A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client
... [Show More] should the charge nurse assign to this new nurse?
(Ans- A multiparous client who is dilated 5 cm and 50% effaced
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client?
(Ans- Oral hygiene should be performed before the medication.
A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client?
(Ans- Sitting upright and forward with both arms supported on an over the bed table
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level?
(Ans- The client's renal function has affected his potassium level.
A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit?
(Ans- Sending medical records to health care providers via the Internet
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.
(Ans- D
The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. (Ans- D
When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive.
C.Check the medical record for the advanced directive and then complete the client assessment.
D. Call for the charge nurse to check the advanced directive while continuing to assess the client.
(Ans- D
Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP?
A.Remove the client's nail polish and dentures.
B.Assist the client to the restroom to void.
C.Obtain the client's height and weight.
D.Offer the client emotional support.
(Ans- D
By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the supervision of the nurse. [Show Less]