Chapter 2: Medical-Surgical Nursing

The nurse is making an initial home visit for a client requiring wound care. What statement is true regarding safety during a home visit by a nurse? -The nurse should take reactive measures. -The nurse should park his or her car away from the home. -The nurse should never walk into a patient's home uninvited. -The nurse should schedule visits according to the patient's lifestyle.

- The nurse should never walk into a patient's home uninvited. Explanation: A nurse should never walk into a client home uninvited. The nurse should take appropriate proactive safety measures, including keeping his or her cell phone and car in working order and having a plan of action in case of emergencies. The nurse should park his or her car close to the client's home. Home visits should only be scheduled during daylight hours.

A home care nurse is performing an initial visit for a client with congestive heart failure. Which questions or statements will the nurse include in the visit to assess the need for additional visits? Select all that apply. -"Do you need help to stand or walk?" -"Can you tell me about the medications you take?" -"Do you live alone?" -"Do you leave your home to perform errands?" -"Can you tell me the date of your last doctor's visit?"

-"Do you need help to stand or walk?" -"Can you tell me about the medications you take?" -"Do you live alone?" -"Do you leave your home to perform errands?" Explanation: The initial home care visit includes a comprehensive assessment of the client's need for additional visits. Included in this assessment are questions related to the client's ability to stand, ambulate, and perform independent ADLs. The nurse will determine what medications the client has and the client's understanding of these medications. Additionally, the nurse will determine if the client has live-in assistance and if the client is homebound. While it is helpful to know when the client's last health care provider visit was, it is not necessary to determine the need for additional visits.

A home care nurse is approached by the client's neighbor while walking to the car after visiting the client. The neighbor asks, "What's wrong with Tom? Is he sick?" How should the nurse respond? -"I'm a nurse caring for Tom. I can say he is improving dramatically." -"I'm a nurse caring for Tom, but I cannot tell you anything about his condition." -"I'm a nurse caring for Tom, but you should ask his wife about his condition." -"I'm a nurse caring for Tom but can't talk now. Here is my contact information for questions."

-"I'm a nurse caring for Tom, but I cannot tell you anything about his condition." Explanation: Friends, neighbors, or family members may ask the nurse about the client's condition. The nurse must remember that the client has a right to confidentiality, and information should only be shared with the client's consent. The nurse should tell the neighbor that the nurse cannot say anything about the client's condition. Asking the neighbor for to call the nurse or to ask the client's wife are not the correct responses.

A nurse educator for a local home care company is teaching staff nurses on the use of the Outcome and Assessment Information Set (OASIS). What statement will the nurse include when teaching about the OASIS? -"Demographic information remains confidential as required by HIPAA." -"Results are used to improve overall quality improvement efforts." -"This document is optional but provides important data." -"This document is required but is only used for reimbursement."

-"Results are used to improve overall quality improvement efforts." Explanation: The OASIS requires documentation that ensures outcome-based care is provided for all care reimbursed by Medicare. Demographic information, along with other data collected, is used to improve the overall quality improvement efforts of the agency and home care in general.

A nurse is evaluating a client's discharge collaboration between the referring agency and the home care agency. What response by the client would indicate an understanding of the discharge planning process? -"The nurse helped me make a list of my needs and goals for recovery and shared them with the home care team" -"The doctor provided a list of behavioral outcomes for me and the nurse faxed them to the home care agency." -"My wife sat down with the discharge planner and established realistic and measurable goals for my recovery." -"My daughter is my health care power of attorney and she decided when I left the hospital and selected my home care provider."

-"The nurse helped me make a list of my needs and goals for recovery and shared them with the home care team" Explanation: Patient-centered goals are essential to identify and require active participation by the patient. Communication with family members will increase the likelihood that patient goals will be met. Transmitting information via fax does not allow collaboration between agencies. Health care power of attorney comes into effect when patients can no longer make decisions for themselves.

What is the purpose of early discharge planning as explained to a client? -"To ensure the hospital gets the reimbursement for your stay" -"To ensure you have learned about the illness that brought you here" -"To ensure you have the resources you need when you leave" -"To ensure the hospital complies with quality improvement"

-"To ensure you have the resources you need when you leave" Explanation: Discharge planning is an essential component of facilitating the transition of the client from acute care to the community or home care setting, or for facilitating the transfer of the client from one health care setting to another. Discharge planning does help to make sure the hospital gets the reimbursement needed and maintains compliance; however, these are not the primary reasons for discharge planning. Discharge planning does involve making sure the client has illness or disease education; however, this is not the primary reason for discharge planning.

A student nurse asks the nursing instructor, "What will my role as a nurse encompass after I graduate?" What is the best response by the nursing instructor?

-"You will care for individuals and families and play a role in health education, illness prevention, and promotion." Explanation: Nursing is concerned with caring for individuals, families, or groups. Nurses not only care for clients when they are ill but also play a significant role in health education, illness prevention, and promotion. Nurses attend to client needs related to hygiene; activity; diet; the environment; medical treatment; and physical, emotional, and spiritual comfort. Therefore, nurses care for clients in a variety of nursing settings, not just hospitals or long-term care facilities. Though nurses may choose to specialize in a certain area of healthcare, all these areas involve health education and promotion and illness prevention.

The charge nurse is making assignments for a group of clients on a medical unit. When reviewing the acuity of the clients, the charge nurse assigns the RN to the clients with higher acuity levels. Why would the charge nurse assign the RN to the clients with a higher acuity? -LPNs do not understand how to care for clients with complex disorders. -Assigning an LPN would allow them to provide care out of their scope of practice. -Higher acuity clients may request the services of an RN versus other care providers. -A higher acuity client requires a greater need for highly skilled care.

-A higher acuity client requires a greater need for highly skilled care. Explanation: Generally, higher acuity requires a greater need for highly skilled care. Clients with complicated or high-risk surgery, massive trauma, or critical illness will be cared for in an acute care hospital, where a high level of professional, skilled, and technological care is available. RNs are instrumental in caring for these clients. LPNs may understand how to care for clients with complex disorders, but RNs are instrumental in the client care. Clients generally do not request care by a specific provider; nurses with different levels of education perform various care activities.

A home care nurse has just completed the initial visit and is documenting the findings. Which of the following would best support reimbursement by the client's third-party payer? -Limited range of motion of upper extremities; client requires assistance with bathing and dressing -Vital signs within expected parameters; client alert and oriented to person, place, and time -Ankle wound with quarter-sized amount of yellow drainage; irrigated with normal saline and redressed -Client ambulates with cane around home; able to go up and down a flight of stairs of 8 steps

-Ankle wound with quarter-sized amount of yellow drainage; irrigated with normal saline and redressed Explanation: For reimbursement, documentation must reflect the need for skilled professional nursing care and the client's homebound status. Wound care and assessment of the wound status would be considered skilled services. Assistance with bathing is not a skilled service. Monitoring vital signs and mental status alone and observation of ambulation and ability to go up and down stairs also would not be considered skilled services.

When would be the best time to begin discharge planning for a patient who will require assistance in the home after leaving the acute care facility? -As the patient is preparing to be picked up from the hospital by family members -At the time of the patient's admission to the hospital -When the patient recovers from the acute phase of the illness -After the patient is discharged from the hospital

-At the time of the patient's admission to the hospital Explanation: Discharge planning begins with the patient's admission to the hospital or health care setting and must consider the potential for necessary follow-up care in the home or another community setting.

A client is admitted to an acute care facility after having a stroke. The client will require a variety of healthcare services throughout the hospital stay as well as coordination of care prior to discharge. What referral would be a priority for overseeing the client's care? -Case management -Physical therapy -Occupational therapy -Dietary services

-Case management Explanation: The person responsible for overseeing the client's care, usually an RN with a bachelor's or master's degree or another highly experienced health professional, is called the case manager. Physical therapy, occupational therapy, and dietary services are all important care disciplines but do not encompass all of the client's needs.

The home health nurse and the parish nurse have separate roles in health care. What best describes the common factor all community-based nurses share? -Community nurses take care of clients with family and friends. -Community health nurses take care of patients after they are discharged from the hospital. -Community health nurses take care of the patients in the home setting. -Community health nurses focus on community needs as well as the needs of individual patients.

-Community health nurses focus on community needs as well as the needs of individual patients. Explanation: Community health nurses have many roles, including epidemiologist, case manager, coordinator of services provided to a group of patients, occupational health nurse, school nurse, visiting nurse, hospice nurse, or parish nurse. (In parish nursing, also called faith community nursing, the members of a faith-based community, typically the parish or the community the parish serves, are the recipients of care.) These roles have one element in common: a focus on community needs as well as the needs of individual patients. The community health nurse cares for clients in the homeless setting along with in family and friend settings. The primary concepts of community-based nursing care are preventive care and self-care within the context of culture and community.

A public health nurse describes the role of the nurse in public health to a group of community stakeholders during a budget meeting. Which category of care will the nurse place public health nursing? -Community-oriented nursing -Community-based nursing -Specialty population nursing -Comprehensive population nursing

-Community-oriented nursing Explanation: Public health nursing combines the discipline of public health with community nursing and is considered a specialty practice within community-oriented nursing.

A home health nurse is visiting a client's home to perform wound care. The client lives in an impoverished neighborhood and the nurse notes that the client does not have running water. What nursing action will best control infection, despite no running water? -Dry dressing changes to wound -Sterile technique and sterile field -Hand hygiene techniques -Antibacterial wipes to surfaces

-Hand hygiene techniques Explanation: Meticulous hand hygiene is always the best way to prevent infection. Alcohol-based hand gels and foams may be used when running water is not available. The type of dressing is ordered by the health care provider and does not decrease the chance of infection. A sterile field and the use of sterile technique may be needed; however, there is no mention of what type of wound care is ordered and as an independent factor, using sterile technique and a sterile field in and of itself does not prevent infection. Antibacterial wipes to surfaces may decrease the risk of infection; however, this is not the best way to do so.

Which capability corresponds with home health care? -Improvises when providing care -Retains maximal control over the client's lifestyle -Is unable to care for those living in substandard conditions -Uses a wide variety of supplies and equipment

-Improvises when providing care Explanation: The nurse has to learn to improvise when providing care. The home health nurse is considered a guest in the patient's home and must have permission to visit and give care. The cleanliness of the patient's home may not meet the standards of a hospital. The kind of equipment and the supplies or resources that are usually available in acute care settings are often unavailable in the patient's home.

What should the school nurse working in the elementary school setting be aware is one of the most frequent health care problems to affect this population? -Eating disorders -Emotional problems -Infections -Drug abuse

-Infections Explanation: School nurses play several roles, including care provider, health educator, consultant, and counselor. They collaborate with students, parents, administrators, and other health and social service professionals regarding student health problems. School nurses perform health screenings, provide basic care for minor injuries and complaints, administer medications, monitor the immunization status of students and families, identify children with health problems, provide teaching related to health maintenance and safety, and monitor the weight of children to facilitate prevention and treatment of obesity. They need to be knowledgeable about state and local regulations affecting school-age children, such as ordinances for excluding students from school because of communicable diseases or parasites such as lice or scabies.

Which setting has been the traditional site for the nursing workforce? -Industrial environments -Inpatient units -Same-day surgery units -Clinics

-Inpatient units Explanation: Although hospitals include all levels of outpatient areas (e.g., industrial environments, clinics, same-day surgery units, related diagnostic departments), inpatient units have been the traditional site for much of the nursing workforce.

A nurse who is considering the possibility of becoming involved in home care asks a home care nurse about the characteristics needed for this practice area. Which of the following would the home care nurse be least likely to include? -Need for control over a situation -Nonjudgmental attitude -Respect for client's differences -Ability to improvise

-Need for control over a situation Explanation: A nurse working in home care needs to be comfortable with the minimal control that he or she has over the lifestyle, living situation, and health practices of the clients being served. In addition, the home care nurse must demonstrate a nonjudgmental attitude and convey respect for the clients' beliefs, even if they differ sharply from those of the nurse. Moreover, the home care nurse must be able to improvise when providing care in the home because the kind of equipment and supplies or resources usually available in acute care settings are often not available in the home.

A novice nurse is learning the difference between community-based nursing and community-oriented nursing. Which scenario does the nurse recognize as a role of the community-oriented nurse? -Nurse working a booth at a health fair performing blood pressure and glucose screenings -Occupational health nurse immobilizing a fractured extremity of an injured employee -Pediatric nurse teaching a group of parents on the treatments for cystic fibrosis -Nurse working at a wound care clinic performing irrigation of a chronic wound

-Nurse working a booth at a health fair performing blood pressure and glucose screenings Explanation: Community-oriented nursing targets improving the health status of groups of clients or individuals in the community. Community-based nursing is directed toward individuals and families with needs related to illness, injury, or disability. The health fair functions to promote improvement of health status while the other answer choices represent teaching or interventions in response to illness, injury, or disability.

Which element is least likely to be a characteristic of an expected outcome of a nursing intervention? -Measurable -Realistic -Behavior-centered -Nurse-centered

-Nurse-centered Explanation: Expected outcomes of the nursing interventions must be stated in terms of patient behaviors and must be realistic and measurable. They must reflect the nursing diagnosis or the patient's problems and must specify those actions that address the patient's problems.

The nurse is providing a community education program about sexually transmitted infections for a group of 13- to 16-year-olds. What type of prevention is the nurse targeting? -Primary prevention -Secondary prevention -Tertiary prevention -Community prevention

-Primary prevention Explanation: Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection, with prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening (Fig. 2-1) and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although they also address primary and secondary prevention.

The nurse is working in an ambulatory health clinic. What is the focus of community-based nursing practice? -Promoting and maintaining population health and preventing and minimizing disease progress -Providing rehabilitation and restorative services -Adapting hospital care to the home environment for less cost -Monitoring clients at home because clients do not have hospital insurance coverage -Delivery of hospice services for clients with terminal illness

-Promoting and maintaining population health and preventing and minimizing disease progress Explanation: Although nursing interventions used by public health nurses might involve individuals, families, or small groups, the central focus remains promoting health and preventing disease in the entire community. Rehabilitation and restorative services are the focus of extended care facilities and home-care nursing. Adapting hospital care to the home environment is the focus of home nursing. Monitoring clients at home because clients do not have insurance coverage for hospitalization is not the focus of community-based nursing practice. Hospice care delivery refers to the delivery of services to the terminally ill that can be done at home or in a medical facility.

A client in an acute care facility is assigned a case manager to oversee and coordinate care. What important function does a case manager have? -Provide early, thorough discharge planning. -Make sure the client is administered medications. -Provide care to the client who is terminally ill and has less than 6 months to live. -Make home visits to see that the client is taken care of after discharge.

-Provide early, thorough discharge planning. Explanation: An important function of case managers is to provide early, thorough discharge planning. The case manager is not responsible for the administration of medications. Hospice care provides care to the client who is terminally ill. The case manager oversees the care of the clients while they are hospitalized. Referrals to community agencies and home healthcare will be made for home visits.

A client receiving home care observes the visiting nurse place a bag on a paper barrier at the beginning of the visit. To avoid misunderstanding, what does the nurse teach the client about the practice of placing the supplies on the barrier? -The placement of the barrier is to follow universal precautions. -The placement of the barrier is a method to prevent the spread of blood-borne illness. -The placement of the barrier is an example of insect-based precautions. -The placement of a barrier is a method to prevent the spread of droplet infections.

-The placement of the barrier is to follow universal precautions. Explanation: Establishing a barrier between a potentially contaminated surface and the health care provider's equipment is an example of universal precautions. A paper barrier will not prevent the spread of blood-borne illnesses, nor is it sufficient for insect-based precautions. Precautions such as wearing a mask stop the spread of droplet-borne infections.

Results from the 2013 OASIS data study revealed that data from the study can be used to identify individuals at greatest risk for readmission to the hospital. Using this data, what can the nurse determine will decrease the readmission rate of hospitalizations? -The shift of resources to the community -Additional paid staff in the home -Longer hospital stays -Shift of funds to the hospital

-The shift of resources to the community Explanation: The identification of individuals at greatest risk for readmission allows the nurse to infer that a shift of resources to the community may decrease the readmission rate of hospitalizations. Longer hospital stays and increased funds to the hospital have not been shown to decrease the readmission rate of hospitalizations. While paid staff in the home may decrease the need for readmission, allocation of resources typically does not provide for this type of services and as such may not be realistic to decrease the readmission rate of hospitalizations.

A public health nurse administers influenza vaccines to a group of individuals during a community vaccination clinic. The nurse understands that this action is considered primary prevention due to which statement? -The vaccination focuses on minimizing deterioration associated with illness. -The vaccination is centered on health maintenance and prompt intervention. -The vaccination focuses on health promotion and prevention of illness. -The vaccination is centered on increasing innate immunity within the population.

-The vaccination focuses on health promotion and prevention of illness. Explanation: Vaccination is considered primary prevention because the vaccination focuses on health promotion and the prevention of illness. Secondary prevention focuses on health maintenance and is aimed at early detection of disease, with prompt intervention to prevent or minimize loss of function. Tertiary prevention focuses on minimizing deterioration associated with disease and improving quality of life through rehabilitation measures.

A community health nurse understands the importance and impact of cultural competence when caring for clients in the community. In what situation will the nurse find that cultural competence is particularly important? -When members of the community request religious resources -When the nurse works in a larger city versus a small community -When the nurse is new to the job and the role within the community -When members of the community share a heritage that is unfamiliar to the nurse

-When members of the community share a heritage that is unfamiliar to the nurse Explanation: When members of the community share a heritage that is unfamiliar to the nurse, the nurse must be very aware of the importance of cultural competence. Although the other answer choices may present challenges to the nurse, these are not universally true and are therefore not the best answer choices.

A client is being treated for injuries resulting from a skateboarding accident and is very agitated as the nurse cleans several gashes on the client's head. Which of the nursing responsibilities outlined by the American Nurses Association is the nurse fulfilling? -administering medications, wound care, and numerous other personal interventions -interpreting patient information and making critical decisions about needed actions -providing health promotion, counseling, and education -performing physical exams and health histories

-administering medications, wound care, and numerous other personal interventions Explanation: In 2012, the American Nurses Association (ANA) outlined seven nursing responsibilities, which include administering medications, wound care, and numerous other personal interventions. The other options are nursing responsibilities, but do not meet the description given in this scenario.

A male client recovering from a stroke is receiving anticoagulant therapy. Which item will the nurse instruct the client to use for self-care? -electric razor -loofah sponge -long-handle shoe horn -hard-bristled toothbrush

-electric razor Explanation: The client is taking an anticoagulant, which increases the risk of bleeding. Because of this, the client should be instructed to use an electric razor, which will decrease the risk of causing bleeding while shaving. A loofah sponge is coarse and is often used to exfoliate the skin. The use of this item could scratch the skin and cause bleeding. A long-handle shoe horn would not help prevent the client from bleeding. A hard-bristled toothbrush could scratch the gums and other oral tissue and cause bleeding.

A client with a physical disability is learning how to walk with a cane. Which activity(ies) will the client need to demonstrate before being independent with the device? Select all that apply. -sitting -standing from seated position -getting in and out of a car -going up and down stairs -getting in and out of a bathtub

-sitting -standing from seated position -going up and down stairs Explanation: A cane helps a client walk with balance and support and relieves the pressure on weight-bearing joints by redistributing weight. Before a client can be considered as independent with a cane, the client needs to learn how to sit, stand from a seated position, and go up and down stairs using the device. Getting in and out of a car and getting in and out of a bathtub are not actions the client needs to demonstrate before being independent with a cane.

The nurse is starting a new position with a home health agency. Which population most frequently uses home care services? -Clients who are older adults -Clients with chronic pediatric illness -Clients with respiratory illnesses -Clients of low socioeconomic status

Clients who are older adults Explanation: The older adult is the most frequent user of home care services. Clients with chronic pediatric illness and respiratory illnesses may use home care services, but not as frequently as older adults. Classifying clients by socioeconomic status is stereotyping a population.

A home care nurse is planning to visit a client newly diagnosed with diabetes. Further review of the chart reveals the client is of Japanese heritage. Upon arriving at the home, the home care nurse observes several pairs of shoes on a mat next to the door. Which of the following actions by the nurse demonstrates cultural competence? -The nurse removes her shoes and announces her arrival. -The nurse places shoe covers on her shoes and proceeds with the visit. -The nurse removes her shoes then teaches the client the importance of wearing shoes because of peripheral neuropathy. -The nurse leaves her shoes on and explains standard precautions to the client.

The nurse removes her shoes and announces her arrival. Explanation: Home care nurses need to adapt to the cultural environment of the client. In this situation, removing the shoes demonstrates the nurse's cultural competence. Shoe covers protect the transfer of potentially contaminated blood and body fluids to the nurse's shoes and are not indicated in this situation. Removing the shoes demonstrates cultural competence; however, teaching needs to demonstrate acceptance of cultural norms and can be directed at the importance of frequent and thorough assessment of the feet for unidentified injury related to neuropathy.