05.01 Overview of the Nursing Process

A nurse is not sure if the provider should be contacted about a client's condition. What elements of the problem-solving method should the nurse consider that would help with this decision? Select all that apply.

A. Creating a document that describes the situation
B. Making a decision to think about the problem
C. Analyzing potential choices the nurse could make
D. Assessing the situation to recognize a potential problem
E. Formulation a plan about the best action to take for the problem
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A nurse is not sure if the provider should be contacted about a client's condition. What elements of the problem-solving method should the nurse consider that would help with this decision? Select all that apply.

A. Creating a document that describes the situation
B. Making a decision to think about the problem
C. Analyzing potential choices the nurse could make
D. Assessing the situation to recognize a potential problem
E. Formulation a plan about the best action to take for the problem
answer

✅Assessing the situation to recognize a potential problem
The problem-solving method is a technique used to help a nurse who has a problem to come to a decision about how to solve the problem. It involves recognizing those aspects of the problem that can be changed, formulating the best approach to come up with a solution, and then acting on that decision.

✅Analyzing potential choices the nurse could make
The problem-solving method is a technique used to help a nurse who has a problem to come to a decision about how to solve the problem. It involves recognizing those aspects of the problem that can be changed, formulating the best approach to come up with a solution, and then acting on that decision.

✅Formulating a plan about the best action to take for the problem
The problem-solving method is a technique used to help a nurse who has a problem to come to a decision about how to solve the problem. It involves recognizing those aspects of the problem that can be changed, formulating the best approach to come up with a solution, and then acting on that decision.

Making a decision to think about the problem
These are not part of the problem solving method. Making a decision to think about the problem is done BEFORE the problem-solving process, and creating a document is not necessary.

Creating a document that describes the situation
These are not part of the problem solving method. Making a decision to think about the problem is done BEFORE the problem-solving process, and creating a document is not necessary.
Prior to a client's surgery, a nurse is assessing whether a PCA would be appropriate during the post-op period. Which factors would the nurse assess that would help determine that the use of a PCA is appropriate? Select all that apply.
A. The client understands when to use the PCA button
B. The client tolerated previously administered IV pain medications
C. The client consistently rates his pain at a high level despite prn medications
D. The client has family nearby who can help him push the button if needed
E. The client has an altered respiratory status because of the procedure
ANSWER

✅The client understands when to use the PCA button

Although a PCA is helpful for controlling a client's pain, it cannot be used for everyone. The nurse should assess the adequacy of pain control the client is experiencing, if the client understands how to use the PCA pump and whether the client has received pain medications before and can tolerate them.

✅The client consistently rates his pain at a high level despite prn medications
This is an appropriate situation for a PCA.

✅The client tolerated previously administered IV pain medications
This is important in order for a client to be able to safely use a PCA.

The client has an altered respiratory status because of the procedure
This is a contraindication to receiving pain control by PCA.

The client has family nearby who can help him push the button if needed
The only person that can push the button is the client. Pain control by proxy is not recommended or allowed.
A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use to assess whether this patient is dehydrated?

A. Decreased BUN level
B. A 10 percent gain in body weight
C. Decreased serum sodium
D. Orthostatic hypotension
ANSWER
✅Orthostatic hypotension
In a patient who did not have orthostatic hypotension previously, this is an indicator of volume depletion and therefore dehydration. A patient who is dehydrated may exhibit several clinical signs that indicate that the nurse needs to intervene to help increase the patients fluid intake. Additional signs of dehydration include dry mucous membranes, dark urine, weight loss, elevated serum sodium or elevated BUN with decreased creatinine.

A 10 percent gain in body weight
Weight loss is a sign of dehydration, not weight gain.

Decreased serum sodium
The opposite happens in dehydration - increased serum sodium.

Decreased BUN level
When the BUN level increases it is a clinical indication of dehydration.
A patient calls the nurse and complains about his IV site. The nurse assesses the site and notes that the skin is red and warm and the client states that the pain travels up his arm. Which of the following potential complications of IV therapy has most likely occurred?

A. Phlebitis
B. Infiltration
C. Circulatory overload
D. Thrombus
ANSWER
✅Phlebitis
This is a complication of IV therapy that is often caused by irritating fluids or medications given intravenously. The client with phlebitis has heat and redness at the IV site, and the IV is sluggish to flush. Pain may travel up the arm along the route of the vein.

Thrombus
With a thrombus the vein feels hard or cordlike at the site.

Infiltration
With infiltration there is edema, numbness and pain at the site and the skin is cool.

Circulatory overload
The symptoms of this condition are systemic, not presenting locally at the IV site. Symptoms include increased blood pressure, distended jugular veins and a moist cough.
A nurse is assessing a 37-year-old client prior to administration of packed red blood cells for post-op hemorrhage. The nurse must use a pressure infusion device to rapidly administer the blood products. The nurse notes that the client has a 24-gauge catheter in her antecubital fossa. Which action of the nurse is correct?

A. Prepare to assist with central line placement
B. Start another IV catheter of 18-gauge or larger in another location
C. Administer the blood through the catheter already in place
D. Contact the physician about the catheter location
ANSWER
✅Start another IV catheter of 18-gauge or larger in another location
Transfusion of blood products must be done safely and correctly to prevent hemolysis, which is the breakdown of red blood cells in the transfusion. Hemolysis may occur if the nurse administers blood into an IV that has too small of diameter. When administering a rapid blood transfusion, the nurse must ensure that an 18-gauge catheter is in place to avoid damage to the vein or blood cells.

Administer the blood through the catheter already in place
A 24-gauge catheter is too small to rapidly infuse blood products.

Contact the physician about the catheter location
It is within the scope of practice of the nurse to change the IV site and gauge. Contacting the provider is unnecessary and would waste precious time.

Prepare to assist with central line placement
In this emergent situation, there is no time to get an order for a central line and wait until it is placed to start the transfusion. The nurse must act quickly to start an appropriately placed 18- or larger gauge peripheral lV.
A nurse is assessing a client's ability to perform activities of daily living. Which action would the nurse have the client perform as part of this assessment process?

A. Ask the client to interact with family members
B. Close the eyes and hold the arms out to the sides
C. Stand on one foot
D. Put both hands together behind the head
ANSWER
✅Put both hands together behind the head
A nurse can assess a client's ability to perform activities of daily living (ADLs) by performing a simple assessment. This helps to inform the nurse about how much care the client needs and what is able to be performed independently. Asking the client to perform small tasks, such as clasping the hands behind the head or pulling against a small amount of resistance can help the nurse discern the client's functional abilities. Simply observing the client performing simple tasks in the room is an additional source of information regarding the client's ability level.

Stand on one foot
This is not a necessary action to accomplish daily living tasks and is potentially dangerous.

Close the eyes and hold the arms out to the sides
This describes a neurological test to detect poor balance. Assessing activities of daily living is not whether a client has poor balance, but rather how the client manages the abilities he or she possesses to complete necessary daily tasks.

Ask the client to interact with family members
This is not related to a client's ability to individually accomplish ADLs.
A patient has been given a nursing diagnosis of Alteration in Comfort related to a back injury. Which nursing intervention would be most appropriate in this situation?

A.Encourage the patient to use mind-body therapy to control pain instead of analgesia

B.Teach the patient to notify the nurse when the pain medication starts working

C.Assess the most likely cause of the patients pain

D. Eliminate environmental stressors and other sources of discomfort
ANSWER

✅Eliminate environmental stressors and other sources of discomfort
When there are stressors and other conditions in the environment that contribute to the pain, pain relief is difficult to achieve. A patient who is distracted may have a more difficult time managing pain; the nurse should try to remove as many distractions and stressful factors in the environment as possible.

Assess the most likely cause of the patients pain
This has already been done. We know the alteration in comfort is related to the patient's back injury.

Encourage the patient to use mind-body therapy to control pain instead of analgesia
While non-pharmacological methods should be encouraged by the nurse, we should be sure we are using all the tools available to make the patient comfortable, including analgesics prescribed by the doctor.

Teach the patient to notify the nurse when the pain medication starts working
This is not a nursing intervention. The nursing intervention was to administer the pain medication that was prescribed.
A 69-year-old client has been diagnosed with cardiomyopathy. The nurse gives the client a nursing diagnosis of powerlessness because the client has said that she feels sad and angry about what she will miss out on with her diagnosis. Which nursing intervention is most appropriate for this nursing diagnosis?

A.Have the client write down all of the things she likes about herself
B.Help the client identify factors that she can control
C.Talk about the client's feelings before she is dismissed to go home
D.Have the client talk to another client who also has the diagnosis of powerlessness
ANSWER
✅Help the client identify factors that she can control
Powerlessness is a nursing diagnosis that can be given when a client feels a lack of control over his or her situation. The client may demonstrate this powerlessness by avoiding self-care measures or grieving heavily over the situation. With a nursing diagnosis of powerlessness, the nurse can help the client to identify those factors that she can control, which may help her to feel as if she has power in some areas of her life, even if she cannot control her medical condition

Have the client write down all of the things she likes about herself
When the client feels a lack of power or control, it is helpful to help the client recognize the power and control that they still possess.

Talk about the client's feelings before she is dismissed to go home
Having the client talk about feelings is the first step, but it must also include directing the conversation in a positive direction toward the realization of power in the client.

Have the client talk to another client who also has the diagnosis of powerlessness
This could result in a worsening of both client's perspectives without direction from the nurse.
A nurse has given a client a nursing diagnosis of Ineffective Coping because of her response to an injury. The nurse helps the client to recognize individual strengths in this situation. Which outcome would most likely be expected as a result of these interventions?

A.The client will effectively be able to spend time alone
B.The client will recognize that she can cope and does not need help
C.The client will not try to harm herself or develop suicidal ideation
D. The client will think about methods she already uses to help her manage her feelings
ANSWER
✅The client will think about methods she already uses to help her manage her feelings
Ineffective coping refers to a situation in which a client is unable to handle the effects of an event. In this case, the client is not coping well after being injured. When the nurse helps the client to recognize the methods of coping she already has, the client will be able to utilize current strengths to reduce anxiety and cope more effectively.

The client will recognize that she can cope and does not need help
The nurse's goal is not to isolate the client from help from others. A support system is healthy and should always be encouraged.

The client will effectively be able to spend time alone
This client would benefit from a supportive network of family or friends. Isolation should not be encouraged.


The client will not try to harm herself or develop suicidal ideation
Yes, the client should not try to harm herself, but the goal of the nursing intervention described is more than this. The goal involves feelings and anxiety management on the part of the client
Reset Test
A 40-year-old woman is talking to a home care nurse about her husband's infidelity and their subsequent divorce. The woman asks the nurse about providing for her children after her husband moves out. Which is an example of the nurse utilizing the planning portion of this client's plan of care?

A. The nurse finds out where the children go to school
B. The nurse asks the woman how she feels about divorce
C. The nurse determines that the woman is helped by therapy
D. The nurse helps the woman find a counselor
ANSWER
✅The nurse helps the woman find a counselor
The planning portion of the plan of care involves the nurse setting measurable and achievable goals for the client, and outlining what interventions will be needed in the situation. For example, 'the client will get up to the chair three times daily for meals', 'the client's pain will be adequately managed with medication' or 'the client will resolve issues through counseling', as in this situation.

The nurse asks the woman how she feels about divorce
This action does not involve planning and setting goals.

The nurse finds out where the children go to school
This action does not involve planning and setting goals.

The nurse determines that the woman is helped by therapy
This action does not involve planning and setting goals.
A nurse works in a medical rehabilitation facility and is developing a plan of care for a 68-year-old client who has been admitted to the facility. Which best describes an appropriate goal in providing healthcare for a client in this age group? Select all that apply. A.Preventing falls B.Establishing dependent care on the nurse C.Preventing physical complications of aging D.Delaying physical decline E. Involving the senior in large group activitiesANSWER ✅Preventing falls Older adults have different healthcare needs when compared to middle age or young adults and children. When working with an older adult, the nurse will need to focus on safe and effective care, such as fall prevention. ✅Delaying physical decline When working with an older adult, the nurse will need to encourage the client to perform activities that will prevent physical decline. ✅Preventing physical complications of aging When working with an older adult, the nurse will need to discuss ways to manage or prevent physical complications related to aging. Establishing dependent care on the nurse Rather than becoming dependent on the nurse, the nurse and client should work towards increased independence. Involving the senior in large group activities Not every client benefits from large group activities. Some clients are better suited for interactions with smaller groups rather than large groups. A more appropriate goal would be to ensure the client is not isolated in the facility.The nurse is caring for a client with cancer. The client has discussed treatment options with the provider and agreed upon a plan that involves chemotherapy. The client tells the nurse that he is nervous about the side effects of the chemotherapy. Which of the following responses from the nurse is most appropriate? A. "There should be a local support group you can join to discuss these feelings related to chemotherapy" B. "You are one of many people who will lose their hair due to chemotherapy treatments" C. "I have time to discuss this with you. What side effects come to mind? D. "I encourage you to discuss these concerns with the provider"ANSWER ✅"I have time to discuss this with you. What side effects come to mind? The best response from the nurse involves an unhurried conversation with the client. Encouraging the client to give more information rather than the nurse assuming which part of chemotherapy the client is worried about is the most therapeutic approach. "There should be a local support group you can join to discuss these feelings related to chemotherapy" By saying this, the nurse is not offering presence or help to the client, but is instead distancing from the client and the client's fears. "I encourage you to discuss these concerns with the provider" This is a discussion for the client to have with the nurse rather than the provider. The client has brought it up with the nurse so it is the nurse's conversation to have. "You are one of many people who will lose their hair due to chemotherapy treatments" This response from the nurse assumes the client is specifically worried about hair loss, and it minimizes the client's concerns by turning the client into a 'number' rather than an individual.A nurse case manager is working with a diabetic client to ensure that the client has the supplies needed to manage the condition at home. The case manager has developed a plan of care for the client and is listing appropriate outcomes related to the client's self-care skills at home. Which of the following examples is most applicable in this situation? A. Client will demonstrate how to check blood glucose and respond appropriately to results before dismissal to home B. The client will be free from pain before dismissal from the healthcare center C. Client will have normal blood glucose levels before discharge D. The client's family will verbalize the client's self-care skills before dischargeANSWER ✅Client will demonstrate how to check blood glucose and respond appropriately to results before dismissal to home A client who will be expected to care for diabetes at home after discharge should be able to demonstrate some forms of self care while in the hospital. The case manager should ask the client to demonstrate self-care measures, such as checking his or her own blood glucose levels and showing how to respond to changes before being expected to do it at home. Client will have normal blood glucose levels before discharge A normal glucose level in the hospital while in the care of the nurse is irrelevant to the client being able to manage their own glucose level at home. The client's family will verbalize the client's self-care skills before discharge The question asks about self-care skills at home, so whether the family is able to verbalize the client's skills is unrelated to whether the client can actually manage the condition at home. Instead, the client needs to demonstrate that he or she is able to manage without another person assisting. The client will be free from pain before dismissal from the healthcare center While it is the nurse's job to control a client's pain, the question does not specifically state that the client is in pain, so this answer is incorrect.The nurse is caring for a client who was informed yesterday that amputation of the left leg is recommended. When the nurse attempts to discuss this with the client, he says the provider informed him that the leg was fine and he will go home any day now. What is most helpful in facilitating this client's plan of care? A. Asking, "Does needing this upcoming surgery make you feel anxious?" B. Notifying the MD of the need for a psych consult C. Informing the client that consent must be signed for surgery tomorrow D. Calling his next of kin for consent ASAPANSWER ✅Asking, "Does needing this upcoming surgery make you feel anxious?" This client is in denial, which is a defense mechanism. Asking the client about feelings of anxiety will help him explore these feelings which may help the client move past the shock of a limb amputation. Informing the client that consent must be signed for surgery tomorrow Getting consent when the client is in denial about the surgery is inappropriate. Calling his next of kin for consent ASAP The next of kin is not authorized to consent for this client. The nurse needs to figure out a way to break through the client's denial before consent can be addressed. Notifying the MD of the need for a psych consult Denial is a normal part of grieving a life change such as a limb amputation. A psych consult may not be necessary if the nurse can find a way to break through the client's denial.A nurse is working as part of an interdisciplinary team to make decisions for a client's plan of care. Which of the following would the nurse utilize as part of collaboration with the interdisciplinary team? Select all that apply. A. Include insights regarding the client's physical, emotional, and social state of wellness B. Serve as a liaison between the team and community resources Find out what other team members suggest for the client's care and then perform those actions for the client D. Ask other team members for their views and expertise about the situation E. Assist with making arrangements for team members to meet with the client to follow up on his conditionANSWER ✅Include insights regarding the client's physical, emotional, and social state of wellness This involves listening to and discussing with other team members about their professional opinions for client care. ✅IAsk other team members for their views and expertise about the situation When collaborating with an interdisciplinary team, the nurse works together with others to provide a comprehensive treatment plan that is specific to the client's needs. Assist with making arrangements for team members to meet with the client to follow up on his condition Team members are responsible for meeting with the client on their own. It is not the nurse's responsibility to arrange these encounters. Serve as a liaison between the team and community resources The case manager may serve as a liaison between the client and community resources, but not between the team and community resources. Find out what other team members suggest for the client's care and then perform those actions for the client A nurse is not responsible for performing every suggestion given by other members of the interdisciplinary team. Team members can suggest certain actions the nurse may take, but it is up to the nurse to decide if the actions are appropriate and necessary, and it is up to other team members to implement their own suggestions when applicable.The nurse is caring for a client with a neutrophil count of 490. Which of the following actions should the nurse implement? Select all that apply. A. Encourage fresh fruit and vegetable intake B. Initiate contact precautions C. Place the client in a private room D. Frequent IV site inspection E. Perform meticulous hand hygieneANSWER ✅Perform meticulous hand hygiene This client is immunocompromised, and is therefore very susceptible to infections. The client will be placed on neutropenic precautions, which means the nurse must take extra precautions not to expose this client to infectious agents, including meticulous hand hygiene . ✅Frequent IV site inspection This client is unable to fight transmittable diseases due to the client's low neutrophil count. The IV site is an area where infection could occur, so frequent site inspection is necessary to catch any infection early. ✅Place the client in a private room This client is immunocompromised and should be placed on neutropenic precautions. Neutropenic precautions includes thorough hand washing, a low microbial diet (no fresh salads, fruits, vegetables, uncooked meats), a daily room cleaning, frequent inspection of the IV site, no rectal temperatures or suppositories, dedicated equipment for the client, a private room, and a mask worn by persons entering the room if they have any respiratory symptoms. Initiate contact precautions Contact precautions are not necessary. The client does not have a multi-drug resistant organism, but rather, is susceptible to getting an infection due to a compromised immune system. Encourage fresh fruit and vegetable intake The client should avoid fresh fruits and vegetables due to potential microbes contained in these foods.The nurse is speaking with the family members about a client's plan of care. The client's daughter states, "Her living will stated she did not want to be intubated." Which of the following actions by the nurse are the most appropriate? Select all that apply. A. Call the PCP to obtain the advance directive B. Request the legal documentation from family C. Make a note in the client's chart that a verbal agreement was made to not intubate the client D. Ask the client if they want to be intubated, and if so, change it in the chart E. Update the client's chart once the legal documentation has been providedANSWER ✅Request the legal documentation from family If the family has the advance directive, they should provide a copy. ✅Update the client's chart once the legal documentation has been provided Living wills must have legal documentation to present in order for it to be changed in the chart. The nurse cannot go by verbal agreement alone. All efforts must be made to obtain the living will, including possibly retrieving a copy from the client's primary provider. A provider is also able to officially place an order for a specific advanced directive after speaking with the client. ✅ Call the PCP to obtain the advance directive The PCP may be able to provide a copy of the advance directive. Ask the client if they want to be intubated, and if so, change it in the chart This cannot be changed by the nurse. The provider must handle this, and there must be physical documentation. Make a note in the client's chart that a verbal agreement was made to not intubate the client The provider must handle any change to a DNR/DNI order.A nurse has arrived at the healthcare center to work the day shift and is getting ready for report. In order to best organize the day, which of the following is most important to consider while planning tasks? A. Whether the client has any prn medications ordered B. Whether a client has a timed test or procedure C. How many nurses are working on the unit that day D. If the client's family is in the room yetANSWER ✅Whether a client has a timed test or procedure When determining which client needs to be seen first for care, the nurse must consider which aspects will affect the timing and ability to carry out tasks. In this case, the nurse would consider whether a client has a timed test or procedure, which would affect when other tasks can be done. How many nurses are working on the unit that day This circumstance does not affect the nurse's organization for the day, because it does not require a time-sensitive task or care consideration. If the client's family is in the room yet This circumstance does not affect the nurse's organization for the day, because it does not require a time-sensitive task or care consideration. Whether the client has any prn medications ordered While schedule medications are taken into account when a nurse organizes care for the shift, PRN medications are not.When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable? A. The client's family will agree to the methods of treatment B. The client will ambulate to the end of the hallway within 2 days C. The client will have control of his back pain D. The client will verbalize feelings about her diagnosisANSWER ✅he client will ambulate to the end of the hallway within 2 days A SMART goal is one that is specific, measurable, action-oriented, realistic, and timely. Nurses should consider the acronym SMART when developing appropriate outcomes for their clients. A goal that is measureable means that the nurse has enough information that it can be measured to determine if the client has reached the goal or not. This involves describing the parameters of the goal and setting concrete criteria to know when the client reaches the goal. The client will have control of his back pain This goal is not measurable and does not include a time frame. Instead, this goal should state: The client will rate his back pain as a 3 out of 10 by lunch. The client's family will agree to the methods of treatment This goal is not directed at a client outcome, so it is inappropriate. The client will verbalize feelings about her diagnosis This goal is not action-oriented or timely. Instead, the goal should state: "The client will be able to discuss feelings about her diagnosis with the nurse by the end of the shift." Reset TestThe nurse is caring for a client who has returned to the floor from the PACU after an appendectomy. Based on this surgical procedure, the nurse knows to implement which of the following interventions for this client? A. Delay assessment of the incision until 24 hours post-op to prevent infection B. Apply heat to the abdomen to promote comfort C. Encourage favorite foods to encourage the return of bowel function D. Monitor temperature and pulse to assess for infectionANSWER ✅Monitor temperature and pulse to assess for infection The nurse will monitor the post-operative appendectomy client for signs and symptoms of infection by taking vital signs, monitoring lab values and assessing the incision site for redness, warmth, swelling and drainage. Pain control is important for the client as well. The bowel sounds are also monitored for return of function and the client remains NPO until bowel function has returned, at which point the client's diet can be slowly advanced. Encourage favorite foods to encourage the return of bowel function The client must remain NPO until bowel function has returned, and THEN the nurse can begin to advance the client's diet. Delay assessment of the incision until 24 hours post-op to prevent infection The nurse must assess the incision site or sites initially, then monitor regularly to detect any changes. Apply heat to the abdomen to promote comfort Heat encourages bacterial growth, and is not recommended for post-op comfort. Rather, the provider will usually order ice for comfort, which can be utilized for the client as needed.A nurse has started working in a clinic where many of the clients do not speak English. While the nurse has some working knowledge of a couple of other languages beyond English, the nurse is not fluent enough to easily communicate with most of the clients. Which actions would best represent the nurse's attempts to implement cross-cultural care in this practice setting? Select all that apply. A. The nurse incorporates hand gestures when teaching clients The nurse asks clients about their preferences for care B. The nurse uses family members when possible to serve as interpreters C. The nurse tries to learn about the common ethnic backgrounds of persons routinely at the clinic D. The nurse avoids making assumptions based on a client's appearanceANSWER ✅The nurse tries to learn about the common ethnic backgrounds of persons routinely at the clinic A nurse may work with clients of varying ethnic backgrounds. In order to provide culturally sensitive care, the nurse would recognize the variety among clients and avoid making assumptions. The best method is for the nurse to ask clients about their preferences, which shows that the nurse is open to helping them maintain their cultural practices while in the hospital. ✅The nurse asks clients about their preferences for care A nurse may work with clients of varying ethnic backgrounds. In order to provide culturally sensitive care, the nurse would recognize the variety among clients and avoid making assumptions. The best method is for the nurse to ask clients about their preferences, which shows that the nurse is open to helping them maintain their cultural practices while in the hospital. ✅The nurse avoids making assumptions based on a client's appearance A nurse may work with clients of varying ethnic backgrounds. In order to provide culturally sensitive care, the nurse would recognize the variety among clients and avoid making assumptions. The best method is for the nurse to ask clients about their preferences, which shows that the nurse is open to helping them maintain their cultural practices while in the hospital. The nurse uses family members when possible to serve as interpreters Hospital policies usually prohibit this, so instead the nurse should use an interpreter or interpreter telephone when available. The nurse incorporates hand gestures when teaching clients Hand gestures mean different things in different cultures, and the nurse must be careful to avoid sending the wrong messages to a client with hand gestures.While caring for a patient who is dying of cancer, the nurse tries to control the patient's pain. The nurse uses the WHO ladder to determine how much pain medicine to give. Which best describes implementation of this ladder? A. The nurse matches the level of pain the patient is having with a level on the pain ladder B. The ladder is similar to the Visual Analog Pain Scale C. The ladder cannot be used for administration of opioid analgesics D. The ladder should be used for patients who want to try non-pharmacological treatmentsANSWER ✅The nurse matches the level of pain the patient is having with a level on the pain ladder The World Health Organization has implemented this ladder to use as a tool for determining what type of medication is most helpful for different pain levels. The ladder ranges between three different levels of mild to severe pain and gives recommendations for treatments at each level. The ladder is similar to the Visual Analog Pain Scale Although they are both pain scales, the WHO ladder is used specifically for cancer pain, and the Visual Analog Pain Scale is typically a straight line with a numeric value, used for any pain causing condition. The ladder should be used for patients who want to try non-pharmacological treatments The WHO ladder incorporates pharmacologic treatments in each section. The ladder cannot be used for administration of opioid analgesics The ladder incorporates opioids as a pain control measure.A nurse is caring for a 12-month old child who is recovering from surgery. Which of the following principles should the nurse implement when managing pain in a patient who cannot communicate with words? Select all that apply. A. Check if the patient is in a situation that would cause pain B. Ask a close family member to assist in pain assessment C. Check for an elevated pulse or respiratory rate D. Look for behaviors such as crying or grimacing that would indicate pain E. Administer pain medication on a scheduled basis to prevent pain as ordered if indicatedANSWER ✅Check if the patient is in a situation that would cause pain When assessing for pain with children, the nurse should also determine if the patient is in a situation that could be causing pain and should provide pain medication as appropriate. ✅Look for behaviors such as crying or grimacing that would indicate pain A patient who cannot communicate his pain, such as an infant or an unconscious patient, should still be treated for potential pain. This requires the nurse to assess the patient for signs or symptoms of pain that are expressed without using words. ✅Ask a close family member to assist in pain assessment Family members, such as a parent or caregiver, typically know their child the best and will be able to assist the nurse in determining if a child is in pain. ✅Check for an elevated pulse or respiratory rate ✅Administer pain medication on a scheduled basis to prevent pain as ordered if indicatedA nurse is discharging a client to home following abdominal surgery. The client has a history of diabetic neuropathy and the nurse is providing discharge instructions. Which of the following instructions should the nurse give to this client to best prevent an injury at home as a result of peripheral neuropathy symptoms? A. Keep furniture and rooms free of clutter B. Maintain carpeted floors or use throw rugs on wood floors C. Install a ramp in the home to avoid using stairways D. Avoid drinking any alcoholANSWER ✅Keep furniture and rooms free of clutterA client with stress incontinence is undergoing treatment through rehabilitation of the pelvic floor muscles. Which statement by the client suggests that the treatment is effective? A. "I have not leaked urine the last several times I have coughed" B. "I have not had any pain with urination lately" C."I no longer feel stress about leaking urine. I have come to accept it" D. "I have not leaked urine when I walked by a bathroom"ANSWER ✅"I have not leaked urine the last several times I have coughed" Stress incontinence describes a condition in which a client leaks urine when there is increased pressure within the bladder, such as with coughing or sneezing. Treatment involves pelvic floor muscle rehabilitation and medications. The client may find success when urine is not leaked during coughing or laughing. "I have not had any pain with urination lately" Stress incontinence does not include pain with urination. "I have not leaked urine when I walked by a bathroom" Stress incontinence occurs when mechanical stress is placed on the bladder and the sphincter leaks urine. It does not occur when a person is reminded of going to the bathroom. "I no longer feel stress about leaking urine. I have come to accept it" The 'stress' in stress incontinence refers to mechanical stress, or pressure, placed on the bladder. It does not refer to emotional stress.A nurse has just completed client education prior to discharging a two-year-old who was just diagnosed with Hemophilia A. Which of the following statements from the parents indicate that the teaching was effective? Select all that apply. A. "Hemophilia is treatable with the right medications" B. "Having hemophilia means that my child will bleed more intensely than people who don't have hemophilia" C. "If my child gets a fever I should give him ibuprofen instead of acetaminophen" D. "Hemophilia is a clotting disorder that occurs due to an excess of vitamin K" E. "Hemophilia means that my child will bleed longer than people who don't have hemophilia"ANSWER ✅"Hemophilia means that my child will bleed longer than people who don't have hemophilia" Hemophilia affects the amount of time it takes for the body to clot which means they would bleed for longer. ✅"Hemophilia is treatable with the right medications" By replacing the missing clotting factors, bleeds can be prevented. "If my child gets a fever I should give him ibuprofen instead of acetaminophen" Ibuprofen increases the risk factors for bleeding. Acetaminophen does not have the side effect of causing bleeding and is, therefore, safer for a client with hemophilia. "Having hemophilia means that my child will bleed more intensely than people who don't have hemophilia" Clients with hemophilia do not bleed more intensely. Rather, they bleed for a longer amount of time due to missing clotting factors. "Hemophilia is a clotting disorder that occurs due to an excess of vitamin K" Some forms of acquired hemophilia may occur with a deficiency in Vitamin K.A nurse is administering medication to a client in the hospital. Which best describes an example of a nursing consideration during the evaluation phase of medication administration? A. Whether the drug produced its intended effects B. If the patient received educational materials about the drug C. If there was a placebo effect associated with the drug D. Whether the nurse stayed with the patient while administering the drugANSWER ✅Whether the drug produced its intended effects The evaluation phase occurs at the end of the nursing process, after the nurse has performed interventions for the client. The evaluation phase determines whether the actions of the nurse were effective. In a case when a nurse administers medication, the evaluation would be to consider whether the drug produced its intended effect. If the patient received educational materials about the drug The client should be educated about the drug before taking it (during the implementation phase), not during the evaluation phase. If there was a placebo effect associated with the drug The purpose of the evaluation phase is to determine if the intervention was successful. A placebo effect is not necessarily relevant to the success of the intervention. Whether the nurse stayed with the patient while administering the drug Drug administration takes place during the implementation phase. The nurse does not have an option to leave the client while he is administering the drug.A client has been hospitalized for symptoms of abdominal pain and diarrhea following exacerbation of stress. The nurse is teaching the client about ways to minimize environmental stress in her life. Which statement from the client indicates that teaching has been effective? A.I will listen to talk radio in the car to distract myself from my problems B. I need to remember to check my voicemail instead of always answering the phone C.I will try to eat more fat in my diet since my body is able to digest it easily D. I am going to organize my home so that I do not have so much clutter lying aroundANSWE ✅I am going to organize my home so that I do not have so much clutter lying around Environmental stressors include noise, air quality, crowding, light levels, clutter. A nurse can educate a client about how best to manage symptoms of stress before the client becomes physically ill. The client can organize her living space and remove clutter, as even seeing excess clutter can sometimes cause a stress response. I will try to eat more fat in my diet since my body is able to digest it easily This statement made by the client does not demonstrate understanding of environmental stressors and how to reduce them. I need to remember to check my voicemail instead of always answering the phone This is unrelated to reduction of environmental stressors. I will listen to talk radio in the car to distract myself from my problems Talk radio has been shown to increase stress in some studies. This statement does not demonstrate understanding of how to reduce environmental stressors.The nurse has a discharge order for your postoperative client who is verbally expressing their want to be discharged as soon as possible. The client needs to be evaluated to see if they are ready for discharge. The nurse knows that all except which of the following assessment findings would indicate it is safe for discharge the client? A.Exhibits adequate ventilation B.Understanding of nonpharmacologic interventions C.Reports pain 0 out of 10 D.Understanding discharge instructionsANSWER ✅ Reports pain 0 out of 10 Most clients will have some amount of pain when they are discharged. If a client is feeling no pain post-anesthesia then they might still have anesthesia in their system and not be ready for discharge this soon. This could indicate that it is unsafe to discharge. Understanding discharge instructions This is necessary for the evaluation for potential discharge of the client. If the client understands their discharge instructions then they are safe to discharge. Exhibits adequate ventilation This is necessary for the evaluation of the potential discharge of the client. If the client has adequate ventilation then they are safe for discharge. Understanding of nonpharmacologic interventions This is necessary for the evaluation of the potential discharge of the client. This client would be safe to discharge if they had an understanding of interventions to assist their pain in non-pharmacologic ways.The nurse has delegated tasks to the unlicensed assistive personnel. Which of the following tasks would the nurse evaluate to ensure proper nursing care was given? Select all that apply. A. Assisting the client with an unsteady gait to walk B. A glucose of >500 C. Repositioning the client to offload pressure areas D. Emptying a foley bag and noting sediment in the urine E. A bed bath after which increased skin redness is reportedANSWER ✅A bed bath after which increased skin redness is reported The principles of delegation to assistive personnel include the idea that the RN or LPN who delegates to unlicensed assistive personnel still maintain accountability for the care, including monitoring and evaluation. There is no task the nurse should not monitor and evaluate in some way. Test taking tip: SATA questions on the NCLEX can have up to 5 correct answers. ✅Assisting the client with an unsteady gait to walk The nurse must evaluate each task. ✅A glucose of >500 The nurse must evaluate each task. ✅Repositioning the client to offload pressure areas The nurse must evaluate each task. ✅Emptying a foley bag and noting sediment in the urine The nurse must evaluate each task.A nurse is working in a community that has a low rate of birth control use and high birth rate among its population. The nurse wants to provide information to community members about birth control. Which factor would the nurse most likely consider when evaluating outcomes of this education program? A.The nurse should recognize that there is not a one size fits all approach B.The nurse should bring in a team of other professionals to address the community's concerns C.The nurse should talk to individuals one-to-one over time D.The nurse should use a program that involves multimedia educationANSWER ✅The nurse should recognize that there is not a one size fits all approach Community education is often a part of public health nursing. When discussing birth control and birth rates with clients in a community, the nurse may need to modify the approach to education about family planning. Some people respond to group meetings, while others appreciate a person-centered approach. The nurse may need a number of educational delivery methods to use when working in this community. The nurse should use a program that involves multimedia education The nurse should recognize that not all persons learn best from multimedia education. Different manners of education should be available. The nurse should talk to individuals one-to-one over time Different manners of education should be available. The nurse should bring in a team of other professionals to address the community's concerns This educational activity is totally within the scope of practice of the nurse, but the nurse must provide more than one type of learning approach to ensure that all types of learners are included.A nurse is working with a diabetic client in the primary care clinic. Which factor regarding the client's health would most likely warrant a referral to a diabetic educator for further teaching? A. The client is overweight B. Routine blood glucose results of >90 mg/dL C. The client has developed diabetic ulcers D. Hemoglobin A1C level of 6.8%ANSWER ✅The client has developed diabetic ulcers Although nurses care for diabetic clients and manage many aspects of their care, a diabetic educator can often provide even more support and help in certain situations when a client's diabetes is out of control. The diabetic educator may be able to provide solutions and spend more time with the client to discern factors that are preventing adequate self-care in certain situations. If the client's diabetes is uncontrolled, such as with the development of diabetic ulcers, a call to a diabetic educator is necessary. Hemoglobin A1C level of 6.8% While this answer demonstrates an area in which the client can improve their management of diabetes, it is not profound enough to warrant a call to a diabetic educator. Routine blood glucose results of >90 mg/dL While this answer demonstrates an area in which the client can improve their management of diabetes, it is not profound enough to warrant a call to a diabetic educator. The client is overweight While this answer demonstrates an area in which the client can improve their management of diabetes, it is not profound enough to warrant a call to a diabetic educator.A nurse has implemented a screening program for members of a neighborhood to screen for diabetes. Which best describes the process the nurse would use to evaluate the success of this program? A. The members of the community can verbalize that they need to be screened for diabetes B. Community members can demonstrate that their blood glucose levels are within normal levels C. The team members follow up with people who were screened for diabetes to check if they received care from a provider D. The location of the screening was suitable for checking blood glucose levelsANSWER ✅The team members follow up with people who were screened for diabetes to check if they received care from a provider Any time that a nurse implements a program that involves education or teaching clients, the nurse should also follow up later to determine how successful the program was in helping others. If not, the program success could not be evaluated. In this case, those doing the screening can keep track of who was screened and can follow up with them later based on their results to determine if they received further help when needed. Community members can demonstrate that their blood glucose levels are within normal levels The goal of this program is to screen clients who do NOT have normal blood glucose levels, but have diabetes and require better blood glucose management. The location of the screening was suitable for checking blood glucose levels While this is a component of planning for this program, it does not describe a successful program. The members of the community can verbalize that they need to be screened for diabetes The program would be a success if community members who have already been screened and showed positive for diabetes are confirmed as following up with a provider. Reset Test