Coordinated Care Assessment

The teenager will require surgery to realign the bones in the fractured tibia.

From whom is it most appropriate to obtain consent to perform the surgical procedure?

A nurse stops to assist an individual who was involved in a motor vehicle accident and thrown from the car.

Under Good Samaritan laws, what action is generally required when a nurse assists at the scene of an accident?

The postoperative client will have antiembolism stockings.

The nurse delegates the application of the client’s antiembolism stockings to the unlicensed assistive personnel. What is the correct time for applying these stockings?

The nurse makes out assignments for nursing staff.

What is the major consideration for determining the person assigned to care for clients?

The client is allowed to ambulate with a walker using a three-point partial weight-bearing gait.

When the client has difficulty ambulating, who should the nurse consult regarding a referral to an extended care facility?

A client who has degenerative arthritis is admitted for a total hip replacement.

The nurse prepares to conduct scheduled performance evaluations on assistive health care workers. What is the best evidence for determining if the care of assigned clients is meeting the clients’ needs?

A small window in the plaster of the hip spica cast is cut to inspect the underlying tissue.

A nurse suspects a colleague is diverting opioids for personal use. What is the first action the nurse should take?

A continuous passive motion machine has been delivered to the nursing unit to care for clients with postoperative knee replacements.

What is the best method for ensuring competence among nursing staff in its use?

During an acute episode of rheumatoid arthritis, there is a prescription to apply a splint to each of the client’s hands.

 When there is a concern about potential breaches of client confidentiality, what observations require immediate remediation? Select all that apply.

The nurse provides discharge planning following a total hip replacement.

 What area of health teaching is essential to include in the discharge instructions?

The nurse provides discharge planning following a total hip replacement.

When a nurse observes a member of the housekeeping staff checking the medical records of clients on the computer for possible discharges, what is the best action the nurse should take?

A low-purine diet is prescribed for the client.

The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?

A rigid plaster shell surrounds the stump of a client who underwent an above-the-knee amputation. A pylon, or temporary prosthesis, allows the client to ambulate with crutches soon after surgery.

What task is most appropriate for the nurse to delegate to a skilled unlicensed assistive personnel assigned to care for the client with the above-the-knee amputation?

After medical stabilization, the client is transferred to a rehabilitation unit.

The nurse plans for the client’s discharge and discusses the home environment with the client. What home care suggestion is best for promoting the mobility of the client with a spinal cord injury?

An older adult diagnosed with Parkinson disease is admitted to a nursing home for basic nursing care.

 What nursing assessment is most important to consider before developing the client’s care plan?

An older adult client with dementia is admitted to the Memory Care unit of an extended care facility.

A nurse responds frequently to shouts from a client with dementia. What action is most appropriate at this time?

An older adult client with dementia is admitted to the Memory Care unit of an extended care facility.

A nurse is concerned about the number of falls clients have been experiencing recently. What initial nursing action is most likely to reduce the incidence of injuries?

The discharge instructions indicate that the client must temporarily wear a metal shield over the operative eye while sleeping.

What information is most appropriate to include in the discharge instructions for the client who has undergone a cataract extraction?

The nurse is assigned to care for a client with a retinal detachment.

The nurse is assisting with preparation of the client’s meal tray. The client self-reports following the Orthodox Judaism religion and following a specific diet. As the nurse prepares the tray, what item should the nurse remove and replace with a substitute?

The team leader responsible for the client’s initial care plan makes a client priority of the risk for impaired verbal communication related to hearing loss.

When the team leader asks the admitting nurse to assist with developing a goal for the identified priority, what goal correlates best?

The client is scheduled for a stapedectomy but does not seem to understand the information about the surgery.

What nursing intervention is the best alternative for helping the client to comprehend the details of the procedure at this time?

The nurse is assessing a client who is experiencing signs and symptoms of acromegaly.

What priority concern should the nursing team consider when developing this client’s plan of care?

A client with Graves’ disease is given several options for treatment: antithyroid drugs, radioactive iodine, and surgery.

When the family of the client with Graves’ disease encourages treatment with antithyroid drugs, but the client favors surgical treatment, what nursing action is best at this time?

A client is undergoing a coronary artery bypass graft (CABG) procedure.

The action that indicates that the nurse needs to provide more instruction to the unlicensed assistive person (UAP) on how to accurately assess the client’s pulse rate is when the UAP:

The client reports having acute pain in the incisional area after coronary artery bypass graft (CABG) surgery.

What information about the client’s use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?

Because the client continues to have periods with an irregular heart rate, an artificial pacemaker will be inserted.

As part of the discharge instructions, what symptom should the nurse instruct the client is a sign of artificial pacemaker malfunction?

A 50-year-old client is scheduled for a heart transplant. Because of the client’s anxiety, the client has difficulty comprehending the nurse’s information.

On the nursing unit, the nurse is a team member following a primary nursing care delivery model. What activity is unique to this delivery system of nursing care?

The client is scheduled for a ligation and vein-stripping procedure as treatment for varicose veins.

When the nurse is planning the client’s postoperative care, what action is the priority?

On the basis of data collection, the client has been diagnosed with thrombophlebitis and is being treated with subcutaneous injections of heparin.

What modification is most appropriate for the nurse to add to the client’s care plan at this time?

Two years after the client’s initial treatment, the client is hospitalized again. Although the client’s condition is stable, the health care provider has informed the client and the family that the client will probably not survive for more than 6 months.

What is the best example of the nurse in the role of client advocate?

Corticosteroid therapy is planned for the client with multiple myeloma.

What approach is most likely to be cost effective to complete all care and teaching the client needs before discharge without exceeding the days allowed by health insurance reimbursement systems?

The health care provider prescribes administration of 60% oxygen with a partial rebreathing mask and reservoir bag to treat the client’s asthma attack.

When administering oxygen to the client through a partial rebreathing mask, what observation is most important for the nurse to report to the respiratory therapy department?

The client requests pain medication after the pneumonectomy.

The nurse calls the health care provider about a client whose condition has changed and follows the SBAR format. The nurse provides self-identification and the identification of the client, the background on the client, and previous and current changes in assessments. What additional information is most important to include?

A high school football player presents to the emergency department with signs and symptoms suggestive of two fractured ribs.

Before discharging a client with fractured ribs from the emergency department, what instruction is most important for the nurse to provide?

During a subsequent visit, the nurse notes that the 17-year-old pregnant client is eating a bag of potato chips and drinking a diet cola. The nurse revises the client’s care plan accordingly.

What expected outcome should the nurse include based on the client’s eating habits?

The client’s diet is restricted to clear liquids.

When the client asks for something to eat, what item(s) is appropriate for the nurse to provide? Select all that apply.

After the cystectomy and ileal conduit procedure, the client wears an appliance that collects the urine. The client tells the nurse that the skin feels raw and irritated near the stoma.

What postoperative information regarding client care is most important for the nurse to relate to the assigned unlicensed assistive personnel during a shift report?

The client returns from surgery with an infusing I.V., nasogastric tube, a T-tube for bile drainage, and a Jackson-Pratt tube for wound drainage in place.

The nurse contacts a client’s health care provider by telephone because prescribed pain medication has not been providing the client with sufficient relief. What is the best initial action when obtaining a phone prescription?

The client’s I.V. line has infiltrated and needs to be removed and restarted in a new site. The licensed practical/vocational nurse (LPN/LVN) collaborates with the registered nurse (RN) as part of the health care team.

Once the new I.V. site is infusing, what nursing action is most appropriately delegated to the LPN?

While at the nurses’ station, a patient care technician (PCT) states in a loud, irritated voice, “He’s wet again. Why can’t he ever stay dry?” in reference to the client who has urinary incontinence.

On the basis of the nurse’s knowledge of client rights, which federal law has the PCT violated?

A client with type 1 diabetes mellitus reports having urinary problems.

When the nurse interviews the client, what symptom(s) will the client most likely report if a bladder infection has been acquired? Select all that apply.

An excisional biopsy is recommended followed by an immediate modified radical mastectomy if the biopsy shows malignant cells.

If the client tells the nurse that she would prefer to postpone the mastectomy until the biopsy has been more thoroughly examined, what nursing action is most appropriate?

Before the client’s discharge, the nurse provides specific mastectomy instructions regarding home care.

What instruction(s) should the nurse include in the client’s discharge plan? Select all that apply.

When the client is brought from the waiting room to the examination room, another female follows the client into the room. The client says to the nurse, “It is OK, we are married.”

What action by the nurse is most appropriate?

Internal radiation therapy is used to treat the client who has been diagnosed with advanced cervical cancer. An applicator containing radioactive material is inserted into the client’s vagina.

What staff nurse is best suited to care for a client with a radioactive implant?

A 64-year-old client with uterine cancer is scheduled to undergo an abdominal hysterectomy under general anesthesia. Postoperative prescriptions include applying antiembolism stockings to the client’s legs after the hysterectomy.

When the nurse observes the unlicensed assistive personnel caring for the client on the second postoperative day, what action(s) indicates a need for further instruction? Select all that apply.

The client is scheduled for a sonogram of the prostate.

When the nurse is discussing the procedure on the client’s signed preoperative permit and identifies a discrepancy on the surgery schedule, what action should the nurse take at this time?

The client is scheduled for a sonogram of the prostate.

A client in a teaching hospital is scheduled for a radical prostatectomy. What action supports the client’s right to privacy?

A participant asks the nurse about the use of the birth control patch. The nurse explains about the use of the contraceptive patch and reviews the side effects of this type of birth control.

A nurse is working at a women’s health clinic. Due to a high client volume, the nurse intends to delegate client instruction on an oral contraceptive method to a second nurse. Prior to delegation, what consideration is most important?

The client asks the nurse if sexual intercourse is safe during pregnancy.

The nurse correctly explains that sexual intercourse should be avoided at what time?