Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials.
Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members.
Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change.
Ask the assistant manager to develop a plan for the review and revision of client-education materials.
Serum potassium level
Follow the chain of command to obtain adequate pain relief for the client.
Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered.
Give the client 1 hydrocodone/APAP tablet every 3 hours.
Give the client 2 hydrocodone/APAP tablets every 4 hours.
Assessing a client's pain
Taking a client's vital signs
Documenting a client's oral intake
Performing a blood glucose check
Evaluating a client's response to a blood pressure medication
Health care power of attorney
Keep instructions simple and brief because the client will have difficulty concentrating.
Speak clearly and slowly because the client will have difficulty hearing.
Assist the client with personal grooming because he'll have difficulty verbalizing his preferences.
Orient the client to time, place, and person as needed because of memory problems.
Assess vital signs frequently because vital bodily functions are affected.
Failure to act as a client advocate
Failure to communicate with the client
Failure to assess, monitor, and communicate
Failure to protect from harm
Apply heat to the fracture site.
Apply ice to the fracture site.
Perform ankle dorsiflexion three times per day.
Use crutches for 1 week.
Reposition the client every 2 hours.
Encourage the client to walk in the hall.
Provide the client dairy products at frequent intervals.
Provide supplemental feedings between meals.
Immediately remind the night-shift nurses of the daily calibrations.
Arrange a meeting of the day-shift and night-shift nurses.
Review the capillary glucose monitoring calibration log book.
Counsel the night charge nurse about the discrepancy.
½″ (1 cm)
2″ (5 cm)
6″ (15 cm)
8″ (20 cm)
Completes the vacation schedule without staff input
Delegates responsibility for evaluating the effectiveness of new equipment to the staff members who use that equipment
Identifies possible solutions to staffing problems and asks staff members for their opinions about each one
Delegates to staff responsibility for selecting a new nursing care delivery system
All personnel should wear protective clothing, including a gown, gloves, and respiratory protection.
Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.
Clients should be instructed to wash thoroughly with soap and water.
Access to the area should be restricted.
Lumbar spinal cord injury and lower extremity paralysis.
Maxillofacial injury and gurgling respirations.
Severe head injury and no blood pressure.
Second-trimester pregnancy in premature labor.
Conduct performance evaluations in a group setting so input from peers and subordinates influences evaluation of a staff member's effectiveness.
Provide feedback on strengths as well as areas for improvement and clarify what she expects the staff member to accomplish before the next performance evaluation.
Provide written documentation of areas for improvement. Areas of strength needn't be documented because these areas are complimentary and don't describe actions the staff member must take to improve.
Whenever possible, delegate responsibility for conducting performance evaluations to primary nurses to help them achieve professional growth.
Laterally, from the center to the opposite side
From top to bottom
In a circle around the drain, outward from the center
In a circle around the drain, from the outer border to the center
Place the client in a prone position.
Approach the client from the left side.
Encourage deep breathing and coughing.
Discourage bending down.
Orient the client to his environment.
Administer a stool softener.
Liquid or semiliquid stools.
Hard, brown, formed stools.
Loss of urge to defecate.
From directly in front of the client
From the right side of the client
From the left side of the client
From directly behind the client
Perform gentle passive range-of-motion exercises.
Gently massage the painful joints.
Use a bed cradle to keep linens from pressing on the child's joints.
Encourage the child to change position in bed every 2 hours.
Duty, breach of duty, damages, and causation
Duty, damages, and causation
Duty, breach of duty, and damages
Breach of duty, damages, and causation
Instructions on when and how to implement the living will
Who may uphold a living will declaration
How long the living will remains in effect
What will happen to the client's valuables after his death
Documenting that the client is resting quietly and denies pain
Calling a family member to obtain information about the client
Giving the client the ordered as-needed pain medication
Checking vital signs and assessing for nonverbal indications of pain
Avoid using cornstarch on the feet.
Avoid wearing canvas shoes.
Avoid using a nail clipper to cut toenails.
Avoid wearing cotton socks.
Aggregate care prevention
Antidiarrheal medication should be given if the client has more than two loose stools.
Eating large meals should be encouraged to prevent weight loss.
The client may require fluid and electrolyte replacement.
Side rails should be raised at all times.
Take daily weight.
Assess urine specific gravity.
Encourage intake of coffee or tea.
Monitor intake and output.
Facility policies and procedures
Standards of care
Nurse practice act
Tips for correctly performing a procedure in the hospital environment.
Bylaws that state clients' rights.
A code of ethics that states the nurse's obligation and responsibility to the client.
Regulations stating criteria for nursing licensure.
Only low doses of opioids are safe; higher doses may cause respiratory depression.
Pain medication should be given only when a client requests it.
A client who can fall asleep isn't in pain.
Terminal cancer clients may develop tolerance to opioids and require progressively higher doses to control pain.
Clear, yellow drainage
Redness and warmth
Pallor around sutures
Brown exudate at incision edges
Withhold all potentially life-prolonging treatments in accordance with the client's living will.
Increase the oxygen flow rate to 4 L, but avoid initiating other interventions.
Call the client's family and ask what they think is best.
Initiate potentially life-prolonging treatment unless the client refuses.
Throw the documents in the trash can.
Shred the documents or place them in a Health Insurance Portability and Accountability Act (HIPAA) trash container.
Place the documents in the client's chart.
Leave the documents at the nurses' station.
By providing a tracheostomy plug to use for verbal communication
By placing the call button under the client's pillow
By supplying a magic slate or similar device
By suctioning the client frequently
When the client has time
When the nurse has time
Administer sleep medication before bedtime.
Ask the client to describe the quality of the previous night's sleep.
Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Determining that the client has authorized release of the information
Making sure the client's name and date of birth are displayed on the fax cover sheet
Reading all information to the client before faxing
Obtaining a written order from the client's primary physician to fax the information
Unhappiness about the change in leadership.
Unexpressed feelings and emotions among the staff.
Fatigue from overwork and understaffing.
Failure to incorporate staff in decision making.
Salem sump tube.
Holding sterile objects above the waist
Pouring solution onto a sterile field cloth
Leaving a 1″ (2.5-cm) edge around the sterile field
Opening the outermost flap of a sterile package away from the body
Baked beans, hamburger, and milk
Spaghetti with cream sauce, broccoli, and tea
Bouillon, spinach, and soda
Chicken cutlet, spinach, and soda
Ignore the comment because nursing staffing decisions aren't within the physician's domain.
Report the nurse-manager to the labor relations board.
Ensure that the nurse-manager receives counseling about her comment.
Tell the staff nurse what the manager said about her.
Monitoring his temperature every 4 hours
Increasing fluid intake
Covering the client with a light blanket
Providing a low-calorie diet
Fresh orange slices.
Ground beef patties.
Putting on an individually fitted mask when entering the client's room
Instructing the client to wear a mask at all times
Wearing a gown and gloves when providing direct care
Keeping the door to the client's room open to observe the client
Call for assistance.
Assess for responsiveness.
Palpate for a carotid pulse.
Assess for pupillary response.
My son can't eat wheat, rye, oats, or barley.
My son needs a gluten-rich diet.
My son must avoid potatoes, rice, and cornstarch.
My son can safely eat frozen and packaged foods.
Leave the bed in the high position when finished.
Place the pillow at the head of the bed.
Tuck the top sheet and blanket under the bottom of the bed.
Roll the client to the far side of the bed.
Nurse practice acts.
Standards of care.
The American Nurses Association.
Position the head of the bed flat.
Help the client dangle his legs.
Stand behind the client.
Place the chair facing away from the bed.
Complaints of deep, sharp incisional pain
Evidence of uneven wound edges
Thick, yellow wound drainage
Oral temperature of 100.6° F (38.1° C)
A nursing assistant administers medications to a client in ICU.
A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client.
A nursing assistant attempts to initiate I.V. therapy.
A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy.
Reduce fluid intake to less than 2,500 ml/day.
Teach diaphragmatic, pursed-lip breathing.
Administer low-flow oxygen.
Keep the client in a supine position as much as possible.
Encourage alternating activity with rest periods.
Teach use of postural drainage and chest physiotherapy.
Determining how planned absences such as vacation time will be scheduled so that all staff are treated fairly
Identifying who will be responsible for making client care decisions
Deciding what type of dress code will be implemented
Identifying salary ranges for various types of staff
Statute of limitations
Alternative dispute resolution
Telling the nurse that she may use the password
Telling the nurse to ask someone else for her password
Writing down the password so the nurse won't forget it
Telling the nurse that she may not use the password
Notifying the American Cancer Society of the client's diagnosis
Requesting Meals On Wheels to provide adequate nutritional intake
Referring the client to a home health nurse for follow-up visits to provide colostomy care
Asking an occupational therapist to evaluate the client at home
Standing with her feet apart.
Lifting the client to the proper position.
Straightening her knees and back.
Standing several feet from the client.
Avoid constrictive clothing.
Lie down for 30 minutes after eating.
Decrease intake of caffeine and spicy foods.
Eat three meals per day.
Sleep in semi-Fowler's position.
Maintain a normal body weight.
First stream of urine from the bladder.
Middle stream of urine from the bladder.
Final stream of urine from the bladder.
Full volume of urine from the bladder.
Planning vacation time for staff
Directing staff activities if a client experiences a cardiac arrest
Evaluating a new medication-administration process
Identifying the strengths and weaknesses of a client-education video
Presence of congestion on X-ray
Breath sounds clear on auscultation
Continued use of oxygen when necessary
Respiratory rate of 28 breaths/minute
Does the pain worsen when you get up in the morning?
Does the pain increase with activity and lessen with rest?
Is the pain relieved when you change position?
Is the pain worse when you point your toes toward your knee?
Notify the nursing supervisor.
Notify the physician.
Try to obtain more information from the client about when and how she acquired these bruises.
Follow the facility's policy and procedures for reporting elder abuse.
Instill isotonic eye drops, as necessary.
Provide several small, well-balanced meals.
Provide rest periods.
Keep the environment warm.
Encourage frequent visitors and conversation.
Weigh the client daily.
Applying the restraint loosely to prevent pressure on the skin
Tying the restraint to the side rail
Positioning the restrained arm in full extension
Monitoring circulatory status every 2 hours
The client takes slow, deep breaths to elevate the spirometer ball.
The client takes rapid, shallow breaths to elevate the ball.
The client tilts the spirometer down when using it.
The client uses the device while lying supine.
Swab the client's lips, teeth, and gums with lemon glycerin.
Clean the client's tongue with gloved fingers.
Place the client in semi-Fowler's position.
Place the client in a side-lying position.
Diminished or absent breath sounds on the affected side.
Paradoxical chest wall movement with respirations.
Tracheal deviation to the unaffected side.
Muffled or distant heart sounds.
Always keeping the bed in a low position
Having the client fold his arms across his chest
Raising the head of the bed
Having the client help himself as much as possible
Incision and drainage
Including the client in the discussion
Using technical terms
Providing detailed explanations
Using loosely structured teaching sessions
Clean from the center outward in a circular motion.
Remove the drain before cleaning the skin.
Clean briskly around the site with alcohol.
Wear sterile gloves and a mask.
Drinking eight 8-oz glasses of water each day.
Limiting the serving sizes of food and water.
Increasing intake of milk and dairy products to amounts higher than what the Food and Drug Administration (FDA) recommends.
Ignoring FDA recommendations regarding fats, oils, and sugars.
The primary nurse
The physician involved with the procedure
The nurse working with the physician
The social worker
Dry sterile dressing
Sterile petroleum gauze
Moist sterile saline gauze
Prevent the client from leaving.
Notify the physician.
Have the client sign an AMA form.
Call a security guard to help detain the client.
The presence of an indwelling urinary catheter
Rectal temperature of 100° F (37.8° C)
Red, warm, tender incision
White blood cell (WBC) count of 8,000/μl
Minors may give informed consent.
The professional nurse and physician must each obtain informed consent.
The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each.
Mentally incompetent clients may legally give informed consent.
The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide.
The client rinses around the clean incision site, using gauze squares moistened with normal saline.
The client rinses around the clean incision site, using gauze squares moistened with tap water.
After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.
Use elevators to travel to the location of the fire.
Make sure all fire doors are open.
Implement the RACE plan.
N't notify the fire department if the fire is small enough for the nurse to extinguish.
Recommending warm milk or a warm shower at bedtime
Gathering more information about the client's sleep problem
Determining whether the client is worried about something
Finding out whether the client is taking medication that may impede sleep
Once, to establish a baseline
Once per year
Every 2 years
Twice per year
Positioning the client
Assisting with gowning and gloving
Handing surgical instruments to the surgeon
Applying surgical drapes
Partial pressure of carbon dioxide (PaCO2).
Partial pressure of oxygen (PaO2).
Assessing the client's temperature every 8 hours
Placing the client in respiratory isolation
Monitoring the client's fluid intake and output
Wearing gloves during all client contact
Remove the raised skin because the blister has already broken.
Wash the area with soap and water to disinfect it.
Apply a weakened alcohol solution to clean the area.
Clean the area with normal saline solution and cover it with a protective dressing.
Administering the penicillin G potassium as ordered
Administering the penicillin G potassium and staying alert for any reaction
Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin
Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction
Leave the client and get help.
Obtain a physician's order to restrain the client.
Read the facility's policy on restraints.
Order soft restraints from the storeroom.
A single male client's human immunodeficiency virus (HIV) status to his family members
A diagnosis of pancreatic cancer to a client's significant other
A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency
The fact that a woman is 32 weeks pregnant with twins to the husband from whom she is legally separated
Determine that the procedures currently in place must be followed and direct staff to follow them without question.
Tell staff members to use whatever procedures they feel are best.
Ask staff members to quickly meet among themselves and decide what procedures to follow.
Tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do.
Orange juice, farina, and coffee.
Apple juice, cream of chicken soup, and vanilla ice cream.
Pineapple juice, a bran muffin, and milk.
Orange juice, custard, and tea.
Place bilateral wrist restraints on the client.
Ask the physician to order sedation for the client.
Delay giving the drug until the client's confusion disappears.
Tell a nursing assistant to stay with the client during the infusion.
Identifying incorrect dosages or potential interactions of ordered medications
Never questioning a physician's order because the physician is ultimately responsible for the client outcome
Notifying the Occupational Safety and Health Administration (OSHA) of workplace violations
Informing the client of the Patient's Bill of Rights
A palpable radial pulse
A palpable ulnar pulse
Cool, pale fingers
Pink nail beds
Anticipated overtime payments for staff
Computers for staff use
Office supplies for secretarial use
Videos for staff education
The nurse makes decisions for clients who can't make decisions for themselves.
The nurse follows the basic standards of care and hospital policies and procedures for providing client care.
The nurse promotes and protects the client's interests and rights.
The nurse adopts a paternalistic approach to client care.
Clients who require frequent pain medication
Clients who are 15 lb (6.8 kg) overweight
Clients who ambulate after the first postoperative day
Clients who are undernourished
Immediately recapping used needles.
Disposing of sharp instruments in an impervious container.
Wearing gloves only for sterile procedures.
Substituting regular eyeglasses for eye protection.
Wear gloves for all client contact.
Consider all body substances potentially infectious.
Place a body substance isolation sign on the client's door.
Wear gloves and a gown if the client is in respiratory isolation.