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A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.
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A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
- A. Make sure the client's room has at least six air exchanges per hour.
- B. Make sure the client wears a mask when outside her room if there is construction in the area.
- C. Place the client in a private room with negative-pressure airflow.
- D. Wear an N95 respirator when giving the client direct care.
Correct Answer: A
Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is essential for a protective environment post-allogeneic stem cell transplant to reduce the risk of infection. Increasing air exchanges helps remove airborne pathogens and maintain a clean environment. Option B is incorrect as wearing a mask outside the room is not a part of a protective environment. Option C is incorrect as negative-pressure airflow is typically used for clients with airborne infections, not for stem cell transplant clients. Option D is incorrect as N95 respirators are not routinely required for providing direct care in a protective environment setting.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
- A. Critical pathway
- B. Situation background assessment and recommendation (SBAR)
- C. Transfer report
- D. Medication administration record (MAR)
Correct Answer: B
Rationale: The correct answer is B: Situation background assessment and recommendation (SBAR). SBAR is a structured communication tool used in healthcare to provide a concise and focused way of relaying important information between healthcare team members. It helps ensure continuity of care by including essential details such as the patient's situation, background information, assessment findings, and recommendations for further care. SBAR improves communication efficiency, reduces errors, and enhances patient safety.
Choices A, C, and D are incorrect because:
A: Critical pathway is a care plan outlining evidence-based guidelines for patient care but does not provide the detailed communication needed for continuity of care.
C: Transfer report is focused on the transfer of a patient between units or facilities and may not include all the necessary information for continuity of care during a shift change.
D: Medication administration record (MAR) is a document used to record medication administration and does not encompass the comprehensive patient information needed for effective shift handoff.
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
- B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
- C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
- D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.