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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 assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
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 in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct Answer: D
Rationale: The correct answer is D: "Is your pain sharp or dull?" This question helps the nurse determine the characteristic of the pain, which is crucial in identifying the underlying cause. Sharp pain is often associated with acute conditions like nerve irritation, whereas dull pain may indicate musculoskeletal issues. Choices A, B, and C are important in pain assessment but do not specifically address the quality of pain. Asking about pain intensity (choice B) or radiation (choice C) can provide valuable information but do not directly address whether the pain is sharp or dull. Therefore, option D is the most appropriate for assessing the quality of the client's pain in this scenario.