Unit 3: Management of care

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which is the priority intervention?

Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.

The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client?

Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Whenever possible, interpreters should be used to communicate with clients who do not speak English. If none is available, however, it may be necessary to have a family member translate. It would be unsafe to put off an emergency assessment pending the arrival of an interpreter.

A client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When can the health care team begin rehabilitation for this hospitalized client?

on admission the hospital

A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant?

altered nutrition (less than body requirements) related to difficulty sucking The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones.

The registered nurse (RN) must assign an unlicensed assistive personnel (UAP) to help care for an oncology client who is on neutropenic precautions. Which factor is most important in making this assignment?

The UAP has had cold symptoms for the last 2 days. The multidisciplinary team, in collaboration with the client and family, must take precautions to protect the patient from infection by following various infection-prevention practices. It's critical to teach the client and family evidence-based practices that support hand hygiene, dietary management, environment management, and medication use to prevent a life-threatening infection. Visitors or staff with potentially communicable diseases should not enter the neutropenic client's room. Pregnancy, fear, or inexperience do not exclude staff members from the assignment.

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse-manager would take which step to meet the needs of the staff?

Contact the institutional ethics committee for strategies. The institutional ethics committee can help the staff develop strategies to resolve their ethical dilemma. The Patient's Bill of Rights states that the client (not the family) has the right to make decisions about the care plan and to refuse recommended treatment. Arranging a meeting with the client's family is inappropriate, whether or not they are in agreement with the client's wishes. Assigning only nurses that agree with the client's wishes is not a reasonable staffing option. Talking to the client about their concerns is inappropriate as it takes the focus away from the client.

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do?

Allow the client to see and hold the baby for as long as she desires. The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the health care provider and social worker.Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client.Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby.Contacting the health care provider for advice related to the client's visitation is not necessary.

The client presents at the clinic but does not speak the same language as the nurse. What actions by the nurse are most appropriate? Select all that apply.

When using an interpreter, talk to the client, not the interpreter. Use a trained medical interpreter to communicate. When using an interpreter, obtain feedback to be sure the client understands. The nurse should use a trained medical interpreter who understands the client's rights. When interviewing the client, the nurse should speak directly to the client, not the interpreter. The nurse should always obtain feedback to ensure the client understands. The nurse should not try to serve as an interpreter because this could lead to misunderstandings, and the nurse should use a family member only as the last choice. Never use another client as an interpreter, as this would be breaking rules of confidentiality.

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

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

A nurse on a neurologic unit is working on performance improvement with a stroke-management team. The nurse identifies a gap between the time a client enters the emergency department (ED) and the time that client is admitted to the intensive care unit (ICU) for aggressive treatment. The nurse's meeting with the team to develop a change strategy using indicators. Which statement by a team member indicates a need for further teaching regarding performance management?

"We can discipline the ED staff for not getting the clients to the ICU fast enough." Using statistics and other indicators, such as ED staffing information, to develop a change strategy is part of performance management. Disciplining staff doesn't reflect a strategy based on indicators. Collaborating with staff from other areas results in performance improvement, not performance management.

A palliative care nurse is caring for a client with end stage pancreatic cancer who is reporting severe pain. The healthcare provider orders morphine sulfate 4mg IV stat followed by morphine sulfate 2mg IV q 1h prn pain. The drug available in a multidose ampule of 2mg/mL. How many mL does the nurse administer for the initial dose? Record your answer as a whole number.

2 The ANA Code of Ethics for Nurses provision 3 states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. This is crucial during medicating a palliative client. The initial dose ordered is 4 mg. The dose available is 2 mg. The quantity is 1mL. It is a multiple dose vial. 4mg/2 mg x 1 mL = 2 mL using the (dose ordered/units) x quantity method.

A client with a history of cardiac problems reports severe chest pain. What should be the nurse's first response?

Assess the client's pain. The nurse's first response is to further assess the client's pain. After a thorough assessment, additional appropriate actions may be to notify the HCP, administer an analgesic, and administer oxygen.

A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. What should the nurse do?

Be aware of personal opinions and views. The nurse must be aware of personal opinions and views when caring for clients with psychosexual disorders. The care plan for the client will be developed to manage both the depression and the pedophilia. It is not necessary to restrict the client's interactions with others on this adult mental health unit. The health care provider (HCP) will determine the type of therapy that will be most appropriate for this client.

The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours?

Client 4, Client 3, Client 2, Client 1 It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse best demonstrates the role of the nurse as a client advocate?

Communicate the client's wishes to the healthcare provider. Nurses advocate on a client's behalf when a change needs to be made in the plan of care. Communicating the client's wishes to the healthcare provider is the best example of client advocacy. Nurses must act as advocates even when they disagree with the client's decisions, so the nurse would not encourage the client to continue with medical treatment. Asking the client what lead to the decision may influence the client's decision. Informing family members of the decision violates the client's right to privacy.

The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart (see third column). The nurse compares these findings to the Apgar score determined by the findings recorded at birth (see second column). What should the nurse do next?

Continue to assess the neonate. The neonate's Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is needed since the color is improving, and stimulating the baby is not necessary as the baby is now flexing the extremities.

A client has been receiving chemotherapy for cancer treatment. The client is competent and has been actively involved in decisions regarding care; however, the client has now decided to refuse treatment. What should the nurse do when the client refuses the next dose of chemotherapy?

Document the client's choice and offer to discuss feelings about the chemotherapy. The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the client not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking). The other options do not allow for client choice or consent.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. What should the nurse do?

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.

The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). What action should the nurse take first?

Notify the health care provider (HCP). The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the HCP immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the first action is to notify the HCP. Placing the child in a prone position will not relieve the herniation or release the arching.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action?

Notify the provider of the pain and request an assessment for potential abruption. The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse should be to ensure that this client is further evaluated by her HCP. Subsequent actions could include assisting with pain control measures, assessing contractions, and checking cervical dilation.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention?

Remove inner cannula and clean using universal precautions. When tracheostomy care is performed, sterile technique is used and standard precautions are not enough. The presence of an inner cannula provides direct access to the lungs for organisms, so sterile technique must be used to decrease the risk of infection. All other steps are appropriate.

The nurse is caring for a client with a fractured fibula who has skeletal traction and skeletal pins. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately?

The traction weights are resting on the floor. The weights should always hang freely. When the weights are on this floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. Attending to the weights may reduce the client's pain and spasm. Skeletal pins usually have a small amount of clear fluid. It is most important to check the traction system after a client changes position, because position changes may alter the traction.

A nurse is prioritizing care for four new admissions to the inpatient psychiatric unit. Which client should the nurse assess first?

a client with new-onset confusion and disorientation. New-onset confusion may be a sign of delirium, which is commonly caused by medications and systemic infection. This client may need urgent medical evaluation. The other clients all need to be assessed, but they aren't the highest priority.

A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first?

a health care provider The client is exhibiting signs of hypothyroidism, which includes hair loss, pain, fatigue, and increased sensitivity to cold. Hypothyroidism may be impacting the client's mood, ability to concentrate, physical sensations, and energy levels. Resolving potential biological causes of her symptoms takes priority over rehabilitation strategies or psychological approaches.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status. A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client cannot make those choices. The living will and health care proxy are both examples of advance directives. A living will is a document that a competent adult prepares and that provides direction regarding medical care if the client becomes incapacitated. A health care proxy is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel?

an 8-month-old with pneumonia who will be discharged today The most appropriate client to assign to unlicensed assistive personnel would be the infant who is stable. Registered nurses have the responsibility for assessment, evaluation, and making nursing judgments. Unlicensed assistive personnel can care for a client with pneumonia who will be discharged because this child is stable.The child with a fractured femur, the adolescent with fluctuating vital signs and a new central line, and the infant who recently underwent surgery should be cared for by a registered nurse who can make appropriate judgments and perform required procedures.

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.

A nurse manager of the pediatric unit is responsible for making sure that each staff member reviews the unit policies annually. What policy should the nurse manager emphasize with the clerical support staff?

logging off a computer containing client information All members of the healthcare team are required to maintain strict client confidentiality, including securing electronic client information. Therefore, the clerical support staff should be instructed about the importance of logging off a computer containing client information immediately after use. Taking a verbal order, administering medications, and client education aren't within the scope of practice of the clerical support staff.

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.

older adult client who had hip replacement surgery and needs to walk in the hall with a walker adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?

pulse deficit The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the difference between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of what? Select all that apply.

the client's agreement to the plan of care freedom from coercion discussion of pertinent information Discussion of pertinent information, the client's agreement to the plan of care, and freedom from coercion are important factors in informed consent. Caregiver preference and opinion could be perceived as coercion. Informed consent does not require verification from next of kin.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

to ensure efficient and accurate communication to prevent medication errors to ensure client safety Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

A nurse is discussing verbal orders with the charge nurse. Which statement made by the nurse indicates understanding of verbal orders? Select all that apply.

"I can take a verbal order from the health care provider if a client experiences cardiac arrest." "I can take a verbal order from the health care provider if a client who is in respiratory distress is being intubated." "I can take a verbal order from the health care provider if my client is unresponsive and has bradycardia." The nurse can take verbal orders if a client is unresponsive and has bradycardia, if a client is being intubated because of respiratory distress, or if a client experiences cardiac arrest. These are emergency situations. The nurse cannot take a verbal order because a health care provider is being paged to another unit, if the health care provider walks into a client's room and gives the nurse a verbal order, or if the client needs an extra dose of furosemide because the client's weight is up from the previous day. These are not emergency situations.

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

"I'm grateful that you're satisfied with the care you're recieving, but I can't accept any form of gift." Because the nurse is in a position of power, it would be an abuse of power to accept the gift; specifically, it would be considered financial abuse. This is also true of non-monetary gifts. Asking the client to speak to the manager on the nurse's behalf is unprofessional.

The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate?

"What are your plans for when you get home and back to getting on with your life?" When preparing the client for discharge, the nurse investigates the client's understanding of the teaching and readiness for discharge by asking open-ended questions when possible. Closed questions such as "do you remember" could result in a "yes" response. Instead, the nurse reframes the client's comment while gathering more information about what activities may be planned and engages the client further depending on the response. The nurse should not lecture the client about lifestye changes or simply praise the client for having a positive attitude.

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse?

Ask the family to identify a spokesperson to be the communicator with the team. In situations with large extended families where frequent updates are required or the state of the child is critical, it is imperative that a spokesperson be identified for receiving information and for disseminating the information to the extended family members.

A physical therapist has instructed the nursing staff on how to perform range-of-motion (ROM) exercises for an infant with torticollis. The nurse is uncomfortable when the infant cries and grimaces during the exercises. What is the most important action for the nurse to take?

Call the physical therapist. The only cure for the torticollis is exercise or surgery. The physical therapist is the expert in exercise and should be called for assistance in this situation. The primary health care provider should only be called if there is concern over the orders written, or an abnormal development in the child.

The nurse is reconciling the medications with a client who is being discharged. Which information indicates there is a "discrepancy"?

There is lack of congruence between a client's home medication list and current medication prescriptions. The medications prescribed for, administered to, or dispensed to the client while under the care of a health care organization are compared to those on the list, and any discrepancies (e.g., omissions, duplications, potential interactions) are resolved. A complete list of the client's medications is communicated to the next provider of service when a client is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization. The complete, accurate list of medications is also provided to the client on discharge from the organization. The next provider of service checks the Medication Reconciliation List again to make sure it is accurate and in concert with any new medications to be prescribed.

The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"?

declined assignment to care for a client with dementia who was incontinent of stool The duty to care in nursing refers to the ethical obligation that nurses have to their clients. Nurses can refuse to care for clients on several grounds such as moral conflict, feeling unsafe, or lacking the skills needed to safely deliver care. The nurse cannot refuse care based on the client's health concerns. Falsifying medical records is a breach of the ethical duty to be truthful and accurate in communications. Sharing information on social media breaches the nurse's ethical duty to protect client confidentiality. Making a medication error is a question of competence related to this skill rather and is not related to the duty to care.

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client?

registered nurse (RN) with 2 years of experience Because this client requires frequent neurovascular assessments, an RN with experience would best receive the client. A registered practical nurse/licensed practical or vocational nurse, although experienced and capable of collecting data, would not be receiving the client and report from the operating room as skilled assessments are necessary. The registered nurse who just finished orientation would best assist the registered nurse and be assigned a more stable client at this time. The charge nurse needs to be available to direct the care of other clients and management of unit.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?

Check the computerized care plan to determine what test was scheduled. Glulisine is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's HCP; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take?

Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment. The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the pediatric nurse's nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if the nurse doesn't have the skills to plan and deliver care.

A young adult is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?

The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client's fiancée cannot sign the consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The HCP should insert the catheter in this emergency. He does not need to get a consultation from another HCP. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin.

Which family should the nurse determine as most in need of follow-up?

a single parent with a toddler who has third-degree burns over 20% of the body Toddlers receive burns usually as the result of not being closely supervised. Toddlers are very inquisitive and need constant supervision; therefore, close follow-up is necessary. In addition, the child probably will need some type of wound care requiring involvement of the parent and possibly others. The amount of support available to the single parent of the 7-month-old child is not known. Although immunization schedules need to be adhered to, it is very possible for a 7-month-old to be delayed in receiving immunizations because of illness or other conflicts. An automobile accident can happen to anyone and does not indicate a lack of safety or supervision. A history of caustic liquid ingestion in a foster child may have been from a time before the child began living with the foster parents; it does not indicate a lack of safety or supervision.

A client is being treated in the emergency department for a leg wound and has been impatient about the wait. The nurse explains how the triage process works and the importance of being assessed. The client tells the nurse, "I am not waiting around here any longer. My leg is fine." What is the best response by the nurse?

Notify the healthcare provider of the client's intent to leave. When a client wants to leave a facility, they are legally free to do so, even though such actions carry an increased risk for problems. The nurse has already attempted to explain the importance of staying, so the next step would be to notify the healthcare provider who should then reinforce the need to stay for an evaluation. If the client continues to voice the desire to leave, the client should sign a form that releases the healthcare provider and facility from any legal responsibility for the client's health status. Alerting security is inappropriate. Administering a sedative is inappropriate at this time.

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?

Acute pain A nurse must collaborate with a physician to achieve the best pain control for the client. A nurse may not give medications, such as analgesics and antibiotics, without a physician order, and the nurse assesses the client's response to pain medications and provides feedback to the physician. The nurse may assist the client with nonpharmacologic activities for pain control. The nurse may implement independent nursing interventions, such as performing assessments, providing appealing fluids, pacing nursing care to promote rest and minimize client fatigue, and providing small frequent meals to address Risk for imbalanced fluid volume, Activity intolerance, and Imbalanced nutrition.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place. Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.

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

Remove the clients to separate areas and set limits Setting limits and removing the clients from the situation are the best ways to handle aggression. Reminders of appropriate behavior are not likely to be effective. Seclusion and restraints are reserved for more serious situations. It is inappropriate for the nurse to provide a demonstration at this time.

A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent. The surgeon can take responsibility for consent in this situation because the condition is life (and limb) threatening and delaying the surgical treatment would have a negative impact on the client. The other options would delay the life-saving surgery and would result in negative outcomes for the client. The hospital chaplain has no authority to sign a consent form on behalf of the client.

The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately?

a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria The nurse should refer the preeclamptic client with 3+ proteinuria to an HCP. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks' gestation with insulin-dependent diabetes and who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until she can obtain an appointment with the care provider. The client at 10 weeks' gestation with nausea and vomiting and +1 ketones should also be seen by an HCP, but at this point, although this client is uncomfortable, her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy, and this would not be considered a problem that requires immediate referral to an HCP.

When developing a discharge plan with a client with chronic obstructive pulmonary disease (COPD), what information should the nurse include in the plan?

develop respiratory infections easily. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP?

Reassign the UAP to a client requiring basic tasks that the UAP has mastered. The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.

The standards of practice in the Nurse Practice Act describe duties of nursing practice according to the nursing process. What are client examples of the evaluation standard of a registered nurse? Select all that apply.

The client consumed 75% of the evening meal after surgery. The client's pulse oximetry was >97% after ambulating in the hallway. The client's pulse oximetry is >97% after ambulating in the hallway and the client consumed 75% of the evening meal after surgery are standards of practice in the evaluation component. The client's blood pressure is 180/58 mmHg, the client experienced shortness of breath, and the client voided 275 mL of clear amber urine are assessment standards.

A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's child asks if the hospital can "treat the sore." What is the nurse's best initial response?

"We will collaborate with the physician to obtain an order for the wound care nurse to see the client." As a member of the health care team, the nurse should initiate collaboration between other team members. She will need a physician's order to establish contact between the client and the wound care nurse. After the client's admission to the acute care facility, the physician must provide orders for referrals and consultations with the services the client needs. The nurse should respond in a therapeutic way that conveys a commitment to helping the client, knowing it cannot be done alone, but with a collaborative effort from all members of the health care team. Assuming that the client will need debridement would not be appropriate to state at this time, nor should the nurse respond in a way that implies only the nurse will take care of the wound. It should be conveyed that all nurses using a collaborative approach with other health professionals will manage the wound care.

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the mostappropriate response by the nurse?

"You have a right to withdraw consent. Can you share more about your decision?" The nurse understands that a client must give consent for a procedure and may withdraw that consent if the client chooses. This answer demonstrates that the client's change of decision is worth exploring. Indicating that the client can have the tube removed afterwards does not respect the current request. Leading the client by assigning the decision to fear is not as helpful as having an open-ended approach. Simply accepting the decision without exploration of the client's feelings is negligent communication by the nurse.

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding. Jaundice that appears before 24 hours of age is considered pathologic. Jaundice appears when bilirubin levels reach 5 to 7 mg/dL (85.5 to 120 μmol). The health care provider should be notified for intervention to prevent kernicterus. This disease process can cause lifelong central nervous system damage. Disregarding the finding or waiting to report the finding will delay treatment and potentially cause permeant harm to the infant. Providing an extra feeding will have no effect on the hyperbilirubinemia that is causing the jaundice.

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to his child declared legally incompetent. Which response by the nurse is most therapeutic?

"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.

A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?

Request information about nursing responsibilities in caring for a client with a pump. Taking the initiative to gain new information relevant to client care as well as expressing a desire to support the unit's needs is an appropriate and professional nursing response. Refusing the assignment is inappropriate because the nurse isn't taking any initiative to learn about the pump. Refusing to care for the client until the nurse receives training is inappropriate; the nurse should gather information and evaluate the client before refusing to provide care. Accepting the assignment doesn't address the issue of lack of knowledge and may put the nurse or the client in jeopardy.

A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the mostimportant for the nurse to consider?

incompatibility between the child's history and the injury Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. For example, the child may have a skull fracture but the parents state that the child fell off of the sofa. The other criteria also may suggest child abuse but are less reliable indicators.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply.

The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The nursing instructor can be liable if the assignment is above the student's competency. Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students can practice as employees during an educational clinical experience. Students are responsible to be familiar with hospital policy and procedures.

A client who has type 1 diabetes is being prepared to have a craniotomy. The nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which statement from the client indicates that the nurse needs to contact the surgeon for further communication with the client?

"There are no major risks from this surgery." There are risks with both the surgical procedure and the general anesthesia required for a craniotomy. The risks involved in the procedure are a part of the informed consent. Other information that is part of an informed consent includes potential complications, expected benefits, inability of the surgeon to predict results, irreversibility of the procedure (if applicable), and other available treatments. Talking about the effects of the diabetes on healing, explaining how the craniotomy is performed, and explaining the consequences of declining treatment (e.g., death if the tumor is not removed) represent appropriate actions to provide information to the client.

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:

ask to see a copy of the advance directive. To have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.

A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer?

Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. The registered nurse should use the ancillary staff to help effectively manage the group of clients. While the registered nurse accepts the client from the ICU, the nursing assistant can provide care for the clients, and the LPN can administer the remaining medications. Telling the ICU to wait or notifying the supervisor that they must assist are incorrect options because the nurse should assess the situation and use the ancillary staff appropriately. The nurse has adequate staff to safely provide care for this group of clients. The nurse shouldn't administer medications quickly because haste is an unsafe practice that could lead to a medication error. Instead of rushing, the nurse should delegate the responsibility to the LPN.

A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next?

Call for and hang the first client's blood transfusion. When two clients are to receive blood at the same time, the nurse should call for and hang the clients' transfusions separately to avoid error. The nurse should call for and hang the first client's blood first because this client has experienced a change in blood pressure over a short period of time. The nurse should next call and hang the second client's blood transfusion as there is no indication that this client is unstable at this time. The nurse should not call for both units of transfusions at the same time due to the increased risk of misidentification. The nurse should not verify compatibility of both units at the same time due to the increased risk of misidentification. It is not necessary to involve two nurses because the second client can wait until the nurse has time to hang the blood.

The nurse-manager on the oncology unit wants to improve documentation of the effectiveness of analgesia medication within 30 minutes after administration. What should the nurse-manager do first?

Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts. To determine the cause of this problem, a quality improvement study should be conducted along with a chart audit. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Changing the time to chart from 30 minutes to 45 minutes does not solve the problem. It is not the pharmacist's role to provide consultation about documentation of drugs administered by nurses. Consulting the evening nurses may be helpful, but this is a systems issue of the entire unit and involves every registered nurse (RN) administering analgesia.

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN?

a 72-year-old client with diverticulitis The client with diverticulitis will need care that the LPN should be able to provide safely.The client with angina is unstable and requires a registered nurse for continuous assessment.The client receiving chemotherapy treatment requires a registered nurse who is certified in chemotherapy administration.A child with Kawasaki's disease must be watched closely for cardiac complications, and it would be best to assign the child to an experienced pediatric nurse, not a new graduate.

A client asks the nurse to help make out a will. What should the nurse tell the client?

"You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer you can call?" A will is an important legal document. It is best to have one prepared with the help of an attorney. It would be unwise to help the client or to seek another nurse's help because a nurse is not a lawyer. Asking the client to delay preparing the will just avoids the problem.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?

Contact the nurse educator for an in-service and support in performing the skill. The nurse has a responsibility to recognize limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide in-service and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in learning or expertise.

The nurse is reviewing the chart of a postoperative appendectomy client with a history of opioid use disorder. The above documentation is noted in the history section. Which adjustment in the plan of care on the surgical floor is a nursing priority to best ensure client safety?

Evaluate the client's pain level every 2 hours. All are options for an adjusted plan of care; however, careful consideration of pain management is most necessary for the postoperative client who has an opioid use disorder. Anxiety is common, and the client may fear that pain management options may be ineffective. It is most important to evaluate the client's pain more frequently because pain is expected in the postoperative period. Pain management is adjusted to nonopioid options and interventions such as client positioning, distraction, and other nonpharmacological options as soon as possible.

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

Give the furosemide dose to the client. The potassium level is within normal limits and the nurse should administer the medication as prescribed. Administering half the furosemide dose, notifying the healthcare provider, and withholding the furosemide is not necessary as the laboratory value is safe.

A client with a history of type 1 diabetes is admitted to the hospital with community-acquired pneumonia. The client's blood glucose level in the emergency care unit was 576 mg/dl (31.97 mmol/L). The physician orders an I.V. containing normal saline solution, an insulin infusion, and I.V. levofloxacin. The nurse piggybacks the insulin infusion into the normal saline solution. The nurse questions whether piggybacking the levofloxacin into the same I.V. line is appropriate. Which health team member should the nurse collaborate with to check the compatibility of these solutions?

the pharmacist covering the floor The nurse should collaborate with the pharmacist covering the floor for drug compatibility information. The physician ordering the drug, the experienced coworker, and the infectious disease nurse aren't experts in drug compatibility issues.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing?

caring for the same child from admission to discharge Primary care nursing requires that the primary nurse care for the same child (to whom the nurse is assigned) during a scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?

development of an increase in mobility This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.

A 15-year-old primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be mostappropriate?

"I'll bring the baby to you for feeding." After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The health care provider (HCP) does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.

A scrub nurse in the operating room has which responsibility?

handing surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and reports have been received about each of these clients. To provide the safest care and bestmanage time, the nurse should plan to see which client first?

a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid The client at 42 weeks' gestation is the greatest concern, and the nurse should make rounds on this client first based on the length of the pregnancy and the green color of the amniotic fluid. Bloody show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic fluid indicates that fetal distress has recently occurred to the point that the fetus had a bowel movement in utero. This occurrence, along with the 42-week gestation, places this fetus at greatest risk. The nurse can see the primipara in active labor at 5-cm dilation last; this client is in pain, but nothing about her situation indicates anything but a normal labor process, and as a primipara, her labor process will be slow. The client who is completely effaced, 8-cm dilated, and at +2 station is also a primipara, and thus will move through labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected situation as a laboring client enters transition. The client with no prenatal care is a cause for concern because the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of mild preeclampsia, but there are no other indications of worsening preeclampsia, such as headache, visual disturbances, or epigastric pain.

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?

initiating caloric and nutritional therapy as ordered A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.

A nurse is caring for a 9-year-old child who has a grave prognosis after receiving a closed injury from being struck by a car. Which health team member should approach the family about organ donation?

transplant coordinator The transplant coordinator is the best health team member to approach the family about organ donation. The transplant coordinator is typically available to hospitals that routinely perform organ transplants. When the coordinator isn't available, the attending physician or another physician not directly involved in determining brain death should approach the family. Although the emergency department nurse may have admitted the child, she and the nurse-manager aren't directly involved with the child's care or with the family. Pastoral care staff members provide emotional and religious support and aren't involved with approaching the family about organ donation; they may, however, be present in a supportive capacity if the family wishes.

A nurse is caring for a newborn of a mother who is positive for group B streptococcus (GBS). Which interventions will the nurse include in the infant's plan of care? Select all that apply.

Monitor for temperature instability. Assess for signs of respiratory distress. Watch for apnea lasting longer than 20 seconds. GBS can be transmitted from the mother to newborn during birth; this can result in the newborn developing septicemia. The newborn will be kept 24-48 hours to monitor for development of a GBS infection. Signs of GBS infection are similar to respiratory distress accompanied by temperature instability. Apnea lasting 20 seconds or longer may also indicate infection. The first bowel movement is unrelted to GBS infection.

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

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies. Physical needs are met first, and then the determination of the existence of abuse will wait until the client's physical condition is stable. It is the duty of the nurse to tell the client the truth about what will happen and to support the client should not be turned away for telling a lie. A nurse should not tell the client that a secret will be held, as the client or another person may be put in danger if the abuser is not stopped.

A nurse is planning care for a hospitalized school-age child and is delegating care to a pediatric care assistant. When a nurse delegates a task to an unlicensed assistive personnel (UAP), which factor is most important?

The task is appropriate for that individual's preparation. Tasks that the UAP can undertake vary greatly. The nurse must be aware of the scope of the UAP's preparation and the policies of the health care agency. The important consideration is that the task is appropriate for that individual and is within the guidelines for practice at the health care agency. The UAP can perform complicated tasks within the scope of the preparation. Although the nurse observes the UAP and evaluates the UAP on his or her ability to perform the task, the most important aspect of delegation is to delegate within the UAP's educational preparation. A positive relationship with clients, while desirable, is not essential to delegation. Delegation involves giving clear directions and following up after the task has been delegated.