Role of a Nurse Summary

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

"To ensure you have the resources you need when you leave"

A nurse practices beneficence when teaching a class of adolescents about the risks of drinking and driving. Beneficence is best described as: A The actions one takes should promote good. B Always telling the truth C The right to self-determination D Do no harm and safeguard the client.

(The ethical issue was the inequality of treatment based strictly upon racial differences. Secondly, the drug was deliberately withheld even after results showed that the drug was working to cure the disease process in the white men for many years. So after many years, the black men were still not treated despite the outcome of the research process that showed the drug to be effective in controlling the disease early in the beginning of the research project. Therefore harm was done. Nonmaleficence, veracity, and justice were not followed.)

1. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours

1) B - The client is having difficulty breathing because of upward pressure on the diaphragm from the ascitic fluid. Elevating the head of the bed enlists the aid of gravity in relieving pressure on the diaphragm. The other options are general measures to promote lung expansion in the client with ascites, but the priority measure is the one that relieves diaphragmatic pressure.

Which of the following is accurate regarding wellness? Select all that apply. 1. One tries to maximize one's own health. 2. It requires a conscious commitment. 3. It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. 4. It is a specific health status with the absence of disease. 5. Is the same for every person.

1. One tries to maximize one's own health. 2. It requires a conscious commitment. 3. It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. Wellness, as a reflection of health, involves a conscious and deliberate attempt to maximize one's health. Wellness requires planning and conscious commitment and is the result of adopting lifestyle behaviors for the purpose of attaining one's highest potential for well-being. Wellness is not the same for every person.

10. A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance

10) B - Hypertension, cigarette smoking, and hyperlipidemia are major risk factors for CHD. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 190 mg/dL and a blood glucose level of 110 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.

2. A nurse is scheduling a client for diagnostic studies of gastrointestinal (GI) system. Which of the following studies, if ordered, should the nurse schedule last? a) ultrasound b) colonoscopy c) barium enema d) computed tomography

2) C - When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed, if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.

21. A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway

21) D - After a transfer from the operating room, the PACU nurse performs an assessment of the client. The ABCs'airway, breathing, and circulation'must be assessed first. Urine output and orientation to the surroundings might also be assessed, but these are not the first actions. The client might not have active bowel sounds at this time because of the effects of anesthesia.

25. A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased

25) B - The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The priority victim is the one who must be treated immediately or life, limb, or vision will be threatened. This victim is categorized as emergent (option 2). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 3). The victim who requires evaluation and possible treatment but for whom time is not a critical factor is categorized as nonurgent and is the third priority (option 1).

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

4. Informatics Informatics is the combination of technology and information.

The nurse notes that a client who was instructed on how to do a prescribed treatment 1 week ago is unable to perform the task. Which action will the nurse take to improve this client's health literacy? Report the client's nonadherence to the health care provider. Review the material to determine that it is appropriate for the client. Ask the client why the treatment is not being performed as instructed. Determine if there is a family member who can provide the treatment.

Review the material to determine that it is appropriate for the client. Assess the material. Asking the client WHY is too confrontational.

Based on the nurse's knowledge of nonadherence to therapeutic regimens, which nurse needs to place extra emphasis on adherence to the treatment plan? The nurse planning to teach adults aged 65 about congestive heart failure management The nurse planning to teach a group of children about healthy eating The nurse planning to teach middle-aged adults about stress management The nurse planning to teach teenagers about mononucleosis

The nurse planning to teach adults aged 65 about congestive heart failure management Eighty percent of people older than 65 years of age have one or more chronic illness, and many have limited activity. These chronic illnesses may be managed with numerous medications and complicated by periodic acute episodes, making adherence to a regimen difficult. Problems of teenagers generally are time-limited and specific and require promoting adherence to treatment in order to return to health. In general, the compliance of children to a regimen depends on the compliance of their parents. Middle-aged adults, in general, have fewer health problems, thus promoting adherence to a regimen.

The nurse develops outcome criteria for a patient with chronic obstructive pulmonary disease. Which outcome criteria are appropriate for this patient? The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. The patient will not experience an alteration in skin integrity. The patient will perform passive range-of-motion exercises once daily. The nurse will obtain a pulse oximetry reading twice a day.

The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. OUTCOMES MUST BE REALISTIC AND MEASURABLE

In which situation is the nurse providing appropriate discharge planning? Assessing the client's support system at home during the admission assessment Contacting the client's insurance company 24 hours before discharge to review the client's medical coverage Providing take-home medication education to the client before discharge Contacting a home care agency by the third hospital day

Assessing the client's support system at home during the admission assessment To prepare for early discharge and the possible need for follow-up in the home, discharge planning begins with the patient's admission. Also, just because you simply provide medications doesn't mean you're helping with discharge. You're not even teaching the client.

The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Illness prevention

B:Secondary prevention

A client is to be discharged from an acute care facility after treatment for pneumonia. The nurse notes that the client's lungs are clear and denies shortness of breath. The nurse's actions reflect which step of the nursing process? Analysis Evaluation Assessment Data collection

Evaluation Key word: "DISCHARGED" The client has already been assessed and treated, now it is time for the client to be evaluated.

5. A client with a history of suicide attempts is admitted to the mental health unit with the diagnosis of depression. Upon the client's arrival, the client's therapist reports to the nurse that the clients telephoned the therapist earlier in the evening and reported having a overwhelming suicidal thoughts. Keeping this information in mind, the priority of the nurse is to assess for: a) interaction with peers b) the presence of suicidal thoughts c) the amount of food intake for the past 24 hours d) information regarding the past medication regimen

5) B The critical information from the therapist is that the client is having thoughts of self-harm; therefore, the nurse needs further information about present thoughts of suicide so that the treatment plan may be as appropriate as possible. The nurse must make sure the client is safe. The items in options A, C, and D should be assessed; however, evaluation for suicide potential is most important

8. A client is scheduled for an arteriogram using a radiopaque dye. The nurse assesses which most critical item before the procedure? a) vital signs b) intake and output c) height and weight d) allergy to iodine or shellfish

8) D - Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary, because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although options A, B, and C are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical.

A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents

D - The question asks about the first thing that the nurse needs to consider. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may or may not be needed at a later date.

A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available

D - The question asks about the immediate concern. The ABCs of community health are always attending to people's basic needs of food, shelter, and clothing. Options A, B, and C are other activities that may be completed at a later time.

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, what phase of the nursing process is being used? A. Planning B. Diagnosis C. Evaluation D. Implementation

D. Implementation

There are many goals for health teaching. Which of the following is the primary goal of family and patient education? Increase knowledge Motivate people to learn Improve patient outcomes Establish trust

Improve patient outcomes Explanation: The primary goal of patient and family education is to achieve, improve, or alter behaviors that directly or indirectly change and improve patient outcomes.

Communicating patient values, preferences and expressed needs to other members of health care team is an example of what Quality and Safety in the Education of Nurses (QSEN) competency? Possible Answers: Quality improvement Evidence-based practice Safety Patient-centered care

Patient-centered care Communicating patient values, preferences and expressed needs to other members of health care team is an example of patient-centered care, which is defined as the act of recognizing the full agency of the patient by providing compassionate and coordinated care based on respect for patient preferences, values, and needs.

Which phase of the nursing process encompasses the establishment of expected outcomes? Planning Assessment Implementation Evaluation

Planning : Planning encompasses specifying expected outcomes. Assessment is directed toward the systematic collection of data about the client's learning needs and readiness to learn. In the implementation phase, the client, the family, and the members of the nursing and health care teams carry out activities outlined in the teaching plan

Using tools such as algorithm flow charts and cause-effect analyses to make processes of care more explicit is an example of what Quality and Safety in the Education of Nurses (QSEN) competency? Possible Answers: Patient centered care Quality improvement Evidence-based practice Safety

Quality improvement Using tools such as algorithm flow charts and cause-effect analyses to make processes of care more explicit is an example of quality improvement, which is defined as the use of data to monitor the outcomes of treatment practices and other efforts to continuously improve the quality and safety of health care systems.

A nurse knows that the use of a learning contract increases motivation and increases the likelihood of patient compliance with the treatment regimen. Which client goal best exemplifies a well-designed learning contract? The client who wishes to stop smoking agrees to cut back on one cigarette a day for the first week of treatment and then decrease smoking by two cigarettes the following week of treatment. The client seeking alcohol treatment agrees to stop drinking all forms of alcohol immediately and plans to chew a stick of gum when they experience the urge to have a drink. The client who wishes to lose weight immediately reduces caloric intake to 1000 calories a day and agrees to keep to this diet plan until a 9-kg weight loss has been achieved. The client who wants to begin an exercise program agrees to participate in a 10-km run 6 months after starting the new exercise regimen.

The client who wishes to stop smoking agrees to cut back on one cigarette a day for the first week of treatment and then decrease smoking by two cigarettes the following week of treatment. A well-designed learning contract is realistic and positive. In a typical learning contract, a series of measurable goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals

17. A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action? a) examine and treat the wound sites b) obtain and record a detailed history c) encourage and assist the client to ventilate feelings d) administer an anti-anxiety agent

17) A - The client has a physiological injury, and the nurse would initially examine and treat the wound sites because of bleeding. Although options B,C, and D may be appropriate at some point, the initial action would need to be to treat the wounds.

19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage

19) C - Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the items in options A, B, and D need to be assessed, they should be performed after initial attempts to locate and correct the air leak.

A nurse practices beneficence when teaching a class of adolescents about the risks of drinking and driving. Beneficence is best described as: A The actions one takes should promote good. B Always telling the truth C The right to self-determination D Do no harm and safeguard the client

A (Beneficence means "the actions one takes should promote good." A nurse teaching a class of adolescents is promoting the health and well-being of the community. Veracity is always telling the truth. The right to self-determination is autonomy. Nonmaleficence means to do no harm and safeguard the client.)

Nurses agree to be advocates for their patients. The practice of advocacy calls for the nurse to: Seek out the nursing supervisor in conflicting situations. Work to understand the law as it applies to the client's clinical condition. Assess the client's point of view and prepare to articulate this point of view. Document all clinical changes in the medical record in a timely manner.

Assess the client's point of view and prepare to articulate this point of view.

The parents of a child with no apparent brain function refuse to permit withdrawal of life support. Which moral principle is applied with the nurse's action to support the family's decision? A Beneficence B Justice C Respect for autonomy D Nonmaleficence

C Respect for autonomy (Autonomy is the client's (or surrogate's) right to make his or her own decision. The nurse is obliged to respect a parent's or significant other's informed decision regarding the client. This situation is not one of nonmaleficence (do no harm) or beneficence (do good). Justice (fairness) generally applies when the rights of one client are being balanced against those of another client. )

13. A nurse is caring for a client who has wrist restraints applied. Which nursing intervention would receive highest priority regarding the wrist restraints? a) providing range-of-motion exercises to the wrists b) removing the restraints periodically per agency guidelines c) applying lotion to the skin under the restraints d) assessing color, sensation, and pulses distal to the restraint

13) D - Assessing color, sensation, and pulses distal to the restraint determines the presence of neurovascular compromise that is associated with the use of restraints. All of the other interventions should be implemented, but option 4 is the priority.

14. A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

14) D - The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

3. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client? a) diarrhea b) risk for aspiration c) risk for deficient flid volume d) imbalanced nutrition, less than body requirements

3) B - Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Although options 1, 3, and 4 may be a concern, these are not the priority.

A nurse meets with the registered dietitian and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

3. Teamwork and collaboration

4. A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis

4) A - The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical assessment needs to be performed but is not the priority.

9. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status

9) D- Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although options A, B, and C may be components of the assessment, option D is the priority.

He raised the issue of giving priority to patient needs. Which of the following offers the best way for setting priority? A. Assessing nursing needs and problems. B. Giving instructions on how nursing care needs are to be met. C. Controlling and evaluating the delivery of nursing care. D. Assigning a safe nurse: patient ratio.

A. Assessing nursing needs and problems. This option follows the framework of the nursing process and at the same time applies the management process of planning, organizing, directing, and controlling. At the basic level, management is a regimen that comprises five standard functions, namely, planning, organizing, staffing, leading, and controlling. These functions are part of a body of practices and theories that educate on becoming an efficient manager.

The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first? A. Respiratory status B. Level of consciousness C. Level of pain D. Reflexes and movement of extremities

A. Respiratory status Remember the ABCs of nursing.

An example of a nursing activity that reflects the American Nurses Association's definition of nursing is: A. diagnosing a patient with a feeding tube as being at risk for aspiration B. Establishing protocols for treating patients in the emergency department. C. Providing antianxiety drugs for a patient who has disturbed sleep patterns D. Identifying and treating dysrhythmias that occur in a patient in the coronary care unit.

A. diagnosing a patient with a feeding tube as being at risk for aspiration Rationale: The American Nurses Association (ANA) defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations." The nursing activity described in option a is related to the prevention of injury.

The World Health Organization defines health by which of the following statements? A. "State of complete physical, mental, and social well-being, not merely the absence of disease" B. "A state of being that people define in relation to their own values, personality, and lifestyle" C. "Mental, social, and spiritual well-being" D. "All people free of disease"

A:State of complete physical, mental, and social well-being, not merely the absence of disease"

A home care nurse educator is providing training to staff nurses on the importance of compliance to medication regimens. What demographic variables may lead to the decrease in compliance of medication regimens? Select all that apply. Age Gender Race Socioeconomic status Severity of illness

Age Gender Race Socioeconomic status Compliance and adherence to medication regimens may be influenced by various demographic variables such as age, gender, race, socioeconomic status, and education level. Severity of illness is a variable that leads to the decrease in compliance of medication regimens; however, this is NOT a DEMOGRAPHIC variable.

phanie delegates effectively if she has authority to act, which is best defined as: A. Having a responsibility to direct others. B. Being accountable to the organization. C. Having a legitimate right to act. D. Telling others what to do.

Answer: C. Having legitimate right to act. Authority is a legitimate or official right to give the command. This is an officially sanctioned responsibility. Managers must possess the authority to give orders, and recognize that with authority comes responsibility. As well as rank, Fayol argues that a manager's intelligence, experience, and values should command respect.

Select all the tasks you could delegate to a UAP as the RN: A. Wound dressing change B. IV flush C. Collecting vital signs D. Weighing a patient E. Mouth care F. Suctioning a patient G. Applying oxygen to a patient H. Connecting a patient to their IV fluids I. Assisting a patient with a bath J. Applying denture paste to dentures

Answers C, D, E, I and J. These are all tasks the RN could delegate to a nursing assistant.

A home care nurse is caring for an older adult with multiple medications after being discharged from the hospital with acute coronary syndrome. Which nursing action promotes self-management of the medication regimen for this client? Select all that apply. Assist to identify non-therapeutic medications. Assist to identify duplicate medications. Call the health care provider for clarification. Place the oral medications in a medication organizer.

Assist to identify duplicate medications. Place the oral medications in a medication organizer. An older adult with multiple medications presents a challenge for the home care nurse. An important aspect of transitioning from hospital to home is self-management of the medication regimen. Assisting the client identify duplicate medication best promotes this. The nurse does not determine non-therapeutic medications, the health care provider does. There is no need to clarify with the health care provider SINCE THIS IS NOT AN EMERGENCY. Helping the client place oral medications in a medication organizer and regularly use it also assists the client.

After a change of shift, you are assigned to care for the following patients. Which patient should you assess first? A. A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab. B. A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. C. A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics. D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator.

D. A 50-year old with asthma who complains of shortness of breath after using a bronchodilator. The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications

When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority? A. Each patient is listed on the worksheet. B. Patients who need the least care. C. Medications and treatments required for all patients. D. Patients who need the most care.

D. Patients who need the most care. In setting priorities for a group of patients, those who need the most care should be the number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care can be attended to later or even delegated to assistive personnel according to rules on delegation. The ability to prioritize and manage time is vital for any successful nurse, whether a novice or expert.

The home health nurse is planning teaching for a client with COPD and a history of noncompliance to the medication regimen. Which factor does the nurse recognize as having the most influence on enabling complete adherence to a health regimen? Motivation Self-esteem Cost of medication Education level

Motivation It's hard to teach a client about treating if they don't have the motivation to learn.

The nurse notes that a client who was instructed on how to do a prescribed treatment 1 week ago is unable to perform the task. Which action will the nurse take to improve this client's health literacy? Report the client's nonadherence to the health care provider. Review the material to determine that it is appropriate for the client. Ask the client why the treatment is not being performed as instructed. Determine if there is a family member who can provide the treatment.

Review the material to determine that it is appropriate for the client.

The nurse cares for clients on the medical/surgical unit. After receiving report, which of the following clients should the nurse see FIRST? 1. An elderly client 2 days postop after a total hip replacement who slipped out of bed when trying to stand. 2. An elderly client with a history of cardiomyopathy who aspirated cooked cereal at breakfast. 3. An elderly client diagnosed with a right-sided CVA who requires assistance going to the bathroom. 4. An elderly client diagnosed with heart failure (HF) who has been vomiting for 3 days.

Strategy: Determine the most unstable client. (2) CORRECT— ensure that client has patent airway; at risk to develop pneumonia (1) assess whether dislocation of prosthesis has occurred; airway takes priority (3) ensure client's safety; client with impaired airway takes priority (4) assess this client second; may have digitalis toxicity; circulatory problem

The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST? 1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.

Strategy: Determine the most unstable patient. (3) CORRECT— vital signs indicate shock; most unstable patient (1) does not require immediate attention (2) potential problems; not the most unstable (4) most stable patient of the four; use Maslow hierarchy of needs theory to prioritize; physiological needs take priority; use ABCs

Asking for help from a co-worker or superior is an example of what Quality and Safety in the Education of Nurses (QSEN) competency? Possible Answers: Evidence-based practice Teamwork and collaboration Safety Informatics

Teamwork and collaboration

The nurse is caring for a patient who is to be discharged from the acute care facility to a rehabilitation unit after having a stroke. What type of prevention is this considered to be? Primary Secondary Tertiary Rehabilitation

Tertiary

A community health nurse has witnessed significant shifts in patterns of disease over the course of a four-decade career. Which of the following focuses most clearly demonstrates the changing pattern of disease? Type 1 diabetes management Treatment of community-acquired pneumonia Rehabilitation from traumatic brain injuries Management of acute Staphylococcus aureus infections

Type 1 diabetes management Management of chronic diseases such as diabetes is a priority focus of the current health care environment. Diabetes is a chronic disease.