The patient is admitted to the cardiac unit.
Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?
STAT
prn
One-time
Standing
The Correct Answer is D
Choice A rationale:
STAT orders are urgent and require immediate action. They are typically used for life-threatening situations or when a rapid response is needed to prevent serious harm. In this case, an EKG is important for patients admitted to the cardiac unit, but it is not necessarily an urgent procedure that requires immediate action in all cases.
STAT orders are often given verbally or over the phone, and they are typically written in all capital letters with the word "STAT" prominently displayed.
Examples of STAT orders include medications for cardiac arrest, intubation for respiratory distress, or emergency surgery for a ruptured appendix.
Choice B rationale:
PRN orders are "as needed" orders, meaning they are only carried out when a specific condition or symptom arises. They are not routinely implemented for all patients in a particular unit or setting.
PRN orders allow for flexibility in treatment plans and can help to manage pain, nausea, anxiety, or other symptoms that may fluctuate over time.
Examples of PRN orders include pain medication, anti-nausea medication, or sedatives.
Choice C rationale:
One-time orders are administered only once and are not repeated. They are often used for procedures, diagnostic tests, or medications that are not required on an ongoing basis.
In this case, an EKG is typically a one-time order for patients outside of the cardiac unit, but it becomes a standing order for patients admitted to the cardiac unit due to the increased importance of cardiac monitoring in this setting.
Examples of one-time orders include a chest X-ray, a blood draw, or a dose of antibiotics.
Choice D rationale:
Standing orders are routine orders that are implemented for all patients in a particular unit or setting, unless otherwise specified. They are designed to provide consistent and standardized care, and they often reflect best practices or guidelines for a specific patient population.
Standing orders can help to streamline care processes, reduce the need for individual orders, and ensure that patients receive necessary treatments or interventions without delay.
In this case, the standing order for an EKG upon admission to the cardiac unit ensures that all patients receive this important cardiac assessment, even if the ordering provider does not specifically write an order for it.
Other examples of standing orders in a cardiac unit might include daily weights, regular vital sign checks, or administration of cardiac medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Indurated describes tissue that is hardened and thickened, typically due to inflammation or fibrosis. While a decubitus ulcer with thick necrotic tissue may feel firm to the touch, induration does not accurately capture the extent of tissue damage and depth of the wound.
Indurated tissue often feels leathery or stiff, while necrotic tissue can be more varied in texture, ranging from dry and crusty to soft and sloughy.
Additionally, induration can occur in wounds that are not full-thickness ulcers, such as pressure injuries that have not yet progressed to the point of tissue loss.
Choice B rationale:
Fluctuant describes a fluid-filled cavity beneath the skin. While a decubitus ulcer with thick necrotic tissue may have some underlying fluid, it would not typically be described as fluctuant.
Fluctuance is more characteristic of abscesses or other fluid collections that have a distinct, palpable pocket of fluid.
The presence of thick necrotic tissue in a decubitus ulcer can obscure the presence of any underlying fluid, making it difficult to assess for fluctuance.
Choice D rationale:
Macerated describes skin that is softened and broken down due to prolonged exposure to moisture. While maceration can occur in the surrounding skin of a decubitus ulcer, it does not accurately describe the ulcer itself.
Maceration is typically seen in areas where skin folds rub together, such as the groin or armpits, and is often associated with incontinence or excessive sweating.
The presence of thick necrotic tissue in a decubitus ulcer indicates a more advanced stage of tissue damage that is not simply due to moisture exposure.
Choice C rationale:
Unstageable is the most accurate term to describe a decubitus ulcer with thick necrotic tissue because it indicates that the extent of tissue damage cannot be fully assessed.
Thick necrotic tissue obscures the base of the wound and the surrounding tissue, making it impossible to determine the depth of the ulcer or the extent of undermining.
This lack of visibility prevents accurate staging of the ulcer using the traditional pressure ulcer staging system, which categorizes ulcers based on their depth and extent of tissue involvement.
Therefore, unstageable is the most appropriate term to describe a decubitus ulcer with thick necrotic tissue.
Correct Answer is C
Explanation
Choice A rationale:
While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.
Choice B rationale:
Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.
Choice D rationale:
Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.
Choice C rationale:
Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:
Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.
Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.
Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.
By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.
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