“We always give morphine to clients at the end-of-life stage.” “We can give oxygen instead of morphine to help with breathing and distress.” “Morphine will reduce anxiety and reduce the sensation of air hunger in your mother.” “We will wait until the very end to give the morphine and use nonpharmacologic measures instead.”
The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?
The client shakes the unit vigorously 3 or 4 times. The client places the inhaler over his tongue and seals his lips tightly around it. The client administers the next puff immediately after exhaling. After administering the dose, the client keeps his lips closed and holds his breath for at least 10 seconds before exhaling.
The nurse is preparing a client with type 2 diabetes for a CT with contrast to evaluate diverticulitis with a possible mass. Which of the following medications on the client’s medication list would be of concern to the nurse?
fish oil warfarin (Coumadin) fluoxetine (Prozac) metformin (Glucophage)
The nurse is caring for a client with a Foley catheter. While rounding on the client, the nurse notices that the client’s urinary output has suddenly stopped over the last 2 hours. The client’s kidney function is within normal limits. Which intervention would the nurse expect to perform? Select all that apply .
check the tubing for any kinks or to see if it is under the client attempt to gently flush the Foley with 30 cc of sterile saline perform a bladder scan, record the results, and notify the health care provider pull back on the catheter about 6 inches, then reinsert it to see if urine…
The nurse is precepting a student nurse who is helping to care for a client with a hip fracture. The client has Buck’s traction applied. Which statement by the student nurse indicates a need for further explanation by the primary nurse?
“The weight on Buck’s traction should be between 5 and 7 pounds.” “Buck’s traction is a type of skeletal traction that helps in bone realignment.” “The weights should hang freely and be checked regularly for correct positioning.” “Diligent pin site care is crucial to prevent infection in clients with skeletal traction.”
The nurse is caring for a client who is intubated and on the ventilator. The client is alert but cannot talk while intubated. Which method of communication would be the best choice for this client?
a clipboard with pen and paper a picture board that the client could point to asking the client to mouth words while a family member interprets the meaning telling the client to blink once for yes and twice for no while asking close-ended questions
A client is on bed rest following surgery for a fractured femur. The nurse is teaching the client about what to expect while on bed rest. Which dietary choice would the nurse advise the client to avoid while on bed rest?
high-fiber fruits grapefruit juice goods high in fat milk or milk-based products
The nurse is caring for a client after an open reduction to the left ulna. The client’s left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain advise the client that if he starts to itch under the cast, he can use…
The nurse is reflecting on the client-nurse relationship. Which statement is correct regarding the orientation (introductory) phase of the relationship?
identifying the client’s strengths and limitations promoting the client’s insight and perception of reality continuously evaluating progress toward the client’s goals exploring feelings about the termination phase of the relationship
Which task is included in the working phase of the nurse-client relationship?
identifying the client’s strengths and limitations establishing rapport and creating an environment of trust continuously evaluating progress toward the client’s goals exploring feelings about the termination phase of the relationship