Nursing Interventions for Various Clinical Scenarios, Exams of Nursing

Download Nursing Interventions for Various Clinical Scenarios and more Exams Nursing in PDF only on Docsity! 1 1. The healthcare provider prescribes bladder irrigation to maintain patency of a client indwelling urinary catheter. Which intervention should the nurse implement? a. use a sterile syringe to irrigate with normal saline (NS) 20 mL b. Use an infusion pump to slowly irrigate the indwelling catheter c. clamp the catheter for 30 minutes prior to irrigating with NS d. power flush with NS 60 ml to remove mucous 2. Two nurses assess a client for a pulse deficit and count an apical pulse of 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurse take? a. obtain a second pulse deficit reading b. report the results to the healthcare provider c. measure the client's BP d. document a pulse deficit of 16 bpm 3. The female client who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? a. remain quietly by the door until the client stops crying b. stay with the client in silence while touching her forearm c. ask the client if she would like her clergy notified d. tell the client it is normal to cry after surgery 4. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. What interventions should the nurse initiate? a. discard the urine and start another 24 hour period b. notify the charge nurse of the problem c. notify the healthcare provider of the situation 2017 FUNDAMENTALS 33 Q&A 2 d. add another hour to the urine collection period 5 b. provide variety of religious literature for the client c. take the client to the chapel d. call the agency chaplain for the client ... 6 11. During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission? a. determine baseline neurologic status b. administer an IV anxiolytic medication c. assess peripheral oxygen saturation d. schedule a sitter around the clock ... 12. PICTURE: The nurse prepares to administer ear drops to an adolescent client as seen in the picture. What should the nurse do next? a. place the drops in the ear canal b. apply gentle pressure to ear tragus 7 c. pull the ear auricle downward d. move dropper closer to the ear canal ... 10 15. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first? a. temperature b. pulse rate c. blood pressure d. respiratory rate ... 16. Which information is most important for the nurse to consider when preparing to transfer a client from the bed to a chair? a. whether the client is wearing antiembolism stockings 11 b. the client's ability to bear weight on the lower extremities c. the presence and volume of the client's pedal pulses d. how long the client is prescribed to remain out of bed ... 17. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? 12 a. prepare equipment to assist with intubation b. assess lungs sounds and capillary refill c. exchange pulse oximeter for another monitor d. discontinue pulse oximetry readings ... 18. Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care? The client will a. show evidence incision healing b. avoid pain-causing activity 15 c. implement a 24-hour schedule of routine administration of prescribed analgesic d. determine client's subjective measure of pain using a numerical pain scale e. assist the client to ambulate as much as possible during waking hours ... 16 21. A client discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client's risk for infection related to the catheter? a. secure the drainage bag at bladder level during transport b. administer a PRN antipyretic if a fever develops c. flush the catheter daily with sterile saline d. encourage increased intake of fluids ... 22. The electronic medication system alerts the nurse that the medication dose scanned is two times higher than the dose prescribed. What action should the nurse implement? a. withhold the medication until the dose is available b. convert the dose on hand to match the prescribed dose 17 c. ask the pharmacist if another dose can be dispensed d. report a mismatch of prescribed and available doses ... 23. A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family with a dose of 20 a. ask the client if he wants this information shared with his grandmother b. ensure that the signed release of information includes the grandmother c. consult with the healthcare provider before sharing this information d. reassure the grandmother by providing an honest response ... 26. When proving health teaching to elderly clients, what action is most important for the nurse to implement? a. underline key words on the written information b. use everyday language when explaining issues c. speak loudly and face the client 21 d. provide a very well-lit meeting space ... 27. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? a. determine the client's sleep and activity pattern 22 b. teach coping strategies to use when feeling stressed c. refer client for a sleep study and neurological follow-up d. obtain prescription for client to take when stressed ... 28. To assess the quality of an adult client's pain, what approach should the nurse use? a. provide a numeric pain scale b. ask the client to describe the pain c. identify effective pain relief measures d. observe body language and movement ... 25 ... 31. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and emesis basin positioned under the ear. What action should the nurse take next? a. confirm the temperature of the irrigating solution b. reposition the client so the affected ear is upward 26 c. direct the flow of the solution toward the ear canal d. place the emesis basin within reach of the client ... 32. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what question should the nurse ask the client? a. "How frequently do you eat processed or canned foods?" b. "Do you drink milk or eat dairy products at each meal?" c. "How much water and ice chips do you have each day?" d. "What amount of your daily meals contains fresh vegetables?" ... 27 ... 33. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How man ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.) 34. The nurse finds a confused female client wandering in the hallway during the night. What actions should the nurse implement? (Select all that apply) a. close the room door