The recent graduate nurse is orienting to the medical surgical care unit. The graduate nurse has prepared a nursing care plan for a client admitted for exacerbation of ulcerative colitis
The goal statement is, "The client will resume normal bowel elimination patterns." The graduate nurse has asked the charge nurse to review the care plan. What action by the charge nurse is indicated? 1. Express to the new nurse that the goal statement meets criteria.
2. Explain to the new nurse that the lack of time frame makes the goal inappropriate.
3. Express to the new nurse that the goal statement is not reflective of the client's admitting diagnosis.
4. Accept the care plan for inclusion into the client's medical record as it is accurate.
2
Rationale 1: This goal statement does not meet criteria as it lacks a time frame.
Rationale 2: Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal.
Rationale 3: The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement.
Rationale 4: This goal statement does not meet criteria as it lacks a time frame.
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Which of these statements about obtaining a clean-catch urine specimen is TRUE?
a. It is a sterile procedure. b. Only the first portion of the voiding stream is saved. c. The client cleanses him- or herself first and places a sterile collection cup after voiding is initiated. d. Only the end portion of the voiding stream is saved.
A 13-year-old boy is brought to the emergency department by his parents because he has lost the use of his right upper extremity
After medical testing, the physician tells the parents that there is no neurologic reason that can be found for the client's loss of functioning. The parents ask the nurse to explain what this means. What would be the nurse's best response? A) "The actual conversion aspect of this disorder refers to the transfer of psychologic conflict or stressors into a perceived paralysis of body parts or sensory functioning." B) "This is not an unusual occurrence in an adolescent when there is trouble in the home." C) "Usually there are related stress or trauma factors that have occurred concurrently with the onset of the symptoms." D) "These types of disease processes are considered pseudoneurologic, or false neurologic."
The nurse is caring for a client with cholecystitis. The client is a poor historian and is unable to tell the nurse when the symptoms started. Which assessment finding indicates to the nurse that the condition is chronic rather than acute?
a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
The patient has chest tubes in place after thoracic surgery. What does the nurse need to know about working with a patient who has a chest tube?
a. The tubes should be clamped, except during patient assessments. b. The tubing should be removed from the connection to check for adequate suction power. c. The tubes should be stripped every 15 to 30 minutes to maintain drainage. d. Periodic lifting and drainage of coiled loop will promote pleural drainage.