Capstone Quizlet
The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care?
Client with black tag
Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.
Dry cleaners Dye workers
Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)?
Federal emergency management agency
Who undertakes the responsibility of identifying the need for and calling of different specialty-trained providers to care for clients in a disaster?
Medical command physician
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
Planning
Which fine-motor skills may be observed in an 8 to 10 month-old infant? Select all that apply.
Using pincer grasp well Picking up small objects Showing hand preference
What type of delivery method is used when the nurse provides care to the same client for the entire work period?
Case method The premise of the case method is that one nurse provides total care for one client during the entire work period. In primary nursing, the primary nurse is accountable for the clients' care 24 hours a day from admission through discharge. 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. In the practice partnership model an RN is paired with a technical assistant. The partner works with the RN consistently.
A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what?
Administering a Fleet enema 1 hour before the procedure
Arrange in order the items of personal protection equipment (PPE) removed after performing a surgical procedure.
After performing a surgical procedure, the nurse should remove his or her gloves first to avoid the gloves coming into contact with other equipment. Next, the nurse removes the face shield, followed by the gown and mask. After removing all personal protection equipment (PPE), the nurse should wash his or her hands.
The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session?
Assess the client's barriers to learning self-injection techniques Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.
Which biologic agent of terrorism is treated with antitoxin?
Botulism Botulism is treated with antitoxin, though several vaccines are being studied. Plague and anthrax can be treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant. Smallpox can be prevented or the incidence reduced by vaccination, even when first given after exposure.
What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.
Decreased auditory alertness Ptosis and blurred vision Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.
Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
Red and dry skin Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.
Which tag color according to the disaster triage tag system is assigned to a client who has an immediate threat to life?
Red tag According to the disaster triage tag system, a red colored tag is used for a client who has an immediate threat to life. A black colored tag is used for a client who is expected to die or is dead. Green colored tags are used for a client who has minor injuries. A yellow colored tag is used for a client who has major injuries and is requiring immediate treatment.
A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn?
A 56-year-old client who had a heart attack last week and is requesting information about exercise A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.
An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client?
Certified nurse midwife (CNM)
The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply.
Occupation status Type of insurance Client's age Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.
Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics?
Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.
A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse?
Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.
A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution?
0.9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.
Arrange the order of steps involved in the evidence-based practice process.
1.Ask a clinical question. 2.Collect the most relevant and best evidence. 3.Critically appraise the evidence you gather. 4.Integrate all evidence with one's clinical expertise and client preferences and values in making a practice decision or change. 5.Evaluate the practice decision or change. 6.Share the outcomes of evidence-based practice.
What would be the respiratory rate in two-year-old child?
30 The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?
What should the team leader identify as a priority when assigning clients to team members?
Each team member's strengths Team nursing uses the strengths of each caregiver. This should be a priority when making client assignments. The length of the work shift, number of clients to assign, and amount of time needed to provide care are not as important when assigning clients to team members.
A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan?
Effectiveness of the interventions When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.
The emergency room nurse is training to be a member of a direct response team to respond to community emergencies. Which new triage level would this nurse be required to learn?
Expectant The expectant classification is not a classification level in emergency room triage. The levels urgent, emergent, and nonurgent are all classification levels within an emergency room triage system.
A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed?
Maintaining a patent airway The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurologic assessment for mental status, sensory level, and motor function, which holds a medium priority.
What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?
Previous experience and cultural values Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.
Which personnel are responsible for identifying the need for and calling in specialty trained providers in emergencies?
Medical command physician The medical command physician is responsible for identifying the resource needs of the clients. Therefore the medical command physician identifies the need for and calls in the specialty trained providers in emergencies. Triage officers are responsible for rapidly evaluating each client to determine priorities for treatment. The public information officer serves as a liaison between the healthcare facility and the media. The hospital incident commander is the one who assumes overall leadership for implementing the emergency plan.
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to do what?
Promote cell growth and bone union There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. Intake of a high protein diet during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.
A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what?
Perception of the change It is not the reality of the change, but the client's feeling about the change, that is most important in determining a client's ability to cope. Although the suddenness, obviousness, and extent of the body change are relevant, they are not as significant as the client's perception of the change.
Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?
Performing a jaw thrust maneuver The jaw thrust maneuver is the recommended procedure for opening the airway of an unconscious client with a possible spinal or neck injury. Needle thoracostomy should be performed in a client with absent breath sounds. Cardiopulmonary resuscitation should be initiated in a client when there is no pulse. Providing oxygen via a nonrebreather mask is mainly performed when the client is conscious.
Which caring intervention helps to provide comfort, dignity, respect, and peace to a client?
Relieving pain and suffering Relieving pain and suffering is not just about giving medications but providing comfort, dignity, respect, and peace to a client. Listening helps to obtain meaningful interactions with clients. Spiritual caring helps clients find balance between their own life values, goals, and belief systems. Providing presence helps to convey closeness and a sense of caring.
The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?
Severity of pain
Which theories are most relevant to development in adults? Select all that apply.
Stage-Crisis theory Life Span approach The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with the psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.
The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?
"I should carry objects close to my body. By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.
Which disasters would the nurse categorize as natural events? Select all that apply.
Blizzard Droughts Wildfires
The nurse is caring for four clients in an emergency department. Which client should be given least priority by the primary healthcare provider based on his/her condition?
Client with closed extremity trauma Care for a client with closed extremity trauma could be delayed because it is considered less severe when compared to other client conditions and triaged in emergency severity index (ESI-4). Therefore this client is given least priority. The client with cardiac arrest is triaged under ESI-1 and should be seen immediately as the condition is more severe. The client with abdominal pain is triaged under ESI-3 and should be seen within 1 hour. The client with multiple trauma should be seen within 1 hour and is triaged under ESI-2.
A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client?
Contact an interpreter provided by the hospital
Which nursing care delivery system works well in emergency situations that necessitate prioritization of care?
Functional nursing The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Team nursing, primary nursing, and Patient-Centered nursing delivery systems are not supported by evidence as working well in emergency situations.
Which method of delivering client care works well in disaster situations?
Functional nursing The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Team nursing, primary nursing, and total patient care nursing are not the ideal models for delivering client care during disaster situations.
Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world?
Gerotranscendence theory The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.
Which color tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system?
Green Green-tags clients usually make up the greatest number in most large-scale multi-casualty situations. These clients have minor injuries and they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries. Clients belonging to these three categories usually do not make up the greatest number in most large-scale multi-casualty situations.
Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply.
Growth and development and emotional status are two psychophysiologic factors that influence communication between a nurse and a client. Privacy level is an environmental factor. Information exchange is a situational factor. Level of caring expressed is a relational factor.
An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client?
Heat stroke Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.
In a mass casualty situation, which is the facility-level organizational model for disaster management used by the hospital or long-term care facility?
Hospital Incident Command System (HICS) The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS). It attempts to standardize disaster operations by formally structuring roles under the hospital or long-term care facility incident commander with clear lines of authority and accountability for specific resources. The EOC, NIMS, and FEMA are not facility-level organizational models for disaster management. The EOC is established by the HICS personnel in a designated location with accessible communication technology to manage the overall incident. The NIMS is the overall system for incident management of which the HICS is a part; it is implemented by the Department of Homeland Security and FEMA. The FEMA provides numerous online resources so that people are better prepared for disasters and are able to respond more self-sufficiently to incidents and hazard situations in their own communities.
Which would the nurse consider to be an example of a potential internal disaster?
Hospital fire An internal disaster is any kind of event inside a healthcare facility or campus that could endanger the safety of clients or healthcare staff. A fire in a hospital is an example of an internal disaster that can cause harm to the clients and the staff. A fertilizer plant explosion is an external disaster. A nuclear reactor explosion may cause radiation exposure to the external environment. Terrorism with explosive devices is an external disaster.
The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?
The client's pain is 7 on a scale of 1 to 10 Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data. Objective data are observations or measurements of a client's health status. The client's weight is measured on a weighing scale; therefore, it is objective data. A laboratory result such as fasting blood sugar and blood pressure are measurable quantities.
How often should a healthcare facility that is Joint Commission accredited plan to test the emergency preparedness plan?
Twice a year The Joint Commission mandates that hospitals have an emergency preparedness plan that is tested through drills or actual participation in a real event at least twice yearly. Annually or every 2 years is not frequent enough to test the emergency preparedness plan. It is not necessary to test the plan as frequently as every three months.
The nurse is advising a client to carry a prescription of epinephrine autoinjector. Which insect bite or sting is responsible for the nurse providing this advice?
Wasp
Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?
Atherosclerosis In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention?
Attempt to identify the client's concerns
What is an expectation of a primary nurse?
Coordinate all aspects of a client's care. The primary nurse coordinates all aspects of client care with other nurses as well as other disciplines. The primary nurse does not identify associate nurses. The primary nurse will provide direct care but will not provide all care since the nurse will have scheduled days off from work. Reporting the status of a client to the charge nurse is a feature of team nursing, not primary nursing.
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?
Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and therefore not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and therefore not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and therefore is not the best choice.
The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year?
two
What services can be provided by level II trauma care centers during mass causality events?
Provide care to most injured clients Level II trauma centers are community-based trauma centers that can provide most trauma care to clients. Level III trauma centers can provide care up to the stabilization of clients. A full continuum of trauma services for all clients is provided in Level I trauma centers. Basic trauma client stabilization and advanced life support are provided in Level IV trauma centers.
A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?
Tubing injection port The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired. The nurse should apply a clamp to the drainage tubing, distal to the injection port, not obtain the specimen from this site. Urine in the bedside drainage bag is not an appropriate sample, because the urine in the bag may have been there too long; thus a clean sample cannot be obtained from the bag. The client's urine will be contained in the indwelling catheter; there will be no urine at the insertion site.
How soon should a client with multiple traumas receive treatment according to the five-level emergency severity index (ESI)?
Within 10 minutes Multiple traumas are considered a level 2 on the emergency severity index (ESI) and require treatment within 10 minutes. Life-threatening and organ-threatening conditions such as cardiac arrest and severe respiratory distress need immediate treatment within 5 minutes. Abdominal pain, gynecologic disorders, and hip fracture in elderly require treatment within 1 hour after the incident. Treatment for minor burns, colds, and other minor conditions may be delayed to within 2 days.
