A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that she's ready to go home to die. What intervention
... [Show More] should the nurse initiate?
Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates client's protein status for the longest length of time?
Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance with bathing?
"I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces?
Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest priority?
Impaired gas exchange
The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing action is most important for the nurse to implement?
Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?
The nurse notes there are numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?
One-inch pressure sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx?
0800, 1200, 1600, 2000
The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain?
1 55y/o woman who has had moderate low back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to relieve the pain. All other clients are having new experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide?
"It may hurt, but we'll give you medicine to help you feel better."
A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency & HTN, who gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24hr diet recall?
1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
What intervention should the nurse include in the care plan for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable.
Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for this client?
Use reflective listening techniques when the client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to impending death." What intervention is best for the nurse to implement when caring for this client?
Assist & support the client in establishing short-term goals.
Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to death.
Nurse who puts meds in her uniform pocket to deliver to clients confides that after arriving home, she found a hydrocodone tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?
Accused of diversion
A signed consent form indicated a client should have an electromyogram, by a myelogram was performed instead. Thought the myelogram revealed the cause of the client's back pain, the client filed a lawsuit against the nurse & HCP for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction?
Assault & battery with deliberate intent to deviate from the consent form
A 75y/o client who has a history of end stage renal failure & advancing lung cancer, recently had a stroke. 2 days ago, the HCP d/c the client's dialysis treatments, stating that death is inevitable, but the client is disoriented & will not sign a DNR directive. What is the priority nursing intervention?
Determine who is legally empowered to make decisions
The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take?
Refuse to perform the task that is beyond the nurse's experience
Rationale: According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency.
Before administering a client's medication, the nurse assesses a change in the client's condition & withholds the medication until consulting with the HCP. The dose is changed & the nurse administers the new Rx 1 hour later than originally scheduled. What action should the nurse implement in response to this situation?
Document the events that occurred in the nurses' notes. [Show Less]