Fundamentals Passpoint flash cards

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action would the nurse include in the care plan?

involving the client and family in planning care. Rationale: including the family and the client in planning care and encouraging visits from family and friends are correct interventions for a patient with a diagnosis of social isolation.

A client's husband has asked that his wife be cared for exclusively by female nurses, a request with which the client herself agrees. What action would the care team take in response to this request?

Correct Answer: Take a reasonable measure to accommodate the request Rationale: care team's guiding principle and obligation in this situation is to accommodate and respect the couple's request.

Care plan preparation

bedside report in most cases allows for the client to be informed and helps identify gaps in information.

postmortem care

care given to the body immediately after death, the client should stay in the bed until the family arrives and the nurse should follow facilities procedures.

Fall Management/ Fall risk

incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members.

Spiritual care

a person may be highly spiritual yet not profess a religion. the client may seek spiritual counseling during hospitalization related to spiritual needs.

he nurse is teaching a group of high school students about risk-taking behaviors. Which topic would be considered an example of healthy behaviors?

correct answer: preventative vaccinations. Rationale: vaccinations are used as vehicles to prevent communicable diseases.

Advance Directives, Long term care

the client has signed a document to not be resuscitated, but the treatment options will still continue and is NOT a resuscitation measure.

Acute Respiratory Failure

the nurse should report the arterial oxygen level of 46 mm Hg. below 50 mm HG the patient is hypoxemia.

Vacuum-assisted closure pressure therapy

when cleaning an area around the drain, you should wipe in a circle around the drain, working from the center outward.

anxiety disorder/ atrial fibrillation

when clients are experiencing moderate anxiety, their attention span is limited, and they are only able to focus on immediate concerns

Level of Consciousness (Decreased)

1. call for emergency help 2. assess the client for breathing and pulse 3. begin emergency resuscitation as needed 4. report findings to the rapid response 5. complete an incident report 6. alert the family of the event