Nursing Priorities
The nurse receives report on four clients at the beginning of the shift. Which client should the nurse assess first?
A. A client admitted with heart failure whose oxygen saturation has decreased from 96% to 92% on room air over the last 2 hours. The client now reports becoming short of breath while walking to the bathroom.
B. A postoperative client who reports pain increased from 3/10 to 8/10 despite receiving prescribed analgesia 45 minutes ago. The client is now reluctant to cough or deep breathe.
C. A client with pneumonia whose respiratory rate increased from 18 to 24/min since the previous assessment. The client states, "I'm more tired than I was this morning."
D. A client with type 2 diabetes whose blood glucose decreased from 118 mg/dL to 74 mg/dL before lunch. The client reports feeling "a little shaky" but remains alert and oriented.
A client admitted with heart failure whose oxygen saturation has decreased from 96% to 92% on room air over the last 2 hours. The client now reports becoming short of breath while walking to the bathroom.
A client has remained silent for nearly one minute after learning they will need long-term treatment. The client avoids eye contact and begins to cry.
The nurse may use two therapeutic communication techniques before asking another question.
Name both techniques and include an open-ended statement.
"Take your time. I'm here with you." or
"What would you like to talk about when you're ready?"
In the SOAP documentation format, what does each letter represent?
A client signs a surgical consent at 6:00 AM after receiving preoperative morphine. The surgery is scheduled for 7:30 AM.
Identify the legal problem.
The consent may not be valid because it was signed after the client received a sedative that could impair decision-making.
The nurse is documenting a client's pain assessment.
What three components should always be included when documenting pain?
A nurse enters a client's room to administer a scheduled antihypertensive medication. The client appears pale, is slow to answer questions, and states, "I feel different than I did an hour ago."
What is the nurse's priority action?
A. Compare the client's current assessment findings with the previous documented assessment.
B. Obtain a complete set of vital signs and perform a focused assessment.
C. Hold the antihypertensive medication until the healthcare provider evaluates the client.
D. Review the client's most recent laboratory and diagnostic results.
Obtain a complete set of vital signs and perform a focused assessment.
A nurse responds to a crying client by saying,
"Everything happens for a reason."
What communication block is the nurse using?
False reassurance (or minimizing feelings)
Name all six characteristics of good nursing documentation.
Which statement best distinguishes a Living Will from a Durable Power of Attorney for Healthcare?
A. A Living Will provides written instructions about a client's future healthcare preferences, while a Durable Power of Attorney for Healthcare appoints a person to make healthcare decisions if the client loses decision-making capacity.
B. A Living Will allows a family member to make end-of-life decisions, while a Durable Power of Attorney for Healthcare documents the client's wishes regarding life-sustaining treatment.
C. A Living Will and a Durable Power of Attorney for Healthcare are both used to communicate end-of-life wishes, but only the Durable Power of Attorney becomes effective if the client is terminally ill.
D. A Living Will and a Durable Power of Attorney for Healthcare both identify treatment preferences; however, only a Living Will allows another person to make healthcare decisions.
A. A Living Will provides written instructions about a client's future healthcare preferences, while a Durable Power of Attorney for Healthcare appoints a person to make healthcare decisions if the client loses decision-making capacity.
A nurse receives report on four clients at the beginning of the shift. Which client should the nurse assess first?
A. A client who is 1 hour postoperative following an abdominal hysterectomy and reports incisional pain 8/10 despite receiving prescribed analgesia 30 minutes ago.
B. A client with COPD whose oxygen saturation has decreased from 94% to 90% while receiving oxygen at 2 L/min via nasal cannula. The client is now slightly restless but denies shortness of breath.
C. A client with heart failure who gained 2 lb (0.9 kg) overnight and has 1+ bilateral ankle edema, but no change in lung sounds or respiratory status.
D. A client with type 1 diabetes has a blood glucose of 68 mg/dL, is awake and alert, and states, "I feel a little shaky."
B. A client with COPD whose oxygen saturation has decreased from 94% to 90% while receiving oxygen at 2 L/min via nasal cannula. The client is now slightly restless but denies shortness of breath.
The practical nurse receives four updates from the nursing assistant. Which client should the nurse assess first?
A. A client who has become unusually quiet during the past hour and now answers questions with one-word responses, although vital signs remain unchanged.
B. A client who reports pain has increased from 4/10 to 7/10 after ambulating for the first time following surgery.
C. A client who independently completed morning hygiene yesterday but now requests assistance because of generalized weakness.
D. A client who refused breakfast and states, "I'm just not hungry today."
A client who has become unusually quiet during the past hour and now answers questions with one-word responses, although vital signs remain unchanged.
The client says all four statements during the assessment.
Which statement should the nurse explore first? What therapeutic response should the nurse make first?
"I wish I could just disappear."
A client refuses a prescribed medication.
Name four items the nurse should document.
A nurse is caring for four clients during a medication shortage.
Which TWO ethical principles are the nurse demonstrating?
Daily Double: A nurse receives the following provider prescriptions:
In what order should the nurse complete these prescriptions?
A. Catheter → Antibiotic → Urine culture
B. Urine culture → Antibiotic → Catheter
C. Urine culture → Catheter → Antibiotic
D. Antibiotic → Urine culture → Catheter
C. Urine culture → Catheter → Antibiotic
The practical nurse is caring for four clients. Which finding requires the highest priority nursing assessment?
A. A client who independently completed morning hygiene yesterday now requests assistance because of generalized weakness.
B. A client who suddenly becomes withdrawn, avoids eye contact, and allows family members to answer all assessment questions.
C. A client who reports increasing incisional pain and is guarding the operative site during movement.
D. A client whose respiratory rate has increased from 16/min to 24/min since the previous assessment while oxygen saturation remains unchanged.
A client whose respiratory rate has increased from 16/min to 24/min since the previous assessment while oxygen saturation remains unchanged.
The nurse says,
"I know this diagnosis is frightening. Many people recover quickly, so try not to worry."
Identify two communication errors in the nurse's statement.
A nurse completes a dressing change scheduled for 1000, but becomes busy caring for another client.
At 1145, the nurse documents:
"1000: Dressing changed. Incision clean, dry, intact. Client tolerated procedure well."
Identify three legal or documentation concerns with this entry.
Name four responsibilities of the nurse during the informed consent process.
A nurse inserts an indwelling urinary catheter into a male client. Urine is visualized in the tubing.
What should the nurse do before inflating the retention balloon?
A. Inflate the balloon immediately once urine is seen.
B. Advance the catheter to the bifurcation (Y-port) before inflating the balloon.
C. Withdraw the catheter 2 to 3 cm before inflating the balloon.
D. Ask the client to bear down while inflating the balloon.
B. Advance the catheter to the bifurcation (Y-port) before inflating the balloon.
Daily Double: A practical nurse is caring for a client who was alert, oriented, and participating in care one hour ago. The nursing assistant reports, "The client seems different now." Upon entering the room, the nurse notes the client answers questions slowly, intermittently loses focus during conversation, and requires repeated prompting to respond. The client's spouse quietly states, "This isn't normal for them."
Which nursing actions are the MOST appropriate at this time?
Select all that apply.
⬜ A. Notify the RN immediately before performing any additional assessment because an unexpected change in condition has occurred.
⬜ B. Perform a focused neurologic assessment while obtaining current vital signs.
⬜ C. Compare the client's current assessment findings with the baseline assessment documented earlier in the shift.
⬜ D. Document the assessment findings immediately before additional interventions to ensure an accurate legal record.
⬜ E. Review laboratory and diagnostic results before determining whether the client's condition has changed.
⬜ F. Review medications administered during the previous shift after completing the immediate assessment.
⬜ G. Ask the spouse to remain available while continuing the assessment to obtain additional information about the client's baseline mental status.
⬜ H. Continue administering scheduled medications because the previous vital signs were within expected limits.
✔ B
✔ C
✔ G
A practical nurse is interviewing a client who was admitted earlier today following a new diagnosis. The client maintains minimal eye contact and says,
"Everyone keeps asking me how I feel. I don't even know what to say anymore."
Which responses by the nurse are therapeutic?
⬜ A. "It sounds like you've been asked that question many times today."
⬜ B. "What has been the most difficult part of today for you?"
⬜ C. "Many clients feel overwhelmed during the first day of hospitalization."
⬜ D. "Would you like a few minutes before we continue talking?"
⬜ E. "You seem frustrated because no one understands what you're experiencing."
⬜ F. "Can you tell me more about what you're thinking right now?"
⬜ G. "At least you were diagnosed early."
⬜ H. "Let's focus on one concern at a time so I can better understand what you're experiencing."
✔ B
✔ F
✔ H
A nurse writes the following SOAP note:
S: Client states, "I feel nauseated."
O: Client had 250 mL emesis. Skin pale. BP 98/60 mm Hg.
A: Client received ondansetron 4 mg IV.
P: Nausea related to postoperative anesthesia.
Identify two documentation errors in this SOAP note.
The Assessment and Plan sections are reversed.
Correct SOAP format:
The nurse reviews the preoperative record. Which findings suggest the informed consent process should be questioned?
⬜ The client signs using an "X" witnessed by two staff members.
⬜ The consent identifies a right total knee replacement, while the operative schedule lists a left total knee replacement.
⬜ The client states, "I signed because I was afraid the surgeon would refuse to treat me."
⬜ The client says, "I know the benefits and risks, but I don't remember discussing possible complications."
⬜ The consent form contains blank spaces below the procedure description.
⬜ The client asks if the procedure can be cancelled after arriving in pre-op.
✔ The consent identifies a right total knee replacement, while the operative schedule lists a left total knee replacement.
✔ The client states, "I signed because I was afraid the surgeon would refuse to treat me."
✔ The client says, "I know the benefits and risks, but I don't remember discussing possible complications."
✔ The consent form contains blank spaces below the procedure description.
A nurse is reviewing four documented nursing diagnoses. Which diagnosis is written correctly using NANDA-I diagnostic statement guidelines?
A. Risk for Infection related to surgical incision as evidenced by redness at the incision site.
B. Acute Pain related to tissue trauma secondary to abdominal surgery as evidenced by the client's report of pain 8/10 and guarding.
C. Diabetes Mellitus related to elevated blood glucose as evidenced by polyuria.
D. Pneumonia related to ineffective airway clearance as evidenced by crackles.
Acute Pain related to tissue trauma secondary to abdominal surgery as evidenced by the client's report of pain 8/10 and guarding.