The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during
... [Show More] surgery?
Taking anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for developing surgical complications. The healthcare provider should be informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. What action will the nurse take next?
Leave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization
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The nurse is instructing a male client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?
Compress the inhaler while slowly breathing in through your mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the inhaler
The nurse is assisting a male client to the bathroom. When 5 feet from the bathroom door, the client states, "I feel faint." Before the nurse can get him to a chair, he starts to fall. What is the priority action for the nurse to take?
Gently lower the client to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury.
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
High risk for infection
Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks in and states that he was struck by lightning while working on his truck bed. He is alert but reports feeling faint. What assessment will the nurse perform first?
Pulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Since the client is talking, he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
Use of careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for prevention of contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. What is the best action for the nurse to take?
Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible?
Daily black, sticky stool
Rationale:
Black, sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the healthcare provider promptly
The nurse is teaching a male client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep despite following the same routine every night. What action should the nurse take first?
Ask the client to describe the routine he is currently following.
Rationale:
The nurse should first evaluate whether the client has been adhering to the original instructions
By rolling contaminated gloves inside out, the nurse is impacting which step in the chain of infection?
Mode of transmission
Rationale:
The contaminated gloves serve as the mode of transmission
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The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication prescribed preoperatively is not listed. What action should the nurse take?
Contact the healthcare provider to renew the prescription for the medication.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the healthcare provider if the antihypertensive medication is not included in the postoperative prescriptions
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
Check the bath water temperature.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?
Inform the surgeon the operative permit is not signed and the client has questions about the surgery.
Rationale:
The surgeon should be informed immediately that the permit is not signed
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. What action by the nurse is best?
Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.
Rationale:
Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care
After the nurse tells an older male client that an IV line needs to be inserted, he becomes very apprehensive, loudly verbalizing his dislike for all healthcare providers and nurses. How should the nurse respond?
Calmly reassure the client that the discomfort will be temporary.
Rationale:
The nurse should respond with a calm demeanor (C) to help reduce the client's apprehension. After responding calmly to the client's apprehension
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." What action should the nurse take first?
Discuss the importance of personal hygiene during menstruation with the client.
Rationale:
Since a shower is most beneficial for the client in terms of hygiene and mobility, the client should receive teaching first (D), respecting any personal beliefs, such as cultural or spiritual values.
When the healthcare provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery, because she "can't handle" the cancer diagnosis. What legal principle is the court most likely to uphold regarding this client's right to informed consent?
If informed consent is withheld from a client, healthcare providers could be found guilty of negligence.
Rationale:
Healthcare providers may be found guilty of negligence (D), specifically, assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so (A) is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
Assess the client's medical record to determine the client's normal bowel pattern.
Rationale:
This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention ( [Show Less]