(Exam 3) IGGY - ch 1, 9, 16, 48, 52

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

A Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority.

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

A In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics.

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a mini-mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

A The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

What does the nurse learn about the function of the colony-stimulating factor? A. triggers the bone marrow to shorten the time needed to produce WBC's B. causes a capillary leak in acute inflammation C. responsible for creating exudate (pus) at infectious sites D. Dilates blood vessels at the site of inflammation leading to hyperemia

A Colony stimulating factor triggers the bone marrow to shorten the time needed to produce mature WBCs from about 14 days to hours. Increased blood flow to the local area of inflammation produces hyperemia or redness. Exudate is formed by neutrophils and consists of dead WBCs, necrotic tissue and fluids that escape from damaged cells. Histamine, serotonin, and kinins dilate arterioles leading to redness and warmth

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How should the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."

B Black widow spider venom produces a syndrome known as latrodectism, which manifests as severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting. Diazepam is a muscle relaxant that can relieve pain related to muscle rigidity and spasms. It does not prevent respiratory difficulty or failure.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client's trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

The older client's adult child questions the nurse as to why the client is at higher risk for infection when the client's white cell count is within the normal range. What response by the nurse is best? A. the white cell count does not tell us everything about immunity B. white blood cells are less active in older people so they are not as efficient. C. older people typically have poor nutrition which makes them prone to infection D. as one ages, immunoglobulins cease to be produced in response to illness

B an age related change in immunity is that neutrophils in the older adult are less active ad therefore less effective in immunity. The white blood cell count is not the only thing that can inform about immunity, but this response is too vague to be useful.

A client has a leg wound that is in stage II of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

B The recipient's immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

What are 3 roles of the medical-surgical nurse?

COORDINATOR of care in collaboration with the health care team CONTINUING CARE PLANNER through case management or discharge planning EDUCATOR of clients and family members-health promotion, disease and illness and specific treatments Client ADVOCATE that interprets information from other health care team members, and assists the client and family with health care decisions CHANGE AGENT within the work setting and the profession-includes planning and implementing a system to change the pt's health related behavior

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? A. "Begin a clear liquid diet 12 to 24 hours before the test." B. "Do not eat or drink anything for 12 hours before the test." C. "Give yourself tap water enemas until the fluid returns are clear." D. "You will have to drink a contrast liquid 2 hours before the test."

"Begin a clear liquid diet 12 to 24 hours before the test." The client is instructed to be on a liquid diet for 12 to 24 hours to cleanse the bowel before a colonoscopy. The client must be NPO (except for water) 4 to 6 hours before a colonoscopy. The client is instructed to drink a liquid preparation for cleaning the bowel (such as sodium phosphate) the evening before the colonoscopy, and may repeat that procedure on the morning of the test. In some cases, the client may require laxatives, suppositories, or one or more small-volume (i.e., Fleet) cleansing enemas. The client is not given an oral contrast liquid to swallow for a colonoscopy.

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? A. "A barium enema every 5 years is a screening option." B. "I will need to have a routine colonoscopy every 5 years." C. "My routine flexible sigmoidoscopy every 5 years is OK." D. "The 'virtual' colonoscopy every 5 years is acceptable."

"I will need to have a routine colonoscopy every 5 years." The 2010 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years. Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? A. "After I hear bowel sounds, you can have a drink." B. "Twenty minutes after the procedure was completed, you may have some liquids." C. "When you are able to pass flatus (gas), you can have a drink." D. "You can have fluids when you get home and are settled."

"When you are able to pass flatus (gas), you can have a drink." Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus, not by auscultation of bowel sounds. There is no set time period after the procedure that is considered safe for the client to have something to drink. The client will not be discharged home without the nurse determining that peristalsis has returned. The client must report that he or she is passing flatus to go home; therefore, the client should be given a drink before being sent home.

What are independent nursing functions?

- Are initiated and carried out without direction from the health care provider. Examples are: weighing a pt listening to breath sounds elevating the head of the bed to facilitate breathing

What are the 3 levels of prevention practices?

-Primary: avoid the onset of disease -Secondary: early detection of signs and symptoms -Tertiary: rehabilitation after condition is stabilized

What are collaborative nursing functions?

-Those that are mutually determined by the nurse and the physician or other health care team member, such as setting activity limitations or providing a special diet - Those that are directed or prescribed by the health care provider (physician, nurse practitioner, or physician assistant) but require nursing judgment to perform (ex. administering medication)

What are the 6 interventions created by the IHI to save patient lives?

1. Deploy Rapid Response Teams 2. Provide reliable, evidence-based care for acute myocardial infarction 3. Prevent central line infections 4. Prevent adverse drug events 5. Prevent surgical site infections 6. Prevent ventilator-associated pneumonia

What are the 6 interventions created by the IHI to prevent patient harm?

1. Prevent harm from High-Alert Drugs (ex. anticoagulants, insulin, opioids) 2. Reduce surgical complications 3. Prevent pressure ulcers 4. Reduce methicillin-resistant Staphylococcus aureus (MRSA) infections 5. Provide reliable, evidence based care for congestive heart failure 6. Get boards of health care organizations to support measures to promote safe patient care

What are the 5 broad core competencies created by the IOM for health professionals to ensure patient safety and quality care?

1. Provide patient-centered care 2. Collaborate with the interdisciplinary health care team 3. Implement evidence-based practice 4. Use quality improvement in patient care 5. Use informatics in patient care

A client's white blood cell count is 7500/mm3. Calculate the expected range for this client's neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3

4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500 ´ 0.55 = 4125 7500 ´ 0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. "It increases the elimination of T lymphocytes from circulation." b. "It inhibits cytokine production in most lymphocytes." c. "It prevents DNA synthesis, stopping cell division in activated lymphocytes." d. "It prevents the activation of the lymphocytes responsible for rejection."

A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. "Avoid large crowds and people who are ill." b. "Check over-the-counter meds for acetaminophen." c. "Take this medicine exactly as prescribed." d. "You have a higher risk of developing cancer."

A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A nursing learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

A primary health care provider notifies the nurse that a client has a "bandemia". What action does the nurse anticipate? A. administer antibiotics B. Place the client in isolation C. administer IV leukocytes D. obtain an immunization history

A A bandemia or shift to the left in the white count differential means that an acute continuing infection has places so much stress on the immune system that the most numerous type of neutrophil in circulation are immature or band cell. The nurse would anticipate administering antibiotics

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? A. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis B. A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography C. A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy D. A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN. Assessment and client teaching should be done by an RN. IV hypnotic medications should be administered by an RN.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) unit? A. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) B. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy C. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention D. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy A nurse who has experience with chronic GI problems will have experience and training in instructing clients on colonoscopy preparation. Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation would be accomplished best by nurses with experience in caring for adults with acute GI problems.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? A. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) B. A 54-year-old who is ready for discharge following a colonoscopy C. A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing D. A 60-year-old with questions about an endoscopic ultrasound examination

A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The other clients are not at risk for depressed respiratory status.

What does the Joint Commission require that health care organizations create?

A culture of safety

What is SBAR?

A formal method of communication between two or more members of the health care team that is used most often when there is an unmet patient need or problem. Can be used to communicate continuing care issues when a patient is transferred from one agency to another.

What is caring?

A process, set of actions, and attitude that show genuine physical and emotional concern for others

What is critical thinking according to Alfaro-LeFevre?

A purposeful, outcome directed thinking that is used to make clinical judgments based on scientific evidence, rather than on tradition or conjecture (guesswork)

What is Informatics?

A specialized computer science that is used to manage information and technology. One of it's major purpose is for retrieval of data for the evidence-based practice process. Examples: EMR - electronic medical records Internet Email

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? Select all that apply A. higher risk for respiratory tract and genitourinary infections B. May not have fever with severe infection C. show expected changes in white blood counts D. should receive influenza, pneumococcal, and shingles vaccinations E. skin tests for tuberculosis may be falsely negative F. booster vaccinations are not likely needed as one ages

A, B, D, E immunity changes during an adult's life and older adults have decreased immune function. The number and function of neutrophils and macrophages are reduced leading to reduced response to infection and injury, such as temperature elevation. The usual response of an increased white blood cell count is delayed or absent. Older adults are less able to make new antibodies in response to the presence of new antigens requiring repeat vaccinations and immunizations

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization f. Production

A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

The nurse learns that which risk factors can affect immunity (select all that apply) A. age B. environmental factors C. ethnicity D. drugs E. nutritional status

A, B, D,E immunity changes during an adult's life as a result of nutritional status, environmental conditions, drugs, disease, and age. Immunity is most efficient in young adults and older adults have decreased immune function. Ethnicity does not affect immunity.

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? select all that apply A. monocyte: matures into a macrophage B. basophil: releases vasoactive amines during an allergic reaction C. plasma cell: secretes immunoglobulins in response to the presence of a specific antigen D. Cytotoxic T- cells: attacks and destroys ingested poisons and toxins E. Natural killer cell: non-selectively attacks non-self cells F. Regulator T-cells: become sensitized for self-recognition in the bone marrow

A, C, E Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of specific antigens and natural killer cells non-selectively attack non self cells. Basophils release histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack and destroy non self cells, including virally infected cells, grafts and transplanted organs. Regulator T-Cells become sensitized for self recognition in the thymus

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. decreased function

A, D, E, F The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

A,B,E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine auto-injector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering."

A,B,E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

A,C,D,F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

A,D,E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102° F. Antipyretics should not be administered.

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent the loss of heat." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached."

A,D,E To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.

6. An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

ANS: A All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.

13. A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Dont go to fireworks displays. d. Use a soft cotton swab to clean ears.

ANS: A Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to hearing loss if the client has repeated infections. Fireworks displays are loud, but usually brief and only occasional. Nothing smaller than the clients fingertip should be placed in the ear canal.

1. A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. A soft cotton swab is alright to clean my ears with. b. I make sure my ears are dry after I go swimming. c. I use good earplugs when I practice with the band. d. Keeping my diabetes under control helps my ears.

ANS: A Clients should be taught not to put anything larger than their fingertip into their ears. Using a cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other statements are accurate.

15. A client has labyrinthitis and is prescribed antibiotics. What instruction by the nurse is most important for this client? a. Immediately report headache or stiff neck. b. Keep all follow-up appointments. c. Take the antibiotics with a full glass of water. d. Take the antibiotic on an empty stomach.

ANS: A Meningitis is a complication of labyrinthitis. The client should be taught to take all antibiotics as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck. Keeping follow-up appointments is important for all clients. Without knowing what antibiotic was prescribed, the nurse cannot instruct the client on how to take it.

17. A client is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover? a. Expecting hearing loss in the affected ear b. Managing postoperative pain c. Maintaining NPO status prior to surgery d. Understanding which medications are allowed the day of surgery

ANS: A Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other teaching topics are appropriate for any surgical client.

12. A client hospitalized for a wound infection has a blood urea nitrogen of 45 mg/dL and creatinine of 4.2 mg/dL. What action by the nurse is best? a. Assess the ordered antibiotics for ototoxicity. b. Explain how kidney damage causes hearing loss. c. Use ibuprofen (Motrin) for pain control. d. Teach that hearing loss is temporary.

ANS: A Some medications are known to be ototoxic. Diminished kidney function slows the excretion of drugs from the body, worsening the ototoxic effects. The nurse should assess the antibiotics the client is receiving for ototoxicity. The other options are not warranted.

7. A client had a myringotomy. The nurse provides which discharge teaching? a. Buy dry shampoo to use for a week. b. Drink liquids through a straw. c. Flying is not allowed for 1 month. d. Hot water showers will help the pain.

ANS: A The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3 weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.

2. The student nurse is performing a Weber tuning fork test. What technique is most appropriate? a. Holding the vibrating tuning fork 10 to 12 inches from the clients ear b. Placing the vibrating fork in the middle of the clients head c. Starting by placing the vibrating fork on the mastoid process d. Tapping the vibrating tuning fork against the bridge of the nose

ANS: B The Weber tuning fork test includes placing the vibrating tuning fork in the middle of the clients head and asking in which ear the client hears the vibrations louder. The other techniques are incorrect.

5. A client has external otitis. On what comfort measure does the nurse instruct the client? a. Applying ice four times a day b. Instilling vinegar-and-water drops c. Use of a heating pad to the ear d. Using a home humidifier

ANS: C A heating pad on low or a warm moist pack can provide comfort to the client with otitis externa. The other options are not warranted.

16. A client with Mnires disease is in the hospital when the client has an attack of this disorder. What action by the nurse takes priority? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the clients room. c. Place the client in bed with the upper siderails up. d. Provide a cool, wet cloth for the clients face.

ANS: C Clients with Mnires disease can have vertigo so severe that they can fall. The nurse should assist the client into bed and put the siderails up to keep the client from falling out of bed due to the intense whirling feeling. The other actions are not warranted for clients with Mnires disease.

4. The nurse works with clients who have hearing problems. Which action by a client best indicates goals for an important diagnosis have been met? a. Babysitting the grandchildren several times a week b. Having an adaptive hearing device for the television c. Being active in community events and volunteer work d. Responding agreeably to suggestions for adaptive devices

ANS: C Clients with hearing problems can become frustrated and withdrawn. The client who is actively engaged in the community shows the best evidence of psychosocial adjustment to hearing loss. Babysitting the grandchildren is a positive sign but does not indicate involvement outside the home. Having an adaptive device is not the same as using it, and watching TV without evidence of other activities can also indicate social isolation. Responding agreeably does not indicate the client will actually follow through.

14. A client has severe tinnitus that cannot be treated adequately. What action by the nurse is best? a. Advise the client to take antianxiety medication. b. Educate the client on nerve cutting procedures. c. Refer the client to online or local support groups. d. Teach the client side effects of furosemide (Lasix).

ANS: C If the clients tinnitus cannot be treated, he or she will have to learn to cope with it. Referring the client to tinnitus support groups can be helpful. The other options are not warranted.

3. The clients chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? a. Do you feel like something is in your ear? b. Do you have frequent ear infections? c. Have you been exposed to loud noises? d. Have you been told your ear bones dont move?

ANS: C Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

9. A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? a. Client with an hour car commute on the freeway each day b. Client who rides a motorcycle to work 20 minutes each way c. Client who sat in the back row at a rock concert recently d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

ANS: D A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.

11. A nurse is irrigating a clients ear when the client becomes nauseated. What action by the nurse is most appropriate for client comfort? a. Have the client tilt the head back. b. Re-position the client on the other side. c. Slow the rate of the irrigation. d. Stop the irrigation immediately.

ANS: D During ear irrigation, if the client becomes nauseated, stop the procedure. The other options are not helpful.

8. A client is going on a cruise but has had motion sickness in the past. What suggestion does the nurse make to this client? a. Avoid alcohol on the cruise ship. b. Change positions slowly on the ship. c. Change your travel plans. d. Try scopolamine (Transderm Scop).

ANS: D Scopolamine can successfully treat the vertigo and dizziness associated with motion sickness. Avoiding alcohol and changing positions slowly are not effective. Telling the client to change travel plans is not a caring suggestion.

10. A nursing student is instructed to remove a clients ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing

ANS: D The student should wash his or her hands, don gloves, and then remove the packing. The other actions are correct.

A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which gastrointestinal health problem is indicated by these laboratory findings? A. Acute pancreatitis B. Cirrhosis C. Crohn's disease D. Diarrhea

Acute pancreatitis These laboratory values are commonly found in clients with acute pancreatitis. They are not indicative of cirrhosis of the liver or Crohn's disease. These laboratory values are not found in a client with diarrhea.

What are Rapid Response Teams?

Also called the Medical Emergency Team (MET), teams that save lives and decrease the risk for harm by providing care to patients before a respiratory or cardiac arrest occurs. They do not replace the Code Team but they intervene rapidly for those who are beginning to clinically decline. They are critical care experts (ICU nurse, respiratory therapist, and intensivist [physician who specializes in critical care]) who are onsite and available at any time. GOAL is to utilize before dire problem exists

What is PACE?

Another method of "Hand-off" communication that helps the receiving nurse maintain continuity of care and address any new patient problems that may have occurred. Patient Problem Assessment/Actions Continuing/Changes Evaluation

The nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? A. Asking the client whether he or she has passed flatus (gas) B. Auscultating bowel sounds in all abdominal quadrants C. Counting the number of bowel sounds in each abdominal quadrant D. Observing the abdomen for symmetry and distention

Asking the client whether he or she has passed flatus (gas) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

A 49-year-old woman comes to the emergency department with reports of black tarry stools that started 2 weeks ago. In taking a gastrointestinal (GI) history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? (Select all that apply.) A. "Are you having any difficulty having sex? How frequently do you have sex?" B. "Do you have any difficulty chewing or swallowing?" C. "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" D. "What is your usual bowel elimination pattern? Frequency? Character?" E. "When was your last colonoscopy?"

B. "Do you have any difficulty chewing or swallowing?" C. "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" D. "What is your usual bowel elimination pattern? Frequency? Character?" E. "When was your last colonoscopy?" Chewing or swallowing difficulties affect the client's ability to get food into her GI system. Pain, diarrhea, gas, and foods that cause these symptoms constitute very important data for collection in the GI history. The client needs to be questioned about usual bowel elimination patterns—frequency and character are two descriptors. Colonoscopy history is also elicited from the client. Sexual difficulties and frequency are not generally affected by GI problems; this would not be a routine question in a GI problem inquiry.

Which factors place a client at risk for gastrointestinal (GI) problems? (Select all that apply.) A. Eating a high-fiber diet B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

B. Smoking a half-pack of cigarettes per day C. Socioeconomic status D. Some herbal preparations E. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. High-fiber diets are generally believed to be healthy for most clients.

A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the client's creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness.

A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."

C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation.

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.

A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client's temperature every 4 hours.

D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

D The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

An older adult has a mild temperature, night sweats, and productive cough. The client's tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client's TB test could be a false negative.

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

D Suppressor T cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

What is a common gastrointestinal problem that older adults experience more frequently as they age? A. Decreased hydrochloric acid B. Excess lipase production C. Increased liver enzymes D. Increased peristalsis

Decreased hydrochloric acid Atrophy of the gastric mucosa causes a decreased ratio of gastrin-secreting cells to somatostatin-secreting cells. This results in a decrease in hydrochloric acid, causing decreased absorption of iron and vitamin B12. In the pancreas, calcification of pancreatic vessels occurs, with a decrease in lipase production. The decrease in lipase results in decreased fat absorption and digestion. Steatorrhea and diarrhea can subsequently occur. The number and size of hepatic cells are decreased, which results in decreased enzyme activity; decreased liver enzyme activity depresses drug metabolism, and therefore may cause accumulation of drugs to toxic levels. In the large intestine, peristalsis is decreased and nerve impulses are dulled, which can result in postponement of bowel movements in older adults.

What is Evidence-based Practice?

EBP -is the deliberate use of current best evidence to make decisions about patient care; it considers the patient's preferences and values, as well as one's own clinical expertise.

A client with newly diagnosed irritable bowel syndrome (IBS) reports having five to six loose stools daily. What is the common psychological client response to this gastrointestinal health problem? A. Acceptance B. Embarrassment C. Euphoria D. Grief

Embarrassment The client who has a new onset of IBS with frequent stools most likely would be embarrassed. The client normally would not react to a new onset of IBS with acceptance or grief. It would be an abnormal reaction for the client to feel euphoria over a new onset of IBS.

What is the emphasis of health promotion and protection?

Emphasis on practices to promote health over emphasis on curing illness

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? A. Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation B. Examines the RUQ of the abdomen last C. Has the client lie in a supine position with legs straight and arms at the sides D. Views the abdomen by looking directly down while standing over the client's abdominal area

Examines the RUQ of the abdomen last If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. It is best to inspect the abdomen by standing at the side of the bed and then looking down on the abdomen, and also from the side at eye level.

A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a postprocedure assessment? A. Excessive diarrhea B. Heavy bleeding C. Nausea and vomiting D. Severe rectal pain

Heavy bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Excessive diarrhea, nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy.

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? A. Auscultation, percussion, palpation, inspection B. Inspection, auscultation, percussion, palpation C. Palpation, percussion, inspection, auscultation D. Percussion, auscultation, palpation, inspection

Inspection, auscultation, percussion, palpation Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.

What is IHI? What did they report and are involved in?

Institute for Healthcare Improvement estimated that there are nearly 15 million health care errors in U.S. hospitals each year, or 40,000 per day. It launched the 100,000 Lives Campaign- an effort to save patient lives for quality improvement changes in care.

What is IOM and what did they report in the year 2000?

Institute of Medicine stated in its "To Err is Human" report that between 44,000 and 98,000 patient deaths result each year from preventable errors in acute care hospitals. The report identified several factors that contribute to these findings and motivated other national bodies to examine ways they could improve patient safety and quality care.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? A. Acute diarrhea B. Aortic aneurysm C. Intestinal obstruction D. Pancreatitis

Intestinal obstruction Peristaltic movements are rarely seen except in thin clients and should be reported since the finding may indicate an intestinal obstruction. Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? A. Glucagon B. Hydrochloric acid C. Intrinsic factor D. Pepsinogen

Intrinsic factor Parietal cells in the stomach produce intrinsic factor, a substance that facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia. Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? A. Auscultate the abdomen to determine the presence of bowel sounds. B. Notify the provider about this finding immediately. C. Palpate the client's abdomen to determine the outlines of the mass. D. Question the client about recent stool habits.

Notify the provider about this finding immediately. A bulging, pulsating mass may indicate an abdominal aortic aneurysm, and the nurse should notify the provider immediately. Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? A. Give cefazolin (Ancef) 500 mg IV. B. Infuse normal saline at 200 mL/hr. C. Give morphine sulfate 2 mg IV. D. Provide oxygen at 6 L/min per nasal cannula.

Provide oxygen at 6 L/min per nasal cannula. Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation. The most immediate concern involves respiratory status, so the client should be placed on oxygen first. An antibiotic request is important, but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.

What are the National Patient Safety Goals?

Published by TJC, these goals require health care organizations to focus on specific priority safety practices, many of which involve nursing care. Addresses high-risk issues such as drug administration, fall reduction, pressure ulcer prevention, and communication among health care team members.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)? A. LLQ, RLQ, LUQ, RUQ B. LUQ, LLQ, RUQ, RLQ C. RLQ, LLQ, RUQ, LUQ D. RUQ, LUQ, RLQ, LLQ

RUQ, LUQ, RLQ, LLQ Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.

What is medical harm?

Refers not just to physician incidents but to errors caused by all members of the health care team that lead to patient injury or death.

What two terms refer to patient autonomy?

Self-determination Self-management

What are the 4 steps of SBAR?

Situation: Describe what is happening at the time to require this communication Background: Explain any relevant background information that relates to the situation Assessment: Provide an analysis of the problem or patient need based on assessment data. Recommendation: State what is needed or what the desired outcome is.

What is health?

The level of wellness of a person's biologic, psychological, and sociologic status -Biologic-structure of tissues/organs; biochemical interactions -Psychological-person's mood, emotions and personality -Sociologic-interaction between person and environment; may include spiritual health -High level of wellness achieved when biopsychosocial needs are met

What is the highest priority in practice for medical-surgical nurses using clinical judgment?

To ensure patient safety as the priority in practice

What is the goal of the case management process?

To provide quality and cost-effective services and resources to achieve positive patient outcomes.

What is a case manager?

Usually a nurse or social worker in acute care hospitals that coordinates inpatient and community-based care before discharge from a hospital or other facility.