Fndmntls Fnl 501 – Flashcards

Observe the rate, depth, and character of the client's respirations. Rationale: The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.

Lower the client to the floor and place a pad under the client's head. Rationale: To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.

Educating clients about the recommended immunization schedule for adults Rationale: Primary prevention includes health education about disease prevention.

Assessment Rationale: The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.

Edema at the infusion site Rationale: Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

Washing dishes Rationale: Washing dishes requires a low level of activity and is appropriate for this client.

Daily weight Rationale: According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.

Inspection Rationale: According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.

A client who has a prescription for a transfusion of packed red blood cells Rationale: Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

"It must be difficult to care for someone who is confined to bed." Rationale: This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

Bounding pulse Rationale: Bounding pulse is an expected finding of fluid volume excess.

Cover the incision with a moist sterile dressing. Rationale: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

Liver Damage Rationale: Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.

"Bear weight on both of your legs." Rationale: The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs.

PC for after meals Rationale: The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.

A 10-month-old infant can pull up to a standing position. Rationale: An 8 to 10-month-old infant can pull himself to a standing position.

The AP hangs the collection bag at the level of the bladder. Rationale: The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

Consult the medication reference book available on the unit. Rationale: A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit.

Place the client in a lateral position with the head turned to the side before beginning the procedure. Rationale: The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

Repeat each joint motion five times during each session. Rationale: To maintain the client's joint mobility the nurse should repeat each motion three to five times.

Cough deeply after each use. Rationale: Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.

Have the client demonstrates the procedure. Rationale: Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.

Gelatin Rationale: Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.

Romberg test Rationale: When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.

WBC 15,000 mm3 Rationale: This finding is above the expected reference range and is an indication of infection.

Ventrogluteal Rationale: According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.

Fill the bag two-thirds full with ice. Rationale: The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.

Wear cotton clothing to avoid static electricity. Rationale: The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

Impaired peristalsis of the intestines Rationale: Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.

"I can see that this is upsetting you." Rationale: The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.

Position the client on his left side. Rationale: Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.

Airway Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway.

Tie the restraint with a quick-release knot. Rationale: The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.

Oil retention Rationale: The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client.

People who practice Judaism stay with the body of the deceased until burial. Rationale: In the Jewish faith, a family member often stays with the body until burial occurs.

Remove the safety pin from the extinguisher. Rationale: Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first.

Place the client in Trendelenburg's position. Rationale: The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

Provide a protein intake of 1.5 g/kg of body weight per day. Rationale: A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.

Cold extremities Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.

Hemolytic Rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

Loss Rationale: At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

Sit at the bedside while feeding the client. Rationale: The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.

Wear gloves when changing the client's gown. Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. Rationale: -Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. -Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. -Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.

Fidelity Rationale: The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

Tachycardia Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.

Decreased calcium Rationale: Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

"Tell me more about how your friends discourage you." Rationale: The nurse should ask an open-ended question that encourages the client to elaborate about the problems that he is having.

When lifting an object, spread your feet apart to provide a wide base of support. Rationale: The AP should spread his feet apart because a wide base of support increases stability.

"All of this equipment can be frightening." Rationale: This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.