A client asks the nurse to explain the different types of advance directives. What information should be provided regarding living wills, durable power of attorney and DNR orders?
Which action will the nurse perform when conducting a Rinne Test?Occlude one ear and whisper three words. Have the client repeat the three words whispered.Place a vibrating tuning fork firmly against the mastoid bone.Place a vibrating tuning fork on top of the client’s head.Straighten the ear canal by pulling the auricle up and back.
A nurse is caring for several clients receiving intravenous therapy. What are actions the nurse should use to prevent IV infections? Suggested Fundamentals Learning Activity: Peripheral IVs
A nurse is caring for a client with abdominal pain. List the correct sequence the nurse will complete the abdominal assessment. Suggested Fundamentals Learning Activity: Gastrointestinal Assessment
A nurse is caring for a client prescribed an Aquathermia pad. What should the nurse monitor this client for during therapy? Suggested Fundamentals Learning Activity: Heat and Cold Therapy
Identify two (2) hand-off tools that a nurse can use to relay information to another health provider to improve communication.
A nurse is preparing for a procedure with a client who has a latex allergy. What action should the nurse take regarding this allergy? Suggested Fundamentals Learning Activity: Medical and Surgical Asepsis
Which nursing action made by the nurse is correct when providing postmortem care?Keep all personal belongings in the client’s roomRemove denturesProvide bright lightingAlign the body in supine position Suggested Fundamental Learning Activity: Palliative Care
A nurse is documenting on the electronic medical record (EMR). How should the nurse ensure client confidentiality during documentation?
A client is on strict bedrest, identify three (3) interventions the nurse can implement to prevent skin breakdown. Suggested Fundamentals Learning Activity: Pressure Ulcers
Which guidelines should the nurse follow when calculating a client’s fluid intake?
A client is unresponsive and breathing agonally after cardiopulmonary resuscitation has been provided. The family asks about “do not resuscitate” (DNR) because of their concern with aggressive treatment with all that has been provided. What is the role of the provider in this situation?
Describe two (2) priority nursing considerations for a client who appears to be having an allergic reaction to his medication.
What are possible role problems in family functioning following an acute event? Suggested Fundamentals Learning Activity: Family Dynamics
A newly diagnosed with diabetes mellitus and is terrified to perform glucose monitoring. Identify two (2) points the nurse should teach the client to minimize pain. Suggested Fundamentals Learning Activity: Glucose Monitoring
What should be included in education for the client who reports insomnia due to increased stress?
A nurse is discussing different complementary and alternative therapies with a client. What instructions should be provided regarding progressive relaxation technique?
A nurse is caring for a postoperative client who is nauseated and vomiting. What are clinical manifestations of dehydration? Suggested Fundamentals Learning Activity: Oral Hydration
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Regarding advance directives, the nurse should explain that a living will allows a person to specify what medical treatments they do or do not want to receive if they become unable to communicate their wishes. A durable power of attorney designates someone to make medical decisions on their behalf if they become incapacitated. A DNR or “do not resuscitate” order indicates that CPR and other life-saving measures should not be performed if the person’s heart stops or they stop breathing.
When conducting a Rinne Test, the nurse will place a vibrating tuning fork firmly against the mastoid bone behind the ear. The client is then asked if they can hear the vibration. The nurse will then place the vibrating fork on top of the client’s head and ask if they can still hear it. This test compares bone conduction to air conduction and is used to assess hearing.
To prevent IV infections, the nurse should follow aseptic technique when accessing and caring for IV sites. This includes hand hygiene, using a clean aseptic technique to access the site without touching any non-sterile surfaces, disinfecting the port with an alcohol swab prior to access, avoiding contamination of the tubing and ports, ensuring the dressing remains dry and intact, and monitoring for signs of infection like redness, swelling, pain or drainage at the site.
The correct sequence for abdominal assessment is: inspection, auscultation, percussion, and palpation. During inspection the nurse observes the abdomen for distension, scars, hernias, pulsations etc. Auscultation involves listening with a stethoscope for bowel sounds in all four quadrants. Percussion helps determine the liver and spleen size and any areas of dullness or fullness. Finally palpation is gently feeling the abdomen with light and deep pressure to check for areas of tenderness, lumps or masses.
When using an Aquathermia pad, the nurse should monitor the client’s skin temperature every 15 minutes. The pad should be removed if the skin becomes dry, flaky, blistered or painful. The nurse should also assess the client for signs of discomfort, burning or increased pain with use of the pad.
Two hand-off tools that can improve communication between providers are SBAR (Situation, Background, Assessment, Recommendation) and IPASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver). These structured communication tools help ensure all relevant information is relayed consistently between team members.
For a client with a latex allergy, the nurse must identify latex-containing items and substances to avoid exposure. This includes latex gloves, blood pressure cuffs, stethoscope tubing, medication vials, tubes and catheters. The nurse should also notify environmental services to use latex-free cleaning supplies when cleaning the client’s room.
The correct nursing action when providing postmortem care is to remove dentures. The body should be left in supine position, personal belongings kept in the room, and lighting can be adjusted based on family request but does not need to be bright.
To ensure confidentiality during EMR documentation, the nurse should log off and close the record when away from the computer. Computers should not be left unattended with a record open. Ace my homework – Write my paper – Online assignment help tutors – Discussions involving clients should be conducted privately and in a low voice tone.
To prevent skin breakdown in a client on bedrest, the nurse can reposition the client every 2 hours, keep the skin clean and dry, and use a special bed pad like a pressure-reducing or air-fluidized mattress. Proper nutrition and hydration are also important to maintain skin integrity.
The guidelines the nurse should follow when calculating fluid intake include recording all intake – including oral intake and IV/tube feedings. Intake should be totaled and compared to output which includes urine, stool, wound drainage, gastrointestinal losses etc. Daily fluid balance should be calculated and goals individualized based on the client’s condition.
In this situation where the family is concerned about aggressive treatment after unsuccessful resuscitation, the provider’s role is to compassionately explain that further interventions would be futile given the client’s condition. The family should be supported through the grieving process with spiritual and bereavement resources as appropriate.
Two priority nursing considerations for an allergic reaction are assessing the airway, breathing, and circulation (ABC’s) and stabilizing the client. Epinephrine should be readily available in case of anaphylaxis. Other signs and symptoms like rash, itching, swelling should also be monitored and reported to the provider.
Possible role problems in family functioning following an acute event can include changes in roles within the family, financial stressors due to medical costs or lost wages, caregiving demands that disrupt work/family balance, and grief/emotional distress impacting relationships and communication.
When teaching a newly diagnosed diabetic about blood glucose monitoring, the nurse should explain how to select a fingerstick site and use a quick, shallow puncture to minimize pain. Rotating sites can also help prevent soreness. Applying pressure after removal of the lancet helps too. Proper hand washing and hygiene is important as well.
Education for a client reporting insomnia due to stress should include relaxation techniques, sleep hygiene practices, identifying and challenging anxious thoughts, stress management strategies, and the short-term use of non-pharmacological remedies when indicated. Referral to a mental health provider or support group may benefit the client long-term as well.
When instructing a client on progressive muscle relaxation, the nurse should explain that it involves tensing and relaxing different muscle groups while focusing on the sensations. This helps relieve physical tension and switch off the “fight or flight” response to promote relaxation. The client should be in a comfortable position and focus on fully tensing then releasing each muscle group, working from the toes up. Breathing deeply throughout also enhances relaxation.
Clinical manifestations of dehydration in a postoperative nauseated and vomiting client can include decreased urine output, dry mucous membranes, sunken eyes, wrinkled skin, dizziness upon standing, and postural hypotension. Other signs are fatigue, thirst, and heart palpitations. The nurse should assess for these and encourage oral rehydration with small frequent sips of water or oral rehydration solution if tolerated. IV fluids may be needed for more severe dehydration.
