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Nurse is caring for client who is 24h post-op following abdominal surgery. Nurse suspects client's pain management is inadequate. Which of following data reinforce suspicion? (Select all that apply.)
- A. Client seems easily agitated
- B. Client is nonadherent with coughing, deep breathing, dangling
- C. Client may have pain med every 4-6h but accepts it every 6-7h
- D. Client reports tenderness in his right lower leg
- E. Client's vital signs are heart rate 110/min, respiratory rate 20/min, temp 37C, BP 136/80 mmHg
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E. Choice B indicates client's nonadherence to post-op respiratory exercises may lead to inadequate pain management. Choice C shows client not taking pain meds as prescribed, suggesting inadequate pain relief. Choice E reveals elevated heart rate and BP, indicating physiological stress from pain. Choices A and D do not directly relate to pain management. Choice A may be due to discomfort but not necessarily indicative of inadequate pain management. Choice D's leg tenderness is not directly linked to post-op pain.
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Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding by evaluating if the client can articulate the key concepts of a heart-healthy diet, demonstrating comprehension. It goes beyond a simple affirmation of understanding and requires the client to apply the knowledge. Encouraging questions (choice A) is important but may not provide a direct assessment of the client's grasp of the material. Choices C and D do not directly assess the client's understanding of the heart-healthy diet teachings.
Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Nurse is preparing a discharge summary for a client who had knee surgery and is going home. Which of the following info about the client should the nurse include in it? (Select all that apply.)
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Providing information on where to go for follow-up care ensures the client continues to receive proper medical attention post-surgery.
C: Instructions for diet/meds are crucial for the client's recovery and to prevent complications.
E: Providing contact info for a home healthcare agency ensures the client has access to additional support and care at home.
Incorrect answers:
A: Advance directives status is important but not directly related to immediate post-operative care.
D: Most recent vital sign data is important for monitoring but does not need to be included in a discharge summary.
Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A, complete fall-risk assessment. This is the priority action because it helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (B) is important but assessing risk comes first. Completing a physical assessment (C) is also important but not the priority in this case. Surveying belongings (D) is not as urgent as assessing the client's fall risk.
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put 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 shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.