NClex / Basic Physical Care 2nd Set
The physician orders hourly urine output measurement for a postoperative client. The
nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which action should the nurse take? - Normal
urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client's output is normal. Beyond continued evaluation, no nursing action is warranted.
A hospitalized client who has a living will is being fed through a nasogastric (NG) tube.
During a bolus feeding, the client vomits and begins choking. Which of the following
actions is most appropriate for the nurse to take? - A living will states that no life-saving
measures are to be used in terminal conditions. There is no indication that the client is
terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as
choking on an enteral feeding device. The nurse should clear the client's airway. Making
the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation
isn't indicated, and removing the NG tube would exacerbate the situation.
The physician orders an intestinal tube to decompress a client's GI tract. When
gathering equipment for this procedure, the nurse identifies which of the following as an
intestinal tube? - A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore
tube is an esophageal tube. A Levin tube and a Salem sump tube are nasogastric
tubes.
A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU)
because there are few clients in the pediatric unit. The nurse has never worked in ICU
and has no critical care experience. Which action is most appropriate for this nurse? -
The pediatric nurse should notify the nursing supervisor about feeling unqualified and
untrained. The nursing supervisor can guide the pediatric nurse as to the tasks the
pediatric nurse is qualified to perform in the ICU without jeopardizing the nurse's nursing
license. When the census on a unit is low, many facilities use staff to float to another
unit as a cost-effective and reasonable manner for managing resources. Option 4 puts
the decision and responsibility for performance on ICU nurses. However, the nursing
supervisor should make those decisions because the supervisor knows the overall
needs of the facility and can, therefore, best allocate nursing resources. A nurse should
never take responsibility for a total client care assignment if the nurse doesn't have the
skills to plan and deliver that care.
A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to
work extra shifts to cover the staffing shortages. One of the staff nurses hasn't
volunteered and states, "Forty hours a week of nursing is all I can manage to do. I won't
volunteer for overtime." The nurse-manager says to an attending physician on the unit,
"I'll adjust her schedule to make her wish she'd volunteered." The physician to whom
she commented should: - It's discriminatory and punitive for the nurse-manager to alter
the staff nurse's schedule. The remark is inappropriate and unprofessional, and the
,nurse-manager should receive counseling. The physician could choose to ignore the
comment, but any provider who hears of discrimination should deal with it. If the matter
can be resolved locally, reporting the nurse-manager to the labor relations board should
be avoided. Institutional documentation should exist for such matters. It's inappropriate
for the physician to inform the staff nurse about what was said. Such action could create
difficult relations on the unit and thereby affect nursing care.
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance.
The goal of care for this client is to mobilize pulmonary secretions. Which intervention
would help meet this goal? - Repositioning the client every 2 hours helps prevent
secretions from pooling in dependent lung areas. Restricting fluids would make
secretions thicker and more tenacious, thereby hindering their removal. Administering
oxygen and keeping the head of the bed at a 30-degree angle might ease respirations
and make them more effective but wouldn't help mobilize secretions.
A client who recently immigrated to the United States from Korea is hospitalized with
second- and third-degree burns. He speaks little English and has been lying quietly in
bed. Ten hours after his admission, the nurse conducts a serial assessment and asks
him whether he's in pain. He smiles and shakes his head vigorously back and forth.
Which nursing action would be most appropriate at this time? - The nurse should
consider the possibility that the client didn't understand the question or has been
conditioned culturally not to complain openly of pain. Checking vital signs and assessing
for nonverbal indications of pain help the nurse determine whether the client is in pain.
Accepting the client's response without question or further assessment may lead to
inadequate intervention. Calling the family or giving pain medication isn't warranted
because the client denies pain.
The staff of an outpatient clinic has formed a task force to develop new procedures for
swift, safe evacuation of the unit. The new procedures haven't been reviewed,
approved, or shared with all personnel. When the nurse-manager receives word of a
bomb threat, the task force members push for evacuating the unit using the new
procedures. Which action should the nurse-manager take? - In an emergency such as a
bomb scare, the nurse-manager must determine, without hesitation, the best action for
the safety and welfare of clients and staff. Allowing staff members to do whatever they
think best will cause confusion and inefficient client evacuation because no one will
know how to function effectively as a team during the crisis. Taking time to have a staff
meet is wasting valuable time.
A child with rheumatic fever complains of painful joints. What nonpharmacologic
measures should the nurse use to reduce the child's pain? - In rheumatic fever, the
joints may be so painful that even the weight of the bed linens can cause pain. A bed
cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased
when the affected joint is moved; therefore, passive range-of-motion exercises aren't
recommended. Pain isn't likely to be relieved by massaging the joints. The child should
be encouraged to change positions at least every 2 hours to reduce the risk of skin
breakdown, but this is unlikely to relieve joint pain.
, Which strategy can help make the nurse a more effective teacher? - An effective
teacher always involves the student in the discussion. Using technical terms and
providing detailed explanations usually confuse the student and act as barriers to
learning. Using loosely structured teaching sessions permits distractions and deviations
from the teaching goals.
A client who's a member of the Jehovah's Witnesses refuses a blood transfusion based
on his religious beliefs and practices. His decision must be followed based on which
ethical principle? - The right to refuse treatment is grounded in the ethical principle of
respect for the autonomy of the individual. The client has the right to refuse treatment as
long as he's competent and aware of the risks and complications associated with that
refusal. The right to die is a difficult decision involving whether to initiate or withhold life-
sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering
with end-stage terminal illness. Sometimes, the client has signed an advance directive,
making his wishes known. An advance directive is a document used as a guideline for
starting or continuing life-sustaining medical care; the client commonly has a terminal
disease or disability and can't indicate his own wishes. Substituted judgment is an
ethical principle used when a decision — based on what's best for the client — is made
for an incapacitated client.
When approaching a family for organ or tissue donation, the nurse should keep in mind
which guideline? - The family should be offered an opportunity to speak with an organ
procurement coordinator. An organ procurement coordinator is knowledgeable about
the organ donation process and should have exceptional interpersonal skills for dealing
with grieving family members. Physician support in the process is desirable but consent
or written orders aren't necessary for a referral to the organ procurement organization.
The requestor must believe in the benefits of organ donation and support the process
with a positive attitude. The family should be approached about speaking to an organ
procurement coordinator only after the family has been made aware of the client's
condition and prognosis. Approaching a family member who believes there's still hope
for recovery will likely result in a negative outcome.
A client who's dehydrated has urinary incontinence and excoriation in the perineal area.
Which action would be a priority? - Because the skin, the body's first line of defense, is
broken and excoriated, keeping the area clean and dry is a priority because it aids
healing. Offering the urinal every 3 hours would help set a voiding schedule; however,
to avoid incontinence, the urinal should be offered more often. Maintaining fluid intake at
1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids
wouldn't aid healing. Continued incontinence as well as moist compresses would
contribute to additional skin excoriation and breakdown.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory
test? - All of these tests help evaluate a client with respiratory problems. However, ABG
analysis is the only test that evaluates gas exchange in the lungs, providing information
about the client's oxygenation status.
The physician orders hourly urine output measurement for a postoperative client. The
nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which action should the nurse take? - Normal
urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this
client's output is normal. Beyond continued evaluation, no nursing action is warranted.
A hospitalized client who has a living will is being fed through a nasogastric (NG) tube.
During a bolus feeding, the client vomits and begins choking. Which of the following
actions is most appropriate for the nurse to take? - A living will states that no life-saving
measures are to be used in terminal conditions. There is no indication that the client is
terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as
choking on an enteral feeding device. The nurse should clear the client's airway. Making
the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation
isn't indicated, and removing the NG tube would exacerbate the situation.
The physician orders an intestinal tube to decompress a client's GI tract. When
gathering equipment for this procedure, the nurse identifies which of the following as an
intestinal tube? - A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore
tube is an esophageal tube. A Levin tube and a Salem sump tube are nasogastric
tubes.
A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU)
because there are few clients in the pediatric unit. The nurse has never worked in ICU
and has no critical care experience. Which action is most appropriate for this nurse? -
The pediatric nurse should notify the nursing supervisor about feeling unqualified and
untrained. The nursing supervisor can guide the pediatric nurse as to the tasks the
pediatric nurse is qualified to perform in the ICU without jeopardizing the nurse's nursing
license. When the census on a unit is low, many facilities use staff to float to another
unit as a cost-effective and reasonable manner for managing resources. Option 4 puts
the decision and responsibility for performance on ICU nurses. However, the nursing
supervisor should make those decisions because the supervisor knows the overall
needs of the facility and can, therefore, best allocate nursing resources. A nurse should
never take responsibility for a total client care assignment if the nurse doesn't have the
skills to plan and deliver that care.
A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to
work extra shifts to cover the staffing shortages. One of the staff nurses hasn't
volunteered and states, "Forty hours a week of nursing is all I can manage to do. I won't
volunteer for overtime." The nurse-manager says to an attending physician on the unit,
"I'll adjust her schedule to make her wish she'd volunteered." The physician to whom
she commented should: - It's discriminatory and punitive for the nurse-manager to alter
the staff nurse's schedule. The remark is inappropriate and unprofessional, and the
,nurse-manager should receive counseling. The physician could choose to ignore the
comment, but any provider who hears of discrimination should deal with it. If the matter
can be resolved locally, reporting the nurse-manager to the labor relations board should
be avoided. Institutional documentation should exist for such matters. It's inappropriate
for the physician to inform the staff nurse about what was said. Such action could create
difficult relations on the unit and thereby affect nursing care.
A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance.
The goal of care for this client is to mobilize pulmonary secretions. Which intervention
would help meet this goal? - Repositioning the client every 2 hours helps prevent
secretions from pooling in dependent lung areas. Restricting fluids would make
secretions thicker and more tenacious, thereby hindering their removal. Administering
oxygen and keeping the head of the bed at a 30-degree angle might ease respirations
and make them more effective but wouldn't help mobilize secretions.
A client who recently immigrated to the United States from Korea is hospitalized with
second- and third-degree burns. He speaks little English and has been lying quietly in
bed. Ten hours after his admission, the nurse conducts a serial assessment and asks
him whether he's in pain. He smiles and shakes his head vigorously back and forth.
Which nursing action would be most appropriate at this time? - The nurse should
consider the possibility that the client didn't understand the question or has been
conditioned culturally not to complain openly of pain. Checking vital signs and assessing
for nonverbal indications of pain help the nurse determine whether the client is in pain.
Accepting the client's response without question or further assessment may lead to
inadequate intervention. Calling the family or giving pain medication isn't warranted
because the client denies pain.
The staff of an outpatient clinic has formed a task force to develop new procedures for
swift, safe evacuation of the unit. The new procedures haven't been reviewed,
approved, or shared with all personnel. When the nurse-manager receives word of a
bomb threat, the task force members push for evacuating the unit using the new
procedures. Which action should the nurse-manager take? - In an emergency such as a
bomb scare, the nurse-manager must determine, without hesitation, the best action for
the safety and welfare of clients and staff. Allowing staff members to do whatever they
think best will cause confusion and inefficient client evacuation because no one will
know how to function effectively as a team during the crisis. Taking time to have a staff
meet is wasting valuable time.
A child with rheumatic fever complains of painful joints. What nonpharmacologic
measures should the nurse use to reduce the child's pain? - In rheumatic fever, the
joints may be so painful that even the weight of the bed linens can cause pain. A bed
cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased
when the affected joint is moved; therefore, passive range-of-motion exercises aren't
recommended. Pain isn't likely to be relieved by massaging the joints. The child should
be encouraged to change positions at least every 2 hours to reduce the risk of skin
breakdown, but this is unlikely to relieve joint pain.
, Which strategy can help make the nurse a more effective teacher? - An effective
teacher always involves the student in the discussion. Using technical terms and
providing detailed explanations usually confuse the student and act as barriers to
learning. Using loosely structured teaching sessions permits distractions and deviations
from the teaching goals.
A client who's a member of the Jehovah's Witnesses refuses a blood transfusion based
on his religious beliefs and practices. His decision must be followed based on which
ethical principle? - The right to refuse treatment is grounded in the ethical principle of
respect for the autonomy of the individual. The client has the right to refuse treatment as
long as he's competent and aware of the risks and complications associated with that
refusal. The right to die is a difficult decision involving whether to initiate or withhold life-
sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering
with end-stage terminal illness. Sometimes, the client has signed an advance directive,
making his wishes known. An advance directive is a document used as a guideline for
starting or continuing life-sustaining medical care; the client commonly has a terminal
disease or disability and can't indicate his own wishes. Substituted judgment is an
ethical principle used when a decision — based on what's best for the client — is made
for an incapacitated client.
When approaching a family for organ or tissue donation, the nurse should keep in mind
which guideline? - The family should be offered an opportunity to speak with an organ
procurement coordinator. An organ procurement coordinator is knowledgeable about
the organ donation process and should have exceptional interpersonal skills for dealing
with grieving family members. Physician support in the process is desirable but consent
or written orders aren't necessary for a referral to the organ procurement organization.
The requestor must believe in the benefits of organ donation and support the process
with a positive attitude. The family should be approached about speaking to an organ
procurement coordinator only after the family has been made aware of the client's
condition and prognosis. Approaching a family member who believes there's still hope
for recovery will likely result in a negative outcome.
A client who's dehydrated has urinary incontinence and excoriation in the perineal area.
Which action would be a priority? - Because the skin, the body's first line of defense, is
broken and excoriated, keeping the area clean and dry is a priority because it aids
healing. Offering the urinal every 3 hours would help set a voiding schedule; however,
to avoid incontinence, the urinal should be offered more often. Maintaining fluid intake at
1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids
wouldn't aid healing. Continued incontinence as well as moist compresses would
contribute to additional skin excoriation and breakdown.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory
test? - All of these tests help evaluate a client with respiratory problems. However, ABG
analysis is the only test that evaluates gas exchange in the lungs, providing information
about the client's oxygenation status.
