The skin barrier covering a client's intestinal fistula keep...

The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.

A. The physical therapist didn't ambulate the client today
B. The skin barrier's seal stays on in bed but loosens when the client stands.
C. The client seemed to welcome having a 'day off' from physical therapy
D. The wound care nurse will see the client later today
E. The client ate all the food on her lunch tray

Correct Answer: A, B, D

Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.

A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?

A. Registered dietitian
B. Occupational therapist
C. Physical therapist
D. Social worker

Correct Answer: D

Rationale: The correct answer is D: Social worker. The social worker can help the older adult client access community resources such as meal delivery services, food assistance programs, or senior centers that provide nutritious meals. The social worker can also assess the client's social support system and address any other psychosocial needs that may impact his ability to prepare meals. Referring to a registered dietitian (choice A) may address the nutritional aspect but not the underlying social issues. Occupational therapists (choice B) focus on improving activities of daily living, physical therapists (choice C) focus on physical rehabilitation, which are not directly related to meal preparation difficulties.

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.

A. Apply petroleum jelly around the inside of the nares
B. Remove the nasal cannula during mealtimes
C. Check the position of the cannula often
D. Report any nasal stuffiness, nausea, or fatigue
E. Post 'no smoking' signs in a prominent location

Correct Answer: C, D, E

Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?

A. Remind the nurse that safe client care is a priority on the unit
B. Ask others on the team whether they have observed the same behavior
C. Report observations to the nurse manager on the unit
D. Conclude that her coworker's fatigue is not her problem to solve

Correct Answer: C

Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.

A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.

A. I will observe for med side effects.
B. I will monitor for therapeutic effects.
C. I will prescribe the appropriate dose.
D. I will change the dose if adverse effects occur.
E. I will refuse to give a med if I believe it is unsafe.

Correct Answer: A,B,E

Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).

A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.

B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.

E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.

Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.

In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?

A. "The roommate is up independently"
B. The client ambulates w/his slippers on over his antiembolic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine

Correct Answer: B, C, D

Rationale: Correct Answer: B, C, D

Rationale:
- Option B: The client should not wear slippers over antiembolic stockings as it can increase the risk of slipping or falling.
- Option C: Knowing that the client uses a front-wheeled walker is crucial for safe ambulation post-knee arthroplasty.
- Option D: Advising on the timing of pain medication helps ensure the client is comfortable during ambulation.

Summary:
- Option A is incorrect because the roommate's ambulation status is irrelevant to the client's care.
- Option E is incorrect as the client's allergy to codeine does not directly impact safe ambulation post-knee arthroplasty.