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Client needs Part 1
A 22-year-old client with an external fixation device attached to his left thigh is unable to bear weight on his left leg. He asks a nurse if he can take a shower on his third postoperative day. After a review of the physician's orders, the nurse notes an order stating, "Client may shower ten (10) days after surgery." In order to meet the client needs, what appropriate action will the nurse take? Assist the client into the shower while he supports himself with one crutch. Wrap the device with plastic and then assist the client into the shower using a wheelchair. Explain that he is not permitted to shower, but the nursing assistant can help him with a sponge bath.
Suggest that the client wait until he's able to bear weight on his left leg. - verified answer Explain
that he is not permitted to shower, but the nursing assistant can help him with a sponge bath. Explanation: The client is permitted to shower while the external fixation device is in place if appropriate and approved by the physician. The client needs can be met by having the nursing assistant give him sponge baths. The fixator does not need to be protected from soap and water. Because the client cannot bear weight on his left leg, it's unsafe to assist the client into the shower while he supports himself with one crutch. The nurse is caring for a preschool-age child who sustained burns in a house fire. The child is prescribed morphine every 4 hours for pain. Which parameter is most important when monitoring a child who's receiving morphine? blood pressure temperature respirations
pulse - verified answer respirations
A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate?
Traction will help prevent skin breakdown. Traction helps with repositioning while in bed. Traction helps to prevent trauma and overcome muscle spasms.
Traction allows for more activity. - verified answer Traction helps to prevent trauma and overcome
muscle spasms. Explanation: Traction prevents trauma and overcomes muscle spasms. Traction doesn't help in preventing skin breakdown, repositioning the client, or allowing the client to become active. For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Crossing the client's ankles every 2 hoursterm- Putting slippers on the client's feet Placing hand rolls on the balls of each foot
Attaching braces or splints to each foot and leg - verified answer Attaching braces or splints to
each foot and leg Explanation: Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment. Slippers can't prevent footdrop because they're too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, which term-4promotes thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because they're too soft to support and hold the feet in proper alignment.
Explanation: The ED nurse is no longer directly involved with the client's care, and has no legal right to information about the client's present condition. Anyone directly involved in their care (such as the telemetry nurse and the on-call provider) has the right to information about the client's condition. Because this client asked the nurse to update their spouse, doing so doesn't breach A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible myocardial infarction (MI), the nurse would anticipate that the health care provider will prescribe which diagnostic test to quickly determine myocardial damage? electrocardiogram cardiac catheterization echocardiogram
cardiac enzymes - verified answer electrocardiogram
Explanation: Electrocardiogram is the quickest, most accurate, and most widely used tool to diagnose MI. Cardiac enzymes also are used to diagnose MI, but the results can't be obtained as quickly. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease. The nurse is collecting data on a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. Which action should the nurse perform first? draw blood for laboratory analysis begin cardiac monitoring give nasal oxygen
take vital signs - verified answer take vital signs
Explanation:
The first step of nursing process is data collection. Taking vital signs would determine hemodynamic stability, and monitoring heart rhythm may be indicated based on data collected. Giving nasal oxygen and drawing blood require a health care provider's order and should not be part of a screening evaluation. The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care? providing mouth care maintaining current weight encouraging ambulation
promoting bowel rest - verified answer promoting bowel rest
Explanation: Promoting bowel rest is the priority during an acute exacerbation. This is accomplished by decreasing activity and initially putting the client on nothing-by-mouth (NPO) status. Weight loss may occur, but the priority is bowel rest. Crohn's disease is a type of inflammatory bowel disease (IBD). It causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Institute isolation precautions. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing.
Obtain a sputum specimen for enzyme immunoassay testing. - verified answer Institute isolation
precautions. Explanation:
Airborne precautions - verified answer Droplet precautions
Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use droplet precautions. This includes wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask. Contact precautions are used to reduce the spread of microorganisms by direct client contact or by contact with items in the client's environment. Examples of illnesses requiring contact precautions include Clostridium difficile infection, diphtheria (cutaneous), and scabies. Airborne precautions are instituted for clients known or suspected to have serious illnesses transmitted by airborne droplet nuclei, including tuberculosis, measles, and varicella. Standard precautions should be used for all clients when exposure to blood or other body fluids is likely. The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair? Parallel to the bed on the right side Perpendicular to the bed on the right side Parallel to the bed on the left side
Parallel to the bed on either side - verified answer Parallel to the bed on the right side
Explanation: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg. A 10-month-old infant with bacterial meningitis was just started on antibiotic therapy. Which nursing action is especially important in this situation? Administer oral gentamicin. Encourage the child to drink 3,000 mL of fluid per day.
Wear a mask while providing care.
Flex the child's neck every 4 hours to maintain range of motion. - verified answer Wear a mask
while providing care. Explanation: With bacterial meningitis, respiratory isolation must be maintained for at least 24 hours after beginning antibiotic therapy. Wearing a mask is an important part of respiratory isolation. Moving the child's head to maintain range of motion would cause pain because his meninges are inflamed. Gentamicin is never administered orally. Encouraging 3,000 mL of fluid would cause overhydration in a 10-month-old infant and place him at risk for increased intracranial pressure. The nurse is admitting a client with abdominal pain, bloody stools, weakness, and dizziness when the client reports feeling the urge to have a bowel movement. What is the priority action by the nurse? Ask the client to wait for specimen collection. Assist the client onto the bedpan. Assist the client to the bedside commode.
Have the client ambulate to the bathroom. - verified answer Assist the client onto the bedpan.
Explanation: A client who is dizzy and weak is at risk for fall injury. Assisting the client with the bedpan would best meet the client's needs at this time without risking safety. If this client attempts to stand up without help, or walk to the bathroom alone, the client may fall and be injured. Asking the client to wait is not an appropriate intervention for toileting. The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism? Wear a face mask when in close contact with the client.
The nurse dries from forearms up toward fingers. The nurse keeps hands lower than elbows while washing. The nurse dries from finger tips down toward elbows.
The nurse uses at least 3 to 5 mL of liquid soap. - verified answer The nurse dries from forearms up
toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices. A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply. Droplet Contact Neutropenic Standard
Airborne - verified answer Contact
Standard Explanation: The purpose of isolation is to prevent the spread of infection to other clients. Contact isolation is normally used for GI infections and diarrhea as well as wound infections with drainage or draining
abscesses. In addition to contact isolation, standard precautions should be observed with this client. Droplet precautions are used for clients with suspected or known infection caused by organisms transmitted by infectious droplets, as in pertussis. Airborne precautions should be instituted for clients suspected or known to be infected with tuberculosis. Neutropenic precautions are instituted to protect the client with a low white blood cell count from infection. Which steps should the nurse follow to insert a straight urinary catheter? Put on gloves, prepare the equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". Prepare the client and the equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus,
and insert the catheter until urine flows. - verified answer Prepare the client and the equipment,
create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. Explanation: Option 3 describes all the vital steps for inserting a straight catheter. Option 1 is incorrect because the nurse must prepare the client and equipment before creating a sterile field. Option 2 is incorrect because the nurse put on gloves before creating a sterile field and performing the other tasks. Option 4 describes the procedure for inserting an indwelling catheter, rather than a straight catheter. A visitor asks the nurse about entering the room of a client who has contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The nurse explains the necessary precautions needed to visit the client. What statement by the visitor reflects understanding of the contact precautions teaching? "The mask will decrease the risk of my friend spreading MRSA." "The use of these masks and gloves will decrease the risk of me getting MRSA."
cataracts - verified answer ophthalmia neonatorum
Explanation: Eye prophylaxis is administered to the neonate immediately, or soon after birth, to prevent ophthalmia neonatorum (conjunctivitis contracted during birth from passage through the birth canal). Erythromycin ointment is not given to prevent cataracts, diabetic retinopathy, or strabismus. Cataracts are opacities of the lens of the eye in children with congenital rubella, galactosemia, or cortisone therapy. Diabetic retinopathy occurs in clients with diabetes when the retina bleeds into the vitreous humor causing scarring, after which neovascularization occurs. Strabismus is neuromuscular incoordination of the eye alignment. The hospice nurse is caring for a client who is approaching death. The client has accepted death, is prepared to transition, but seems to forestall death. When asked by a new hospice nurse about forestalling death, which appropriate psychological event will the nurse relay to the new hospice nurse? anticipatory grieving nearing death awareness waiting for permission phenomenon
central nervous system alterations - verified answer waiting for permission phenomenon
Explanation: A dying client may accept death, but also realize that an important person is not ready to let go. The client tries to forestall death until the person gives permission - waiting for permission phenomenon. Central nervous system alterations occur from hypoxia of the brain. Anticipatory grieving is mourning the loss, whether by the client or family member, it is anticipating the change in life due to death. When the client has a premonition of the time or date of death, it is known as the nearing death awareness. After a nurse reinforces discharge education to the parents of a child with hypospadias, which statement by the parent indicates that additional education is needed?
"I'll need to learn irrigation techniques." "It's important to keep the catheter free of kinks and blockages." "Proper catheter care helps prevent infection."
"I should bathe my child in the tub daily." - verified answer "I should bathe my child in the tub
daily." Explanation: A tub bath should be avoided to prevent infection until the stent has been removed. Parents are taught to care for the indwelling catheter or stent and how to perform irrigation techniques if indicated. They need to know how to empty the urine bag and how to avoid kinking, twisting, or blockage of the catheter or stent. A nurse is assisting with an educational session for a group of women on the topic of urinary tract infection (UTI) prevention. Which information should the nurse expect to be included in this session? Take prescribed medications until the symptoms subside. Limit fluid intake to reduce the need to urinate. Wear only nylon underwear to reduce the chance of irritation.
Report any urinary difficulty to the health care provider. - verified answer Report any urinary
difficulty to the health care provider. Explanation: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. Clients should notify their healthcare provider so that microscopic urinalysis can be done and appropriate treatment can be initiated. Women should be instructed to drink 2 to 3 qt (1.9 to 2.9 L) of fluid per day to dilute the urine and reduce irritation on the bladder mucosa. The full course of antibiotics prescribed for UTIs must be taken, even if symptoms subside. Doing so helps to prevent recurrences. Women should avoid scented toilet tissue and bubble baths and should wear cotton (not nylon) underwear to reduce the chance of bladder irritation.
The nurse is discussing cocaine, amphetamines, and caffeine with a client. How would the nurse classify these substances? analgesics opiates stimulants
anticholinergics - verified answer stimulants
Explanation: Cocaine, amphetamines, and caffeine are all stimulants. Acetaminophen is an analgesic. Oxycodone is an opiate. Atropine is an anticholinergic. A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate? Tell the client that her milk is starting to come in because she's in labor. Perform a culture on the discharge, and inform the client that she might have mastitis. Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.
Complete a thorough breast examination, and document the results in the chart. - verified answer
Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Explanation: After the fourth month of pregnancy, colostrum may be noticed. The breasts normally produce colostrum for the first few days after birth. Milk production begins 1 to 3 days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.
A client who is 36 weeks pregnant appears anxious and tells the nurse that she will never be able to handle labor and delivery. What is the appropriate action by the nurse? Assess the client for intimate partner violence. Document this common concern during the third trimester. Discuss the concern with the client's partner.
Obtain a referral order for psychotherapy. - verified answer Document this common concern
during the third trimester. Explanation: It is common for clients to verbalize feelings of anxiety and concern over the impending labor and delivery during the third trimester of pregnancy, so the nurse simply needs to document the finding. There is no indication that the client needs psychotherapy. All clients should be screened for intimate partner violence but there is no indication that this client needs screening more than another client. Discussing the client's concerns with her partner would not help the client. A nurse has started working in a long-term-care facility. During the evaluation of an older adult client, the nurse should expect which finding? change in the structure of the eyes decreased facial hair in female clients increased facial hair in male clients
quick wound healing - verified answer change in the structure of the eyes
Explanation:
"I can eat after the test is finished." - verified answer "It will be important for me to eat the
breakfast my mom makes for me before I take the test." Explanation: The exercise stress test will monitor the heart rate, blood pressure, and oxygen consumption during a period of activity. The child will be NPO (nothing by mouth) for at least 4 hours prior to the test. The remaining statements are correct. According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage of development? Trust versus mistrust Identity versus role confusion Industry versus inferiority
Initiative versus guilt - verified answer Industry versus inferiority
Explanation: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence. A client has been prescribed a diet that limits purine-rich foods. Which would the nurse teach the client to avoid eating? milk, ice cream, and yogurt bananas and dried fruits anchovies, sardines, kidneys, sweetbreads, and lentils
wine, cheese, preserved fruits, meats, and vegetables - verified answer anchovies, sardines,
kidneys, sweetbreads, and lentils Explanation: Anchovies, sardines, kidneys, sweetbreads, and lentils are high in purines. Bananas and dried fruits are high in potassium. Milk, ice cream, and yogurt are rich in calcium. Wine, cheese, preserved fruits, meats, and vegetables contain tyramine. A client who is 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse provide which information that at 16 weeks' gestation the client's fetus will most likely present? Be able to suck and swallow Have open nostrils Open the eyes
Have audible heart sounds - verified answer Have audible heart sounds
Explanation: Fetal heart tones are usually audible with a fetoscope between 16 and 20 weeks' gestation. The fetus can suck and swallow at about 20 weeks' gestation. The eyes are open at approximately 28 weeks' gestation. The nostrils are open at about 21 to 28 weeks' gestation. A 55-year-old male client wishes to be proactive about health issues. To help ensure early identification of prostate cancer, the client should: get a transrectal and transabdominal ultrasound every 5 years. have a blood urea nitrogen (BUN) and creatinine assessment every year. have a yearly digital rectal exam and prostate-specific antigen (PSA) test.
perform monthly testicular self-examinations, especially after age 50 years. - verified answer have
a yearly digital rectal exam and prostate-specific antigen (PSA) test.
