STUFF
A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?
Check the client's blood glucose level.
A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what?
Clostridium difficile
A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client?
The client should be approached on the side where visual perception is intact
Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the client. Which of the following is the best example of a collaborative practice model?
The nurse making a referral on behalf of the client
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and “staring into space,” according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure
A neurologic flow chart is often used to document the care of a client with a traumatic brain injury. At what point in the client's care should the nurse begin to use a neurologic flow chart?
As soon as the initial assessment is made
A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments?
Assessment of respiratory status
A nurse provides community-based care and acts as the case manager for a small town about 60 miles (100 km) from a major health care center. When planning care in the community, what is the most important variable in community-based nursing that the nurse should integrate into planning?
Community resources available to clients
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to “cool the burn.” How should the nurse cool the burn?
Wrap cool towels around the affected extremity intermittently
A client is brought to the ED by paramedics, who report that the client has partialthickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?
Airway management
While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client?
Risk for Ineffective Peripheral Tissue Perfusion
A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected?
An area matching the color and texture of the skin at the surgical site is selected.
The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate?
Hypocalcemia
The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status?
The client's rating of her pain
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?
Fluid status
A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture?
Increase fluid intake and perform prescribed foot exercises
A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?
“It's been found that using computers improves our clients' care and improve communication. "
A client who has sustained third-degree facial burns and a facial fracture is undergoing reconstructive surgery and implantation of a prosthesis. The nurse has identified a nursing diagnosis of Disturbed Body Image related to disfigurement. What would be an appropriate nursing intervention related to this diagnosis?
Teaching the client how to use and care for the prosthesis
The nurse is conducting an assessment of a client in her home setting. Your client is a 91-year-old woman who lives alone and has no family members living close by. What should the nurse be aware of to aid in providing care to this client?
What resources are available to the client
A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do?
Perform life-saving measures.
Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the client's clothing and then perform what action?
Rinse the client with water.
A client is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system. Using this system achieves what goal of the client's care?
Maintaining continuity of the client's care
An elderly woman diagnosed with osteoarthritis has been referred for care. The client has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention will best promote the client's mobility?
Administer an analgesic as prescribed to facilitate the client's mobility
A 91-year-old client is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client?
Use of a pressure-relieving mattress
The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?
Performing hand hygiene before and after contact with every client