Prioritization and Delegation
A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. What is the nurse's priority intervention? maintaining nasogastric tube patency administering and monitoring parenteral nutrition testing the neonate's gag and swallowing reflex frequent endotracheal suctioning to protect the airway
maintaining nasogastric tube patency Explanation: Maintaining a patent airway is essential and requires proper gastrointestinal drainage. Maintaining the nasogastric tube is the best way to prevent the aspiration of gastric contents. Neonates should not be routinely suctioned after surgical repair for tracheoesophageal fistula, because this could injure the suture line. Parenteral nutrition may be prescribed but does not take priority over protecting the airway. The neonate will not be given anything by mouth immediately after surgery, so the ability to swallow is not a priority.
A client's laboratory results indicate hypokalemia, hyperglycemia, and increased white blood cell (WBC) count. Which newly prescribed medication should the nurse associate as most likely to contribute to these changes? albuterol (salbutamol) prednisone furosemide ciprofloxacin
prednisone Explanation: Many of the medications listed can contribute to hypokalemia, including prednisone (a corticosteroid), albuterol (a beta-2 agonist), and furosemide (a loop diuretic). Fluoroquinolone antibiotics such as ciprofloxacin can cause hyperglycemia, as can prednisone and albuterol. However, only prednisone can be linked to hyperglycemia, hypokalemia, and increased white blood cell count. The elevation in WBC with corticosteroid use is primarily due to the anti-inflammatory effects, which result in decreased adhesion of neutrophils to endothelium and an associated increase in the number circulating in the blood; it is not an indication of infection related to immunosuppressive effects of the drug.
A nurse is caring for a client with pheochromocytoma. What is the most important intervention by the nurse? promoting an environment free from emotional distress avoiding analgesia administration advising a low-calorie, high-nutrient diet avoiding parents rooming in because they make the client less dependent on staff
promoting an environment free from emotional distress Explanation: The child experiencing hyperfunctioning of the adrenal gland or pheochromocytoma has excessive epinephrine resulting in an accelerated metabolism. Symptoms include hypertension, headaches, hyperglycemia with weight loss, diaphoresis, and hyperventilation. Through provision of a low-stress environment, analgesia as needed, a high-calorie diet, and supportive parents, the child will be able to prepare for surgery to eliminate the tumor causing the hypersecretion of epinephrine.
Which client would be considered to be at the highest risk for respiratory failure? A client with breast cancer A client with cervical sprains A client with a fractured hip A client with Guillain-Barré syndrome
A client with Guillain-Barré syndrome Explanation: Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.
A nurse's initial client assessment indicates probable opioid overdose complicated by alcohol ingestion. What intervention should the nurse perform first? Administer IV fluids Administer IV naloxone Continue monitoring of vital signs Draw blood for a drug screen
Administer IV naloxone Explanation: If a client has ingested opioids, naloxone would reverse the effects and rouse the client. Intravenous fluids would most likely be administered, and this client would be closely monitored over a period of several hours to several days. The client should be screened for drugs, but results may not come back for several hours.
A male neonate has just been circumcised. Which nursing intervention is part of the initial care of a circumcised neonate? Wash the circumcised penis with warm water. Change the diaper as needed. Keep a bandage on the site for 24 to 48 hours. Apply petroleum jelly to the site for 24 to 48 hours.
Apply petroleum jelly to the site for 24 to 48 hours. Explanation: Petroleum jelly should be applied to the site for the first 24 to 48 hours to prevent the skin edges from sticking to the diaper. A gauze or other type of bandage may or may not be used. Washing the area with warm water is indicated, but is not part of the initial care.
A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? Provide reassurance that the client is safe and the voices are not real. Provide reassurance that the client is safe and promise the staff will protect the client. Assess the nature of the commands by asking what the voices are saying. Administer a neuroleptic medication before speaking with the client.
Assess the nature of the commands by asking what the voices are saying. Explanation: Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.
A new mother states, "My baby spits up after every feeding." Which interventions should the nurse teach to this mother first? Feed the baby smaller, more frequent feedings. Change the infant to a soy formula. Elevate the head of the crib to 30°. Burp the infant more frequently during each feeding.
Burp the infant more frequently during each feeding. Explanation: Frequent burping decreases the amount of air the infant has in the stomach and should be the first intervention. Feeding smaller portions more frequently may help if the infant is taking large amounts. Infants should be fed every 2 to 4 hours. Elevating the head of the bed 30° may help if the cause is gastroesophageal reflux. Formula may have to be changed if it is determined that the spitting is related to milk intolerance.
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention? Assess LOC every 12 hours. Monitor temperature every 4 hours. Decrease environmental stimulation. Encourage the parents to hold the child.
Decrease environmental stimulation. Explanation: A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry, in turn, increasing intracranial pressure. Vital signs should be assessed initially every hour and temperature monitored every 2 hours. Neurological signs should be assessed according to the child's condition, but more frequently that every 12 hours. Children are usually much more comfortable if allowed to lie flat because this position reduces meningeal irritation.
A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? Prepare to administer a whole blood transfusion Prepare to administer a plasma transfusion Perform active range-of-motion (ROM) exercise on the affected part Elevate the affected part
Elevate the affected part Explanation: Bleeding into the joint is the most common type of bleeding episode in the more severe forms of hemophilia. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor rather than whole blood or plasma, which won't stop the bleeding promptly, and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.
A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? Limit fluid intake after 8 pm. Buy well-fitting walking shoes. Elevate the feet several times a day. Wear a pair of knee-high support hose.
Elevate the feet several times a day. Explanation: Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.
A child has ingested poisonous hydrocarbons. What is the mosti mportant nursing intervention? Induce vomiting. Keep the child calm and relaxed. Administer activated charcoal. Monitor the parent-child interactions for possible child abuse.
Keep the child calm and relaxed. Explanation: Keeping the child calm and relaxed will help prevent vomiting. If vomiting is induced, the esophagus will be damaged from regurgitation of the gastric poison. The risk of chemical pneumonitis exists if vomiting occurs. Activated charcoal poorly absorbs hydrocarbons, and it tends to distend the stomach and cause vomiting. The parents should remain with the child to help keep the child calm. It is not necessary to monitor parent-child interactions for possible child abuse.
The nurse is caring for three-year-old client who has polycythemia. What is the most important intervention for the nurse to include in this child's plan of care? Encouragement of fluid intake Administration of analgesics Sodium-restricted diet Use of a soft toothbrush
Encouragement of fluid intake Explanation: Dehydration needs to be prevented. The blood of a child with polycythemia is thicker and more viscous, which leaves it prone to thrombus development. Dehydration makes the blood even thicker, leading to increased risk of clot formation. Analgesics are good to include in the plan of care, especially if the child is experiencing pain, but they will not prevent thrombus formation. A soft toothbrush is used when the child is at risk for bleeding and will not be useful in preventing thrombus formation. A sodium-restricted diet will have no effect on clotting, and is not recommended for infants and children.
The nurse is teaching the parents of a child diagnosed with celiac disease. What is the nurse's priority goal? Promote developmentally appropriate activities for the child. Stress the importance of good health in preventing infection. Introduce the parents and child to a peer who has celiac disease. Help the parents and child follow the prescribed dietary restrictions.
Help the parents and child follow the prescribed dietary restrictions. Explanation: It takes a long time to describe the disease process, the specific role of gluten, and the foods that must be restricted. Parents need to carefully read food labels to avoid hidden sources of gluten. Promoting developmentally appropriate activities for the child, stressing good health in preventing infection, and meeting a peer who has celiac disease are also important nursing considerations, but are not the priority.
What is the most important information for a nurse to teach a client with chronic obstructive pulmonary disease (COPD)? How to assess his own pulse and respiratory rates How to recognize when a change in his oxygen therapy is needed How to treat respiratory infections without the use of antibiotics How to recognize the signs of an impending respiratory infection
How to recognize the signs of an impending respiratory infection Explanation: Respiratory infection, in clients with a respiratory disorder, can be fatal. It's important that this client understands how to recognize the signs and symptoms of an impending respiratory infection. It isn't appropriate to teach this client how to listen to his own lungs or change his oxygen therapy regimen. If this client has signs and symptoms of an infection, he should contact his health care provider immediately.
A nurse caring for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease) administers furosemide. What is the priority intervention following the administration of this medication? Obtain daily weights. Obtain vital signs every 2 hours. Obtain a vision screen. Monitor electrolyte status.
Monitor electrolyte status. Explanation: Furosemide is a potent diuretic. If given in excessive amounts it can lead to a profound diuresis of water and electrolyte depletion that could lead to life-threatening arrhythmias. Input and output should be monitored along with vital signs. Furosemide can be ototoxic; therefore, hearing should be evaluated.
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first? Assist the client to get up to use the toilet. Allow the client to use a bedpan. Perform a pelvic examination. Check the fetal heart rate (FHR).
Perform a pelvic examination. Explanation: A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.
A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? Administer prescribed antihypertensive medication Prepare the client for an aortogram Administer prescribed beta-adrenergic blocker medication Prepare the client for surgical intervention
Prepare the client for surgical intervention Explanation: When the vessel ruptures, prompt surgery is required for it's repair. Antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.
A primiparous client arrives for her first prenatal visit at 10 weeks' gestation. The client seems nervous and has many questions. What is the most important intervention by the nurse? Provide the client with reading material for newly expectant mothers. Ask the client to undress to prepare for the physical examination. Reassure the client that all her questions will be answered during the visit. Tell the client not to worry, because the health care provider will take good care of her.
Reassure the client that all her questions will be answered during the visit. Explanation: The nurse has made the observation that the client requires reassurance and should attempt to establish a positive nurse-client relationship. Providing initial reassurance helps set the client's mind at ease. Offering reading materials will not help develop this relationship. Asking this client to immediately disrobe does not address her concerns and could make the client more nervous. Telling a client "not to worry" is dismissive. The client should be treated as a partner in her care rather than being told that her health care provider will take care of everything.
A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? The leg in traction is kept externally rotated. The weights are allowed to hang freely over the end of the bed. The UAP instructs the client to perform ankle rotation exercises. The UAP lifts the weights while assisting the client as he moves up in bed.
The weights are allowed to hang freely over the end of the bed. Explanation: In Buck's traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment.
A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request? Assess the child's pain by asking the child to rate the pain on a 1 to 10 scale. Prepare to administer the ordered pain medication. Use the Faces Pain Scale to assess the child's degree of pain. Document the report of pain, and note the time of the last pain medication.
Use the Faces Pain Scale to assess the child's degree of pain. Explanation: The nurse should assess the client's pain level using the age-appropriate Faces Pain Scale. After the pain assessment, the nurse should determine the time previous pain medications were administered and medicate accordingly.
The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN? passing dinner trays emptying a Foley catheter bag administering daily am medications suctioning a client who is 1-day postoperative following a tracheostomy
administering daily am medications Explanation: LPNs should be assigned higher level skills in stable, predictable situations. Lower level custodial skills should be assigned to UAP. A new tracheostomy may be unstable. The task of suctioning should be retained by the RN.
A nursing student asks a nurse how to manage the morning assignment prior to breakfast. The nurse responds with prioritizing the needs of the clients and time management for safe care delivery. What should be the nurse's priority action(s) at the start of the shift? Select all that apply. assessing a client prior to scheduled physical therapy appointment administering all medications prior to breakfast following the room order to assess clients obtaining the client's vital signs prior to breakfast applying a new ostomy appliance
assessing a client prior to scheduled physical therapy appointment obtaining the client's vital signs prior to breakfast Explanation: The nurse will assess a client prior to a physical therapy appointment to be sure that the client is able to participate in the therapy session. The nurse will also need to obtain vital signs to begin assessments at the beginning of the shift. If the nurse administers all medications prior to breakfast, there may be food interactions with some medications. If the nurse follows the room order to assess clients the nurse may not be safe and client care is not prioritized. The nurse may not have time to change the ostomy appliance as well as complete a five-client assessment prior to breakfast.
A nurse is developing a care plan for a family with a member who has anorexia nervosa. What is the most important information for the nurse to include? coping mechanisms that have been used in the past concerns about changes in lifestyle and daily activities rejection of feedback from family and significant others appropriate eating habits and social behaviors centering on eating
coping mechanisms that have been used in the past Explanation: Examination of positive and negative coping mechanisms used by the family in the past will allow the nurse to build a new care plan specific to the family's strengths and weaknesses. The way this family copes with concerns is more important than the concerns themselves. Feedback from the family and significant others is vital when building a care plan. Eating habits and behaviors are symptoms of the way people cope with problems.
The nurse in the emergency department is caring for a 12-year-old child with full-thickness, circumferential burns to the chest who has difficulty breathing. What is the priority intervention? chest tube insertion escharotomy intubation needle thoracentesis
intubation Explanation: Intubation is performed to maintain a patent airway. Escharotomy is a surgical incision used to relieve pressure from edema. It's needed with circumferential burns that prevent chest expansion or cause circulatory compromise. Insertion of a chest tube and needle thoracentesis are performed to relieve a pneumothorax.
