Activity & Sleep
Communication
Asepsis
Communication
Asepsis
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follows relocation to new surroundings.
When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond?
What is concerning you this morning?
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
It is important that you continue your medication while learning to meditate.
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Instruct the client that the stoma will become smaller when the initial swelling diminishes
A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement?
Advise the client to sit on the side of the bed for a few minutes before standing again.
A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time?
Tell me what you would like to see happen with your children in the future.
An African American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
Notify the healthcare provider of the family's request.
On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?
Provide warm prune juice before the client goes to bed at night.
The nurse is caring for a pregnant patient who is nervous about having a cesarean delivery. The nurse says, “Don’t worry. You may not need a cesarean section.” Which action is the nurse performing?
Giving false reassurance
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?
Hot remedies restore balance after surgery, which is considered a "cold" condition.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
It is OK if you don't want to talk about your surgery. I will be available when you are ready.
The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care?
Fluid volume imbalance
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
Acknowledge the client's distress and tell her it is all right to cry.
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first?
Notify family members of the client's condition
While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?
Instruct the client to take slow deep breaths and stop bearing down.
What action should the nurse implement when adding sterile liquids to a sterile field?
Consider the sterile field contaminated if it becomes wet during the procedure.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
Many complimentary healing practices can be used in conjunction with conventional practices
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client?
Assist and support the client in establishing short-term goals.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sim's position with the client's weight on the anterior ilium
The nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement?
Withhold the administration of the suppository until contacting the healthcare provider