NU471 Week 5 EAQ #4 Evolve Elsevier: Prioritizing Care - Mastery Level Target: Level 3

Which comments by the student nurse indicate the need for the further teaching about caring for the client with sealed implants of radioactive sources? Select all that apply. o "I should encourage visitors to spend as much time as possible with the client for support." o "I should keep visitors at least 3 feet from the source of radiation." o "I should keep the door to the room of the client open as a nursing priority." o "I should deposit the radioactive source in the lead container kept in the client's room." o "I should save all dressings and bed linens in the client's room until after the radioactive source is removed."

o "I should encourage visitors to spend as much time as possible with the client for support." o "I should keep visitors at least 3 feet from the source of radiation." o "I should keep the door to the room of the client open as a nursing priority." · The nurse would limit each visitor to 90 minutes per day. The nurse would keep visitors at least 6 feet from the source of the radiation, not 3 feet. The nurse keeps the door to the client's room closed as much as possible. The nurse would deposit the radioactive source in the lead container kept in the client's room. The nurse would save all dressings and bed linens in the client's room until after the radioactive source is removed.

Which statement(s) made by the student nurse indicates the need for further learning about caring for a hospitalized client with immunosuppression? Select all that apply. o "I should avoid the use of indwelling urinary catheters." o "I should change gauze-containing wound dressings daily." o "I should inspect the client's mouth daily" o "I should monitor the vital signs of the client every 8 hours." o "I should ensure that that the client's room and bathroom are cleaned at least once a week."

o "I should inspect the client's mouth daily" o "I should monitor the vital signs of the client every 8 hours." o "I should ensure that that the client's room and bathroom are cleaned at least once a week." · When caring for a hospitalized immunosuppressed client, it is imperative for the nurse to inspect the mouth of the client at least every 8 hours, not daily. The nurse would monitor the vital signs of the client, including body temperature, every 4 hours, not every 8 hours. The nurse would ensure that that the client's room and bathroom are cleaned at least once daily, not weekly. The nurse would avoid using indwelling urinary catheters. The nurse would change the gauze-containing wound dressings on a daily basis.

Which statements made by a student nurse would a registered nurse need to correct about emergency treatment procedures for the local complication of intravenous therapy involving thrombosis? Select all that apply. o "I should lower the extremity of the client." o "I should apply warm compresses to stabilize the clot." o "I should apply cold compresses to decrease the blood flow." o "I should use low-dose thrombolytic agent that can lyse the clot." o "I should stop the infusion but keep the short peripheral catheter in place."

o "I should lower the extremity of the client." o "I should apply warm compresses to stabilize the clot." o "I should stop the infusion but keep the short peripheral catheter in place." · It is essential that the nurse elevate the extremities of the client. The nurse would always use cold compresses, not warm, to stabilize the clot in case of thrombosis. The nurse would use a low-dose thrombolytic agent that can help in lysing the clot. The nurse would stop the infusion and would remove the short peripheral catheter rather than keeping it in place. It is imperative for the nurse to use cold compresses to decrease the blood flow in case of thrombosis.

Which client would the nurse prioritize when triaging clients in the emergency department? o An adult client experiencing mild chest pain o An adolescent client with a possible fractured wrist o An older adult client with a hip fracture who is in pain o A school-age client with asthma presenting with dyspnea

o A school-age client with asthma presenting with dyspnea · According to the Five-Level Emergency Severity Index (ESI), a client experiencing severe respiratory distress such as the school-age client with asthma who is having difficulty breathing (dyspnea) would receive priority care as an ESI-1. An adult client experiencing mild chest pain would be an ESI-2. An adolescent client with a possible wrist fracture would be an ESI-4. An older adult client with a hip fracture who is experiencing pain would be an ESI-3.

Which action of the nurse is most appropriate when working with a client who has been sexually assaulted? o Monitoring the vital signs and emotional status o Asking the client to brush the teeth and take a bath o Inquiring about the date of the last tetanus immunization o Asking the client to stand on a sheet to remove the clothing

o Asking the client to stand on a sheet to remove the clothing · When assessing a client who has been sexually assaulted, the nurse should place a sheet on floor and ask the client to stand on the sheet to remove clothes. Monitoring the vital signs and emotional status is done last to ensure the client's safety. The nurse should then place the sheet with the clothing in a paper bag for investigation of assault. The client should not brush, take a bath, douche, urinate, or gargle until all evidence is collected. Inquiring about the date of the last tetanus immunization and providing prophylaxis are of medium priority.

Which condition in a client with carbon monoxide poisoning would be given the top priority of care? o Altered mental state o Cardiopulmonary instability o Decreased cerebral function o Increased threshold to visual stimuli

o Cardiopulmonary instability · A client with cardiopulmonary instability has severe carbon monoxide poisoning, which is a life-threatening problem. This client should be given first priority for care. The client with moderate carbon monoxide poisoning may experience an altered mental state and should be given treatment after the clients with severe poisoning are treated. Clients with mild poisoning may exhibit decreased cerebral function, which may not require immediate treatment. The client with an increased threshold to visual stimuli likely has a normal level of exposure to carbon monoxide.

Which of four clients in a pediatric unit of a health care facility would the nurse provide immediate care for first? o Chest pain and diaphoresis o Bruises and superficial lacerations o Severe pain as a result of displaced tendons o Complex lacerations associated with moderate hemorrhage

o Chest pain and diaphoresis · The three-tiered triage system in an emergency department includes emergent, urgent, and nonurgent levels in which care should be provided to the clients accordingly. The client with chest pain and diaphoresis has a life-threatening situation and requires immediate intervention. The client with bruises and superficial lacerations and the client with severe pain resulting from a displaced tendon have urgent situations but can wait for some time. Clients with complex lacerations but with moderate hemorrhage have an urgent situation but can be treated even after some time because there is no life-threatening problem.

Which of the four clients in the postoperative unit should be monitored for fluid volume overload as nursing safety priority? Client A: Client with lymph node dissection Client B: Client with laparoscopic cholecystectomy Client C: Client with surgical intervention for hemorrhoids Client D: Client with liver transplant o Client A o Client B o Client C o Client D

o Client A · The nursing safety priority for client A with lymph node dissection is monitoring for manifestations of fluid overload. The nursing safety priority for client B with laparoscopic cholecystectomy is to assess the oxygen saturation level frequently until the effects of the anesthesia have passed. The nursing safety priority for client C with surgical intervention for hemorrhoids is ensuring the presence of someone near the client during the first postoperative bowel movement because it is very painful. The nursing safety priority for client D with liver transplantation is monitoring for clinical manifestations of rejection such as tachycardia and fever.

The health care triage team is caring for a group of clients who were injured in a large industrial accident. Which client would receive immediate care from the nurse? Client A: Severe open head trauma; bleeding nose Client B: Open fractures; bodily injuries Client C: Bleeding lacerations; severe injuries Client D: Closed fractures; minor wounds o Client A o Client B o Client C o Client D

o Client C · Client C with bleeding lacerations and severe injuries is given immediate care with a red tag, because the client's condition can be treated with the available resources. Client A with severe open head trauma and bleeding from the nose would be given a black tag, because resources may not be sufficient to provide care to the client. Client B with open fractures and bodily injuries is given a yellow tag, and the client is given care after client C. Client D with closed fractures and minor wounds is given a green tag and treated with least priority because his or her condition is stable.

Which client would the nurse categorize as urgent level according to the 3-tiered triage system based on condition? Client A: Stroke Client B: Active hemorrhage Client C: Pneumonia Client D: Skin rash o Client A o Client B o Client C o Client D

o Client C · The 3-tiered triage system classifies clients into 3 levels based on their conditions. The urgent level includes those clients who need quick treatment but do not have immediate life-threatening complications. Client C with pneumonia is categorized as urgent level because pneumonia is not immediately life-threatening but does require immediate treatment. Client A has stroke, which is life threatening and is classified as emergent level. Client B has active hemorrhage, which is life threatening and is classified as emergent level. Client D has skin rash, which does not require immediate treatment and is classified as a nonurgent level.

Which action would the nurse take when caring for clients through a Community-Based Care Transition Program (CCTP)? o Asking a pharmacist to review expected effects of a medication to a client o Contacting the client and health care provider through a conference call line to discuss medication issues o Reporting that a client's temperature has increased while receiving a unit of packed red blood cells o Directing unlicensed assistive personnel (UAP) to measure vital signs and pass linen on an assigned group of clients

o Contacting the client and health care provider through a conference call line to discuss medication issues · One activity within a Community-Based Care Transition Program (CCTP) is assisting with communication between the client and primary and specialty caregivers. Contacting the client and health care provider through a conference call line to discuss medication issues would be an example of this activity. Asking a pharmacist to review medication effects would be a part of the client-focused care delivery system. Reporting a client's change in vital signs would be an activity conducted by a nurse providing care in a variety of delivery systems. Directing UAP to measure vital signs and pass linen would be direction provided by a team leader.

According to priority, in which order would the nurse perform the following interventions for a client with injuries from a motor vehicle collision? o Elevate the injured limb. o Apply ice packs. o Monitor for temperature elevation. o Control external bleeding.

o Control external bleeding. o Elevate the injured limb. o Apply ice packs. o Monitor for temperature elevation. · Clients who sustained injuries from a motor vehicle collision should be first assessed for bleeding areas. The bleeding should be controlled either by applying direct pressure or by elevating the extremity. Elevating the injured limb should be done next. Ice packs should be applied to the injured sites to relieve pain. Monitoring temperature is an ongoing assessment that will begin after providing complete treatment.

Which kind of snakebite requires the priority of ensuring that the client's airway is patent and that resuscitation equipment is immediately available? o Rattlesnake o Coral snake o Copperhead o Cottonmouth

o Coral snake · The client has been bitten by a coral snake, and the physiological effect of the venom involves blocking of neurotransmission, which produces weakness, cranial nerve deficits, an altered level of consciousness, and, ultimately, respiratory paralysis. Rattlesnakes, copperheads, and cottonmouths are in the category of pit vipers.

Which client conditions if selected by the student nurse as lowest priorities of care would indicate effective understanding of prioritizing care for clients with different conditions in an emergency department? Select all that apply. o Cystitis o Cold symptoms o Closed fracture o Intubation trauma o Moderate abdominal pain

o Cystitis o Cold symptoms o Moderate abdominal pain · Care for clients with cystitis and cold symptoms can be delayed because these conditions may be stable when compared with conditions of other clients and these are not life-threatening conditions. Clients with closed fractures can be cared for within an hour. The client with intubation trauma should be given immediate care because the client's condition with trauma may not be stable. The client with moderate abdominal pain can wait for some time to receive care.

Which nursing actions have the highest priority when caring for a client who presents to the emergency department (ED) in cardiac arrest? Select all that apply. o Documenting care o Notifying family members o Determining the need for rapid defibrillation o Administering pain medication o Performing adequate chest compressions

o Determining the need for rapid defibrillation o Performing adequate chest compressions · The priority nursing actions for a client who presents with cardiac arrest include determining need for rapid defibrillation and performing adequate chest compressions. Documenting care, notifying family members, and administering pain medications are all appropriate nursing actions, but these to not address the client's immediate life-threatening condition.

In which order would the nurse perform secondary survey assessments for a group of clients during an emergency situation? o Focused adjuncts o Comfort measures o Full set of vital signs o Inspecting posterior surfaces o Facilitating family presence

o Full set of vital signs o Focused adjuncts o Facilitating family presence o Comfort measures o Inspecting posterior surfaces · The secondary survey is a brief, systematic process that is performed as a part of emergency assessment. It identifies all injuries after addressing each step of the primary survey and before beginning any lifesaving interventions. The full set of vital signs should be obtained first and includes blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. This is followed by assessing focused adjuncts to determine additional procedures. Then the family presence should be facilitated to determine their desire to be present during invasive procedures. Then the nurse would provide comfort measures and finally inspect posterior surfaces.

Which conditions of the client with chronic pain who is on opioid treatment would the nurse consider as the highest priority? Select all that apply. o Pruritus o Level 3 sedation o Constipation o Respiratory rate of 8 breaths per minute o Nausea and vomiting

o Level 3 sedation o Respiratory rate of 8 breaths per minute · Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation, and respiratory distress. The client with a level 3 of sedation has frequent drowsiness, arousals, and episodes of sleep during conversation and needs immediate intervention. A respiratory rate of 8 breaths per minute leads to respiratory distress, which must be supported by adequate oxygenation. Pruritus can be resolved slowly because it is less life threatening. Constipation can be relieved by providing the client with a stimulant laxative and a stool softener. Nausea and vomiting may be resolved by providing antiemetics to the client.

What action is most appropriate for the nurse to take for a client who began receiving furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L (2.8 mmol/L)? o Hold the morning dose of the diuretic and have the laboratory repeat the test. o Continue to monitor the level to ensure that it stays within the normal limits. o Notify the primary health care provider of the critically low result. o Anticipate a prescription for an increase in the dosage of the furosemide.

o Notify the primary health care provider of the critically low result. · The health care provider should be notified because a potassium level of 2.8 mEq/L (2.8 mmol/L) is low. Normal range for serum potassium is 3.5 to 5 mEq/L (3.5-5 mmol/L). Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. The nurse should not hold the diuretic or repeat the laboratory test unless advised by the health care provider. The client's serum potassium level is critically below the normal limit, and the health care provider should be notified. An increase in furosemide would cause an increased loss of potassium.

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the postanesthesia care unit (PACU) who had an abdominal cholecystectomy? o Change the dressing. o Reinforce the dressing. o Replace the tape with Montgomery ties. o Support the incision with an abdominal binder.

o Reinforce the dressing. · The nurse would anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time.

In which order based on priority would the emergency department nurse perform interventions for a severely traumatized client with difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin? o Apply bandages on the bruises. o Administer intravenous glucose. o Remove the debris from the mouth. o Apply pressure bandages to the bleeding areas.

o Remove the debris from the mouth. o Apply pressure bandages to the bleeding areas. o Administer intravenous glucose. o Apply bandages on the bruises. The highest priority intervention for a severely traumatized client is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. The priority nursing intervention is to remove the debris from the client's mouth to ensure a patent airway. After ensuring a patent airway, the priority is to ensure effective circulation. External hemorrhage may cause shock and pressure bandages are applied to manage severe bleeding. After ensuring effective breathing and circulation, metabolic abnormalities are assessed. The nurse administers intravenous glucose to correct hypoglycemia. A bruise

The emergency department nurse would provide immediate care based on priority to the client with which condition? o Second-degree burns o Blunt abdominal trauma o Closed fracture of the right arm o Repeated tonic-clonic seizures

o Repeated tonic-clonic seizures · The client with tonic-clonic seizures may experience severe muscle contractions, which is a life-threatening complication. This client should be provided with immediate care. Clients with second-degree burns should be given second priority of care because their conditions may worsen if treatment is not provided as early as possible. Blunt abdominal trauma can be a serious condition if internal bleeding is found, but still does not require as immediate care as the seizures. Clients with closed arm fractures can be provided with care later, depending on the other clients in the emergency department.

In which order would the nurse care for the clients according to priority for receiving care by condition? o Neck sprain o Shortness of breath o Severe abdominal pain o Simple hip fracture

o Shortness of breath o Severe abdominal pain o Simple hip fracture o Neck sprain · The 3-tiered triage system in the emergency department includes emergent, urgent, and nonurgent levels in which the clients should be cared for accordingly. A client reporting shortness of breath indicates a life-threatening situation in which the client requires immediate intervention. The client reporting severe abdominal pain may not be in a life-threatening condition, and the treatment can be delayed for some time. Simple fractures and sprains indicate nonurgent situations in which the client can be treated even after a few hours because there is no life-threatening problem.

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client? o Oral hydroxyurea o Vitamin B12 injections o Oral iron supplements o Erythropoietin injections

o Vitamin B12 injections · A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200-835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia because of a vitamin B12 deficiency and should be given vitamin B12 injections. Vitamin B12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb vitamin B12. Hydroxyurea is administered orally to clients with hemochromatosis. Oral iron supplements are given to clients with iron-deficiency anemia. Erythropoietin injections are given to clients who have low red blood cells, hemoglobin, and hematocrit.

Which intervention is a priority in the care of clients with frostbite? o Administering analgesics o Warming the frostbite area in water bath o Elevating the area above heart level o Applying a loose, nonadherent sterile dressing

o Warming the frostbite area in water bath · For clients suffering partial-thickness to full-thickness frostbite, rewarming in a water bath at a temperature range of 104°F to 108°F (40°C to 42.2°C) is needed to thaw the frozen part. The client may experience severe pain during this process. The client should be administered analgesics, especially intravenous opiates. When the rewarming process is complete, the injured area should be gently handled and elevated above heart level to decrease tissue edema. Then the area should be covered with a loose and nonadherent sterile dressing.