. C) The nurse should inform the client that once consent is given, it cannot be changed. D) The nurse should inform the client of alternative treatment.
A) The nurse should witness the client signing the informed consent document. It is the nurse's role to witness the signature of the client on the informed consent document. ----------------- Rationale: The nurse should ensure that the client understands the benefits of the procedure. It is the responsibility of the provider to disclose the risks, benefits, alternatives, and consequences of refusal of the procedure to the client. -------------- The nurse should inform the client that once consent is given, it cannot be changed. Clients should be informed that consent can be revoked at any time, even after the treatment or procedure has begun. ---------------------- The nurse should inform the client of alternative treatment. It is the responsibility of the provider to disclose the risks, benefits, alternatives, and consequences of refusal of the procedure to the client.
A nurse is providing change-of-shift report for a client who is 3 days postoperative following a transurethral resection of the prostate. Which of the following information should the nurse include? A) The provider changed the client's morphine prescription from IV to PO. B) The client's partner visited for the first time since the surgery. C) The client requires sterile asepsis when the nurse irrigates their bladder. D) The client becomes demanding when they don't get their meal tray on time.
A) The provider changed the client's morphine prescription from IV to PO. Rationale: The nurse should include significant changes to the client's plan of care, such as new medication prescriptions. Using a standard communication method such as the situation-background-assessment-recommendation (SBAR) tool can help the nurse communicate priorities about the client's care. -------------------- The client's partner visited for the first time since the surgery. Unless there is a specific issue or concern about visitation, it is not necessary to report that the client had a visitor or to convey any opinions about the frequency or duration of visitation. ------------------- The client requires sterile asepsis when the nurse irrigates their bladder. The nurse should not describe the steps of a procedure during change-of-shift report. Instead, the nurse should report any essential changes or discontinuation of routine procedures. ----------------- The client becomes demanding when they don't get their meal tray on time. The nurse should not offer personal opinions about the client's behavior during change-of-shift report. The nurse should keep the report factual and objective.
A nurse is reviewing the medical records of a group of infants and children. Which of the following is a national notifiable infectious condition and requires reporting? A) Varicella B) Scarlet fever C) Fifth disease D) Roseola infantum
A) Varicella Rationale: The nurse should report varicella because it is a nationally notifiable infectious condition. ------------------- Scarlet fever Scarlet fever is not a nationally notifiable infectious condition. ----- Fifth disease Fifth disease is not a nationally notifiable infectious condition. ---- Roseola infantum Roseola infantum is not a nationally notifiable infectious condition.
A nurse is caring for a group of clients on a medical-surgical unit. The nurse should take which of the following actions to protect client confidentiality. (Select all that apply). A) Store clients' charts in a secure location. B) Ensure that emails containing client health information are encrypted. C) Give a verbal report at change of shift outside the clients' rooms. D) Remove client information from fax machines after use. E) Dispose of written report sheets into the trash container.
A, B, D Rationales: Store clients' charts in a secure location is correct. A client's medical record or chart is a legal document and contains information describing the care that is delivered to a client. Medical records are required to be stored in a locked, secured area in all departments within the facility. The client's current records on the unit should be kept in a secured location at the nurses' station or in cabinets out of reach of visitors or family members. - Ensure that emails containing client health information are encrypted is correct. Emails that contain client information should be encrypted to protect client confidentiality. - Remove client information from fax machines after use is correct. It is imperative to remove client medical information immediately from fax and copy machines to prevent other people who are not involved in the client's care from viewing the information. Fax machines should be placed in areas that do not provide access to anyone other than health care providers. ---------------------------- Give a verbal report at change of shift outside the clients' rooms is incorrect. Although the practice of a walking change-of-shift report is a common practice in many facilities, it can contribute to a breach in client confidentiality. Family members, visitors, or other hospital employees can overhear information related to a client's health care. ------ Dispose of written report sheets into the trash container is incorrect. Disposing of written report sheets into the trash container is inappropriate and can contribute to a breach in confidentiality. Anyone could retrieve the report sheet and view confidential health care information about clients. The nurse should shred the report sheet in a locked receptacle within the facility and then incinerate the contents of the receptacle.
A charge nurse is discussing the steps to complete an incident report with a newly licensed nurse. Which of the following statements should the nurse include? A) "Place a copy of the incident report in the client's medical record." B) "Complete the incident report after ensuring the client is not injured."
B) "Complete the incident report after ensuring the client is not injured." Rationale: An incident report is the record of an occurrence, such as a client fall or medication error. The first step the nurse should take following an unusual occurrence is to collect data from the client to determine if an injury has occurred. After providing care to the client, the nurse should contact the provider and complete the incident report as soon as possible. ---------------------------- "Place a copy of the incident report in the client's medical record." The nurse should not place a copy of the report in the client's medical record. The incident report is an internal document and is not part of the medical record, which is a legal document. ------------------------ "Document the completion of the incident report in the nurse's notes." The nurse should document the facts of the event in the client's medical record. However, they should not document that an incident report was completed in the nurse's notes. ------------------- "Include subjective data in the incident report." The nurse should include objective statements that are factual and complete, with a clear description of the incident that occurred.
A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following statements should the nurse make to the client? A) "We will keep your vital signs on a message board in your room." B) "You need to give written permission for your medical information to be released." C) "We must let you know each time new health care personnel looks at your chart." D) "You can sign a general consent now that will cover all hospital procedures."
B) "You need to give written permission for your medical information to be released." Rationale: Under HIPAA privacy laws, client consent is required to release medical information. The nurse should reinforce with the client that the requirement is in place to protect the client's information. Only those directly involved in client care have a right to access the information. ------------------------------ "We will keep your vital signs on a message board in your room." The nurse should not include a client's personal health information on a message board in the client's room. This is a violation of confidentiality. -------------------------------- "We must let you know each time new health care personnel looks at your chart." HIPAA laws allow information to be shared with health care personnel directly involved in client care. This can include providers, nurses, and therapists from various disciplines. It is not a requirement to notify the client each time the medical record is reviewed. -------------- "You can sign a general consent now that will cover all hospital procedures." A general consent form is signed on admission to a facility and covers most routine procedures. A separate consent must be obtained before certain procedures or invasive diagnostic tests are performed.
A nurse is contributing to a discussion about informed consent during a staff meeting. Which of the following clients should the nurse identify as requiring a guardian to provide consent for general treatment? A) A young adult client who has schizophrenia B) A 17-year-old client who dropped out of high school C) A 16-year-old client who has a newborn D) An older adult client who has brain cancer
B) A 17-year-old client who dropped out of high school Rationale: Minors are required to have a parent or guardian provide consent for general medical care. Some states allow minors to give consent for certain treatments, such as for a mental illness or sexually transmitted infection. An emancipated minor can give consent. ------------------------ A young adult client who has schizophrenia Mental illness does not make an individual incapable of providing consent. If the client's mental capacity becomes questionable, health care personnel should determine whether the client is still competent. A court ruling might be required to declare incompetence. ---------------------- A 16-year-old client who has a newborn A minor who has a child is considered emancipated and can provide consent. Minors also are able to provide consent for children of whom they are guardians or have custody. In some states a client who is pregnant might be considered emancipated. ----------------------- An older adult client who has brain cancer An older adult client who has brain cancer can provide legal consent for care and treatment. The nurse should encourage all clients to complete advance directives, especially in situations where the client's diagnosis could affect judgment in the future.
A nurse in a long-term care facility is assisting with teaching a group of nurses about client rights. Which of the following information should the nurse include in the teaching? A) Clients should receive a 45-day notice of being transferred or discharged to another facility. B) Clients can request to review their own personal medical records. C) Clients have the legal right to refuse restraints. D) Clients in long-term care do not have the right to manage their own financial affairs or choose their own provider.
B) Clients can request to review their own personal medical records. Clients have the right to review their own medical records, participate in their own care, and expect adequate and appropriate care from the facility's personnel. ----------- Clients should receive a 45-day notice of being transferred or discharged to another facility. The client has the right for the long-term care facility's personnel to provide 30-day notice of being transferred or discharged to another facility due to financial reasons, when care is no longer needed, or for the client's welfare. -------------- Clients have the legal right to refuse restraints. Clients have the right to participate in their own care and to refuse treatment; however, if they are a harm to themselves or others, they do not have the right to refuse seclusion or restraints. ----------- Clients in long-term care do not have the right to manage their own financial affairs or choose their own provider. Clients in a long-term care facility have the right to make independent choices, which include managing their own financial affairs and choosing their own provider, as long as they are mentally competent.
A nurse is assisting with updating the facility response plan regarding natural disasters. With which of the following agencies should the nurse plan to collaborate? A)World Health Organization (WHO) B) Federal Emergency Management Agency (FEMA) C) Centers for Disease Control and Prevention (CDC) D) Centers for Medicaid and Medicare Services (CMS)
B) Federal Emergency Management Agency (FEMA) Rationale: FEMA is the federal agency that plans for management of response and coordinates response to emergency situations including natural disasters. Medical facilities plan response by organizing teams that follow FEMA's incident command system. This system provides a structure and chain of command for managing emergencies. Centers for Disease Control and Prevention (CDC) ----------------------------- World Health Organization (WHO). The WHO provides leadership and guidance for global health issues. However, the nurse should recognize that the WHO facilitates programs to reduce risks associated with disasters on community or national levels, not for individual medical facilities. ---------------- Centers for Disease Control and Prevention (CDC). The CDC focuses on occurrence and prevention of diseases in the U.S. The CDC has a strategic plan in place for mass casualty incidents that are the result of radioactive, biologic, or biochemical acts of terrorism. ----------------- Centers for Medicaid and Medicare Services (CMS). The CMS is a federal government agency that oversees the Medicaid and Medicare systems for payment of health care services. It does not provide assistance for natural disasters.
A nurse is contributing to a plan of care for a client and recognizes that one of the established goals is unrealistic. Which of the following actions should the nurse take? A) Document the client's noncompliance with the plan of care. B) Recommend a revision to the plan of care. C) Discontinue nursing interventions related to the goal. D) Create a new plan of care.
B) Recommend a revision to the plan of care. Rationale: The nurse should recommend a revision to the plan of care to reflect the client's current state of health and abilities to adhere to the plan. ------------------------ Document the client's noncompliance with the plan of care. The nurse should provide objective documentation of the client's current state of health and abilities to comply with the plan. ------------- Discontinue nursing interventions related to the goal. The nurse should not discontinue nursing interventions related to the goal. The nurse should assist the RN to revise the interventions to meet the goal of the plan of care. ---------------------------- Create a new plan of care. It is beyond the scope of practice for the PN to create a new plan of care. The nurse should assist the RN in revising the client's plan of care.
A newly licensed nurse is preparing to administer a subcutaneous medication to a client and is unsure of the correct technique. Which of the following actions should the nurse take? A) Ask the pharmacist to explain the procedure. B) Review the institutional policy and procedure manual. C) Refer to the American Nurses Association (ANA) Code of Ethics. D) Complete an incident report.
B) Review the institutional policy and procedure manual. Rationale: The institutional policy and procedure manual will provide detailed information about how the nurse should perform client care procedures. It establishes the standard of practice for employees of an institution. Nurses should be familiar with their institution's policies and procedures and how to locate the manual if necessary. ------------------- Ask the pharmacist to explain the procedure. A pharmacist prepares and distributes prescribed medications and can provide information about medication adverse effects, toxicity, interactions, and incompatibilities. However, the pharmacist cannot provide information regarding medication administration procedures. ---------------- Refer to the American Nurses Association (ANA) Code of Ethics. The ANA Code of Ethics is a set of principles nurses use for guidance in providing ethical client care. The code does not outline the steps of procedures, such as injections. Complete an incident report. The nurse should complete an incident report if an event occurs outside the standard care of a client. Examples of variances include falls, medication errors, and needlestick injuries.
A nurse is participating in disaster planning for an acute care facility. When using the color-coded triage tag system, which of the following tag colors should the nurse assign to a client who as an open fracture? A) Red B) Yellow C) Green D) Black
B) Yellow Rationale: The nurse should issue a yellow tag to clients whose injuries are urgent, such as open fractures or large wounds. Clients who have a yellow tag can wait a short time for treatment, but that treatment should occur within 30 min to 2 hr. -------------------------- Red The nurse should issue a red tag to clients whose injuries are emergent, including those who have life-threatening injuries, such as hemorrhagic shock or airway compromise. Clients who have a red tag typically have critical injuries that require immediate intervention to preserve life. ---------------- Green The nurse should issue a green tag to clients whose injuries are nonurgent, such as those who have contusions, sprains, strains, and closed fractures. Clients who have a green tag have injuries that can wait more than 2 hr for treatment without serious consequence. --------------- Black The nurse should issue a black tag to clients who are not expected to live, even with extensive intervention. These clients are given the lowest priority and are allowed to die naturally. The nurse should also place a black tag on clients who have already died.
A nurse is assisting with assigning care for a group of clients. The nurse should instruct the assistive personnel (AP) to assist with ADLs for which of the following clients? (Select all that apply). A) A client who is newly admitted and is having an episode of status asthmaticus B) A client who has a history of mild chronic heart failure and had a knee arthroplasty 2 days ago C) A young adult client who is 1 day postoperative following a laparoscopic appendectomy D) A client who is being discharged to home and has a new diagnosis of Crohn's disease E) A client who has diabetic ketoacidosis and is receiving regular insulin via a continuous IV infusion
B, C, D Rationale: A client who is newly admitted and is having an episode of status asthmaticus is incorrect. Status asthmaticus is a life-threatening episode of bronchoconstriction that can be unresponsive to usual treatment. Manifestations include wheezing and labored respirations, which can lead to cardiac or respiratory arrest. The range of function for an AP includes assisting with ADLs for stable clients; a client experiencing status asthmaticus is not stable. A client who has a history of mild chronic heart failure and had a knee arthroplasty 2 days ago is correct. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in inadequate cardiac output. Knee arthroplasty is the replacement of the knee that requires a short hospital stay followed by physical therapy and rehabilitation. The range of function for an AP includes assisting with ADLs for stable clients; a client who has a history of mild chronic heart failure and is 2 days postoperative is stable. A young adult client who is 1 day postoperative following a laparoscopic appendectomy is correct. Clients are usually discharged to home 12 to 24 hr following a laparoscopic appendectomy. The range of function for an AP includes assisting with ADLs for stable clients; a client who is 1 day postoperative following a laparoscopic appendectomy is stable. A client who is being discharged to home and has a new diagnosis of Crohn's disease is correct. Manifestations of Crohn's disease include fever, fatigue, diarrhea, and abdominal pain. The range of function for an AP includes assisting with ADLs for stable clients; a client who is being discharged to home is stable. A client who has diabetic ketoacidosis and is receiving regular insulin via a continuous IV infusion is incorrect. Diabetic ketoacidosis is an acute, life-threatening condition characterized by hyperglycemia and acidosis. The range of function for an AP includes assisting with ADLs for stable clients; a client who is experiencing diabetic ketoacidosis is not stable.
A nurse is reinforcing discharge instructions with a client who has a permanent tracheostomy. Which of the following equipment should the nurse verify is available at the client's home? (Select all that apply) A) Stethoscope B) Oxygen C) Suction machine D) Portable ventilator E) Replacement cannula
B,C,E Rationale: Oxygen is correct. The nurse should reinforce that the client needs portable oxygen in the home care setting, even if continuous oxygen therapy is not required. Suction machine is correct. The nurse should reinforce the availability of suction equipment in the home so the client is able to clear airway secretions effectively. Replacement cannula is correct. The nurse should reinforce teaching about having a replacement cannula available in the home in case dislodgment of the tracheostomy cannula occurs. ------------------------- Stethoscope is incorrect. The nurse should reinforce teaching about indications of airway obstruction to report to the provider immediately. However, the client is not required to have a stethoscope in the home. --- Portable ventilator is incorrect. There is no indication of a need for a portable ventilator for this client.
A charge nurse is reinforcing about ethical priniciples with a group of nurses. Which of the following statements by one of the nurses indicated an understanding of the ethical principle of justice? A) "I should respect a client's decisions regarding their treatment." B) "I should avoid causing unintentional harm to all clients." C) "I should divide my time among my clients." D) "I should keep the promises I make to clients."
C) "I should divide my time among my clients." Dividing time among clients upholds the ethical principle of justice. The nurse should plan care to share time as equally as possible to best meet all clients' needs. ------------- "I should respect a client's decisions regarding their treatment." Respecting a client's decisions regarding treatment upholds the ethical principle of autonomy. The nurse should include the client when making decisions regarding care. The nurse does not need to agree with a client's choices but should respect the client's decisions. ----------- "I should avoid causing unintentional harm to all clients." Doing no harm to clients upholds the ethical principle of nonmaleficence. The nurse has a duty not to harm clients, either intentionally or unintentionally, while providing care. ----------- "I should keep the promises I make to clients." Keeping promises and being faithful to agreements made to clients upholds the ethical principle of fidelity. The nurse should be responsible for following up on promises made to clients to maintain trust in the nurse-client relationship.
A nurse is caring for a group of clients who are postoperative. Which of the following findings should the nurse report to the charge nurse? A) A client who has diabetes mellitus and a capillary blood glucose level of 98 mg/dL B) A client who had a closed reduction of a right femur fracture and has a +2 pedal pulse in the right foot. C) A client whose blood pressure decreased from 138/86 to 106/60 mm Hg in 4 hr D) A client who is 12 hr postoperative and reports a pain level of 3 on a scale from 0 to 10
C) A client whose blood pressure decreased from 138/86 to 106/60 mm Hg in 4 hr. Rationale: A decrease in blood pressure is an unexpected finding and can be an indication of hemorrhage, hypovolemia, or decreased cardiac output. Therefore, the nurse should report this finding to the charge nurse for further evaluation. --------------------- A client who has diabetes mellitus and a capillary blood glucose level of 98 mg/dL A capillary blood glucose level of 98 mg/dL is within the expected reference range of less than 200 mg/dL for a casual blood glucose. Therefore, the nurse does not need to report this finding to the charge nurse. ------------- A client who had a closed reduction of a right femur fracture and has a +2 pedal pulse in the right foot. A +2 pedal pulse on the affected side is an expected finding. For a client who has a skeletal fracture, the nurse should report a weak (+1) or absent pulse. The nurse should also check the client's distal circulation, movement, and sensation to monitor for circulatory complications. --------------------------- A client who is 12 hr postoperative and reports a pain level of 3 on a scale from 0 to 10. A pain level of 3 out of 10 is an expected finding for a client who is 12 hr postoperative. A pain rating of 1 to 3 indicates mild pain, 4 to 6 indicates moderate pain, and 7 to 10 indicates severe pain. The nurse should continue to administer pain medication as prescribed and notify the provider if pain is not controlled by analgesia.
A nurse observes two assistive personnel (AP) at a client's bedside disagreeing about the way to bathe a client. Which of the following actions should the nurse take? A) Ask the client if they want a bath. B) Tell the AP to proceed with the client's bath. C) Ask the AP to speak to the nurse outside the client's room. D) Request assistance from a security officer.
C) Ask the AP to speak to the nurse outside the client's room. Rationale: The nurse should remove the AP from the client's room and use active listening to resolve the conflict. ---------------------------- Ask the client if they want a bath. It is not appropriate to ask the client if they want a bath while the staff is having a conflict. The conflict should be resolved without involving the client. ------------- Tell the AP to proceed with the client's bath. Instructing the AP to proceed with the client's bath is not in the best interest of the client. The conflict must be addressed, and without resolution, the conflict might have a negative impact on the client. ------------------------- Request assistance from a security officer. There is no indication that a security officer needs to be involved in the conflict.
A charge nurse is assisting in the teaching of a newly licensed nurse about using critical pathways. Which of the following information should the nurse include in the teaching? A) Critical pathways provide detailed nursing actions. B) Critical pathways prioritize daily nursing care tasks. C) Critical pathways are designed to standardize care. D) The nurse should complete each step on the critical pathway.
C) Critical pathways are designed to standardize care. Rationale: Critical pathways are a guideline for standardized care within established timelines, resulting in improved client outcomes, decreased morbidity, and decreased mortality. Clinical practice guidelines reflect evidence-based practice and best practices. ------------------- Critical pathways provide detailed nursing actions. Critical pathways include client interventions but do not include detailed nursing actions. A critical or clinical pathway or care map can be used to reduce mistakes, improve outcomes and quality of care, and decrease duplication of effort. -------------- Critical pathways prioritize daily nursing care tasks. The nurse should continuously set and reset priorities to meet the needs of clients. A critical pathway does not prioritize daily nursing care tasks. A critical pathway can be used to support the implementation of clinical guidelines and protocols. ------------ The nurse should complete each step on the critical pathway. Critical pathways include interventions for various disciplines within the health care team. The nurse should carefully consult the pathway and protocol of the agency prior to implementing any pathway to become familiar with the process. The nurse should modify care to meet client needs. The nurse might not need to complete each step in the critical pathway.
A nurse is contributing to the plan of care to meet the nutritional needs of a client who has dysphagia. To which of the following interdisciplinary team members should the nurse refer the client? A) Physical therapist B) Social worker C) Speech pathologist D) Respiratory therapist
C) Speech pathologist Rationale: A speech pathologist assesses and makes recommendations for clients experiencing speech, language, and swallowing difficulties. The speech pathologist can teach swallowing techniques and exercises to facilitate swallowing. ----------------------------- Physical therapist A physical therapist provides treatment to improve mobility and strength for clients who have musculoskeletal difficulties. There is no indication this client requires physical therapy. ------------------------- Social worker A social worker helps meet the client's psychosocial needs by coordinating financial and community resources, completing advance directives, and discharge planning. There is no indication this client requires a social worker. --------------------------- Respiratory therapist A respiratory therapist administers oxygen and performs respiratory treatments for clients who have respiratory difficulties. There is no indication this client requires respiratory assistance.
A charge nurse is reinforcing teaching about advance directives with a newly licensed nurse. Which of the following information should the charge nurse include? A) The provider must be present when the client signs the advance directives. B) A risk manager needs to review the client's advance directives. C) The client can change their decision about treatment at any time. D) The client must choose a relative as a health care surrogate.
C) The client can change their decision about treatment at any time. Rationale: Advance directives consist of a living will and a health care proxy. A client can change their decision about treatment at any time after signing advance directives. The living will provides instructions to direct treatment in the event the client is unable to make their own treatment decisions. ---------------- The provider must be present when the client signs the advance directives. The provider is not required to be present when the client signs the advance directives. However, the provider should also sign the advance directives in acknowledgement of the client's wishes. ---------- A risk manager needs to review the client's advance directives. A client does not need to have a risk manager review the advance directives. The nurse should expect a risk manager to investigate unexpected injuries to clients and visitors, or situations that do not comply with typical operations. ----------------- The client must choose a relative as a health care surrogate. The durable power of attorney or health care proxy is a legal document that designates a person who will speak on the behalf of the client when the client is unable to do so. The client can choose anyone to be their health care surrogate.
A nurse is reinforcing teaching with a client about advance directives. Which of the following statements by the client indicated an understanding of the teaching? A) "Advance directives limit my ability to make health care decisions." B) "A living will determines who will make treatment decisions on my behalf." C) "I am required to choose a family member to be my durable power of attorney." D) "I will be asked by health care staff if I have advance directives each time I am admitted."
D) "I will be asked by health care staff if I have advance directives each time I am admitted. Raitonale: The Patient Self-Determination Act requires health care personnel to ask clients with every admission if they have advance directives in place that outline their health care wishes if they are unable to make or communicate their own decisions. --------------- "Advance directives limit my ability to make health care decisions." Advance directives are legal documents that specify clients' wishes regarding treatment if they become unable to make their own decisions. A client retains the right to refuse treatment following implementation of advance directives. ------------- "A living will determines who will make treatment decisions on my behalf." A living will is a document that allows clients to specify what treatment they want to receive or refuse in the event they become terminally ill or are unable to make their own decisions. The living will does not determine who makes treatment decisions for the client. ------- "I am required to choose a family member to be my durable power of attorney." A durable power of attorney is a document specifying whom a client has chosen to make health care decisions on their behalf should they become unable to do so. Clients can choose anyone they trust to function as their health care surrogate, including a friend or clergy member.
A nurse is receiving change-of-shift report on a group on clients. Which of the following clients should the nurse plan to see first? A) A client who had a urine output of 280 mL on the previous 8 hr shift B) A client who reports a pain level of 4 on a 0 to 10 pain scale 1 hr following analgesia C) A client who had a laparoscopic appendectomy 2 hr ago and is vomiting D) A client who has tachycardia and a respiratory rate of 32/min
D) A client who has tachycardia and a respiratory rate of 32/min Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify that a client who has tachycardia and a respiratory rate of 32/min is at increased risk for respiratory compromise and cardiac arrest. Therefore, the nurse should plan to see this client first. --------------- A client who had a urine output of 280 mL on the previous 8 hr shift A urine output of 280 mL is within the expected reference range of greater than or equal to 30 mL/hr. The nurse should continue to monitor the client's output for any changes. However, the nurse should plan to see another client first. ------------------ A client who reports a pain level of 4 on a 0 to 10 pain scale 1 hr following analgesia A pain level of 4 on a 0 to 10 pain scale is moderate pain and is a common occurrence 1 hr after a procedure requiring analgesia. The nurse should address the client's pain. However, the nurse should plan to see another client first. ----------------------- A client who had a laparoscopic appendectomy 2 hr ago and is vomiting Nausea and vomiting following surgery is common. The nurse should monitor the client and likely administer an antiemetic. However, the nurse should plan to see another client first.
A nurse is reviewing policies with a newly hired staff member about client refusal of treatment. Which of the following information should the nurse include? A) A client must have advance directives on file to refuse treatment. B) A family can overrule a competent adult's choice to refuse life-saving treatment. C) A client attempting to cause harm can refuse chemical restraint. D) A court can overturn a parent's decision to refuse treatment for a child.
D) A court can overturn a parent's decision to refuse treatment for a child. Rationale: A parent can choose to refuse treatment for a child for many reasons, including religious preference. However, the nurse has a responsibility to ensure the safety of the child. Legal intervention can be required to overturn the parent's decision if it threatens the child's life. --------------------- A client must have advance directives on file to refuse treatment. Advance directives are not required for a client to refuse treatment. Advance directives are helpful in showing decisions made by a once-competent individual. A client can determine in advance directives which treatments should not be administered in the future. ---------------- A family can overrule a competent adult's choice to refuse life-saving treatment. Competent clients have the right to refuse treatment. The nurse should encourage communication between the client and family to promote understanding, but the decision is up to the client. When competency is questioned, the nurse should consider the client's advance directives. ------------------- A client attempting to cause harm can refuse chemical restraint. A client who is actively attempting to harm themselves or another person can be given sedation against their will. A court hearing may be required to determine whether a client is competent to refuse medication for mental health disorders in non-emergent situations.
A nurse is assisting with planning care for a client who has had a stroke. The nurse should initiate a referral to an occupational therapist for which of the following tasks? A) Assisting with ambulatory devices B) Introducing a bladder training program C) Incorporating RDAs D) Completing ADLs
D) Completing ADLs Rationale: An occupational therapist assists the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. ---------------------- Assisting with ambulatory devices A physical therapist assists a client with mobility skills, including the use of ambulatory devices such as a walker or a cane. ----------------------- Introducing a bladder training program The nurse should assist the client with bowel and bladder training. This training can include a regular toileting schedule and applying light pressure to the bladder to facilitate urination, which is known as Crede's maneuver. ------------------------- Incorporating RDAs A dietitian should help the client meet recommended dietary allowances (RDAs). The dietitian also can assess the client for dysphagia and develop meal plans based on the client's needs.
A nurse in a long-term care facility is preparing for an interprofessional team conference. Which of the following actions should the nurse take? A) Assist the provider in determining which medications are appropriate for the client. B) Calculate a client's energy requirements based on a specific disease process. C) Review insurance requirements for the client's length of stay. D) Create a list of needs based on questions or concerns from the client.
D) Create a list of needs based on questions or concerns from the client. Rationale: The nurse is the client advocate. As the direct caregiver, the nurse is often aware of needs and issues affecting the client that other members of the interprofessional team are not. The nurse should ensure the client's concerns are addressed during the interprofessional conference. ------------ Assist the provider in determining which medications are appropriate for the client. The nurse should identify this as a task for a pharmacist. The pharmacist has in-depth knowledge of medications, interactions, and effects. The pharmacist can recommend appropriate prescriptions and dosages to the provider. ------------- Calculate a client's energy requirements based on a specific disease process. The nurse should identify this as a task for a dietitian. The dietitian has advanced knowledge of disease and how to determine client calorie needs. The dietitian can design special diets and serve as a resource person to staff. The nurse should reinforce information provided by the dietitian. ----------------- Review insurance requirements for the client's length of stay. The nurse should identify this as a task for a case manager. The case manager oversees client care to ensure that needs are covered and prevent financial waste. A case manager or social worker is knowledgeable of client insurance requirements and other financial needs.
A nurse is reinforcing teaching with a client who is postoperative about the use of an incentive spirometer. Which of the following information should the nurse include? A) Take shallow breaths when using the spirometer. B) Cough prior to using the spirometer. C) Use the spirometer twice every 3 hr. D) Hold breath for 2 seconds, then exhale slowly.
D) Hold breath for 2 seconds, then exhale slowly. Rationale: The nurse should instruct the client to inhale slowly and deeply, hold their breath for 2 to 3 seconds, and then exhale slowly. This allows for the alveoli of the lungs to expand, which reduces the risk of progressive collapse of the alveoli. The client should work up to holding their breath for 6 seconds following inhalation. --------------- Take shallow breaths when using the spirometer. The nurse should instruct the client to take slow, deep breaths when using an incentive spirometer. The client should hold their breath after inhalation to maintain lung expansion. --------------- Cough prior to using the spirometer. The nurse should instruct the client to cough after taking deep breaths with an incentive spirometer. Deep breaths can loosen secretions in the lungs, and coughing helps to remove them. --------------------- Use the spirometer twice every 3 hr. The nurse should instruct the client to use an incentive spirometer 4 to 10 times per hr. This increases lung expansion and prevents atelectasis.
A nurse is reinforcing teaching with an adult client who has stress incontinence. Which of the following is an evidence-based intervention the nurse should include? A) Wearing a bladder incontinence pad B) Using intermittent bladder catheterization C) Limiting fluid intake during waking hours D) Performing exercises that strengthen pelvic floor muscles
D) Performing exercises that strengthen pelvic floor muscles Rationale: Evidence-based practice is the integration of current research with clinical skills to improve clients' outcomes. Stress incontinence can be reduced by using exercises that strengthen the pelvic floor muscles, such as Kegel exercises. ----------------- Wearing a bladder incontinence padThis intervention can help prevent urine leaking through clothing. However, it is not an evidence-based guideline for reducing stress incontinence. ------ Using intermittent bladder catheterization Intermittent bladder catheterization is not recommended for stress incontinence. The procedure puts the client at risk for infection and is unlikely to resolve the problem of stress incontinence. Bladder catheterization might be required for a client who has urinary retention. ------------- Limiting fluid intake during waking hours The nurse should encourage the client to take most fluids during the waking hours (between 0600 and 1800) to prevent nocturia and to schedule fluid intake around social occasions when possible.
A nurse is caring for a client who has parapalegia following a stroke. Which of the following actions should the nurse take to prevent deep vein thrombosis (DVT)? A) Massage the client's lower extremities daily. B) Apply cold packs to the client's calves three times a day. C) Elevate the head of the client's bed. D) Place sequential compression devices on the client's lower legs.
D) lace sequential compression devices on the client's lower legs. Prevention of DVT includes client education, leg exercises, early ambulation, adequate hydration, graduated compression stockings, and intermittent pneumatic compression, such as sequential compression devices (SCDs) and venous plexus foot pumps. The use of SCDs helps prevent venous stasis by promoting circulation. ------------------------ Massage the client's lower extremities daily. A client who has limited mobility is at an increased risk for the development of DVT. The nurse should not massage the lower extremities as this can dislodge a thrombus, leading to an embolism. ---------------- Apply cold packs to the client's calves three times a day. A client who has limited mobility is at an increased risk for the development of DVT. Application of cold packs causes vasoconstriction, which increases the risk for venous stasis. If the client develops a thrombus, the nurse should apply warm, moist heat to the area. ----------------- Elevate the head of the client's bed. A client who has limited mobility is at an increased risk for the development of DVT. Following a stroke, the nurse should elevate the head of the client's bed to a 30° angle to reduce intracranial pressure and to promote venous drainage. Elevating the client's legs promotes venous return and helps prevent the development of DVT.
A nurse is assisting with the planning of an in-service for a group of staff nurses about establishing a sterile field. Which of the following information should the nurse include? A) Pour sterile liquids while holding the bottle with the label facing the table. B) Discard any object that touches the outer 2.5 cm (1 in) border of the sterile field. C) Choose a work area 5 cm (2 in) below the level of the waist. D) Pull the outer flap of a sterile package toward the body.
Discard any object that touches the outer 2.5 cm (1 in) border of the sterile field. Rationale: The nurse should instruct staff nurses that the outer 2.5 cm (1 in) border of a sterile field is considered unsterile. If an object comes into contact with this border, the nurse should discard it since it is no longer sterile. ------------------------ Pour sterile liquids while holding the bottle with the label facing the table. The nurse should instruct staff nurses to pour liquids onto a sterile field by holding the label of the bottle in the palm of the hand. This prevents the liquid from running onto the label and making it unreadable. ---------------------------- Choose a work area 5 cm (2 in) below the level of the waist. The nurse should instruct staff nurses to choose a work area that is at or slightly above waist level. This decreases the chance of contaminating the sterile field. The nurse should consider any object below waist level as contaminated. --------------------- Pull the outer flap of a sterile package toward the body. The nurse should instruct the staff nurses to open sterile packages by pulling the outer flap away from the body. This prevents the nurse from later having to reach across the package to open the last flap, which could contaminate the package.
A nurse is making client care assignments at the beginning of a shift. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A) Document a client's output from a nasogastric tube. B) Update a client's plan of care following a minor surgical procedure. C) Determine the effectiveness of a client's pain medication. D) Administer milk of magnesia to a client who has constipation.
Document a client's output from a nasogastric tube. Rationale: The nurse can assign the task of measuring and documenting a client's output to an AP because this task does not require interpretation of data or decision making. Tasks within an AP's range of function include taking vital signs, feeding, bathing, ambulation, and providing postmortem care. --------------------- Update a client's plan of care following a minor surgical procedure. A nurse is required to update a client's plan of care as this task requires interpretation of the client's needs. The nurse should assign an AP tasks that have a low potential for client harm. ----- Determine the effectiveness of a client's pain medication. A nurse is required to evaluate the effectiveness of care provided to a client as this requires assessment or data collection, which are outside the range of function for an AP. The nurse should assign an AP tasks that are predictable and repetitive. --------------------- Administer milk of magnesia to a client who has constipation. A nurse should administer medications to a client as this requires assessment or data collection, which are outside the range of function for an AP, before and after administration. The nurse should assign an AP tasks that are generally noninvasive.
A charge nurse is supervising a newly licensed nurse who is caring for a client who is in skeletal traction and requires pin site care. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A) Checks the pin sites every 8 hr for infection B) Administers an analgesic prior to pin care Plans to cleanse the pin sites once daily. D) Plans to cleanse the pin sites once daily.
Plans to cleanse the pin sites once daily. Rationale: The nurse should clean pin sites daily with a chlorhexidine solution using aseptic technique to reduce the risk for infection. The nurse can use 0.9% sodium chloride solution to cleanse the pin sites if chlorhexidine is contraindicated for the client. ------------------ Checks the pin sites every 8 hr for infection. The nurse should check the pin sites every 8 to 12 hr for indications of pin site loosening or of infection, such as drainage, redness, and swelling. Pins placed in areas of soft tissue have increased incidence of infection. -------------------- Administers an analgesic prior to pin care The nurse should administer an analgesic 30 min prior to performing pin care to decrease pain. The client should also receive analgesia before performing exercise, such as range of motion of unaffected joints. ---------------- Plans to cleanse the pin sites once daily. The nurse should clean the pin sites daily using chlorhexidine solution. Drainage from the pins is particularly heavy during the first 48 to 72 hr postoperatively.
