Nokea
A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
- A. Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low fiber diet.
- B. Administer a bronchodilator two times a day for child who has cystic fibrosis.
- C. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
- D. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Correct Answer: B
Rationale: Bronchodilators for cystic fibrosis are needed more frequently, typically before each chest physiotherapy session, requiring revision of the care plan.
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A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.
A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
- A. Withhold the benzodiazepine but continue the opioid.
- B. Administer the benzodiazepine but withhold the opioid.
- C. Continue the medication dosages that relieve the client's pain.
- D. Contact the provider about replacing the opioid with an NSAID.
Correct Answer: A
Rationale: The correct answer is A: Withhold the benzodiazepine but continue the opioid. Benzodiazepines can potentiate the sedative effects of opioids, leading to increased somnolence and difficulty arousing the client. By withholding the benzodiazepine, the nurse can help decrease the sedative effects, allowing the client to become more responsive while still receiving pain relief from the opioid. Continuing the opioid ensures that the client's pain is adequately managed. Administering the benzodiazepine alone (choice B) may exacerbate the sedative effects. Continuing the medication dosages (choice C) without adjusting the benzodiazepine dose may not address the sedation issue. Contacting the provider about replacing the opioid with an NSAID (choice D) is not indicated as opioids are typically the mainstay for managing severe pain in terminal illness.
Exhibit 1 Nurses' Notes 1315:
Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment
Plan of Care
1300:
Case management referral for discharge planning.
Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager.
- A. Client reports being unable to find transportation to follow-up appointment
- B. Client expresses concern regarding the cost of prescription medications
- C. Case management referral for discharge planning
- D. Client will need home health referral for dressing changes
Correct Answer: A
Rationale: []
Rationale:
- Correct Answer (A): The client reporting being unable to find transportation to the follow-up appointment is a critical issue that requires immediate follow-up by the case manager to ensure continuity of care and adherence to the treatment plan.
- Incorrect Answer (B): Although concerns about the cost of prescription medications are important, they do not directly relate to the immediate follow-up needed postoperatively.
- Incorrect Answer (C): Case management referral for discharge planning is essential but does not specifically address the immediate follow-up after the postoperative period.
- Incorrect Answer (D): While the client needing a home health referral for dressing changes is important, it does not pertain to the immediate follow-up that the case manager needs to address.
The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?
- A. The client
- B. The partner
- C. The provider
- D. The oldest adult child
Correct Answer: A
Rationale: A mentally competent client retains legal authority to make healthcare decisions, despite a durable power of attorney, which only applies when the client is incapacitated.
A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?
- A. Instructing a client on self-administration of a tap water enema
- B. Suctioning a client's long-term tracheostomy
- C. Performing a dressing change on a client's peripherally inserted central catheter
- D. Using a pain rating scale to monitor a client's pain level
Correct Answer: D
Rationale: The correct answer is D: Using a pain rating scale to monitor a client's pain level. This task can be safely delegated to assistive personnel as it involves non-invasive monitoring that does not require specialized medical knowledge. Assistive personnel can accurately record the pain level reported by the patient without interpreting or making clinical decisions based on the information. In contrast, choices A, B, and C involve invasive procedures or specialized skills that require clinical judgment and assessment, making them inappropriate for delegation to assistive personnel. Choice D allows the nurse to focus on more complex nursing assessments and interventions while ensuring the client's pain is monitored effectively.