A nurse is instructing an AP in caring for a client who has...

A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?

A. Don't measure the client's temperature rectally.'
B. Count the client's radial pulse for 30 seconds & multiply by 2.'
C. Don't let the client know you are counting her respirations.'
D. Let the client rest for 5 minutes before you measure her BP.'

Correct Answer: A

Rationale: Correct Answer: A: Don't measure the client's temperature rectally.

Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.

Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.

A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all.

A. Provider
B. CNA
C. Pharmacist
D. RN
E. Respiratory therapist

Correct Answer: A, C, D

Rationale: The correct answer is A, C, and D. The provider, pharmacist, and RN are key members of the interprofessional care team who can assist the client in understanding the medication's effects. The provider can explain the rationale for prescribing the medication and address any concerns the client may have. The pharmacist can provide detailed information about the medication, including potential side effects and interactions. The RN can monitor the client's response to the medication, educate them on how to take it properly, and address any immediate concerns. Choices B, E, and F are incorrect because CNAs and respiratory therapists typically do not have the expertise to provide in-depth medication counseling to clients.

A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

A. I'll wait to use the device until it's absolutely necessary.
B. I'll be careful about pushing the button so I don't get an overdose.
C. I should tell the nurse if the pain doesn't stop after I use this device.
D. I will ask my son to push the dose button when I am sleeping.

Correct Answer: C

Rationale: The correct answer is C because the client demonstrating understanding of using the PCA infusion device should know to communicate with the nurse if the pain persists after using the device. This indicates the client's awareness of the importance of monitoring pain levels and seeking help if needed. Choice A does not demonstrate understanding of the device's purpose or functionality. Choice B shows awareness of the risk of overdose but not necessarily how to use the device correctly. Choice D is incorrect as the client should be the one responsible for administering the medication through the PCA device.

A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all.

A. Cover errors w/correction fluid, & write in the correct info
B. Put the date & time on all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of the shift to document

Correct Answer: B, C

Rationale: Correct Answer: B, C

Rationale:
B: Putting the date and time on all entries is crucial for accurate documentation, ensuring a clear timeline of events for continuity of care and legal purposes.
C: Documenting objective data without opinions maintains professionalism and accuracy, preventing subjective biases from affecting the client's record.

Incorrect Choices:
A: Covering errors with correction fluid can be seen as tampering with records, potentially leading to legal issues and compromising the integrity of the documentation.
D: Using excessive abbreviations can lead to misinterpretations and errors in communication, jeopardizing patient safety and legal clarity.
E: Waiting until the end of the shift to document can result in information being missed or forgotten, impacting the quality of care and legal accountability.

A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling?

A. Carbon monoxide has a distinct odor
B. Water heaters should be inspected every 5 years
C. The lungs are damaged from carbon monoxide inhalation
D. Carbon monoxide binds w/hemoglobin in the body

Correct Answer: D

Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is crucial information because carbon monoxide binds to hemoglobin more strongly than oxygen, leading to oxygen deprivation in the body's tissues. This can result in serious health consequences, including brain damage and even death.

Explanation for why the other choices are incorrect:
A: Carbon monoxide is odorless, so it does not have a distinct odor.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body's ability to transport oxygen, rather than directly damaging the lungs.
E, F, G: No additional choices provided.

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.