Nokea
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
- A. Modify the nursing interventions to achieve the client's goals.
- B. Determine if the expected outcomes were realistic.
- C. Obtain current client data to compare with expected outcomes.
- D. Review related professional standards of care.
Correct Answer: C
Rationale: Current data assesses goal achievement.
You may also like to solve these questions
A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?
- A. Offer comfort that healing can happen at any point in time.
- B. Offer strategies the spouse can use to provide comfort to the client.
- C. Suggest that the spouse go home for a while and get some sleep.
- D. Explain that the staff will strive to keep the client comfortable.
Correct Answer: D
Rationale: Reassurance about care addresses concerns.
A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
- A. Confer with the physical therapist for correct crutch size.
- B. Ask the client to sit down while the crutch length is adjusted.
- C. Assess the client for signs of diminished circulation in the hands.
- D. Proceed with teaching the client how to walk with the crutches.
Correct Answer: D
Rationale: Three-finger gap indicates proper fit.
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Document the site where the medication was given.
- B. Notify the healthcare provider of the allergic response.
- C. Elevate the area and apply light pressure over the site.
- D. Apply a cold pack to the area for twenty minutes.
Correct Answer: A
Rationale: Wheal is normal and should be documented.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Slip-on rubber shower shoes
- B. Tennis shoes with Velcro
- C. Leather-soled loafers
- D. Rubber-soled slippers
Correct Answer: B
Rationale: Velcro shoes provide support and ease of use.
History and Physical
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
Chart Reviewed: For each statement, click to indicate whether the statement is true or false.
- A. Hand washing only needs to be performed when exiting the client’s room.
- B. This client requires contact and droplet precautions.
- C. A gown and gloves should be worn any time there is potential for contact with secretions.
- D. A mask should always be worn when in the client’s room.
- E. This client would require a private room if admitted.
Correct Answer:
Rationale: Hand washing only needs to be performed when exiting the client’s room.
B . This client requires contact and droplet precautions.
C . A gown and gloves should be worn any time there is potential for contact with secretions.
D . A mask should always be worn when in the client’s room.
E . This client would require a private room if admitted.
Solution
Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.
Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.
Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.
Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.
Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.