Question 1 See full question
Several hours into a shift, a nurse on a very busy medical-surgical unit
privately asks the charge nurse to change her assignment. She is
frustrated because she has had to devote so much time and energy to
helping a newly licensed nurse provide discharge teaching for clients with
diabetes mellitus. The charge nurse should:
Correct response:
•
offer to assist with the discharge teaching needs.
Explanation:
Staff members need to know the charge nurse is a supportive leader who
respects their honesty and stands behind them. By offering to help with
discharge teaching, the charge nurse is actively engaging with her staff at a
time of need. Changing all the assignments on this extremely busy floor
would be counterproductive. Insisting that the staff member follow through
with her assignment disrespects her request and genuine need. Providing a
float nurse could help, but there are no guarantees a float nurse is available.
Remediation:
•
Discharge
Question 2 See full question
During chemotherapy, an oncology client has a nursing diagnosis of
Impaired oral mucous membrane related to decreased nutrition and
immunosuppression secondary to the cytotoxic effects of chemotherapy. Which
nursing intervention is most likely to decrease the pain of stomatitis
Correct response:
•
Providing a solution of viscous lidocaine for use as a mouth rinse
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of
hydrogen viscous lidocaine for the client to use as a mouth rinse.
(Commercially prepared mouthwashes contain alcohol and may cause
dryness and irritation of the oral mucosa.) The nurse also may administer
systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after
chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or
practical. Instead, the nurse should stay alert for this potential problem to
ensure prompt treatment. Monitoring platelet and leukocyte counts may
help prevent bleeding and infection but wouldn't decrease pain in this highly
susceptible client. Checking for signs and symptoms of stomatitis also
wouldn't decrease the pain.
Remediation:
, •
Impaired Oral Membrane
Question 3 See full question
A nurse has been caring for an adolescent client in a residential facility.
The child has been through a series of foster placements since infancy with
no success in any placement until the age of 7 when placed with a middle-
aged single woman. The client thrived there until the woman was killed in a
car accident. The client attempted suicide after her foster mother died in
response to the loss and the child was placed in the residential facility. The
nurse has become close to this client and wants to help her address her
issues and move on with her life. Which comment to the manager
demonstrates that the nurse understands the client’s issues and is able to
respond appropriately to the client’s needs?
You Selected:
•
"It is difficult for her to love and trust again after her losses. In this
facility, she can learn to deal with her loss in a less emotionally
charged environment than a foster home."
Explanation:
The severe emotional trauma the girl has experienced will likely make it
difficult for her to be successful in an adoptive placement at the present
time, whether that placement is with someone she knows (the nurse) or
another adoptive family. Additionally, adoption by the nurse is inappropriate
because it blurs the lines between her professional and personal life and is
likely to confuse the client. It is clear that the client has many issues and
that love alone is not likely to solve all her problems. Treatment at the
residential facility will allow her to work through emotional issues in a more
therapeutic environment. Though not currently ready for adoption, she may
be ready for adoption in the future after sufficient treatment.
Question 4 See full question
A client is about to undergo cardiac catheterization for which he signed an
informed consent. As the nurse enters the room to administer sedation for
the procedure, the client states, "I'm really worried about having this open
heart surgery." Based on this statement, how should the nurse proceed?
Correct response:
•
Withhold the medication and notify the physician immediately.
Explanation:
The nurse should withhold the medication and notify the physician that the
client does not understand the procedure. The physician then has the
obligation to explain the procedure better to the client and determine
whether or not the client understands. If the client does not understand, he
cannot give a true informed consent. If the medication is administered
before the physician explains the procedure, the sedation may interfere
,with the client's ability to clearly understand the procedure. The nurse may
not just medicate the client and document the finding; the physician must
be notified. The procedure does not need to be cancelled, only postponed
until the client receives more education and is able to give informed
consent.
Remediation:
•
Decisional Conflict
Question 5 See full question
Which action associated with restraint use on a confused client can be
delegated to an unlicensed healthcare worker/nursing assistant?
•
Completion of range of motion on limbs restrained
Question 1 See full question
Four clients have been admitted to the cardiac intensive care unit after
experiencing acute myocardial infarctions. Each client has sustained a
percentage of cardiac damage. Which client is most in need of interventions
to prevent the development of cardiogenic shock?
Correct response:
•
The client with 40% damage
Explanation:
At least 40% of the heart muscle must be involved for cardiogenic shock to
develop. In most circumstances, the heart can compensate for up to 25%
damage. An infarction involving 70% of the heart would have likely already
caused cardiogenic shock.
Question 2 See full question
The nurse is providing postoperative care to a client with sickle cell anemia.
What is the most important intervention for the nurse to include in the plan
of care?
Correct response:
•
Increasing fluids
Explanation:
The main surgical risk of anesthesia is hypoxia. Emotional stress,
demands of wound healing, and the potential for infection can each
increase the sickling phenomenon.
Increased fluids are encouraged because hydration promotes
hemodilution, and decreases sickling. Preparing the child psychologically
to decrease fear will minimize undue emotional stress, but is not a priority.
Deep coughing is encouraged to promote pulmonary hygiene and prevent
respiratory tract infection. Analgesics are used to control wound pain and
, to prevent abdominal splinting and decreased ventilation.
Several hours into a shift, a nurse on a very busy medical-surgical unit
privately asks the charge nurse to change her assignment. She is
frustrated because she has had to devote so much time and energy to
helping a newly licensed nurse provide discharge teaching for clients with
diabetes mellitus. The charge nurse should:
Correct response:
•
offer to assist with the discharge teaching needs.
Explanation:
Staff members need to know the charge nurse is a supportive leader who
respects their honesty and stands behind them. By offering to help with
discharge teaching, the charge nurse is actively engaging with her staff at a
time of need. Changing all the assignments on this extremely busy floor
would be counterproductive. Insisting that the staff member follow through
with her assignment disrespects her request and genuine need. Providing a
float nurse could help, but there are no guarantees a float nurse is available.
Remediation:
•
Discharge
Question 2 See full question
During chemotherapy, an oncology client has a nursing diagnosis of
Impaired oral mucous membrane related to decreased nutrition and
immunosuppression secondary to the cytotoxic effects of chemotherapy. Which
nursing intervention is most likely to decrease the pain of stomatitis
Correct response:
•
Providing a solution of viscous lidocaine for use as a mouth rinse
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of
hydrogen viscous lidocaine for the client to use as a mouth rinse.
(Commercially prepared mouthwashes contain alcohol and may cause
dryness and irritation of the oral mucosa.) The nurse also may administer
systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after
chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or
practical. Instead, the nurse should stay alert for this potential problem to
ensure prompt treatment. Monitoring platelet and leukocyte counts may
help prevent bleeding and infection but wouldn't decrease pain in this highly
susceptible client. Checking for signs and symptoms of stomatitis also
wouldn't decrease the pain.
Remediation:
, •
Impaired Oral Membrane
Question 3 See full question
A nurse has been caring for an adolescent client in a residential facility.
The child has been through a series of foster placements since infancy with
no success in any placement until the age of 7 when placed with a middle-
aged single woman. The client thrived there until the woman was killed in a
car accident. The client attempted suicide after her foster mother died in
response to the loss and the child was placed in the residential facility. The
nurse has become close to this client and wants to help her address her
issues and move on with her life. Which comment to the manager
demonstrates that the nurse understands the client’s issues and is able to
respond appropriately to the client’s needs?
You Selected:
•
"It is difficult for her to love and trust again after her losses. In this
facility, she can learn to deal with her loss in a less emotionally
charged environment than a foster home."
Explanation:
The severe emotional trauma the girl has experienced will likely make it
difficult for her to be successful in an adoptive placement at the present
time, whether that placement is with someone she knows (the nurse) or
another adoptive family. Additionally, adoption by the nurse is inappropriate
because it blurs the lines between her professional and personal life and is
likely to confuse the client. It is clear that the client has many issues and
that love alone is not likely to solve all her problems. Treatment at the
residential facility will allow her to work through emotional issues in a more
therapeutic environment. Though not currently ready for adoption, she may
be ready for adoption in the future after sufficient treatment.
Question 4 See full question
A client is about to undergo cardiac catheterization for which he signed an
informed consent. As the nurse enters the room to administer sedation for
the procedure, the client states, "I'm really worried about having this open
heart surgery." Based on this statement, how should the nurse proceed?
Correct response:
•
Withhold the medication and notify the physician immediately.
Explanation:
The nurse should withhold the medication and notify the physician that the
client does not understand the procedure. The physician then has the
obligation to explain the procedure better to the client and determine
whether or not the client understands. If the client does not understand, he
cannot give a true informed consent. If the medication is administered
before the physician explains the procedure, the sedation may interfere
,with the client's ability to clearly understand the procedure. The nurse may
not just medicate the client and document the finding; the physician must
be notified. The procedure does not need to be cancelled, only postponed
until the client receives more education and is able to give informed
consent.
Remediation:
•
Decisional Conflict
Question 5 See full question
Which action associated with restraint use on a confused client can be
delegated to an unlicensed healthcare worker/nursing assistant?
•
Completion of range of motion on limbs restrained
Question 1 See full question
Four clients have been admitted to the cardiac intensive care unit after
experiencing acute myocardial infarctions. Each client has sustained a
percentage of cardiac damage. Which client is most in need of interventions
to prevent the development of cardiogenic shock?
Correct response:
•
The client with 40% damage
Explanation:
At least 40% of the heart muscle must be involved for cardiogenic shock to
develop. In most circumstances, the heart can compensate for up to 25%
damage. An infarction involving 70% of the heart would have likely already
caused cardiogenic shock.
Question 2 See full question
The nurse is providing postoperative care to a client with sickle cell anemia.
What is the most important intervention for the nurse to include in the plan
of care?
Correct response:
•
Increasing fluids
Explanation:
The main surgical risk of anesthesia is hypoxia. Emotional stress,
demands of wound healing, and the potential for infection can each
increase the sickling phenomenon.
Increased fluids are encouraged because hydration promotes
hemodilution, and decreases sickling. Preparing the child psychologically
to decrease fear will minimize undue emotional stress, but is not a priority.
Deep coughing is encouraged to promote pulmonary hygiene and prevent
respiratory tract infection. Analgesics are used to control wound pain and
, to prevent abdominal splinting and decreased ventilation.
