FUNDAMENTALS Flashcards
exhibit: continuous positive airway pressure (CPAP) device
You are called to assist in caring for a client depicted in the Exhibit. Which of the following diagnoses would you suspect when you see the client?
A. Chronic obstructive pulmonary disease (COPD)
B. An airway obstruction from the accumulation of respiratory secretions
C. Hypoxia related to a cardiovascular of pulmonary disorder
D. Central sleep apnea related to muscular dystrophy
Explanation
Choice D is correct. The device shown in the exhibit is a continuous positive airway pressure (CPAP) device. You would suspect central sleep apnea when you see a client like shown in the picture above. Central sleep apnea, which is treated with CPAP device, often results from muscular dystrophy and a compromised brain stem, which houses the respiratory control mechanisms for the body. By providing continuous pressure, CPAP keeps airways open and promotes better ventilation.
Sleep apnea is classified in to central and obstructive types. CPAP is also used for the treatment of obstructive sleep apnea.
Choice A is incorrect. CPAP device is not used to treat chronic obstructive pulmonary disease (COPD), and it does not deliver oxygen. A BiPAP (Bi-level positive airway pressure) machine is often used in providing ventilation to clients with chronic obstructive pulmonary disease (COPD) exacerbations. Both CPAP and BiPAP are considered methods to deliver non-invasive positive pressure ventilation (NPPV).
Choice B is incorrect. CPAP device is not used to treat airway obstruction from the accumulation of respiratory secretion. It does not deliver oxygen or suctioning.
Choice C is incorrect. CPAP device is not used to treat hypoxia related to a cardiovascular or pulmonary disorder. In some cases of respiratory distress due to congestive heart failure (CHF) exacerbations, a BiPAP may be used. By increasing intrathoracic pressure, a BiPAP results in decreased preload and decreased afterload. It may prevent intubation by decreasing respiratory effort, and improving gas exchange.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
You are taking care of a client with moderate to severe dementia. Select the nursing intervention that insures and protects the client’s safety in terms of bathing.
A. Ensure that there is a scatter rug outside the shower to prevent the collection of water which could lead to a slip and fall.
B. Check and insure that the bathing water for the client is no more than 101 degrees in order to prevent client burns.
C. Clients with dementia should be encouraged to shower in privacy and without supervision so they do not become hostile.
D. Never allow the client to remain in the tub alone without monitoring and supervision so that accidents do not occur.
Explanation
Correct Answer is D
Correct. Bathing safety is highly important. Many accidents occur in the bathrooms of healthcare facilities and the homes of clients. You should never allow the client to remain in the tub alone without monitoring and supervision because accidents can and do occur.
Other aspects of bathing safety include the presence and use of assistive bathing devices like grab bars and shower chairs, checking and ensuring that the water in the shower, bathtub and used for a bed bath is less than 110 degrees to prevent burning, and monitoring the client when they are taking a tub bath or shower bath.
Choice A is incorrect. You would not ensure that there is a scatter rug is outside the shower to prevent the collection of water, which could lead to a slip and fall because scattering rugs are a safety hazard in themselves so they would only increase the risk of slipping and tripping.
Choice B is incorrect. You would not check and ensure that the bathing water for the client is no more than 101 degrees to prevent client burns, but you would ensure that the temperature is no more 110 degrees. One hundred one degree is an uncomfortable cold temperature for bathing water, and water that is too hot can be harmful, and it can even cause burns.
Choice C is incorrect. Clients with dementia should not shower in privacy and without supervision, so they do not become hostile; they must be closely monitored and supervised at all times.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
he nurse is assisting a client of the Orthodox Jewish faith while serving lunch. A kosher meal has been delivered to the client. What is the next appropriate action to perform with this client?
A. Substitute plastic utensils with metal utensils
B. Unwrapping the eating utensils for the client
C. Carefully transferring the food from Styrofoam tray to a ceramic plate
D. Allow the client to unwrap the utensils and prepare his own meal.
Explanation
Choice D is correct. A person of the Orthodox faith should be able to unwrap the utensils and prepare his meal.
Choices A, B, and C are all incorrect. The nurse should not assist or touch the kosher meal in any way.
NCSBN client need | Topic: Fundamentals; SubTopic: Culture and Spirituality
Reference: Perry A, Potter P, Ostendorf W, Perry A. Skills Performance Checklists For Clinical Nursing Skills & Techniques. Maryland Heights, MO: Elsevier Mosby
The nurse is caring for a client receiving a continuous heparin infusion. Which of the following laboratory data should the nurse monitor? Select all that apply.
A. Partial thromboplastin time (PTT)
B. Platelet count
C. Prothrombin time (PT)
D. Neutrophil count
E. International normalized ratio (INR)
Explanation
A client receiving a heparin infusion will need their PTT and platelet count monitored closely. Heparin prolongs the PTT (goal is 1½ to 2 times the control value) and should be observed frequently. Platelet counts that decrease approximately 50% may be indicative of heparin-induced thrombocytopenia, which should be reported. PT and INR are significant if the client is taking warfarin.
When collecting data about a client’s pain, the first step in pain assessment is for the nurse to:
A. Accept the client’s report of pain
B. Get the description of the location and intensity of the pain
C. Have the client identify coping methods
D. Determine the client’s status of pain
xplanation
Assessment of pain is a vital part of any nursing assessment. Pain is often called the “Fifth Vital Sign.” If a patient does not immediately report pain, it is still the nurse’s responsibility to question if he/she feels any pain. If the patient reports pain (under any circumstance), the nurse should validate the patient’s concern by acknowledging he/she is feeling discomfort and then assess more thoroughly to find out the location and intensity, to identify coping mechanisms and follow up with pain status.
The correct answer is A.
B, C, and D are incorrect. Although each of these Answers is part of the pain assessment, the nurse must first accept the client’s report of pain before the other Options are implemented.
NCSBN Client Need
Topic: Physiological IntegritySubtopic: Basic Care and Comfort
Fundamentals of Nursing (Kozier and Erb’s)
Chapter 46: Pain
Lesson: Pain Assessment
The nurse is caring for a 5 year old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother’s request?
A. Finding metal utensils instead of plastic
B. Placing the food on plastic plates instead of paper
C. Helping the child unwrap the plastic utensils from their packaging
D. Allowing the child and his mother to unwrap the eating utensils
Explanation
Choice D is correct. It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested.
A is incorrect. It is not appropriate for the nurse to replace the utensils that come with the tray with metal utensils. Kosher meals will arrive on the unit on paper plates with sealed plastic utensils which the nurse should not open.
B is incorrect. It is not appropriate for the nurse to transfer the food to another dish. The nurse should deliver the tray to the client on the paper plate that it arrives on.
C is incorrect. It is not appropriate to help the child unwrap the plastic utensils from their packaging. The nurse should deliver the paper plate and sealed plastic utensils directly to the client and the mother. The mother can assist in the unwrapping, but the nurse should not do it for the client unless otherwise instructed.
NCSBN Client Need: Topic: Psychosocial Integrity; Sub-Topic: Culture & Spirituality
You are preparing for morning medication passes and have a patient with the following order:
20 mg Sildenafil TID, PO
The bottle you pull from the medication bin reads:
10 mg/mL
How many mL’s of Sildenafil do you administer to your patient? Round to the nearest tenth of an mL. Enter the numeric only.
Explanation
Answer: 2
To calculate the proper amount of medication to administer to your patient use the following formula:
(Desired amount of medication ÷ Amount of medication you have) x vehicle
(D÷H) x V
Your desired amount of medication is 20 mg. D = 20.
The amount of medication you have is 10 mg. H = 10.
The vehicle that this amount of medication comes in is 1 mL. V = 1
(20mg ÷ 10mg) x 1mL = 2 mL
The Certified Nurse Assistant ( CNA) is helping a female patient with early ambulation post-surgery. The CNA has just applied a gait belt to the patient’s waist. Which of the following actions by the CNA will need interference and correction by thesupervising nurse?
A. Holding onto the belt’s outer edge or center, preventing the patient from leaning or drooping to one side.
B. Pulling from the front of the belt, keeping forward momentum.
C. Bringing the client to a nearby chair when she feels dizzy.
D. Keeping the patient’s body weight close to her own.
Explanation
Choice B is correct. The nurse will need to correct the CNA if the CNA is found pulling the patient in any direction. Pulling unsteady or unfit patients is dangerous and should never be performed. Instead, the nurse’s aide should walk alongside the patient, moving only at the pace the patient can maintain.
Choice A is incorrect. Holding the belt’s side or center while the patient moves is a safe nursing action when using a gait belt.
Choice C is incorrect. The CNA is practicing safe nursing skills by bringing the patient to a chair, or the bed should the patient feel light-headed or dizzy.
Choice D is incorrect. The CNA is protecting herself from straining or pulling her muscles by keeping the patient’s bodyweight pulled in close to her own body. This is the proper way to use a gait belt and does not need correction.
NCSBN client need |Topic: Basic Care and Comfort: Assistive Devices
Reference:
Perry A, Potter P, Ostendorf W, Perry A. Skills Performance Checklists For Clinical Nursing Skills & Techniques. Maryland Heights, MO: Elsevier Mosby.
ou are preparing to administer Omeprazole to your 5-year-old patient, Jane Doe. The order is for 5 mg PO. After checking the six rights of medication administration and looking at the bottle Exhibit label showing 5mg/ml, TAKE 1 MG BY MOUTH), which oral syringe do you select to administer the medication safely? A .Tuberclin syringe 1 CC SYRINGE B . 5 cc syringe C . 10 cc syringe D . 30 cc syringe
Explanation
Answer: A
A 1 mL syringe is the best choice for this medication administration. You see that 5 mg is ordered for Jane Doe, and check the bottle. The suspension reads 5mg/1mL. You calculate the mL’s to administer:
(5mg/5mg) x 1mL = 1 mL
You prepare to administer 1 mL of omeprazole to Jane Doe. You look at the syringe choices: 1 mL, 5 mL, 10 mL, and 30 mL. The most appropriate syringe size is the smallest syringe that the full medication dosage can fit into. The 1 mL syringe allows you to measure medications of 1 mL or less with the most accuracy. The next size, 5 mL, will not be nearly as accurate.
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Pharmacological therapies
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
The nurse is preparing a client for angiography using a contrast medium. The nurse should tell the client that he will experience all of the following when the contrast medium is injected, except:
A. The client might feel possible nausea.
B. The client might have a headache lasting several days.
C. The client might feel flushing of the face.
D. The client might feel a sudden urge to urinate.
Explanation
Choice B is correct. A headache lasting several days is not an expected effect of injection of the contrast media to the client.
Choices A, C, and D are incorrect. The nurse should tell the client that when the contrast medium is injected, he will feel possible flushing of the face or a sudden urge to urinate. These are expected effects of intravenous contrast media. A mild allergic reaction such as nausea may also be experienced.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier
The nurse places a patient with hypovolemia in the position depicted in the Exhibit. Which of the following positions does it represent?
A. The prone position.
B. The supine position.
C. The Trendelenburg position.
D. The Sims’ position.
Explanation
Correct Answer is C. This picture shows the Trendelenburg position. In this position, the body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. It is also used to improve the effects of spinal anesthesia and also to prevent air embolism during central venous cannulation.
Choice A is incorrect. The prone position is when a patient is placed in a horizontal position with the face oriented down. A prone position is often used during surgical procedures, especially for those needing access to the spine and the back. It is also used to increase oxygenation in patients with respiratory distress. A Prone position is depicted in the image below:
Choice B is incorrect. The supine position is when a patient is placed in a horizontal position with the face oriented up. A supine position is often used during surgical procedures, especially for those needing access to the thoracic area/ cavity. A Supine position is depicted in the image below:
Choice D is incorrect. A Sim’s position is when a patient lies on his/her left side, left hip and lower extremity straight, and right hip and knee bent. It is also called a lateral recumbent position. Sim’s status is usually used for rectal exams, treatments, and enemas. A Sims position is shown below:
Additional Reading
Fowler’s position: is another position an RN needs to be aware of since it has many implications during nursing care. This is when a patient is seated in a “semi-sitting” position when the head of the bed is elevated at a 45 to 60 degrees angle. There are variations in Fowler position: Low ( 15-30 degrees), Semi-Fowler (3-45 degrees), Standard (45-60 degrees), and High Fowler’s (60-90 degrees). Fowler’s position is depicted in the image below:
Fowler has been used as a way to help with peritonitis. Fowler’s can be used:-
To promote oxygenation during respiratory distress because it allows maximum chest expansion and relaxation of abdominal muscles. E.g., infants with respiratory distress. To increase comfort during eating and other activities. To improve uterine drainage in post-partum women. To minimize the risk of aspiration in patients with oral or nasal gastric feeding tubes. Fowler's position aids Peristalsis and swallowing by the effect of gravitational pull.
NCSBN Client Need:
Topic: Basic Care and Comfort. Sub-Topic: Non-pharmacological comfort interventions.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.
Beliefs and conceptions about pain and pain management are often not based in fact and scientific evidence. Which of the following is a commonly held misconception about pain and pain management? Select all that apply.
A. Infants do not have developed pain sensors.
B. The lack of physiological and behavioral signs of pain do not negate pain.
C. The amount of pain has a positive correlation with the extent of tissue damage.
D. The amount of pain has a negative correlation with the extent of tissue damage
Explanation
Choices A and C are correct.
The two commonly held misconceptions about pain and pain management are that infants do not have developed pain sensors and that the amount of pain has a positive correlation with the extent of tissue damage. These beliefs are contrary to facts and scientific evidence.
These false beliefs continue to be held by some healthcare providers who believe that infants do not experience pain and that the amount and intensity of grief are increased with significant tissue damage.
Choice B is incorrect. The lack of physiological and behavioral signs of pain does NOT negate the anxiety and pain. People are uninformed when they believe that the lack of physiological and behavioral symptoms of pain indicates the absence of pain.
Choice D is incorrect. The amount of pain has a negative correlation with the extent of tissue damage is not accurate, but this is not a commonly held misconception about pain and pain management. The widely held misconception about pain and pain management is that the amount of pain has a positive and not a negative correlation with the extent of tissue damage.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016).
Which of these medications can be mixed in the same syringe without the risk of any incompatibility?
A. Morphine and Furosemide
B. Metoclopramide and Dexamethasone
C. Lignocaine and Ampicillin
D. Promethazine and Furosemide
Explanation
Correct Answer is B. Metoclopramide and dexamethasone can be mixed in the same syringe because these two medications are compatible with each other.
Morphine and furosemide cannot be mixed in the same syringe because they are not compatible; lignocaine and ampicillin cannot be incorporated in the same syringe because they are incompatible, and promethazine and frusemide cannot be incorporated in the same syringe because they too are not compatible.
Choice A is incorrect. Morphine and furosemide cannot be mixed in the same syringe because they are not compatible. Morphine and other medications such as ketamine, however, are consistent, and as such, they can be mixed in the same syringe.
Choice C is incorrect. Lignocaine and ampicillin cannot be mixed in the same syringe because they are not compatible. Lignocaine and other medications such as metoclopramide, however, are compatible and as such, they can be mixed in the same syringe.
Choice D is incorrect. Promethazine and furosemide cannot be mixed in the same syringe because they are not compatible. Promethazine and other medications such as atropine, however, are fit, and as such, they can be mixed in the same syringe.
Reference:
Kee, Joyce LeFever, Evelyn Hays, and Linda McCistion (2011) Pharmacology: A Nursing Process Approach 7th edition.
According to the Centers for Medicare and Medicaid Services and the Joint Commission on the Accreditation of Healthcare Organizations, which of the following is not considered a restraint?
A. A loose bed sheet around the client’s waist while in a chair prevents slipping and falling to the floor.
B. A slightly higher dosage of medication is needed for medical treatment to promote sleep.
C. The use of the upper bedside rails to prevent a fall.
D. A restrictive arm board to secure an intravenous line.
Explanation
Choice D is correct. A restrictive arm board to secure an intravenous line, although conditional, is not considered a restraint because it is a beneficial and regular part of client care.
Choices A, C, and D are incorrect. Restraint is the intentional restriction of an individual’s voluntary movement or purposeful behavior by physical, chemical, mechanical, or other means.
A loose bed sheet around the client’s waist (Choice A) while in a chair to prevent slipping and falling to the floor is considered a physical restraint. A slightly higher dosage of a medication than is needed for medical treatment to promote sleep (Choice B) is considered a chemical restraint. The use of the upper bedside rails to prevent a fall (Choice C) is considered a physical restraint.
When full-length bed rails or side rails are used for the primary purpose of fall prevention, they are considered as “restraints.” Many studies have shown a potential increased risk of injury with routine use of bed rails for fall prevention. Therefore, routine use of bed rails for fall prevention is discouraged. They are used in select clients if benefits outweigh risks. Alternative strategies for fall precautions should be considered and implemented before resorting to bed rails.
Depending on the indication, bed rails/ side rails are used both as medical assistive devices and as restraints. As a safety/ assistive device, padded side rails are used for seizure precautions in patients at high risk of seizures. Bed rails may also be used as assistive devices for repositioning while transporting the patients or if the patient requests them. In many states, single or two-quarter bedrails that extend the bed’s full length are prohibited from use as safety or assistive device. For use primarily as safety or assistive device, a bedrail that extends from the head to half the bed’s length is allowed.
Reference: Sommer, Johnson, Roberts, Redding, Churchill, et al. Fundamentals for Nursing
Which of the following medication orders for a patient with pulmonary embolism and fever is a priority to clarify with the physician before administration?
A. Warfarin 1.0 mg PO
B. Morphine Sulfate 2 to 4 mg IV
C. Ceftriaxone 1gm IV
D. Heparin infusion at 1500 units/hr
Explanation
The correct answer is A. The trailing zero in this order could be misread/misinterpreted and result in an accidental overdose of medication. It is essential to clarify whether the physician meant 1.0mg or 10mg of Warfarin.
Trailing zeros appear on the Joint Commission on the Accreditation of Hospitals (JCAHO) “Do Not Use” list. The use of a zero after a decimal point (trailing zero) is unnecessary. It may sometimes result in the administration of a drug at ten times its prescribed dose if the decimal point is illegible or not seen.
B, C, and D are incorrect. All these answer options are appropriate based on the patient’s diagnosis.
Morphine (Choice B) is appropriate to address the pain that is often associated with a pulmonary embolism– no additional clarification is needed. Pulmonary embolism patients tend to have tachypnea, not baseline respiratory depression. Some get distracted by this option since some are concerned about opioid safety in cases of dyspnea/ respiratory distress. Such a thought process is wrong for two reasons. There is no indication of respiratory depression in this case detail b. Many small studies have established the safety of opioids when used in appropriate doses for pain, even in those dyspneic patients with advanced cardiopulmonary disease. The incidence of real respiratory depression in a review of cases where morphine was used for acute moderate to severe pain was 0.5% or less.
Low-grade fever can be seen with Pulmonary Embolism, but it appears like the physician is giving empiric antibiotic coverage with Ceftriaxone is reasonable (Choice C) – no additional clarification needed.
Heparin infusion (Choice D) is appropriate initial anticoagulation while overplaying with warfarin. No additional clarification needed.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Pharmacological Therapies.
Reference:
Core Concepts in Pharmacology (Holland/Adams); Chapter 1: Introduction to Pharmacology; Lesson: Methods to Prevent Medication Errors
The nurse is teaching a patient about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply.
A. “Foods such as canned vegetables and luncheon meat should be avoided.”
B. “Weigh yourself daily and notify physician when weight gain is more than ten pounds in a week.”
C. “You may continue to take ibuprofen for your aches and pains.”
D. “Annual immunizations such as the influenza vaccine are recommended.”
E. “If you feel sick, you will need to check your urine for ketones.”
Explanation
Choices A and D are correct.The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided.Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF.
Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output.
Choice B is incorrect. The client should be taught to weigh themselves daily and to report a weight gain of five pounds or more within one week. The client must not wait until he/ she gains 10lbs/ week.
Choice C is inorrect. NSAIDs such as ibuprofen may contribute towards fluid retention and should not be used in clients with CHF.
Choice E is incorrect. Assessing the urinary ketones is only done for those with hyperglycemia secondary to diabetes mellitus. This is done to check for potential development of ketoacidosis.
Which nursing theorist is known and recognized for Self Care theory?
A. Martha Rogers.
B. Rosemarie Parse.
C. Virginia Henderson.
D. Dorothea Orem.
Explanation
The correct answer is D. Dorothea Orem developed the theory of Self Care. Martha Rogers is credited with the method of Unitary Man; Rosemarie Parse developed the theory of Human Becoming, and Virginia Henderson is credited with the Theory of the 14 Fundamental Needs.
Choice A is incorrect. Martha Rogers is credited with the theory of Unitary Man and not Self Care theory.
Choice B is incorrect. Rosemarie Parse is credited with the theory of Human Becoming and not Self Care theory.
Choice C is incorrect. Virginia Henderson is credited with the Theory of the 14 Fundamental Needs and not Self Care theory.
References: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice; Ellis, Janice Rider, and Celia Love Harley. Nursing in Today’s World: Trends, Issues and Management and Sommer, Johnson, Roberts, Redding, Churchill et al. Fundamentals for Nursing; ATI Nursing Education.
Which of the following practices does the nurse recognize as typical in the Amish community? Select all that apply.
A. Health is viewed as a gift from God.
B. They commonly use alternative healthcare.
C. Women and men are equal and can both make healthcare decisions.
D. Most of the Amish community choose to have health insurance.
Explanation
Answer: A and B
A is correct. The belief that health is a gift from God is prevalent in Amish society. While they believe that their health is a gift, they also believe that clean living and a healthy diet are essential to maintain their health.
B is correct. Members of the Amish society commonly use alternative healthcare in addition to traditional healthcare. Healers, herbs, and massage are all widely used in their alternative medicine practices.
C is incorrect. Women and men do not have equal authority in the Amish community. Their society is patriarchal, and men typically have power when making healthcare decisions.
D is incorrect. Most of the Amish community chooses not to have health insurance. Instead, they may want to save the money they would have spent on health insurance to maintain a mutual aid fund amongst the community for members who need help with medical costs.
NCSBN Client Need:
Topic: Psychosocial Integrity
Subject: Fundamentals of care
Lesson: Culture/Spirituality
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
You are caring for a client at the end of life who is terminally ill, confused, and no longer able to give informed consent. The doctor has spoken to the spouse about the need for a feeding tube because the client is malnourished and has a failure to thrive. The spouse, who is the client’s healthcare surrogate, states that she wants the tube feedings to begin as soon as possible so that the spouse will “not die of starvation”; however, the client’s advance directive, which was written five years ago, states that the client does not want a feeding tube or any other life-saving measures. What should you say to the client’s spouse about the feeding tube?
A. “I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive.”
B. “I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube.”
C. “You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube.”
D. “Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and a failure to thrive.”
Explanation
Choice A is Correct. You would respond to the client’s spouse with, “I understand your feelings and beliefs about the feeding tube, but your spouse has chosen not to have a feeding tube in his advance directive.” An advance directive supersedes the wishes of the healthcare surrogate.
Choice B is incorrect. You would not respond to the client’s spouse with, “I agree that starvation is a bad way to die. I will contact the doctor and let the doctor know that you have agreed to place the feeding tube.” The client should not get the feeding tube because they have chosen to NOT have one in their advance directive.
Choice C is incorrect. You would not respond to the client’s spouse with, “You cannot make that decision for your husband even though the doctor will probably give your husband the feeding tube” because this statement does not recognize or address the client’s spouse’s feelings or beliefs in a therapeutic manner.
Choice D is incorrect. You would not respond to the client’s spouse with “Feeding tubes are not recommended for clients at the end of life who are affected with malnutrition and a failure to thrive” because this statement is not only false, it does not underscore the need to follow the client’s wishes as stated in their advance directive.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Which of the following is the best approach for a nurse on the Quality Improvement (QI) team working on a project to reduce medication errors?
A. Ensure that all staff members are educated on how to appropriately fill out an incident report if they make a medication error
B. Ensure the staff has been educated on the five rights of medication administration
C. Track the incident reports for repeating offenders and report findings to the next chain in command
D. Have an inservice to supervise staff members during medication administration to determine if further education needs to be given
Explanation
Choice A is correct. Reporting errors is fundamental to prevent errors. One crucial way to have a successful continuing quality improvement project is to have a procedure to file organized, accurate incident reports. This enables tracking of when, how, and why errors occurred, thus helping prevent future mistakes.
Problems in the systems can be detected through incident reports of errors (errors that may or may not have harmed the patients). Even “near misses” must be reported. Reporting a near miss (i.e., an event where harm to the patient was avoided) can provide beneficial information for proactively reducing errors. Analysis of such reported errors often reveals many deviations/ near misses that point to system vulnerabilities. Such vulnerabilities may eventually cause patient’s harm. Fixing such systems problems is the idea behind Quality Improvement (QI) projects.
Choices B, C, and D are incorrect. The question here is about the goals of a “Quality Improvement (QI)” committee in reducing medication errors. Such projects aim to reduce future errors and errors in the entire hospital system. Educating a single nurse or staff members about medication rights alone or supervising certain staff members are not considered a “quality improvement” project because these interventions do not address entire system problems. There are many reasons why an error can occur. Preventing those needs “knowledge” regarding what led to an error. The single most proven method to reduce future medication errors has been filing an “incident report” because it helps the QI committee identify “what” caused the error. Once the cause is identified, the QI committee can put in place protocols to prevent the recurrence.
Reference:
“Reporting errors is fundamental to error prevention” - https://www.ncbi.nlm.nih.gov/books/NBK2652/
The nurse is about to change a dressing on an elderly man with Stage III pressure ulcer. What should be the nurse’s first action?
A. Gather all the necessary equipment.
B. Use non sterile gloves to remove the old dressing.
C. Explain the procedure to the client.
D. Check the medication record if she has been given pain medications.
Explanation
Choice D is correct. Changing a dressing on a Stage III pressure ulcer is very painful. The nurse should check first if the client has been given pain medication at least 30 minutes before changing the dressing.
A is incorrect. The nurse should prepare all the needed equipment for the procedure before attending the patient. This is not, however, the first action to take.
B is incorrect. The nurse can use non-sterile gloves to remove the old dressing. This is not, however, the first action to take.
C is incorrect. The nurse should explain the procedure to the client immediately before the process is to be done. This should not be the first action of the nurse.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed.
The nurse observes a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. What should the nurse assess the patient?
A. Pain
B. Anxiety
C. Depression
D. Fluid volume deficit
Explanation
The correct answer is A. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.
The transmission of information without the use of words is termed nonverbal communication. It is also known as body language. Nonverbal communication helps nurses to understand subtle and hidden meanings in what a patient is trying to say verbally. Additionally, nonverbal communication is reflected in a person’s actions, such as the way he/she walks or facial expressions.
Nurses must be aware of nonverbal messages that they send and the ones they receive from patients so they can identify patients who are suffering from or at risk of certain conditions.
Choices B, C, and D are incorrect. The above nonverbal expressions of stooped gait and gasping sounds do not indicate Anxiety, Depression, or Fluid-volume deficit.
Nonverbal signs associated with generalized anxiety( Choice B) disorder include tenseness, difficulty sleeping, and stomach problems.
Nonverbal expression of depression ( Choice C) may include head and lips down expression, adaptive hand gestures, social withdrawal, frown and cry, and lower levels of eye contact and smile.
Nonverbal expression of Fluid-deficit (Choice D) may include slowed responses and agitation.
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Basic Care and Comfort.
Reference: The Art and Science of Person-Centered Nursing Care (Wolters/Klewer)
Chapter 20: Communicator; Lesson: Nonverbal Communication
When a client with mid-stage Alzheimer’s disease becomes agitated, which intervention should the nurse use?
A. Putting an arm around the client’s waist
B. Turning on the television
C. Place the client in a darkened room
D. Leading the client to a group activity
Explanation
Choice A is correct. Nursing interventions for Alzheimer’s patients who are agitated include providing a safe environment free of external stimulation and offering calm and emotional support. Therapeutic touch is widely accepted by nurses as an appropriate and effective treatment of agitation in patients with dementia. It is a very effective non-verbal communication technique that can offer immediate security and reassurance. Alzheimer’s disease patients often exhibit behavioral symptoms. Such symptoms include agitation/ restlessness, disruptive vocalization (screaming), pacing, sleeplessness, or aggression. Caregivers and health care providers use a wide range of interventions to treat these behavioral symptoms. However, these conventional interventions are fraught with safety problems and limited effectiveness. Examples include chemical and physical restraints, which can lead to an increased risk for falls. Therapeutic touch is a non-pharmacologic intervention that is harmless to patients. Several studies have provided good evidence for the beneficial effects of regular therapeutic touch on reducing agitation in demented patients.
Choices B, C, and D are incorrect. When a client with Alzheimer’s disease becomes agitated, frustrated, or hostile, the nurse should respond in a calm and supportive way. Decreasing external stimuli will help lower the patient’s agitation level. Turning on the television ( Choice B) and leading the client to a group activity ( Choice D) are inappropriate because they increase external stimulation and make agitation worse. Finally, the client should not be left alone in a darkened room ( Choice C), as this may cause fear and result in increased agitation.
Agitation in Alzheimer’s patients can occur from a wide variety of causes or the disease process itself. Identifying the cause of agitation ( pain, drug interactions, infection) is crucial to managing the agitation effectively. Apart from Therapeutic Touch, one can follow the following guidelines to manage agitation effectively.
NCSBN Client Need : Topic: Health Promotion and Maintenance;
You are caring for an elderly woman who is a practicing Orthodox Judaism. Which meal would you most likely offer this client?
A. Cottage cheese and fruit
B. Beef lasagna
C. A hamburger and milk
D. Pork cutlet parmigiana
Explanation
Correct Answer is A
Correct. You would offer this client a meal consisting of cottage cheese and fruit because Orthodox Jewish people are not permitted to have dairy products and meat in one meal.
Choice B is incorrect. You would not offer this client a meal consisting of beef lasagna because Orthodox Jewish people are not permitted to have dairy products, and meat in one meal and beef lasagna has both meat and cheese.
Choice C is incorrect. You would not offer this client a meal consisting of a hamburger and milk because Orthodox Jewish people are not permitted to have dairy products and meat in one meal.
Choice D is incorrect. You would not offer this client a meal consisting of pork parmigiana because Orthodox Jewish people are not permitted to have dairy products, and meat in one meal and pork parmigiana has both meat and cheese in addition to the fact that Orthodox Jewish people do not eat pork or pork products.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)
