The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.
A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?
A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device.
The physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, the nurse identifies which of the following as an intestinal tube?
A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. A Levin tube and a Salem sump tube are nasogastric tubes.
A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this n
The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained. The nursing supervisor can guide the pediatric nurse as to the tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the nurse's
A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn't volunteered and states, "Forty hours a week of nursing is all I can manage to do. I
It's discriminatory and punitive for the nurse-manager to alter the staff nurse's schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention would help meet this goal?
Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the be
A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and ask
The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine wheth
The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When the nurse-manager receives word of a bomb th
In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client
A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?
In rheumatic fever, the joints may be so painful that even the weight of the bed linens can cause pain. A bed cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased when the affected joint is moved; therefore, passive ra
Which strategy can help make the nurse a more effective teacher?
An effective teacher always involves the student in the discussion. Using technical terms and providing detailed explanations usually confuse the student and act as barriers to learning. Using loosely structured teaching sessions permits distractions and
A client who's a member of the Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?
The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal.
When approaching a family for organ or tissue donation, the nurse should keep in mind which guideline?
The family should be offered an opportunity to speak with an organ procurement coordinator. An organ procurement coordinator is knowledgeable about the organ donation process and should have exceptional interpersonal skills for dealing with grieving famil
A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?
Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority because it aids healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the ur
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
All of these tests help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.
Standard precautions were designed for the care of all clients in hospitals, regardless of their diagnosis or infection status. Guidelines for standard precautions include:
Disposing of sharp instruments in an impervious container is included in the guidelines for standard precautions. Used needles are never recapped; they should be disposed of in a sharps container. Gloves are used if contact with body fluids is anticipated
A client suddenly loses consciousness. What should the nurse do first?
The nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpat
A day shift nurse gives a client a medication injection for pain. The nurse forgets to document the injection on the medication administration record (MAR). The day shift nurse reports to the evening shift nurse that she gave the client 4 mg of morphine a
This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day shift
Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance?
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a th
To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?
The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front be
The nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
When a child with celiac disease is placed on a gluten-free diet, fat, bulky, foul-smelling stools should be eliminated. This indicates that the disease is controlled and the child is utilizing nutrients effectively. Taking vital signs, measuring blood ur
A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best assist the staff nurse?
The nurse-manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several clients with multiple problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrat
A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?
Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful whe
The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother would indicate understanding?
A child with celiac disease must eat a gluten-free diet. If foods containing gluten are eaten, changes occur in the intestinal mucosa that prevent the absorption of foods, especially fats. Therefore, all foods containing wheat, rye, oats, and barley must
The nurse-manager of a 20-bed coronary care unit isn't on duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the accountability of the nurse-manage
The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. The other choices don't accurately reflect the accountability of the nu
A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, the nurse will:
Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.
The nurse is assigned to a client with a cardiac disorder. When monitoring body temperature for this client, the nurse should avoid which route?
When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for me
Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
Because of lethargy, the posttonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler, supine, and high-Fowler positions don't al
Which procedure or practice requires surgical asepsis?
Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V.
When discussing the Food Guide Pyramid with a 75-year-old client, the nurse should remember that the guide has been modified for older people. Unlike the standard Food Guide Pyramid, the version for elderly individuals:
The Food Guide Pyramid version for older people adds a base that includes eight 8-oz glasses of water to prevent constipation and dehydration. The pyramid sets no upper limits on servings of most food and water. It doesn't increase the milk and dairy reco
A client with a history of heart disease is scheduled for cataract surgery when he tells the nurse that he's experiencing chest discomfort and shortness of breath. The nurse administers a nitroglycerin tablet sublingually as ordered by the admitting physi
The nurse has a responsibility to assess and monitor clients who are under the nurse's care. Nurses also have a responsibility to communicate with interdisciplinary health care members particularly if the client's status changes. In this case, the change
During discharge teaching, a client with a fractured toe asks the nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?
Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. The other options are inaccurate descriptions of the effects of ice application.
A client has suffered an extensive brain injury and can't make his own treatment choices. Which written document is recognized by state law and provides directions for provision of care at a time when the client can't make his own choices?
An advance directive is a document written or completed by the client and used by a facility to provide care at a time when the client can't make his own choices. The living will and durable power of attorney are both examples of advance directives. A liv
A client's blood test results are as follows: white blood cell (WBC) count is 1,000/?l; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal would be most important for this client?
The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
The care plan is revised for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan include early in this mother's hospital stay?
Assessment of the mother's strengths and weaknesses in her coping mechanisms and the presence or absence of support systems is important in the implementation process. Assessment will also help identify situations that the mother perceives as stressors. P
The managers of the physical and occupational therapy neurologic departments have expressed concern to the nurse-manager of an adult neurologic rehabilitation unit that clients have been arriving late for therapy. In response, the nursing staff of the reh
In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The manager, however
A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.
When changing a sterile surgical dressing, the nurse first must:
To prevent the spread of microorganisms, the nurse always should wash the hands before providing client care. When changing a sterile surgical dressing, the nurse also must apply sterile gloves, remove the old dressing with clean gloves, open sterile pack
The nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:
Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collecte
A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention?
Interventions should address the etiology of the client's problem � poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition but doesn't address poor coughing. Improving airway clear
During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective in destroying the hepatitis B virus.
A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit's decision-making process and helps them improve their clinical skills. This nurse is functioning effectively in which rol
A leader doesn't have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager has formal power and authority from the sta
The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which of the following meals as high in protein?
Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides pr
Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?
Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the
The nurse is preparing to boost a client up in bed and instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take would be to:
The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense has been broken when the blisters opened; removing the ski
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important?
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client
The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by:
Air leaks commonly occur if the system isn't secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage � not to prevent air leaks. The head of the bed may be elevated to promote dr
The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The other options don't enable communication. The physician must order a tracheostomy plug,
Delegation is the process of transferring work to subordinates. A nurse-manager can appropriately delegate which task?
Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.
Four clients injured in an automobile accident enter the emergency department at the same time and are immediately seen by the triage nurse. The nurse would assign the highest priority to the client with the:
Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate
Which of the following clients would qualify for hospice care?
Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's
Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true?
Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap dispensers are pr
The nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
Sodium, the major cation in the ECF, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involv
Which nursing theorist addressed self-care deficits in her nursing theory?
Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as
When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction?
The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenail
A 66-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which of the following statements would be the nurse's best response?
Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
A severe winter storm has prevented most of the staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. The nurse-manager must dec
Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system requires the least staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited numb
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?
Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mas
The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
The client should be encouraged to consume foods high in vitamin C because it's essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for
The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse plan to emphasize?
Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes
Which guidelines define and regulate the scope of the nursing professional practice (that is, set rules on what the nurse can and can't do as a professional)?
The Nurse Practice Act is a series of statutes, enacted by each state legislature, that outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. Nurse practice acts set educational requireme
A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do?
If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for a
Which is the role of the nurse in a domestic abuse situation?
The nurse must carefully and adequately document the assessment of the abused victim. The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The victim s
Which group of clients is at an increased risk for developing a wound infection?
Nutrition plays an important role in wound healing. Vitamins and protein are essential for wound healing; therefore, a malnourished client is at an increased risk for developing a wound infection. Frequent pain medication allows the client to be more comf
A client with heart failure must be monitored closely after starting diuretic therapy. What is the most accurate indicator of this client's status?
Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the most accurate indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate
Which nursing action is essential when providing continuous enteral feeding?
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should
Which statement is correct regarding the Omnibus Reconciliation Act of 1986?
The federal Omnibus Reconciliation Act of 1986 mandates that all hospitals establish written protocols for the identification of potential organ and tissue donors. The act sets standards for organ procurement agencies. The medical examiner should be notif
Which assessment finding by the nurse contraindicates the application of a heating pad?
Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.
Which member of the health care team is responsible for obtaining informed consent from a client?
The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature. In some health care facilities, a physician's
The nurse is transferring a client from the bed to a chair. Which action does the nurse take during this client transfer?
After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse helps the client sit on the edge of the bed and dangle his legs. The nurse then faces the client and places the chair next to and facing the head of
A client with a fecal impaction frequently exhibits which clinical manifestation?
Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clien
In a client who had major surgery 5 days ago, which assessment finding would be the best indication of a wound infection?
Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguineous. Although an elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, they aren't as specific as the drai
Which finding best indicates that suctioning has been effective?
Clear breath sounds, which indicate that secretions have been removed, are the best indicator of effective suctioning. An above-normal respiratory rate, as in option 1, may indicate that the airway isn't clear of secretions and the client's respiratory ra
The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. and indwelling urinary catheters. The nurse should:
It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be
Which action by the nurse is essential when cleaning the area around a Jackson-Pratt wound drain?
The nurse should always move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin
A client who's scheduled for open heart surgery in 2 days has been having circulation problems in the feet and legs, so the physician orders antiembolism stockings. Now, the nurse is teaching the client about this treatment. What is the purpose of antiemb
Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing � not decreasing � arterial and venous blood circulation to the legs and feet. They don't m
When changing the dressing on a pressure ulcer, the nurse notes that the wound has necrotic tissue on the edges. Which action should the nurse anticipate that the physician will order?
Because necrotic tissue won't allow the wound to heal, it must be removed. This is accomplished by debridement. Necrotic tissue can't be removed by incision and drainage, culture, or irrigation. An incision and drainage are performed to drain a wound absc
When moving a client in bed, the nurse can ensure proper body mechanics by:
When moving a client in bed, the nurse stands with her feet apart to establish a wide base of support. To reduce the energy needed to move the client's weight against gravity, the nurse slides, rolls, pushes, or pulls rather than lifts the client. The nur
Which statement is true concerning informed consent?
When the professional nurse is involved in the informed consent process, the nurse is only witnessing the consent process and doesn't actually obtain the consent. Only a minor who is married or emancipated can give informed consent. Obtaining consent is t
When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first?
When leaving a strict-isolation room, the nurse should remove the gloves first because they're considered the most contaminated. Removing other protective equipment before removing the gloves and washing hands could cause contamination of the hair and uni
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the nausea and discomfort. If residual volume is greater than 100 ml, hold the f
As the nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?
The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.
A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says t
A durable power of attorney transfers all rights that the individual normally has regarding health care decisions to the designated agent. It's within the power of the twin sister to change the physician caring for her terminally ill twin. The dismissed p
A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication isn't taken, restraints will be applied and the medication will be given by injection. The nurse's statement c
Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standa
In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize its effect on:
Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.
Which concept refers to the role of the professional nurse in client advocacy?
The nurse who understands the advocacy role promotes, protects, and, thereby, advocates a client's interests and rights in an effort to make the client well. The nurse recognizes that the first duty is to protect and care for the client's health and safet
The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment finding
In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffl
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing is most appropriate for the nurse to apply?
Sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent; how
A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should:
Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed
A nurse-manager must include which items as part of the personnel budget?
Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Office supplies and videos are part of the day-to-day operating budget. Any expense or single item of equipment costing more than $500 is part of the
To assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:
A pulse oximeter is a noninvasive method of monitoring oxygen saturation. It doesn't measure hemoglobin, PaCO2, or PaO2 levels. Hemoglobin, the main component of the red blood cell that carries oxygen from the lungs, is measured by a simple laboratory tes
The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?
The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue usually is more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressin
The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days after discharge. Which client action indicates an accurate understanding of the technique?
When using an incentive spirometer, the client should take slow, deep breaths to ensure maximum ventilation, which elevates the ball (or disc) inside the spirometer. Rapid, shallow breathing doesn't allow maximum ventilation and lung expansion. The client
Which laboratory test result is the most important indicator of malnutrition in a client with a wound?
Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differentia
A client's attorney can file a lawsuit within which time frame?
Statute of limitations is the time period during which a case must be filed or the injured party is barred from bringing the lawsuit. Discovery rule is the actual term for when the client has discovered the injury. The statute of limitations typically giv