Nokea
The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.
- A. Obtaining an informed consent for a surgical procedure
- B. Providing information necessary for a client to make informed decisions
- C. Providing assistance in asserting the client's human and legal rights if the need arises
- D. Including the client's religious or cultural beliefs when assisting the client in making an informed decision
- E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being
Correct Answer: B,C,D,E
Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would include the client's religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients' rights in a general by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Informed consent is part of the primary health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.
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A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.
- A. Assess the client's visual acuity.
- B. Observe the client's gait and posture.
- C. Evaluate the client's muscle strength.
- D. Look for any hazards in the home care environment.
- E. Ask a family member to move in with the client until recovery is complete.
- F. Request that the client transfer to an assisted living environment for at least 1 month.
Correct Answer: A,B,C,D
Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.
The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?
- A. Uses sterile technique for needle insertion
- B. Wears full protective clothing such as goggles, mask, gown, and gloves
- C. Covers the connection site with a bath blanket to enhance extremity warmth
- D. Puts on a mask and gives one to the client to wear during connection to the machine
Correct Answer: C
Rationale: While the client is receiving hemodialysis, the connection site should not be covered, and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the procedure. Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and a gown.
The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
A client asks the nurse how to become an organ donor. Which information should the nurse include in the discussion?
- A. The client can donate by written consent.
- B. A family member must witness the consent.
- C. The donor must be older than 21 years of age.
- D. A family member must be present when a client consents to organ donation.
Correct Answer: A
Rationale: The client has the right to donate her or his own organs for transplantation, and any person who is 18 years of age or older may become an organ donor by written consent without the permission or presence of the family. In the absence of suitable documentation, a family member or legal guardian can authorize donation of the decedent's organs.
A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery?
- A. Prone position
- B. Semi-Fowler's position
- C. Trendelenburg's position
- D. Supine position with a wedged right hip
Correct Answer: D
Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, so a wedge placed under the right hip provides displacement of the uterus off of the vena cava. A semi-Fowler's or prone position is not practical for this type of abdominal surgery. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation.