Readiness exam 2 Flashcards
Conducting a tornado season safety review for acute care unit staff. Most clients on the unit are non-ambulatory or have treatments that prevent relocation.
a) We will place towels over all clients prior to a building evacuation.
b)All beds and equipment will be moved to the nurse’s station
c) All window coverings and privacy curtains will be closed
d) All beds will be placed in a corner and the door will be securely locked.
c
d-This is not an effective measure to ensure client safety during a tornado as the corner may not be the safest place, and not every bed will fit in the same spot. Locking a door is also dangerous and may prevent first responders from rescuing victims.
The nurse is assessing the feet of 4 clients who are diagnosed with diabetes mellitus:
Which assessment finding is the greatest concern for the nurse?
a) Client with dirty feet
b) Client with a dry calloused area on the foot
c) Client exhibiting charcot foot
d) Client with skin macerated from overexposure to moisture
c
Charcot foot is a complication of diabetic neuropathy that is noted by changes in the foot shape. If untreated, it can cause the collapse of the joints in the foot and may permanently impair walking.
The home health nurse consider as potential safety concerns for an elderly client who lives alone, with a medical history of asthma, osteoarthritis, and hearing and vision deficits? SATA
a) Lightweight dishes stored at chest height on open shelves
b) Lights which are programmed to turn off and on and predetermined times
c) A stationary telephone located in the living room of the house
d) Cast iron cookware stored in cupboards beneath the stove
c,d
c-Clients with vision deficits should have easy access to a mobile phone as opposed to a stationary phone that is located in one area of the home
d-All cookware should be stored at chest height so that the client does not have to bend over or reach above his/her head. Also, cast iron cookware is likely heavy and poses additional safety concerns for elderly clients.
The nurse is developing a plan of care for a client after an ileostomy placement.
➤Which is the priority for the nurse to include in the plan of care?
a) Increasing intake of high fiber foods
b) Decreasing daily fluid intake
c) Implementing meticulous skin care
d) Expressing feelings about body image
c
ileostomy output, called effluent, is watery to semi-watery in consistency, contains enzymes, the skin around the stoma can become easily irritated
a-decrease
b-incerease
A client with bipolar disorder is being treated with lithium carbonate. The client tells the nurse about experiencing fine hand tremors, fatigue, and dry mouth. Which conclusion by the nurse is correct?
a) The client needs assurance that the symptoms are expected side effects
b) The client has symptoms of toxicity and the health care provider needs to be notified
a
b-these findings are common expected side effects
excessive urination, extreme thirst, and vomiting and diarrhea are indicators of lithium toxicity.
A client with DKA. Which laboratory result(s) expected findings consistent with DKA? SATA
a) A pH of 7.5 per arterial blood gas (ABG)
b) The urine is positive for ketones.
c) A serum HCO3 of 13.5 mEq/L
d) A serum glucose of 324 mg/dL.
e) The osmolar gap has decreased
b,c,d
c-Serum glucose is elevated above 300 mg/dL in DKA
e-increased osmolar gap
Substance disorder? Bipolar?
a) Hypomania
b) Boundary issues
c) Suicidal thoughts
d) Demanding and irritable
e) Odd,inappropriate clothing
Substance: all
Bipolar:all
Substance use disorder
Substance use disorder (including drugs and alcohol) is a mental disorder
Clients with substance use disorder may display anxiety and demanding/irritable behavior because stimulants and depressants interact with brain chemistry and functioning in a variety of ways.
Stimulants may lead to hypomania. Additionally, suicidal and/or homicidal thoughts may occur, especially in instances of intoxication and withdrawals that cause dysphoria.
Clients with substance use disorder may neglect personal hygiene or present with odd or disheveled clothing and appearance.
Contraindication of mania
Offer caffeinated beverages with the client’s meals
Wake the client every 2 hours during the night to assess respiratory status
Provide detailed explanations regarding the therapeutic plan of care
Why?
Periods of mania impact and shorten the client’s attention span, so explanations should be brief, factual, and simple
The nurse obtains a venous blood sample from a client without existing access. Which is an appropriate action when performing this procedure?
a) Verify the client using an identifier before beginning the procedure
b) Strongly tap the client’s extremity to promote vein plumping
c) Apply a tourniquet to assist in identifying an accessible vein
tur·nuh·kuht
d)Insert the needle at a 45 degree angle into the selected vein
c
a-be carful!! it says an identifier
b-should firmly apply an alcohol swab to apply pressure over the vein
d-the needle should be initially inserted at a 15-30º angle
The nurse is caring for a client who is scheduled for surgery.
➤In preparing the client, which of the following nursing actions are appropriate for the nurse to perform?
a) Raise all side rails after administering ordered pre-anesthetic medications
b) Remove jewelry and/or dentures and give them to a family member.
a) Yes,Side rails are raised after administering the ordered pre-anesthesia medications. Pre-anesthesia medication often includes a sedative that can create a safety hazard.
b) Yes, If a family member is not available, the nurse follows the facility protocol to ensure that all valuables are safely secured.
The nurse is caring for a client who is 12 weeks gestation with a history of 3 consecutive spontaneous abortions prior to 16 weeks of pregnancy.
➤Which interventions does the nurse anticipate?
a) Tocolytic therapy
b) Cervical cerclage
c) Dilation and curettage
d) Prophylactic antibiotic therapy
b
A client who sustained a closed head injury following a serious motor vehicle crash.
➤Which nursing interventions should the nurse include in the client’s initial nursing plan of care? SATA
a) Maintain the head of the bed as prescribed
b) Assist the client to turn and deep breathe every 2 hours
c) Perform neurological assessment every hour, or as needed
d) Report changes in the client’s level of consciousness immediately
e) Assist the client to sit up in a chair, as tolerated every four hours
a,c,d
b-Coughing can increase the client’s intracranial pressure
d-The client’s activity level should be ordered and verified by the physician
The nurse overhears shouting in a client’s room and discovers that two visitors are shoving and threatening one other. The client is crying but is not in physical danger.
➤Which initial step does the nurse take?
a) Implement the facility security plan for the management of violence
b) Verbally tell both visitors they must leave the client’s room immediately
c) Attempt to calm or remove the client from the environment
a
once it is determined that the client is not in danger. The nurse should always follow facility protocol
b-this is likely to escalate the anger between the visitors
c-The client has been determined to be safe
Bipolar this order, what speech is this?
Sky is blue, I like red, I’m feeling hot, everything on fire
Flight of ideas
the speaker talks continuously with sudden, frequent topic changes.
