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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
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A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
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 nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
- A. Stage III pressure ulcer
- B. Sutured surgical incision
- C. Casted bone fracture
- D. Laceration sealed with adhesive
- E. Open burn area
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring. Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents.'
- B. It's been so stressful for me to even think about having my own family.'
- C. I don't even know who I am yet, & now I'm supposed to know what to do.'
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.'
Correct Answer: C
Rationale: The correct answer is C: "I don't even know who I am yet, & now I'm supposed to know what to do." This statement highlights an existential crisis and identity confusion, which are common developmental challenges in young adulthood. It indicates a lack of self-awareness and direction, which can significantly impact the individual's overall well-being and decision-making capabilities. Addressing this issue is crucial as it forms the foundation for addressing other concerns effectively. Choices A, B, and D focus on external stressors and specific situations, which are important but secondary to the core issue of self-identity. Therefore, prioritizing assessment and intervention for the client's self-identity crisis is essential to promote holistic growth and resolution of other challenges.
An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is unlawfully restrained against their will. In this scenario, the nurse administering a sedative without the client's consent is considered an act of restraint, which restricts the client's freedom to leave. This action constitutes false imprisonment as the client is being detained without proper legal authority.
A: Assault involves the threat of harm or unwanted physical contact, which is not present in this situation.
C: Negligence refers to a failure to provide proper care or fulfill duties, which is not the case here.
D: Breach of confidentiality involves disclosing private information without consent, which is not relevant in this scenario.
In summary, the nurse committed false imprisonment by restricting the client's freedom of movement without legal justification.