Care
Folic acid deficiency
Macrocytic, megaloblastic anemia; no neurologic Sx (as opposed to vitamin B12 deficiency). Most common vitamin deficiency in the USA. Seen in alcoholism and pregnancy.
Cystic Fibrosis Treatment
- Oral capsules containing pancreatic enzymes to compensate for lack of pancreatic digestive enzymes - Various treatments to preserve as much pulmonary function as possible - Vigorous treatment of pulmonary bacterial infections - Lung transplant may eventually be required if lungs are severely damaged
Digoxin (Lanoxin) level
0.8-2.0 ng/mL
The nurse plans to reinforce teaching with a client on how to manage the use of a behind the ear hearing aid. What strategies should the nurse include? You answered this question Correctly 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.
1. & 4. Correct: The residual from the hair spray causes the hearing aid to become oily and greasy. The client should routinely inspect the hearing aid for damage, especially where damage is more likely: ear mold, earphone, dials, cord, and connection plugs. 2. Incorrect: A whistling sound indicates incorrect ear mold insertion, improper fit of aid, and buildup of earwax or fluid. 3. Incorrect: Do not submerse hearing aid in water, as it will damage the device. 5. Incorrect: Batteries last 1 week with daily wearing of 10-12 hours.
The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? You answered this question Incorrectly 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.
1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.
Parathyroidectomy for primary hyperparathyroidism is recommended for patients who have any of the following clinical features?
1. Serum calcium level > 1 mg/dL above the upper limit of normal 2. Young age < 50 3. Bone mineral density T-score <-2.5 at any site 4. Reduced renal function (eGFR<60)
Central Venous Pressure (CVP)
2-6 mmHg
A client, hospitalized for a respiratory infection, must leave the room for a test procedure. What intervention is appropriate for the nurse to perform so that spread of infection is less likely? You answered this question Correctly 1. Ask the primary healthcare provider if the test can be performed in the room. 2. Ask the client to wear a mask when out of the room. 3. Make sure that all staff wear masks when providing care. 4. No special precautions are needed.
2. Correct: The client should wear a mask when out of the room to prevent spread of droplets when coughing or sneezing. 1. Incorrect: Not all tests may be performed in the room. There is a way to lessen spread of infection. 3. Incorrect: Staff should wear masks while performing care; however, the client should wear the mask if out of the room. 4. Incorrect: Special precautions are needed to prevent spread of infection via droplets
A client receiving palliative care is reporting constipation. What action should the palliative care nurse provide first? You answered this question Incorrectly 1. Increase foods high in fiber. 2. Administer an enema 3. Increase fluid intake 4. Administer docusate sodium
3. Correct: Increase fluid intake is correct. Dehydration is one of the most common causes of constipation. Fluids keep your stool soft and easy to pass. 1. Incorrect: Fiber should be increased. This is true but water is the first intervention that should be implemented. Fiber will increase bulk and help with passage of stool but fluids should be first. 2. Incorrect: Administering an enema would not be the first thing to try for constipation. Least invasive first. Avoid medicines as long as possible. 4. Incorrect: Docusate sodium is colace and a stool softener, although appropriate avoid medicines as long as possible.
The nurse is observing crutch walking of a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to reinforce teaching? You answered this question Correctly 1. Swing through 2. Two point 3. Three point 4. Four point alternating
3. Correct: Three point gait. All of the weight bearing is done by the unaffected leg and the crutches. The injured leg does not touch the ground during the performance of this gait. This is most appropriate for the client with a lower leg cast. 1. Incorrect: The swing through alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client. 2. Incorrect: The two point alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client. 4. Incorrect: The four point alternating gait would require some form of weight bearing on the fractured leg. This would not be an acceptable form of crutch walking for this client.
Normal urine output
30 mL/hr
Normal heart rate
60-100 bpm
A nurse is reinforcing teaching with a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? You answered this question Correctly 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."
A nurse is reinforcing teaching with a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? You answered this question Correctly 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."
Trousseau's sign
A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.
Enoxaparin (Lovenox)
Anticoagulant
Levothyroxine (Synthroid)
Hypothyroidism
A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? You answered this question Incorrectly 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.
It is not unusual for clients with allergies to be hospitalized for treatment of an illness. That is why "Do you have any allergies?" is among the first questions asked upon admission. This allows staff to protect the client as much as possible by decreasing exposure to potential allergens. Nurses stress to clients that allergies include not only medications, but food and non-food items like dander or dust. Hospitalized clients are already in a compromised state which may lead to a flare-up, or even newly acquired allergies! All of this information falls under the category of protecting the client. This "select all" question asks you to focus on specific ways to prevent client exposure to allergens. While there is no mention of a medication, the question does tell you the client's allergies are many and severe. Think for a moment about your experience on a clinical floor. Where did you see information about client allergies, other than the official chart? More importantly, where should there be allergy information? Option 1: Definitely not! Did you see the word "sterile"? Such a room is not possible outside of an operating room, and while the OR is aseptic, even that room is not entirely sterile. There is also no information indicating the client's precise allergies; however, not even a private room is necessary except in situations where the client may be immunocompromised. Option 2: Great! Step one is to get an allergy bracelet on the client immediately upon admission! Many facilities require that band to be placed on the same arm as the identification bracelet so that it will be clearly visible to staff every single time client ID is checked. Sometimes the allergy bracelets are a bright color, such as red, to really draw attention to the issue. Option 3: Not this one. Even if the client has an allergy to dust, dander, or environmental items, wearing a mask would not necessarily prevent an allergy attack. Remember these things are air-borne, and could potentially penetrate a mask or even settle behind the mask, intensifying the client's reaction. One other point to consider: most clients do not want to draw attention to health issues, and a mask every time they leave the room is a bit obvious. Option 4: Did you pause here? What makes this option wrong? It is a violation of HIPAA privacy laws to post any client health information where it can be viewed by the public. This option indicates the allergies are listed on the sign...a clear violation. Additionally, how does this action protect the client from an allergic reaction, which is the nurse's focus? Try again. Option 5: Excellent! Even though there may be some non-food items on the list, all departments that interact or supply items to the client must be notified IN WRITING of known allergies. This would also include the pharmacy, and, depending on the type and severity of client allergies, possibly even housekeeping department. Some clients bring pillowcases from home because of allergies to hospital detergents.
A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? You answered this question Incorrectly 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide
When hired at a new facility, orientation always includes basic fire and emergency protocols in addition to designated escape routes. Staff must know the type and location of all types of fire extinguishers. Fires are classified by the material burning, which determines the type of extinguisher needed. Substances are classified into five main groups, regardless of whether the location is residential, industrial or commercial. Class A fires involve solid combustibles such as wood, paper or textiles. Class B fires include flammable liquids like gasoline, alcohol, or paints. Class C fires are flammable gases such as methane, propane or even natural gas. Class D is less common except in laboratories and involves combustible metals such as magnesium, potassium or lithium. Class F is generally found only in commercial kitchens and is appropriate for cooking fires started by deep fryers, oils or fats. The most crucial aspect of fire safety is knowing which extinguisher is appropriate for what type of fire and what kind might cause a bigger problem or even an explosion! Most extinguishers have this information printed on the side of the container...but during a fire is no time to start reading! Notice the scenario does not address the mnemonic "RACE" entirely, but rather focuses on the "Contain-Extinguish" aspect of a fire. So consider the Class of materials in this question in relation to the most appropriate extinguisher. Option 1: Not quite. It is true that foam-type extinguishers can be used on both Class A and Class B fires because it helps prevent re-ignition of the flames. However, many facilities utilize a linen room to store, or even charge, I.V. pumps and blood pressure machines. The nurse may not be aware of electric equipment plugged in and foam is not appropriate around electrical equipment. Option 2: Excellent. The "water only" extinguisher is definitely the best extinguisher for linens. It is generally the most common and readily available extinguisher in facilities. While it is possible electric pumps might be charging in that linen room, the nurse would aim the extinguisher directly at the linens, buying more time for additional emergency response personnel. Option 3: Nice try but no. While it is true that dry powder extinguishers can be utilized for Class A, B, C and D fires, their use in a small enclosed space is not advised. An individual could easily inhale the dangerous dry chemical plus the powder is extremely difficult to clean up afterwards. A linen closet is not an appropriate location for the dry chemical extinguisher. Option 4: No. A carbon dioxide extinguisher is most appropriate for flammable Class B liquids or large electric fires such as those that may occur in an office full of computers and printers. This particular extinguisher is not appropriate for solid combustible materials like linens.
Anhedonia
a diminished ability to experience pleasure
neologism
a new word, expression, or usage; the creation or use of new words or senses
Cetirizine (Zyrtec)
antihistamine
Septicemia (sepsis)
bacteria growing and flourishing in the blood
pancytopenia
deficiency of all types of blood cells
Echopraxia
imitating another's actions
dysphoria (dysphoric mood)
A condition in which a person experiences intense feelings of depression, discontent, and in some cases indifference to the world around them.
The nurse is assisting the client in changing clothes. The client says, "Stop. I don't want you or anyone touching me." What should the nurse do? You answered this question Correctly 1. Stop assisting the client if he does not want it. 2. Inform the client that she is just helping him to get into hospital gown. 3. Tell the client that it is okay. The nurse just wants to help. 4. Say, "Nurses help clients all the time. There is nothing wrong with it."
1. Correct: To continue is an act of battery, an intentional tort. 2. Incorrect: The client has already expressed that no help is wanted. 3. Incorrect: Continuing to touch the client without his permission is an act of assault or battery. 4. Incorrect: The client is trying to coerce the client, and this could be considered assault
The nurse cares for a client who takes multiple antibiotics for treatment of an infection. The microbiology laboratory informs the nurse the client's stool is positive for Clostridium difficile. Which actions are most appropriate for the nurse to take? You answered this question Incorrectly 1. Use standard precautions. 2. Perform hand hygiene by using alcohol hand rub. 3. Implement contact precautions. 4. Perform hand hygiene by washing hands with soap and water. 5. Implement droplet precautions.
1., 3. & 4. Correct: Since Clostridium difficile is a spore (killed by sterilization), the friction performed during washing hands with soap and water rinses organisms off the hands. The nurse should also implement standard and contact precautions to protect the client and the nurse. 2. Incorrect: Clostridium difficile is killed only by sterilization but can be removed with the friction of hand washing. Alcohol based products do not kill Clostridium difficile. 5. Incorrect: Droplet precautions will not prevent the spread of Clostridium difficile
The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? You answered this question Correctly 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?
1., 3. & 4. Correct: There may be a physical reason for the difficulty sleeping, perhaps pain or presence of an infection. Diuretics should be scheduled early in the day so as not to interfere with sleep. Perhaps there has been a change in medication schedule. Changes in the sleep environment, such as an additional TV in the home or other noise, may impact sleep. 2. Incorrect: This may be necessary; however, the nurse is working toward helping the mother of the family to sleep better. 5. Incorrect: The family may need to do this over time; however, the focus is to help the mother of the family to sleep better.
The client has the need for droplet precautions due to a respiratory illness. When providing care for this client, when is it appropriate for the nurse to wear a mask? You answered this question Correctly 1. Performing tracheostomy care. 2. Delivering mail to the client's room. 3. Bathing the client. 4. Feeding the client. 5. Making routine room checks
1., 3., & 4. Correct: The nurse will be in close contact with the client and may become contaminated by droplets from the client's respiratory tract. The client may cough while the nurse is feeding or bathing the client. 2. Incorrect: Delivering the mail without close contact with the client should not require the nurse to apply a mask. 5. Incorrect: Routine rounds do not necessarily involve close contact with the client.
A nurse from the Emergency Department (ED) calls the floor to ask about a client who was admitted from the neighborhood. What is the appropriate response by the ED nurse to the nurse's question? You answered this question Correctly 1. Answer the question for the nurse. 2. Refrain from answering the question for the nurse. 3. Tell the nurse that the client is no longer in the hospital. 4. Give the nurse the client's family phone number.
2. Correct: The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation. 1. Incorrect: The ED nurse has no need to know about the client's conditions. 3. Incorrect: The floor nurse should not give any information about the client to the ED nurse. 4. Incorrect: The floor nurse would be giving out client information by giving the nurse the family's phone number. The floor nurse should simply state the limit that she cannot give any information about a client to someone who is not in the position for "need to know".
Prior to signing a consent form for surgery, the client states "I am not sure that I understand the possible risks for this surgery and alternative treatments." What should the nurse do first? You answered this question Correctly 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.
3. Correct: The nurse should call the primary healthcare provider. Further discussion with the client is warranted from the primary healthcare provider that has scheduled and most likely will be performing the surgery. This also provides the client the opportunity to ask questions appropriately. 1. Incorrect: The client has the right to make informed decisions. The client should not sign until all questions are answered by the primary healthcare provider. 2. Incorrect: Recognizes client concerns, but does not take care of problem. The nurse has a responsibility to be an advocate for the client and practice within the law. 4. Incorrect: The informed consent comes from discussion between the primary healthcare provider and the client. The nurse can do this, but it doesn't fix the problem.
The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? You answered this question Correctly 1. Assault 2. Libel 3. Slander 4. Negligence
A clue is the use of a word or phrase that leads you to the correct answer. First let's identify the key words in the stem. The key words are client, surgeon, second opinion, lawsuit, and not involved. This question asks you to choose which tort the nurse committed. 1. Physical contact .....Assault is a physical attack on another person. The nurse is not physically touching the client or the surgeon, but is verbally accusing the surgeon of untrue rumors. 2. Written or published....Libel is the defamation of character by print or pictures. The nurse is not writing her statement about the surgeon, but verbally expressing rumors about the surgeon. 3. Verbal action....Slander is sharing verbal untruths that will harm the reputation of the surgeon being accused of untrue rumors. The nurse is verbally defaming the surgeon about possible lawsuits. 4. Wrongful act resulting in harm....Negligence is the commission of an act that of reasonably prudent nurse would not do under similar situation. The nurse slandered the surgeon, but did not fail to do an act that another nurse would do under the same situation.
A unlicensed assistive personnel (UAP) enters the unit with artificial fingernails in place. What should the nurse explain to the UAP? You answered this question Incorrectly 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial fingernails are allowed to be worn on the unit. 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of infection to the client. 4. A more vigorous handwashing is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands.
Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are unit and artificial fingernails Each option stands alone with the question. After reading each answer, you need to ask yourself is this answer true or false. Remember client safety is always a priority. This question is clarifying whether artificial fingernails can be worn in the unit. So let's look at the options. Option 1 is a true statement. Pathogenic is a medical term that describes viruses, bacteria, and other types of germs that can cause some kind of disease. These bacteria are commonly found under artificial nails. Option 2 is false. Because artificial fingernails harbor pathogenic bacteria, they are not allowed to be worn on the unit. Option 3 is true. Pathogenic bacteria cause disease, so fungal and bacterial growth under artificial fingernails can contribute to infection of the client. Option 4 is false. A vigorous handwashing will not decrease the bacterial and fungal count under the fingernails enough to prevent the spread of infection. Option 5 is true. Both long, natural nails and artificial fingernails increase the risk of infection. fingernails should be no longer than 1/4 inch (6.35 mm) long.
Cholelithiasis (gallstones)
Solid, round stones in the gallbladder
Cholinesterase inhibitors
These enzymes destroy acetylcholine, the cholinergic neurotransmitter; interacts with: side effects:
ferrous sulfate (Feosol)
iron supplement
integrative medicine
simultaneous use of both traditional and alternative medicine
laryngospasm
the sudden spasmodic closure of the larynx
Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? You answered this question Incorrectly 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.
What do you notice about the question and options in this scenario? All the options are correct actions by the nurse and they are all quite important! The question is asking you to select a "priority" action, which can be quite challenging at times. Recall what you know about instilling eye drops. Your focus must be on aseptic technique to prevent infection. The nurse must always start by washing hands, and if providing drops to several clients, must wash hands between each client. After verifying the medication and the expiration date on the bottle, the nurse must roll the bottle gently between hands to be certain medication is properly mixed. The next step is to clean around client's eyes carefully with a soft cloth and warm water to remove exudate. Positioning clients is always important so the nurse will ask the client to tilt head back slightly and look upward at the ceiling. After gently pulling down the lower conjunctival sac, only one drop is placed in the eye at a time, and the client will close eyes while dabbing away any fluid that drains out of the eye. If more than one drop is ordered, the eyes must stay closed for 5 minutes before that next drop. If another eye med, or ointment, is ordered, the nurse must wait 15 minutes before instilling another medication. All these actions are important, but what is the greatest concern? Option 1: Not quite! Cleaning off any exudate around the client's eye is vital, since the presence of drainage could easily contaminate the eye during instillation of drops. However, there is an even greater safety concern for the nurse. Option 2: No. While it is true that instilling the exact number of drops prescribed by the primary healthcare provider is crucial to the health of the client, this is still not the nurse's main safety priority. Option 3: Close but not most important. Instilling eye drops requires being careful and precise in which the client should look upward to prevent loss of drops. However, think about safety as a nursing priority. Option 4: Awesome! You have selected the most important priority action for the nurse! The other three options could potentially cause problems; however, placing drops directly on the cornea would absolutely cause injury to the eye because of the sensitivity of the cornea. This is the nurse's priority.
The nurse is caring for a client with fluid volume overload. What is the best position for this client? You answered this question Correctly 1. Prone 2. Flat supine 3. Sims 4. Head of bed elevated
4. Correct: Yes! Help the fluid move away from the heart and lungs when you sit people up cardiac output goes up- breathing is better too! 1. Incorrect: No! The prone position will not help with cardiac output or breathing difficulties from fluid volume overload. 2. Incorrect: No! The flat supine will not help with cardiac output or breathing difficulties from fluid volume overload. 3. Incorrect: No! The sims is a side lying position. This will not help with cardiac output or breathing difficulties from fluid volume overload.
Ensuring the confidentiality of client health information and documentation is the responsibility of whom? You answered this question Correctly 1. The primary healthcare provider and all consulting primary healthcare providers. 2. The health care personnel involved in direct care of the client. 3. The client's family members and friends. 4. All members of the multidisciplinary team and employees of a health care facility. 5. The client's spiritual leader.
1., 2. & 4. Correct: Ensuring the confidentiality of client health information is the responsibility of every employee of a health care organization including its primary healthcare provider. 3. Incorrect: The health care facility cannot ensure the client's family and friends will keep client health information confidential. 5. Incorrect: The health care facility cannot ensure the client's spiritual leader will keep client's health information confidential
The nurse observes an unlicensed assistive personnel (UAP) bathing an elderly client with dementia. Which interventions, if performed by the UAP, would be correct actions? You answered this question Incorrectly 1. Uses mild soap on axillary and genital areas. 2. Uses tepid water. 3. Tests water temperature with elbow or a thermometer. 4. Applies vigorous scrubbing motions. 5. Bathes immediately prior to bedtime.
1., 2., 3. & 5 Correct: Avoid soap or use only mild soap on genital and axillary areas; rinse well. Soap can alter skin pH and thus skin defenses, and it may increase skin dryness that results from decreased oil and perspiration production in the elderly. Tepid water would be appropriate for bathing. Client could become chilled. Water should be tested with elbow or a thermometer to ensure that the temperature is not too hot or too cold. Hot water promotes skin dryness and may burn a client with decreased sensation. Bathe elderly clients before bedtime to improve sleep. An evening bath helps elderly clients sleep better. Bathe cognitively impaired clients before bedtime. 4. Incorrect: Use a gentle touch when bathing; avoid vigorous scrubbing motions. Aging skin is thinner, more fragile, and less able to withstand mechanical friction than younger skin.
The nurse has a duty to act as client advocate. What are the consequences of failure to act as a client advocate? You answered this question Incorrectly 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or health care facility. 3. Suspension of license or loss of license to practice nursing. 4. Suspension of license or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions.
1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or health care facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions. 4. Incorrect: The nurse does not have a license to practice medicine. The nurse may have suspension of license or loss of license to practice nursing.
A client undergoes hip replacement surgery and requires assistance to ambulate. The client needs to use the bathroom, but the call light has been left out of reach rendering the client unable to summon staff for assistance. Which client right is violated? You answered this question Correctly 1. The right to participate in the plan of care and treatment decisions 2. The right to freedom from unreasonable restraint 3. The right to privacy 4. The right to considerate and respectful care
2. Correct: A client requiring assistance for any activity of daily living needs access to call for assistance from the health care staff. Denial of access to care by removal of access devices is unreasonable restraint. 1. Incorrect: The right to participate in the plan of care and the right to privacy are not violated in this scenario. 3. Incorrect: The right to participate in the plan of care and the right to privacy are not violated in this scenario. 4. Incorrect: The right to considerate and respectful care is an important element of client care, but is not the client right in this scenario.
What action by the nurse is most helpful when responding to a bomb threat phone call? You answered this question Incorrectly 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others
Did you know that most bomb threats are received by phone? Yes, and it makes sense if you think about it, because most callers are just seeking attention. Nevertheless, ALL Bomb threats are considered serious until proven otherwise. So, act quickly, but remain calm and obtain information. Option 1: Yes, you are right!! It is important to keep them talking and show interest. Be polite, you don't want to be rude to someone who might detonate a bomb! Option 2: This option is just wrong. Try to keep them on the phone for as long as possible. Don't hang up, even if the caller does. Option 3: This option looks good, but it's not the most helpful. Now you may be thinking: I know that the Office of Homeland Security has a published Bomb Threat Checklist!! But, remember, first things first! So, keep them on the phone talking and if possible get someone to get the checklist for you while you are on the phone. Option 4: Now you've scared me and everyone else on the nurses' unit, by running for cover! No! You should stay calm, don't panic!!
A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. You answered this question Incorrectly
First, elevate the client's head of bed to Fowler's position. Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward until resistance is met. Sixth, rotate catheter and advance into oropharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.
During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? You answered this question Incorrectly
Whether a disaster is internal or external, client safety is always the initial concern. The question indicates that the client had cigarettes and the room is filled with smoke. There is no mention of any visual flames; however, this is one of those situations in which the nurse must assume the worst. National fire safety codes use the pneumonic "R-A-C-E", which stands for rescue -alarm -contain- extinguish. You know in a real life situation, multiple personnel would be jumping into action to complete the facility's own internal disaster steps. However, in the NCLEX® world, we expect the nurse to complete all the actions listed. Keep that in mind when considering the correct order in which the nurse should complete all actions. First: Assuming the environment is safe for the nurse to enter, as is indicated in the question, client safety is always the initial concern; therefore, the nurse would remove the client from the room. Second: After removing the client from the danger area, the nurse must pull the fire alarm in order to activate the local EMS system. This automatically notifies the local fire and rescue personnel to proceed immediately to the facility. Third: Notifying the hospital operator is part of activating EMS. Although the main fire alarm would have been pulled, the hospital switchboard operator notifies additional personnel, including administrators, of the situation, by facility policy. Fourth: Containing the smoke or fire is vital in any situation. But it is especially critical in circumstances where a multitude of individuals is involved. Once EMS has been activated, the client's room door should be closed to contain the fire and smoke. It could also help to place blankets or wet towels in front of the bottom of the door, to keep smoke from escaping. Fifth: Using the appropriate fire extinguisher is the final action step. Depending on the type of fire, hospitals have a variety of extinguishers to be utilized on different types of fires. When newly hired, all facility personnel are oriented to a facility's internal disaster plan, including types and locations of the fire extinguishers. Though EMS fire personnel may have arrived before the extinguisher is actually used, the nurse must still secure the appropriate extinguisher and stand by in case the closed room door does not contain the smoke/fire.
