Fundamentals B Flashcards
A nurse receives report about a client who has 0/9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following action should the nurse take first?
A. Document the client’s IV intake in the medical record.
B. Reposition the client.
C. Check the IV tubing for obstruction.
D. Request a new IV fluid prescription.
C. Check the IV tubing for obstruction.
The first action the nurse should take using the nursing process is to assess the client. By checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client’s pain?
“Does the pain radiate?”
“Is your pain sharp or dull?”
“What would you rate your pain on a scale of 0 to 10?”
“Is your pain constant or intermittent?”
“Is your pain sharp or dull?”
Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain
A nurse is caring for a client who is postoperative . When the nurse prepares to change her dressing, she says “every time you change my bandage, it hurts so much.” Which of the following interventions is the nurse’s priority action?
Administer pain medication 45 min before changing the client’s dressing.
Encourage the client to relax and take deep breaths during the dressing change.
Educate the client about the importance of the dressing change to prevent infection.
Assist the client to a comfortable position for the dressing change
Administer pain medication 45 min before changing the client’s dressing.
The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the client’s physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client’s dressing.
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Tell the parents that this is a necessary procedure.
The nurse should provide information about the procedure; however, telling the parents that this is a necessary procedure is disregarding the parents’ religious beliefs.
Examine personal values about the issue.
MY ANSWER
The nurse should examine her own personal values about the issue to help her provide care that is without bias.
Contact a spiritual support person to explain the importance of the procedure.
The nurse should provide information about the procedure; however, it is not appropriate to contact a spiritual support person without the parents’ consent.
Inform the parents that the staff does not require their consent.
Parents must give consent for a child to receive a blood transfusion.
Examine personal values about the issue.
MY ANSWER
The nurse should examine her own personal values about the issue to help her provide care that is without bias.
A middle adult client tells the nurse, “I feel so useless now that my children do not need me anymore.” which of the following responses should the nurse make?
“You should be proud that your children are becoming independent.”
This response conveys the nurse’s approval of people who are proud of their children’s independence, as though that is the only acceptable behavior in this situation.
“Maybe you should consider why you are feeling useless.”
Clients might interpret “why” questions as accusatory, and they can elicit feelings of mistrust and resentment. With this response, the nurse is asking for an explanation instead of acknowledging the client’s feelings.
“Most people are happy when their children grow up and leave home.”
This is an automatic or stereotypical response that minimizes the client’s feelings by implying that he should be like everyone else.
“People in middle adulthood often find satisfaction in nurturing and guiding young people.”
According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people.
“People in middle adulthood often find satisfaction in nurturing and guiding young people.”
According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people.
