EXAM 1 Flashcards
A client with end-stage lung cancer & metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client?
Releasing the restraints at least every 2 hours
RATIONALE: The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, re-positioning, and toileting. The restraints must be checked every 30 to 60 minutes. Chemical sedation is also considered a restraint. The least restrictive devices should be used.
The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is MOST important in promoting health & safety?
“Stop driving when your vision, motor skills, and confidence begin to diminish.”
RATIONALE: Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer. Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.
Which older adult client’s living situation typically presents HIGHEST risk for abuse?
With adult daughter and grandchildren
RATIONALE: Older adults are often abused by a family member who becomes frustrated or distraught over the burden of caring for the older adult. Prolonged caregiving by a family member is a new and unexpected role for adult children, most often women (as in this case), and is highly stressful. The client living at home alone may suffer from self-neglect, but not from neglect and abuse by another person. Although it is possible that the client living at home with a spouse or in a long-term care facility may suffer from abuse, this is not as common as with clients who live with children and grandchildren.
Which result is frequently seen in older adults who have undiagnosed depression?
Under-nutrition
RATIONALE: Older adults may respond to depression by not eating, and this can lead to under-nutrition. Many who live alone lose the incentive to prepare or eat balanced diets, especially if they do not “feel well.” Falls are not typically the result of undiagnosed depression. Increased socialization is the antithesis of depression. Older adults, especially those with depression, do not typically go on spending sprees.
The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client’s daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do NEXT?
Copies the list to the assessment data form
RATIONALE: Copying the list to the assessment data form should be done first. Then, the health care provider should be notified of all drugs, which may or may not be ordered during the client’s stay, depending on the client’s diagnosis. Calling the pharmacy and calling the provider are not the priority for admission. The client may not require all the medications during the hospital stay.
At a follow-up visit after repair of a fractured radial bone, an older adult client states, “I am not sleeping at all during the night.” The client’s partner reports that the client is sleeping all day. Which intervention does the nurse suggest?
Increasing the client’s daytime activities
RATIONALE: Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal. The client did not report interruptions, but insomnia; placing a “Do not disturb” sign on the door, although it may be effective in increasing “sleep time,” does not address the client’s symptom. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal sleep remedies to try to enhance the effects of other medications is not an appropriate suggestion for the nurse to make.
The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as a resource, which drug poses a potential risk for this client?
Digoxin (Lanoxin)
RATIONALE: Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.
The RN is arriving for night duty at an acute care hospital. Which client does the RN assess FIRST?
A 72-year-old who was admitted to the unit with postoperative delirium
RATIONALE: Clients with delirium are at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters. The other clients should be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications.
The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning clients in a long-term care setting. Which client requires extreme caution is at GREATEST risk for a skin tear?
An 85-year-old client with breathing problems receiving daily doses of prednisone
RATIONALE: UAPs need to use extreme caution when handling members of the old old age group and clients who are on long-term steroid therapy. These groups are most prone to skin tears. This client has both of these high-risk indicators. Although the client with paraplegia has limited mobility, no other factors place the client at high risk for a skin tear. Most total hip repairs have short periods of immobility, with minimal skin breakdown potential; no specific risk factors are evident in this client’s history. Although the client with a recent stroke is at risk for skin breakdown because of age and immobility, fewer risk factors are present than in the older client on steroid therapy.
The RN has delegated nursing actions to experienced assistive personnel (UAP) working in a long-term care facility. Which actions require direct supervision by the RN?
- Assisting a 70-year-old client who has new-onset leg pain when ambulating
- Repositioning a 69-year-old client who has recently become unconscious
RATIONALE: supervision required when there is a change in the client’s condition, such as a change in the client’s level of consciousness
A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient’s fall risks. Which of the following is the proper order of steps for the “Timed Get-up and Go Test” (TGUGT)?
- Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down
- Have patient rise from straight-back chair without using arms for support
- Begin timing
- Look for unsteadiness in patient’s gait
- Have patient return to chair and sit down without using arms for support
- Check time elapsed
At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take FIRST?
Prepare for an influx of patients
You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint?
- Identify patient using two identifiers
- Introduce self and ask patient about his feelings of being restrained
- Be sure patient is comfortable with arm in anatomic alignment
- Assess condition of skin where restraint will be placed
- Wrap wrist with soft part of restraint toward skin and secure snugly
A nurse knows that the people most at risk for accidental hypothermia are:
- People who are homeless
- People with cardiovascular conditions
- The very old
(also: the young, people who have ingested drugs or alcohol in excess)
A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly?
- Inadequate lighting
- Throw rugs
- Multiple medications
- Doorway thresholds
- Cords covered by carpets
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation?
- Ask the family to stay with the patient if possible
- Inform the family of the risks associated with side-rail use
- Discuss alternatives that are appropriate for this patient with the family
You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include?
- Drive shorter distances
- Drive only during daylight hours
- Use the side and rearview mirrors carefully
- Keep a window rolled down while driving if has trouble hearing
- Look behind toward the blind spot
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?
Encouraging use of an overhead trapeze for positioning and transfer
To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?
Ambulate patient to chair in the hall
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
Use of incentive spirometer every 2 hours while awake
Which of the following are physiological outcomes of immobility?
Decreased lung expansion
Also: decreased metabolism, increased cardiac workload, increased oxygen demand
A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding:
- Bruising
- Bleeding gums
- Coffee ground-like vomitus
The nurse evaluates that the NAP has applied a patient’s sequential compression device (SCD) appropriately when which of the following is observed?
- Inflation pressure averages 40 mmHg
- Patient’s leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve
The effects of immobility on the cardiac system include which of the following?
- Thrombus formation
- Increased cardiac workload
- Orthostatic hypotension
A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use?
Four-point
Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age?
My granddaughter and I walk together around the high school track 3 times a week
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
The patient received an injection of morphine 30 minutes ago for pain
The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient’s:
Use of glucose & fatty acids, thereby decreasing blood glucose level
Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association is advocating which of the following?
Require the use of assistive equipment and devices
The body alignment of the patient in the tripod position includes the following:
- An erect head and neck
- Straight vertebrae
- Extended hips and knees
- Patient in the tripod position
Which of the following is a principle of proper body mechanics when lifting or carrying objects?
- Maintain a wide base of support
- Encourage patient to help as much as possible
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather?
- Patient’s weight
- Patient’s level of cooperation
- Patient’s ability to assist
- Presence of medical equipment
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
Cleansed wound
What is the correct sequence of steps when performing a wound irrigation?
- Place water proof bag near bed
- Fill syringe with irrigation fluid
- Attach angio catheter to syringe
- Position angio catheter over wound
- Use slow continuous pressure to irrigate wound
On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?
Unstageable
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions?
- Notify the surgeon
- Cover the area with sterile, saline-soaked towels and immediately
Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence?
- Frequent position changes
- Using an incontinence cleaner
- Applying a moisture barrier ointment
When is an application of a warm compress to an ankle muscle sprain indicated?
- To relieve edema
- To improve blood flow to an injured part
Which of the following are measures to reduce tissue damage from shear?
- Use a transfer device, e.g. transfer board
- Have head of bed flat when repositioning patients
- Raise head of bed 30 degrees when patient positioned supine
The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.)
- With patient on floor, clear surrounding area of furniture or equipment.
- Do not restrain patient; hold limbs loosely if they are flailing.
- Never force apart a patient’s clenched teeth.
Rationale: During a seizure, if a patient is standing, guide to floor. Do not try to place in bed. Do not position the patient supine; instead turn patient onto one side with head tilted slightly. When patient is on the floor, remove any furniture or objects that he or she could strike during tonic and clonic activity. Never force apart a patient’s clenched teeth; you might be bitten. Do not restrain patient; hold limbs loosely if they are flailing. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep.
The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN?
Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road
RATIONALE: An LPN/LVN would be appropriate to care for an adult client with a facial suture. This nurse would be familiar with wound monitoring for potentially contaminated wounds and would recognize the manifestations of infection.
Conducting an admission assessment and discharge teaching is more complex nursing actions that require RN-level education and scope of practice. The older adult with stage I pressure ulcers who needs to be turned every 2 hours could be cared for by a nursing assistant.
Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN?
Administer an antihistamine to a client who is describing pruritus
RATIONALE: LPN/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects.
Developing care plans and client assessment requires more critical judgment and education and should be done by an RN. Providing client instruction is a more complex skill that is included in the RN scope of practice.
An older, immobile client has slipped to the bottom of the bed. What does the nurse do first?
Get help and lift the client
RATIONALE: The first action by the nurse would be to get help and gently lift the client with a sheet.
Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority.
During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response?
Reddish blue area on the calf
RATIONALE: A reddish blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention.
Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Erythema is expected at the incision site and does not warrant an urgent response.
While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include?
“Administration of local anesthetic agents may cause burning.”
RATIONALE: The nurse needs to tell the client having an excisional biopsy that local anesthetic agents may cause a burning sensation.
Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy, and may be an indication of infection.
The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client?
Body image counseling
RATIONALE: Damage to the epidermis (the outer layer of the skin) can cause body image disturbance for clients. The nurse needs to include body image counseling when discussing this topic with the client.
Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.
The nurse is teaching a client who has loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client’s teaching plan?
Lift hips off the chair at least every hour
RATIONALE: The daily prevention strategy the nurse includes in the client’s teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers.
Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.
During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first?
Clean and dry the client’s skin
RATIONALE: Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection.
Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.
An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for?
Pressure ulcer development
RATIONALE: This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden.
Anemia and weight gain have no correlation with this client’s protein deficiency. The client does not have an indicated wound.
A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother?
“Keep the site covered with a bandage.”
RATIONALE: Keeping the site covered with a bandage prevents spread of the infection.
Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.
The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy?
Hyperbaric oxygen
RATIONALE: Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.
Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically debrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.
The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration?
Serum albumin
RATIONALE: Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.
Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.
Which statement by a client with psoriasis indicates that teaching about the condition has been effective?
“I should practice good handwashing technique.”
RATIONALE: Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection.
Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.
The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order.
- Select injection port of intravenous (IV) tubing closes to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy.
- Clean injection port with antiseptic swap. Allow to dry
- Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port.
- Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.
- Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration.
- After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.
