Nur 204 exam 1

Which condition would the nurse give the highestpriority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia? Hypoglycemia Chest wall trauma Airway obstruction External hemorrhage

Airway obstruction The highest priority intervention is to establish a patent airway because inadequate oxygen supply to the brain may quickly cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.

Which actions by the nurse is a priority when caring for a client who reports sudden onset of dyspnea and has a stridor on the first postoperative day after a pneumonectomy ? A. Activate the rapid response team B. Check the chest tube drainage. C. Inspect the incision for bleeding D. Auscultate the breath sounds.

A. Activate the rapid response team Sudden onset of shortness of breath and stridor may indicate compression of the trachea, larynx, and remaining lung by mediastinal shift. The rapid response team would be notified so that needed collaborative actions such as intubation, mechanical ventilation, and infusion of intravenous fluids can be rapidly implemented. Because chest tubes are not needed to assist with lung reinflation after pneumonectomy, if a chest tube is place, it will be clamped and no drainage will be present. The nurse will check for incisional bleeding, but bleeding would not cause the client's current symptoms. Breath sounds will be auscultated, but the rapid response team should be activated first, because a team of health care professionals will be needed to address the client's complication.

Which important component is included in the nurse's advocate role for a victim of intimate partner violence (IPV)? Select all the apply. One, some, or all responses may be correct. A. Planning for future safety B. Normalizing victimization C. Validating the experiences D. Promoting access to community services E. Providing housing for the victim

A. Planning for future safety C. Validating the experiences D. Promoting access to community services The nurse would include planning for future safety, validating the experiences and promoting access to community services. Planning for the client's future safety need , validating the client's experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victims relationship and failing to respond to the disclosure of the adbuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.

The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. Which instruction would the nurse include in the teaching plan? Select all that apply. One, some, or all responses may be correct. A. The client should obtain a finger-stick blood glucose reading before each meal. B. The client does not need to follow a specific diet until insulin is required. C. The teaching plan should include signs and symptoms of hypoglycemia D. The teaching plan should include how to administer regular insulin. E. The teaching plan should include sick day rules.

A. The client should obtain a finger-stick blood glucose reading before each meal. C. The teaching plan should include signs and symptoms of hypoglycemia E. The teaching plan should include sick day rules. All diabetic clients, regardless of type, should check finger-stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore, the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day rules. All diabetic clients should follow the American Diabetes Association diet. The teaching plan is focusing on oral antidiabetic medications; therefore, regular inulin education would not be needed.

Which strategy would improve safety when the nurse manager institutes strategies to decrease the omission of important information during communication between staff nurses and health career providers ? A. Require health care providers to print prescriptions instead of using cursive writing B. Use the "read-back" method when taking phone prescriptions from health care providers C. Employ SBAR (situation, background, assessment, and recommendation) communication D. Devise standing orders for the five most common admitting diagnoses on the client care unit

C. Employ SBAR (situation, background, assessment, and recommendation) communication to improve communication and prevent omissions of important information between staff nurses and health care providers, the nurse manager could employ SBAR communication as a guiding framework. Handwritten prescriptions should bee avoided, but, if the need presents, the health care provider should take care to write legibly, and the nurses should verify the understanding of the written prescription. Using the read back method is helpful for telephone prescriptions if electronic medical records are not in use; however, it does not guarantee that there will be no omissions of information.