Think Like a Nurse
A client says, “I feel dizzy when I stand,” although the seated vital signs are normal. This type of assessment information comes from the client’s experience.
What is subjective data?
Before treating an unexpectedly low pulse oximeter reading, the nurse checks the probe, assesses breathing, and repeats the reading. This action checks whether the finding is accurate.
What is validation of assessment data?
These infection prevention measures apply to every client, even without a known diagnosis.
What are Standard Precautions?
A client on oxygen asks for a candle at the bedside. The nurse explains that oxygen supports combustion and keeps the area free of these.
What are flames, sparks, and smoking materials?
Before a weak client stands, the nurse checks balance, leg strength, ability to follow instructions, and this prescribed limit on the affected leg.
What is weight-bearing status?
A postoperative client reports pain at 8 out of 10 and has shallow breathing. You give the ordered analgesic and reassess pain and respiratory effort 45 minutes later. This nursing process step compares results with the goal.
What is evaluation?
A client who wears hearing aids is struggling to understand discharge teaching in a noisy room. Facing the client and reducing this environmental factor improves communication.
What is background noise?
A nurse handles contaminated bedding gently and places it directly in the proper bag to avoid sending microorganisms into the air. This action should be avoided when handling soiled linen.
What is shaking or agitating linen?
An exhausted client’s pain medicine is due before bedtime. Giving it as ordered and combining nonurgent nighttime care supports this need.
What is restorative sleep?
A client with a weak right leg is learning to use a cane. The cane belongs in this hand.
What is the left hand?
A client with weakness will transfer to a chair with one person assisting by 1400. This statement is measurable and time limited.
What is a client-centered expected outcome or SMART goal?
After walking, a client feels faint and the blood pressure drops on standing. The nurse should support the client safely and assess for this positional change in blood pressure.
What is orthostatic hypotension?
A coughing client needs an essential trip to imaging while on respiratory precautions. The nurse uses indicated source control and gives advance notice to this team.
Who is the receiving department or imaging team?
A client with shortness of breath is helped upright with the head of the bed raised. Name this positioning family.
What is Fowler’s or high Fowler’s position?
An immobile client develops new unilateral calf swelling and tenderness. The nurse stops activity and reports the finding because it may indicate this complication.
What is deep vein thrombosis?
At handoff, one client has a new gurgling sound on inspiration, while another asks for a blanket, and a third needs routine teaching. This client takes priority.
The client with an airway concern.
A client says, “I cannot sleep because I am afraid of tomorrow’s procedure.” The therapeutic response begins by acknowledging the feeling and inviting this.
What is an open-ended discussion of the client’s concerns?
An older adult has new confusion and poor appetite, but no fever. The nurse considers this possible cause and reports the change.
What is infection with an atypical presentation?
A client with limited mobility has a red heel that stays red when pressed. The nurse relieves pressure and reports the finding instead of doing this harmful action.
What is massaging the reddened heel?
A casted client reports worsening pain and tingling; the toes are pale and cool. The nurse urgently reports these findings because they suggest impaired this.
What is distal neurovascular circulation or possible compartment syndrome?
A client’s goal was to walk 50 feet without dizziness by noon. The client walks only 20 feet before becoming dizzy. The nurse identifies barriers and changes the care plan. Name the two nursing process steps demonstrated.
What are evaluation and planning?
A client’s blood pressure is much higher than usual. The nurse notices the cuff is too small. Explain how the cuff affects the reading and what the nurse should do next.
What is a falsely high reading, requiring a correctly sized cuff and repeat measurement?
An isolation gown becomes contaminated during care. After removing the gown and gloves, the nurse prepares to help another client. This action is required even though gloves were worn.
What is performing hand hygiene?
A confused client keeps attempting to leave the bed. Before considering restraints, the nurse checks for pain, toileting needs, and environmental stressors. Name two additional interventions that could reduce injury risk.
What are close observation and keeping the bed low with a clear, well-lit walking path? Accept other appropriate alternatives.
A client’s left leg is non-weight-bearing. Using a three-point crutch gait, the client advances these together, then moves this leg forward while keeping weight off the injured leg.
What are both crutches and the left leg, followed by the right leg?
A client is recovering from hip surgery and has been in bed for several days. During the first assisted transfer, the client becomes dizzy; the operative leg is newly swollen and painful in the calf, and the client says breathing feels harder. Identify the immediate nursing actions in priority order and explain which two serious complications these findings may signal.
Stop the transfer, support the client in a safe position, assess breathing and vital signs, call for immediate help/notify the provider per protocol, and avoid massaging or exercising the leg. Suspect pulmonary embolism and deep vein thrombosis. Escalate acute respiratory distress as the first priority.