EAQ Prioritization

Which information supports the development of a critical pathway? Select all that apply. One, some, or all responses may be correct. 1 Actions occur in steps. 2 Health problems are unpredictable and variable. 3 Client improvement is measured against criteria. 4 Algorithms are used in the provision of client care. 5 Care requires participation by physical and occupational therapists.

-Actions occur in steps. -Client improvement is measured against criteria. -Algorithms are used in the provision of client care. -Care requires participation by physical and occupational therapists. Pathways are considered useful if the intervention occurs in steps, progression or client improvement is criteria-based, and an inventory of actions such as algorithms are used. A critical pathway is a multidisciplinary structured plan of care such as requiring participation by physical and occupational therapists. Health problems that are unpredictable and variable would not be appropriately managed with a critical pathway.

In which order would the nurse perform these intraoperative nursing interventions for an older adult client during the intraoperative stage?

1. Use a small pillow under the client's head. 2. Lift the client into position to prevent shearing forces. 3. Position arthritic and artificial joints carefully to prevent postoperative pain. 4. Pad bony prominences to prevent pressure sores. 5. Use warming device to prevent hypothermia. 6. Cover the client's head and feet. 7. Warm intravenous (IV) and irrigation fluids as indicated by agency policy and manufacturer's recommendations. 8. Follow aseptic technique. 9. Carefully monitor the input and output of fluids, including blood.

Which nursing care intervention is the priority for the client status-post mastectomy and breast augmentation receiving anthracycline chemotherapy? 1 Reminding the client to expect soreness in the chest 2 Teaching the client to avoid blood pressure measurements on the affected side 3 Teaching the client that she or he may face difficulty in raising the arm 4 Instructing the client to report a chronic cough and shortness of breath

4 Instructing the client to report a chronic cough and shortness of breath Anthracyclines can cause cardiotoxic side effects. A client who is undergoing chemotherapy with anthracyclines is instructed to report a chronic cough and shortness of breath. After breast augmentation, a client is taught that she should expect soreness in the chest. After a mastectomy, a client is taught to avoid blood pressure measurements in the affected limb. After mastectomy and breast augmentation, a client is taught that she may have difficulty in raising the arm.

Which considerations have the highest priority when conducting a primary client survey during the emergency assessment? Select all that apply. One, some, or all responses may be correct.

Airway Cervical Spine Airway and stabilization of the cervical spine are the top priorities when conducting a primary client survey during the emergency assessment. The nurse will then focus on breathing, circulation, and disability.

The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated first? 1 0 for dysarthria 2 1 for limb ataxia 3 3 for facial palsy 4 0 for level of consciousness

Correct3 3 for facial palsy The NIHSS helps in evaluating the effect of an acute stroke and assigns a score based on severity of condition. According to the NIHSS, the score of 3 for facial palsy is given to the client with complete paralysis of 1 or both sides of the face and therefore should be treated first to ensure safety. The client with an NIHSS score of 0 for dysarthria is normal and therefore can be treated last. The client with limb ataxia in the leg and an NIHSS score of 1 can be treated after the client with score 3 for facial palsy is treated. The NIHSS score of 0 for level of consciousness is normal, and this client can be treated after the clients with complete facial paralysis and partial limb ataxia are treated.

In which order would the nurse perform these intraoperative nursing interventions for an older adult client during the intraoperative stage?

First, the nurse uses a small pillow under the client's head if his or her head and neck are normally bent slightly forward. Next, the nurse lifts the client into position; dragging or sliding an older adult client might cause skin shearing. In the third step, the nurse would position arthritic and artificial joints carefully to prevent postoperative pain and discomfort from strain on those joints. In the next step, the nurse would pad the bony prominences to prevent pressure sores. It is essential that the nurse use warming devices to prevent hypothermia. The next step would involve the nurse covering the client's head and feet for the prevention of hypothermia. In the seventh step, the nurse would warm IV fluid and irrigation fluid as indicated by the agency policy and the recommendation of the manufacturers. The nurse would follow strict aseptic technique throughout the procedure as compared with clean technique for some of the interventions performed before the procedure. The final step would involve the nurse monitoring the intake and output of fluid, including blood.

The hospital's board of directors would evaluate cost information about which activities when considering implementing client-focused care delivery for a 300-bed community hospital? Select all that apply. One, some, or all responses may be correct. 1 Training charge nurses 2 Redesigning all care areas 3 Cross-training support personnel 4 Hiring additional nurse managers 5 Hiring an all registered nurse (RN) staff

Redesigning all care areas Cross-training support personnel For client-focused care units, all care areas need to be redesigned and support personnel need to be trained. Additional charge nurses, nurse managers, and creating an all-RN staff are not needed for this care delivery method. Topics

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the postanesthesia care unit (PACU) who had an abdominal cholecystectomy? 1 Change the dressing. 2 Reinforce the dressing. 3 Replace the tape with Montgomery ties. 4 Support the incision with an abdominal binder.

Reinforce the dressing. The nurse would anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.

Which condition in a client with burn injuries from a chemical plant explosion requires immediate surgical intervention based on priority? Erythema 2 Fluid-filled vesicles 3 Mild to moderate edema 4 Visible thrombosed vessels

Visible thrombosed vessels The client with third- to fourth-degree burns suffers with dry, waxy white hard skin with visible thrombosed vessels. Immediate surgical intervention is required in these clients. Conditions such as erythema, pain, and mild swelling are observed in clients with superficial burns, which may not require surgery. Fluid-filled vesicles that are red and shiny or mild to moderate edema is observed in clients with second-degree burns. These clients may not require surgery.

Which color triage tag would be appropriate for a client whose blood test results show a ferritin level of 3 ng/mL and a hemoglobin level of 5 mg/dL based on priority? 1 Red 2 Black 3 Green 4 Yellow

Yellow A ferritin level of 3 ng/mL (normal: 10-150 ng/mL) and a hemoglobin level of 5 mg/dL (normal: 13.5-17.5 g/dL) indicates severe iron deficiency anemia. A client with severe anemia has to undergo rapid treatment to replenish the stores of iron and a yellow tag is given to the client. A red tag is indicated for a client with life-threatening complications who needs immediate treatment. A black tag is given to a client who is expected to die. A green tag is appropriate for minor conditions that do not require immediate treatment.

Which nursing intervention is the priority action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? 1 Treating pain 2 Assessing respirations 3 Initiating defibrillation 4 Monitoring blood pressure (BP)

Correct3 Initiating defibrillation The priority nursing action for a client who is admitted to the emergency department during cardiac arrest caused by ventricular fibrillation is initiating defibrillation. Treating pain, assessing respirations, and monitoring BP will not occur until this action has been initiated.

Which nursing intervention is the priority for a client in the acute-care setting with urine output of 250 mL in 24 hours, blood osmolality of 310 mOsm per kilogram, and a systolic blood pressure of 90 mm Hg? 1 Consider it as a normal finding. 2 Advise the client to drink 2 to 3 L of water daily. 3 Assess the creatinine and blood urea nitrogen (BUN) levels. 4 Request an increase in the intravenous fluid rate from the health care provider.

Correct4 Request an increase in the intravenous fluid rate from the health care provider. Normal urine output is in the range of 600 to 2500 mL per 24 hours and normal blood osmolality is in the range of 275 to 295 mOsm per kilogram. The normal systolic pressure is 120 mm Hg. The client's medical record indicates an abnormal urine output of 250 mL in the past 24 hours, blood osmolality of 310 mOsm per kilogram, and systolic blood pressure of 90 mm Hg, which indicate severe volume depletion. The priority nursing intervention is requesting an increase in the intravenous fluid rate from the health care provider to prevent permanent kidney damage. A healthy individual is advised to drink 2 to 3 L of water daily. The client's creatinine and BUN level are assessed to detect kidney function, but only after the client is made stable.