NURSING A CONCEPT-BASED APPROACH TO LEARNING VOLUMES I II & III 3RD EDITION PEARSON EDUCATION

1) A nurse has just received a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath - Correct Answer Answer: D Explanation: A) The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive individual. The nurse can also delegate assisting a client who needs help with a bath. 2) A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking - Correct Answer Answer: D Explanation: A) After assessing the client, the nurse sets goals for and with the client. To arrive at the goal, the nurse uses critical thinking to make the decision to provide the client with optimum ability to breathe. Delegating involves giving the task to another team member. There is no conflict in this decision. Conflict resolution usually involves a compromise that affects two sides that are in disagreement. Priority-setting involves deciding which task to perform first. 3) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) A response to a change in the client's condition - Correct Answer Answer: D Explanation: A) Each client has a plan of care, but, it is the nurse who constantly evaluates the client for changes that the nurse responds to, if needed. Prioritizing involves choosing tasks in order of importance. Time management is completing the assigned tasks in the given time frame by organizing and using efficiency. The goal has not been met if the client is experiencing pain. 4) The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching. - Correct Answer Answer: C Explanation: A) The client with a PaCO2 of 85 could be in serious trouble. The nurse would decide to assess that client first in order to prevent dire consequences for the client. The client with pneumonia probably needs more care than the client preparing for discharge, but the reason for the decision is based on a potentially critical need by the client with pneumonia. The nurse cannot delegate discharge teaching to a UAP; even if delegation were permitted, the nurse would see the client with a high PaCO2 as being the greater priority. Placement of the client's room can be a decision that is made when considering time management issues; however, the physiological needs of the clients are the first consideration of the nurse. 5) A client seen in an urgent care clinic is complaining of abdominal pain and believes that the food eaten the previous evening was tainted. What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the physician does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid. - Correct Answer Answer: A Explanation: A) The nurse must recognize that the client has not given the nurse enough information. The client could, indeed, have eaten bad food or may be experiencing appendicitis. The nurse asks more questions followed by a physical examination. Short-cut decisions here could be harmful for this client. The nurse would not give advice about taking a medication. The nurse does not have enough information to make the decision to call an ambulance. Because the nurse does not have enough information, telling the client that a physician does not need to assess the client is inappropriate. 6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing. - Correct Answer Answer: B Explanation: A) The first step in the nursing process is to complete an assessment of the client. The client is indeed experiencing difficulty, but the nurse needs to assess the extent of the need and the reason for the problem before taking action. The physician will ask the nurse to identify the reason for the problem