Nokea
Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.)
- A. Give morphine sulfate 1-2 mg IV every 1h as needed for pain
- B. Insert NG tube to relieve client's gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C, D, E
Rationale: Correct Answer: C, D, E
Rationale:
C: Showing a client how to use progressive muscle relaxation is an example of a nurse-initiated action as it involves client education and does not require a provider's prescription.
D: Performing a daily bath after the evening meal is a routine nursing care activity that can be initiated by the nurse without a provider's prescription.
E: Re-positioning a client every 2 hours to reduce the risk of pressure ulcers is an essential nursing intervention that can be initiated by the nurse without a provider's prescription.
Summary of Incorrect Choices:
A: Giving morphine sulfate IV every 1 hour as needed for pain requires a provider's prescription due to the administration of a controlled substance.
B: Inserting an NG tube to relieve gastric distension is an invasive procedure that typically requires a provider's order and specialized training.
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Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
Nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. The nurse indicates understanding when she states that which are manifestations of systemic infection? (Select all that apply.)
- A. Fever
- B. Malaise
- C. Edema
- D. Pain/tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A,B,E
Rationale: The correct answer is A, B, and E. Fever is a hallmark sign of a systemic infection as the body's response to infection. Malaise, a general feeling of discomfort, is also common in systemic infections due to the body's immune response. An increase in pulse and respiratory rate occurs in systemic infections as the body tries to combat the infection. Edema and pain/tenderness are more indicative of localized infections and are not typically seen in systemic infections. Therefore, choices C and D are incorrect in this context.
Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
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.