Nokea
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.
You may also like to solve these questions
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. Foreskin should not be retracted.
- C. An erection may occur while providing care.
- D. Pubic area should be kept shaved.
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.
A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
- A. I can only give medical information to the client with an approved interpreter.'
- B. The healthcare provider will share this information with you.'
- C. I'm sorry, but your sibling's medical information is none of your business.'
- D. I can give you those results as soon as I get them back from the lab.'
Correct Answer: A
Rationale: Approved interpreter ensures confidentiality.
History and physical
The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Review H and P and nurse's note.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Create a toilet training program;Place an indwelling catheter;Place an incontinence containment product under the client;Teach the client to use mobility aids;Provide skin care
- B. Urge incontinence;Reflex urinary incontinence;Overflow urinary incontinence;Functional incontinence
- C. Intake and output;Blood pressure;Postvoid residual volume;Skin integrity;Blood glucose
Correct Answer:
Rationale: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.
History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
- A. Gather materials to change soiled items only;
- B. Thoroughly clean wound using normal saline prior to redressing;
- C. Place sterile gauze directly on wound bed;
- D. Apply sterile gloves prior to changing;
- E. Apply sterile foam dressing over wound bed;
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.