Med surg 3 Ch 1,8,12

1. A nurse cares for a dying client. Which manifestation of dying does the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss

ANS: B Only symptoms that cause distress for a dying client would be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they would be treated only if the client is distressed by their presence. The nurse would treat the client's pain first.

11. A nurse is caring for a client who is terminally ill. The client's spouse states "I am concerned because he does not want to eat." How does the nurse respond? a. "Let him know that food is available if he wants it but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

ANS: A Anorexia often causes distress in family members. When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family and contributes to client discomfort.

6. Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients.

ANS: A Autonomy is self-determination. The client would make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.

13. A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan? a. Store basic supplies to last for at least 3 days. b. Have short-term arrangements for child care. c. Store enough frozen foods in freezer for 5 days. d. Keep cooking utensils needed in a separate bag.

ANS: A Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan with enough supplies for 3 days. Any food needs to be nonperishable with no cooking required. Arrangements for children pets or older adults would be made for extended period of time.

2. A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a safety partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does.

5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider's phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room.

ANS: A Medication reconciliation is a formal process in which the client's actual current medications are compared to the prescribed medications at the time of admission, transfer, or discharge. This National client Safety Goal is important to reduce medication errors. The client would not have to be responsible for providers washing their hands, and even if the client does so, this is too narrow to be the most important action to prevent errors. Keeping the provider's phone number nearby and documenting everyone who enters the room also do not guarantee safety.

3. A nurse is caring for a client who has lung cancer and is dying. Which prescription does the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate enema once a day PRN for impacted stool

ANS: A Pain medications would be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The dying client should not have to request medications for serious pain. The other medications are appropriate for this client.

12. A nurse discusses palliative care with a client and the client's family. A family member expresses concern that the loved one will receive only custodial care. How will the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

ANS: A Palliative care provides an increased level of personal care designed to manage symptom distress. It does not specifically relieve the family's burden of caring for a client at home. It is not a place where only pain medications are given. The client is involved in this discussion so the nurse would not state he or she is unaware of surroundings. The goal of palliative care is to improve the quality of life for the patient and the family.

4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client's basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room.

ANS: A Showing respect for the client and family's preferences and needs is essential to ensure a holistic or "whole-person" approach to care. By assessing the effect of the client's culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client-centered care.

8. A nurse wants to become involved in community disaster preparedness and is interested in helping setup and staff first-aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals establish first-aid stations or special needs shelters or set up acute care centers in the community. The National Guard often performs search-and-rescue operations and law enforcement. The health department focuses on communicable disease tracking treatment and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours providing many types of relief services.

3. A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes.

ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse would call the RRT. Changes in blood pressure, mental status, heart rate, temperature, oxygen saturation, and last 2 hours' urine output are particularly significant and are part of the Modified Early Warning System guide. Documentation is vital, but the nurse must do more than document. The primary health care provider would be notified, but this is not more important than calling the RRT. The client's blood pressure would be reassessed frequently, but the priority is getting the rapid care to the client.

1. A hospital responds to a local mass casualty event. What action would the nurse supervisor take to prevent staff posttraumatic stress disorder during and after the event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

ANS: A To prevent staff posttraumatic stress disorder during a mass casualty event the nurses would use available counseling encourage and support co-workers monitor each other's stress level and performance take breaks when needed talk about feelings with staff and managers and drink plenty of water and eat healthy snacks for energy. Nurses would also keep in touch with family friends and significant others and not work for more than 12 hours/day. Encouraging counseling upon deactivation of the plan or after the emergency response is over does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent posttraumatic stress disorder. These actions also help mitigate PTSD after the event.

9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis licensure issues would not be the government's priority concern." d. "If you are deployed you will be issued a temporary license in the state in which you are working."

ANS: A When deployed DMAT health care providers act as agents of the federal government and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with but no programs for temporary licensure or rapid activation are available.

5. A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster? (Select all that apply.) a. Know the institution's Emergency Response Plan. b. Participate in the institution's disaster drill. c. Develop a personal preparedness plan. d. Understand that nurses play a role in every phase of a disaster. e. Be prepared to report immediately to the emergency department. f. Be willing to be flexible working during a crisis situation.

ANS: A B C D F Nurses play a major role in disaster and need to be prepared for any type of disaster. Knowing the institution's emergency management plan and participating in disaster drills will help the nurse be prepared for a disaster. Concerns for their home and family can impact the willingness to report in an emergency and can be diminished by being prepared with a personal preparedness plan. Nurses play key roles before during and after a disaster in the development of emergency management plan in defining specific nursing roles. During a crisis nurses may be assigned to different areas of the facility or to different job functions and must remain flexible while working to their best ability.

1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A C D F Clients with burns spine injuries eye injuries and stable abdominal injuries would be treated within 30 minutes to 2 hours and therefore would be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag f. A 33-year-old male unconscious with bilateral leg amputations: yellow tag

ANS: A D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that need to be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag and the client with shortness of breath would receive a red tag. The client with the amputated legs will probably be black tagged if the unconsciousness is from massive blood loss.

2. A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress. e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately.

ANS: A, B, C, D, F Collaborating with the interprofessional team involves planning, implementing, and evaluating client care as a team with all other involved disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with them.

4. A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication

ANS: A, B, C, E The SBAR method of communication has been identified as an excellent method of communication between health care professionals. It is a formalized structure consisting of Situation, Background, Assessment, and Recommendation/Request. Using a formalized mechanism for communication helps ensure successful hand-off and fewer client errors. When establishing this new format for report, the most helpful actions by the manager would be to provide initial education on the process, develop a template with suggested topics under each heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify information. Basing raises on compliance would not be the most helpful method because raises are often determined only once a year and are based on multiple criteria.

1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care

ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interprofessional team, implementing evidence-based practice, providing patient-focused care, using informatics in client care, and using quality improvement in client care. Systems thinking is required for quality improvement but is not a specified part of the IOM report.

1. A hospice nurse is caring for a dying client and family members. Which interventions does the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent. f. Allow the client and family to voice concerns and fears.

ANS: A, B, D, F The nurse would teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the client's religion is the same. The nurse shows presence by allowing the client and family members to voice their fears and concerns openly.

2. A nurse admits an older adult client to the hospital. Which criteria does the nurse use to determine if the client can make his or her own medical decisions? (Select all that apply.) a. Can communicate treatment preferences. b. Is able to read and write at an eighth-grade level. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information. e. Has completed an advance directive. f. The family states the client can make decisions.

ANS: A, C, D To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented evaluate, deliberate, and mentally manipulate information and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to. The family may or may not be correct in stating the client is capable, but the nurse would listen openly to their statements.

3. A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies does the nurse incorporate in this client's pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine. f. Involve the client in guided imagery.

ANS: A, C, F Complementary therapies for pain management include massage therapy, music therapy, therapeutic touch, guided imagery, and aromatherapy. Nurses would not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Health care errors have been widely reported for 25 years, many of which result in client injury, death, and increased health care costs. There are several national and international organizations that have either recommended or mandated safety initiatives. Every nurse has the responsibility to guard the client's safety. The other actions are important for quality nursing, but they are not as vital as providing safety. Not making medication errors does provide safety, but is too narrow in scope to be the best answer.

10. A nurse assesses a client who is dying. Which sign or symptoms does the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-10 scale

ANS: B Although all of these assessments would be performed during the dying process, periods of apnea and Cheyne-Stokes respirations indicate that death is near. As peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse would continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

6. A nurse teaches a client who is considering being admitted to hospice. Which statement does the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is not designed to hasten death but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

ANS: B As both a philosophy and a system of care, hospice care uses an interprofessional approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

10. After a hospital's emergency department (ED) has efficiently triaged treated and transferred clients from a community disaster to appropriate units the hospital incident command officer wants to "stand down" from the emergency plan. Which question would the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"

ANS: B Before "standing down " the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED that number may not be predictable. Giving staff the chance to eat and rest is important but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident the CMO does not determine when the hospital can "stand down."

9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action will the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure the primary health care provider completed the death certificate. d. Request family members to prepare the client's body for the funeral home.

ANS: B Before moving the client's body to the funeral home, the nurse asks family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first would ask family members if they would like to be alone with the client. The client's family would not be expected to prepare the body for the funeral home but they could be asked if they wish to provide some care such as brushing the hair.

7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian gay bisexual transgender and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse would never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is more likely to answer honestly.

8. The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

ANS: B Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.

8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. "I would like you to order a different pain medication." b. "This client has allergies to morphine and codeine." c. "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." d. "This client had a vaginal hysterectomy 2 days ago."

ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on-call health care provider might order. Situation describes what is happening right now that must be communicated, the client's surgery 2 days ago would be considered background. Assessment would include an analysis of the client's problem none of the options has assessment information. Asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired.

10. A newly graduated nurse in the hospital states that because of being so new participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. "All staff nurses are required to participate in quality improvement here." b. "Even being new you can implement activities designed to improve care." c. "It's easy to identify what indicators would be used to measure quality." d. "You should ask to be assigned to the research and quality committee."

ANS: B The preceptor would try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice.

2. A nurse plans care for a client who is nearing end of life. Which question will the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your primary health care provider?"

ANS: B When developing a plan of care for a dying client, consideration would be given for where the client wants to die. Different states have different laws regarding legal requirements for advance directives, but this would not take priority over establishing client preferences. A physical therapist would not be involved in end-of-life care. The client would discuss resuscitation with the primary health care provider and children do-not-resuscitate status would be the client's decision, not the family's decision.

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic—decides the number acuity and resource needs of clients b. Hospital incident commander—assumes overall leadership for implementing the emergency plan c. Public information officer—provides advanced life support during transportation to the hospital d. Triage officer—rapidly evaluates each client to determine priorities for treatment e. Medical command physician—serves as a liaison between the health care facility and the media

ANS: B D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number acuity and resource needs of clients.

3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients would the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care f. Client with symptoms of influenza after traveling abroad

ANS: B E The client with the femur fracture could be transferred to a rehabilitation facility and the client on the medical unit for wound care could be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit would be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis. The client who has recently traveled abroad may have either seasonal influenza or may have a novel or potential pandemic respiratory virus and should not be transferred to avoid spreading the illness.

3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model

ANS: B, C, D, E EBP consists of utilizing current evidence, the client's values and preferences, and the nurse's expertise when planning care. It does not include cost-saving measures. The PDSA model is a systematic model for quality improvement, but is not a specific component of EBP.

14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion? a. Roman Catholic—autopsies are not allowed except under special circumstances. b. Christian—upon death a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism—a person who is extremely ill and dying should not be left alone. d. Islam—an ill or a dying person should receive the Sacrament of the Sick.

ANS: C According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest usually performs the Sacrament of the Sick for ill or dying people.

5. After teaching a client about advance directives a nurse assesses the client's understanding. Which statement indicates that the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

ANS: C An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want to be taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence or financial matters.

11. A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school.

ANS: C Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can demonstrate how best current evidence guides their practice. New technology doesn't necessarily mean that the hospital is safe. Affiliation with a health profession school has several advantages, but safety is most important.

7. A nurse cares for victims during a community-wide disaster drill. One of the victims asks "Why are the individuals with black tags not receiving any care?" How does the nurse respond? a. "To do the greatest good for the greatest number of people it is necessary to sacrifice some." b. "Not everyone will survive a disaster so it is best to identify those people early and move on." c. "In a disaster extensive resources are not used for one person at the expense of many others." d. "With black tags volunteers can identify those who are dying and can give them comfort care."

ANS: C In a disaster military-style triage is used this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness so that they can be allocated to others who have a reasonable expectation of survival. Victims are not "sacrificed." Telling victims that is important to move on after identifying the expectant dead does not provide an adequate explanation and is callous. Victims are not black-tagged to allow volunteers to give comfort care.

5. An emergency department manager wants to mitigate the possible acute and chronic stress after mass casualty events in the staff. What action would the manager take? a. Encourage all staff to join a Disaster Medical Assistance Team. b. Instruct all staff members to prepare go bags for all family members. c. Use available resources for broad education and training in disaster management. d. Provide incentives and bonuses for responding to mass casualty events.

ANS: C Research indicates that education and training in disaster management before an incident occurs is associated with improved confidence and better coping after the incident. Go bags are important to maintain for all family members but would not be effective in mitigating stress. A DMAT is a medical relief team made up of civilian medical paraprofessional and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. Incentives and bonuses will not help mitigate stress.

9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task

ANS: C Supervision is one of the five rights of delegation and includes directing, evaluating, and following up on delegated tasks. The nurse would either have asked the AP about the vital signs or instructed the AP to report them right away. An experienced AP would know how to take vital signs and the nurse would not have to assess this at this point. Double-checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction to the AP.

11. A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does the nurse anticipate has the highest need for further assessment and referral? a. Client who is still trying to locate relatives who are missing b. Family awaiting the ability to travel out of state for temporary housing c. Client with a score of 48 on the Impact of Event Scale-Revised (IES-R) d. Client who has trouble sleeping and who startles easily

ANS: C The IES-R is an assessment tool is a 22-item self-administered questionnaire that scores individuals on signs and symptoms of acute stress disorder or posttraumatic stress disorder. A score of 33 or higher out of 88 is a positive finding and this client would be referred a psychiatrist or other licensed mental health care provider. The nurse would administer the assessment to the client with difficulty sleeping after ensuring he or she can read at the 10th grade level which is the reading level of the tool. The other two clients do not show evidence of particular needs for referral beyond what is usually provided in a natural disaster.

13. An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How will the nurse respond? a. "I understand your concerns but in this state discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the primary health care provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

ANS: C The nurse validates the family's concerns and provides accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse would provide unbiased information about these topics.

12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action would the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for postincident crisis support. d. Talk individually with staff members.

ANS: C The staff may be suffering from stress related to the multiple traumas and needs to have crisis support. A crisis support team can assist the staff with developing appropriate coping methods. Speaking with staff members individually does not provide the same level of support as trained health care providers who can offer emotional first aid. Organizing a party and revisiting the sick-leave policy may be helpful but are not as important and beneficial as formalized crisis support.

6. A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client says "I can't believe that my spouse is gone and I am left to raise my children all by myself." How would the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation.

3. A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority are placed in the emergent or class I category and are given a red triage tag. The client with multiple rib fractures and shortness of breath has a threat to oxygenation and is the most critical. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II (urgent yellow tag) these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent (class III green tag).

2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How would the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."

ANS: D Clients would be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

4. A nurse is caring for a dying client whose adult child confides frequent crying episodes to the nurse. How does the nurse respond? a. "It's normal. Most people move on within a few months." b. "Whenever you start to cry distract yourself with pleasant thoughts of your parent." c. "You should try not to cry. Your parent will be in a better place soon." d. "Your feelings are completely normal and may continue for a long time."

ANS: D Everyone grieves and mourns differently. The nurse would offer support to the client and family during this time. By telling the adult child that the feelings are normal and may continue, the nurse is providing support to whatever the person is feeling. The other statements all show lack of compassion and respect

4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask nursing staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D The ED charge nurse would direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims however they would not be assigned to the most critically ill or injured clients. The hospital incident commander's role is to take a global view of the entire situation and facilitate patient movement through the system while bringing in personnel and supply resources to meet patient needs. The medical command physician would kept the incident commander informed about victims and capacity of the ED.

7. A nurse is caring for a dying client. The client's spouse states "I think he is choking to death." How would the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your spouse comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your spouse onto the side."

ANS: D The choking sound or "death rattle" is common in dying clients. The nurse acknowledges the spouse's concerns and provides interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse would not minimize the spouse's concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client and may cause agitation.

4. A nurse teaches a client's family members about signs and symptoms of approaching death. Which of the following does the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling f. Incontinence

ANS: D, E, F Common physical signs and symptoms of approaching death include coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.