Planning EAQ
The professional obligation of a nurse to assume responsibility for actions is referred to as: Correct1 Accountability. 2 Individuality. 3 Responsibility. 4 Bioethics.
1 Accountability. Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biological and medical procedures, treatments, and so on.
What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea? Correct1 Improvement of fluid balance 2 Continuation of an antidiarrheal diet 3 Preservation of perianal skin integrity 4 Retention of weight appropriate for height
1 Improvement of fluid balance Rehydration and correction of electrolyte imbalances are the priorities; diarrhea causes loss of fluid and electrolytes that can be life threatening. Antidiarrheal diets are no longer prescribed for children with diarrhea. Oral rehydration therapy is the treatment of choice. Although maintaining skin integrity in the presence of diarrhea is important, the risk of disrupted skin integrity is not life threatening, nor is it the priority when a young child is dehydrated. There are no data to indicate that the child is overweight or underweight.
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1 Maintain the head of the bed at 35 degrees or less. Correct2 With the help of another staff member, use a drawsheet when lifting the client in bed. 3 Reposition the client at least every 2 hours and support the client with pillows. 4 At least once every 8 hours, perform passive range-of-motion exercises of all extremities.
2 With the help of another staff member, use a drawsheet when lifting the client in bed. Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows, and, at least once every 8 hours, performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.
A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. The priority nursing care is: 1 Controlling intracranial pressure 2 Adding pads to the side of the bed Correct3 Administering prescribed antibiotics 4 Hydrating the client with hypotonic saline
3 Administering prescribed antibiotics The Brudzinski sign (when the neck is flexed while in the supine position, flexion of the hips occurs) indicates bacterial meningitis, a complication of sinusitis; the client's greatest need is a regimen of antibiotics, to which the causative agent is sensitive. Bacterial meningitis causes increased intracranial pressure and it is important for the nurse to monitor for manifestations of increased intracranial pressure; however, in this circumstance, it is not the priority. Because of the risk for seizures in bacterial meningitis, padded side rails are an important nursing intervention; however, this intervention does not have priority over instituting the appropriate antibiotic therapy to eradicate the cause of the meningitis. The data do not indicate a need for a hypotonic solution for hydrating the client.
A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? 1 Contact precautions are necessary. 2 It occurs during sexual intercourse. Correct3 It can be acquired during a vaginal birth. 4 Protection is provided by way of maternal immunity.
3 It can be acquired during a vaginal birth. Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit. Although contact precautions are necessary, herpes infection can occur during sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing process.
A health care provider writes prescriptions for a young child with a tentative diagnosis of Wilms tumor. Which prescription should the nurse question? 1 MRI 2 CT scan Correct3 Renal biopsy 4 Abdominal ultrasound
3 Renal biopsy A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.
A 12-year-old child is to be bedridden at home for several weeks after orthopedic surgery. What activity should the nurse encourage the parents to plan? 1 Drawing pictures 2 Playing card games 3 Watching television Correct4 Continuing schoolwork
4 Continuing schoolwork Schoolwork provides the child with a familiar routine; it encompasses the age-appropriate developmental tasks of industry versus inferiority. Drawing pictures is an appropriate activity for the preschooler. Although social interaction and mental stimulation are important at this age, continuing with schooling is the priority. Television watching is satisfactory but should not replace active participation.
A school-aged child who has just arrived from Africa has been exposed to diphtheria, and a nurse in the pediatric clinic is to administer the antitoxin. Which type of immunity does the antitoxin confer? 1 Active natural 2 Passive natural 3 Active artificial Correct4 Passive artificial
4 Passive artificial In the creation of passive artificial immunity an antibody is produced in another organism and then injected into the infected or presumed infected person to provide immediate immunity against the invading organism. Active natural immunity takes too much time to develop; this child needs immediate protection. Passive natural immunity is acquired from the mother and is effective only during the first few months of life. Active artificial immunity takes too much time to develop; the child needs immediate protection.
A 1-year-old child is found to have nutritional iron-deficiency anemia. What nursing interventions are most important in the care of an infant with iron-deficiency anemia? (Select all that apply.) Correct1 Conserving the infant's energy Correct2 Protecting the infant from infection Correct3 Teaching the parents about nutrition 4 Telling the parents to offer small, frequent feedings 5 Instructing the parents to increase the amount of milk offered
Correct1 Conserving the infant's energy Correct2 Protecting the infant from infection Correct3 Teaching the parents about nutrition Conservation of energy is important because anemic children are usually fatigued. There are inadequate amount of red blood cells (RBCs) and hemoglobin to carry oxygen to body cells. Anemic children are prone to infection. Parents should know which foods are high in iron. Iron promotes the formation of RBCs. The time and amount of feedings are not as important as the quality of foods that are offered. Usually anemia results from drinking unfortified milk and little else; there should be an increase in the variety and quality of the foods offered.
A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. 1. Assess client's vital signs and lung sounds 4. Administer oxygen via a ventilation bag 2. Insert the catheter without applying suction 3. Rotate the catheter while suction is applied
The nurse should first assess the client's vital signs and lung sounds to determine if suctioning is needed. Then 100% oxygen should be administered to compensate for the lack of oxygen intake during the suctioning process. Suctioning should not be applied during catheter insertion to limit trauma. Rotating the catheter during withdrawal ensures thorough removal of secretions.