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When caring for an older adult client with a pulmonary infection, what action should the nurse take first?
- A. Encourage the client to increase fluid intake.
- B. Assess the client's level of consciousness.
- C. Raise the head of the bed to at least 45 degrees.
- D. Provide the client with humidified oxygen.
Correct Answer: B
Rationale: The correct answer is B: Assess the client's level of consciousness. This is the priority because changes in consciousness can indicate deteriorating respiratory status or potential respiratory distress. Next steps would depend on the assessment findings.
A: Encouraging fluid intake is important but not the first priority.
C: Raising the head of the bed helps with breathing but doesn't address potential immediate respiratory distress.
D: Providing humidified oxygen may be necessary but assessing consciousness comes first to determine the urgency of oxygen therapy.
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A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:
- A. excoriation.
- B. dehiscence.
- C. decortication.
- D. evisceration.
Correct Answer: D
Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.
A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?
- A. I can have clear liquids up to 2 hours before the procedure.
- B. I need to take a laxative the night before the procedure.
- C. I will be sedated during the procedure.
- D. I should avoid eating solid foods for 24 hours before the procedure.
Correct Answer: D
Rationale: The correct answer is D because the statement indicates a need for further teaching. The client should avoid solid foods for a specific period, usually 24 hours, before a colonoscopy to ensure a clear view of the colon. This helps the healthcare provider to perform the procedure effectively and reduces the risk of complications. Choices A, B, and C are incorrect because having clear liquids up to 2 hours before, taking a laxative the night before, and being sedated during the procedure are all standard preparations for a colonoscopy and do not indicate a need for further teaching.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.
How can a nurse manager best improve hand-off communication among the staff? (SATA)
- A. Attending hand-off rounds to coach and mentor.
- B. Conducting audits of staff using a new template.
- C. Creating a template of topics to include in the report.
- D. Utilizing the SHARE model as a tool for standardizing hand-off reports and other critical communication.
Correct Answer: D
Rationale: The correct answer is D because utilizing the SHARE model helps standardize hand-off reports and communication.
1. S stands for Situation: providing context.
2. H stands for History: outlining relevant information.
3. A stands for Assessment: sharing assessment findings.
4. R stands for Recommendation: suggesting actions.
5. E stands for Explanation: clarifying any questions.
This model ensures all necessary information is communicated effectively. A, B, and C are incorrect because attending hand-off rounds, conducting audits, and creating templates may not ensure standardized communication like the SHARE model does.
Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is
- A. vital signs.
- B. surgical site.
- C. respiratory adequacy.
- D. level of consciousness.
Correct Answer: C
Rationale: Respiratory adequacy is critical immediately postoperatively to ensure oxygenation and ventilation.