NCLEX EAQ 9 Health Care delivery and infrastructure

Which theme is part of the design of "Transforming Care at the Bedside"? 1 Validity 2 Reliability 3 Cost-effectiveness 4 Evidence-based practice

Correct2 Reliability In the Transforming Care at the Bedside model, reliability is a theme that ensures the care provided for moderately sick clients who are hospitalized is safe, reliable, effective, and equitable. Validity, cost-effectiveness, and evidence-based practice are not themes within the design of Transforming Care at the Bedside.

A client with diabetes mellitus experiences a sudden fall in blood glucose levels while traveling by air. The client is not carrying any medications or a copy of a personal medical record. Which type of health information technology would be beneficial for this client? 1 Personal health record (PHR) 2 Clinical health care informatics 3 Electronic medical record (EMR) 4 Regional health information organization (RHIO)

1 Personal health record (PHR) The PHR is an electronic health record that consists of health data and the treatment provided for the client. The client can enter the data and maintain these health records. It is easy to carry and helps health care providers provide treatment in emergency conditions. Health care facilities maintain an EMR for each client. The client does not have access to these records in the air. Clinical health care informatics seeks to transform client health by educating and training health care professionals. It does not help provide emergency treatment to the client while traveling. RHIO oversees the exchange of the client's information among the client's health care providers and across geographic areas

Which threats included in the term "NBC" lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. One, some, or all responses may be correct. 1 Nuclear 2 Biological 3 Botulism 4 Chemical 5 Nipah virus

1,2,4 The term "NBC" was coined to describe nuclear, biological, and chemical threats. In response, EMS agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. Botulism and Nipah virus are two specific examples of biological threats.

In which instances can an adult give consent for a minor's medical treatment? Select all that apply. One, some, or all responses may be correct. 1 As the guardian for a ward 2 As the parent of an emancipated minor 3 As the parent of an unemancipated minor 4 As an adult for the treatment of his or her minor brother or sister (if an emergency and parents are not present) 5 As a grandparent for a minor grandchild under normal circumstances

1,3,4 An adult can give consent for medical treatment as a guardian for his or her ward. An adult can give consent for medical treatment as a parent for his or her unemancipated minor. An adult can give consent for the medical treatment of his or her brother or sister in case of an emergency if the client's parents are not present. An adult cannot give consent for his or her emancipated minor. An adult can only give consent as a grandparent for a minor grandchild in emergency cases when the parents are not present.

Which terms, synonymous with critical pathways, will the nurse educator include in a presentation regarding the role of the case manager? Select all that apply. One, some, or all responses may be correct. 1 Critical path 2 Plan of care 3 Integrated care pathway 4 Collaborative care pathway 5 Multidisciplinary care pathway

1,3,4,5 Critical path, integrated care pathway, collaborative care pathway, and multidisciplinary care pathway are all terms that are synonymous with critical pathways that the nurse educator can include when presenting information regarding the role of case manager. Plan of care is not synonymous with critical pathways.

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. One, some, or all responses may be correct. 1 Client is able to self-administer pain-relieving medications as necessary 2 Amount of medication received is determined entirely by the client 3 Decreases client dependency 4 Relieves the nurse of monitoring the client 5 Increases client sense of autonomy

1,3,5 The purpose of patient-controlled analgesia is to give the client the ability to self-administer pain-relieving medications as necessary; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Medication levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. The client isn't dependent on the nurse availability to administer medication. This increases the client's sense of autonomy. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with the prescribed narcotic, and charting the amount administered and the client's response are required.

Before client examination, the registered nurse provides education for a student nurse regarding the gross anatomy and physiology of the kidneys. Which statement made by the student nurse indicates the need for additional teaching? 1 "The right kidney is a little longer and narrower than the left kidney." 2 "The existence of three kidneys with normal kidney function is normal." 3 "The presence of a single kidney with normal kidney function is normal." 4 "The urinary bladder lies directly behind the pubic bone."

Correct1 "The right kidney is a little longer and narrower than the left kidney." Generally in a human body, the left-side kidney is slightly longer and narrower compared with the right-side kidney. The nurse should intervene to correct this misconception. All the other statements are correct. There could be three kidneys in a human body, and as long as the kidney function is normal, the client would be normal. A single horseshoe-shaped kidney could occasionally be found in certain clients, and this is normal if the kidney function is normal. The urinary bladder lies directly behind the pubic bone.

Which is the most important action the nurse would take in preparation for a lumbar puncture for a child with a tentative diagnosis of bacterial meningitis? 1 Asking the parents what they were told about the test 2 Using a doll to demonstrate the procedure to the child 3 Obtaining a pacifier for the child to suck on during the procedure 4 Telling the parents that they may stay with their child during the test

Correct1 Asking the parents what they were told about the test Informed consent is required. The procedure should be explained to the parents by the health care practitioner, and the nurse would confirm the parents' comprehension and have them sign the consent form. The child is too young to comprehend a demonstration of the procedure. Although staying with the child may be important to the parents, it is not the priority. Although a pacifier may keep the child calm, this is not the priority either.

During the delegation process, which health care professional acts as a liaison between the team leader and health care providers? 1 Charge nurse 2 Nurse manager 3 Nursing supervisor 4 Chief nursing officer

Correct1 Charge nurse The charge nurse is responsible for acting as a liaison between the team leader and health care providers. The nurse manager cannot act as a liaison between the team leader and other health care providers because the nurse manager is often responsible for more than one unit and has other managerial responsibilities. The nursing supervisor will be delegated to supervise and ensure effective outcomes for the tasks delegated to the delegatees. The chief nursing officer is responsible for establishing the systems for assessment.

A Spanish-speaking client is being cared for by English-speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client? 1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.

Correct1 Contact an interpreter provided by the hospital. Interpreters provided by the health care organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate health care information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A client is admitted to the hospital for an adrenalectomy. Before the client's replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication? 1 Hypotension 2 Hypokalemia 3 Hypernatremia 4 Hyperglycemia

Correct1 Hypotension Because of instability of the vascular system and the lability of circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy. Hyperglycemia is a sign of excessive adrenal hormones; after an adrenalectomy, adrenal hormones are not secreted. Sodium retention is a sign of hyperadrenalism; it does not occur after the adrenals are removed. Potassium excretion is a response to excessive adrenal hormones; after an adrenalectomy, adrenal hormones are decreased until replacement therapy is regulated.

Which role would the unlicensed assistive personnel (UAP) have when caring for a client receiving intravenous (IV) therapy? 1 Monitoring clinical manifestations 2 Collecting the data to be used in the assessment of the IV site 3 Administering IV fluids and medications 4 Evaluating the client for clinical manifestations

Correct1 Monitoring clinical manifestations In IV therapy the role of the registered nurse (RN) is to collect the data that can be used in the assessment of the IV site. Monitoring clinical manifestations is performed by the unlicensed assistive personnel and the data are reported to the RN. Administering IV fluids and medications is done by an RN or licensed practical nurse (LPN). Evaluating the client for clinical manifestations is performed by the RN.

Between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. Which is the priority nursing action? 1 Notify the health care provider. 2 Resume continuous fetal heart monitoring. 3 Continue to monitor the maternal vital signs. 4 Document the fetal heart rate as an expected response to contractions.

Correct1 Notify the health care provider. The expected FHR is 110 to 160 beats/min between contractions. An FHR of 100 beats/min is bradycardia (baseline FHR slower than 110 beats/min) and indicates that the fetus may be compromised, requiring notifying the health care provider and medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. Although a fetal heart rate slower than 110 beats/minute should be documented, it is not an expected response.

Which delivery system was developed to provide care through others as an adaptation to functional nursing? 1 Team 2 Primary 3 Case management 4 Differentiated practice

Correct1 Team The hallmark of team nursing is "care through others," which was designed as an adaptation to functional nursing. Primary nursing is an adaptation to the case method. Case management is the process of coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes. Differentiated practice consists of models of care delivery that are differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision-making.

Which definition of assault would the nurse include in teaching a group of parents about child abuse? 1 Threat to do bodily harm to another person 2 An unintentional act committed by one person against another person 3 A legal wrong committed against the public that is punishable by federal law 4 The application of force to another person without lawful justification

Correct1 Threat to do bodily harm to another person Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by federal law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery. Assault is not defined as an unintentional act committed by one person against another.

Which variable is an internal variable? 1 Family practices Correct2 Emotional factors 3 Cultural background 4 Socioeconomic factors

Correct2 Emotional factors Emotional factors are internal variables. Family practices, cultural background, and socioeconomic factors are external variables.

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. Which should promote psychological adjustment and early function immediately after surgery? 1 Allow the client to change the first dressing. 2 Help the client adjust to the temporary prosthesis. 3 Assign the client to a room with another adolescent. 4 Have the client meet with a member of a cancer survivor organization.

Correct2 Help the client adjust to the temporary prosthesis. A temporary prosthesis attached to a cast with a metal extension can be applied immediately after surgery. This will allow the adolescent to walk within several hours and helps start the adjustment process. The first dressing change is usually done by a member of the surgical team; also, this is too early to expect the adolescent to be ready to look at the surgical site. Assigning the adolescent to a particular room is usually done out of necessity rather than to promote psychologic adjustment. It is too early to have another cancer survivor visit, but this may be done later in the recovery process.

Which is the priority nursing care after a child has a cardiac catheterization procedure? 1 Encouraging early ambulation 2 Monitoring the site for bleeding 3 Restricting fluids until the blood pressure has stabilized 4 Comparing blood pressure readings in the lower extremities

Correct2 Monitoring the site for bleeding Hemorrhage is a major life-threatening complication because arterial blood is under pressure and a catheter has been inserted into an artery. The child is kept in bed for 6 to 8 hours after an arterial catheterization. Fluids may be given as soon as they are tolerated. Pulses, not blood pressure, must be compared for quality and symmetry.

Which task is achieved by the delegator when engaging in self-care to enhance his or her ability to care for the health care team? 1 Managing 2 Renewing 3 Explaining 4 Motivating

Correct2 Renewing Renewing is the task achieved by the delegator when engaging in self-care to enhance his or her ability to care for the health care team. Managing is achieved when the delegator assists the staff in planning, priority setting, and decision-making. Explaining occurs when the delegator teaches and interprets information for client well-being. Motivating is achieved when the delegator inspires the staff to fulfill a mission.

Which does beneficence in health ethics refer to? 1 The agreement to keep promises 2 Taking positive actions to help others 3 The ability to answer for one's actions 4 Avoiding harming or hurting an individual

Correct2 Taking positive actions to help others Beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Accountability refers to the ability to answer for one's actions. Nonmaleficence refers to avoiding harm to an individual.

Which statement made by the nursing student needs correction about Maslow's hierarchy of needs? 1 "The hierarchy of basic human needs includes five levels of priority." 2 "The second level includes safety and security needs, which involve physical and psychological security." 3 "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." 4 "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."

Correct3 "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization.

Clients with which color triage tag are often referred to as the "walking wounded" in a mass casualty scene? 1 Red 2 Black 3 Green 4 Yellow

Correct3 Green Green-tagged clients have minor injuries that can be managed in a delayed fashion, and they can evacuate themselves from the mass casualty scene and leave by private vehicle. They are termed the "walking wounded" clients. Red-tagged clients need immediate intervention because they have an immediate threat to life. Black-tagged clients are those who are dead or considered about to die. Yellow-tagged clients also have major injuries that need treatment within 30 minutes to 2 hours and are not considered "walking wounded" clients.

Who has the authority to decide if a postmortem will be conducted if a client dies 2 hours after being admitted to the hospital? 1 Surviving spouse 2 Nursing manager 3 Medical examiner 4 Primary health care provider

Correct3 Medical examiner If a client dies within 24 hours of being admitted to the hospital, the medical examiner has the right to decide whether a postmortem will be conducted. If the client's death does not need to be reviewed by the medical examiner and the client has not requested an autopsy in writing, the surviving spouse may request a postmortem. The nursing manager and the primary health care provider are not authorized to make decisions regarding a postmortem.

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? 1 Develop a basic teaching plan. 2 Ask the mother if she understands. 3 Observe the mother feeding the infant. 4 Determine the mother's readiness to learn.

Correct3 Observe the mother feeding the infant. A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.

Which events can result in an adventitious crisis? Select all that apply. One, some, or all responses may be correct. 1 Divorce 2 Marriage 3 Terrorism 4 Earthquake 5 Mental illness

Correct3 Terrorism Correct4 Earthquake Adventitious crises result from events that are unplanned and that may be accidental, caused by nature, or human-made. Terrorism and earthquakes can result in adventitious crises. Situational crises arise from events that are extraordinary, external rather than internal, and often unanticipated. Divorce can precipitate situational crisis. As the maturation process occurs across the life cycle each developmental stage represents a maturational crisis. Marriage is an example that can precipitate maturational crisis. Mental illness can also precipitate a situational crisis.

Which is the rationale for performing sponge, needle, and instrument counts in the operating room? 1 The hospital is not liable if a client is injured resulting from a retained sponge or instrument. 2 The nursing student is liable for client injuries resulting from a retained sponge or instrument. 3 The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. 4 The primary health care provider is responsible for providing an accurate count of sponges and instruments.

Correct3 The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. The nurse would perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury resulting from a retained sponge or instrument, the hospital is liable if the nurse recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary health care provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container? 1 Bubble wrap/packaging wrap 2 A garbage bag in the trash can 3 A cardboard box with a firmly secured lid 4 A plastic liquid detergent bottle with a screw-top lid

Correct4 A plastic liquid detergent bottle with a screw-top lid Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which accurately describes hospice care? 1 A resident's temporary or permanent home, where the surroundings have been made as homelike as possible 2 Offers an attractive long-term care setting with an environment akin to the client's home, which offers the client greater autonomy 3 Service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult 4 System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness

Correct4 System of family-centered care that allows clients to remain at home in comfort while easing the pains of terminal illness Hospice care is a system of family-centered care that allows clients to remain at home in comfort while easing the pain of terminal illness. A nursing center is a resident's temporary or permanent home, where the surroundings are made as homelike as possible. Assisted living offers an attractive long-term care setting with an environment that is like the client's home and offers the client greater autonomy. Respite care is a service that provides short-term relief for people providing home care to an ill, disabled, or frail older adult.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? 1 Notifying the receiving unit of the transfer 2 Having the client's records ready for the transfer 3 Verifying that the family has been notified of the transfer 4 Validating availability of a bag-valve-mask during the transfer

Correct4 Validating availability of a bag-valve-mask during the transfer Validating availability of a bag-valve-mask during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important, but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important, but not of primary urgency; the respiratory status is the priority. Verifying notification of the family regarding the transfer is important, but not of primary urgency; the respiratory status is the priority.

Which example is representative of a passive strategy for health promotion? Select all that apply. One, some, or all responses may be correct. 1 Offering healthy nutrition classes 2 Engaging clients in wellness programs 3 Ensuring that parents to properly use child safety seats 4 Encouraging client engagement in exercise programs 5 Lobbying for government funds to address potential lead in local water

Correct5 Lobbying for government funds to address potential lead in local water Passive strategies include public health or governmental interventions such as clean water legislation. Active strategies are those that actively engage an individual through changes in lifestyle such as nutrition classes, wellness programs, use of child safety seats, and participation in exercise programs