Review NURS 4500 Examplify Thomas Edison state University

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NURS 4500 Examplify Thomas Edison state University

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Total Questions : 68

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Question 1:

A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

A. A client admitted for a cholecystectomy 2 days ago with decreased bowel sounds. B. A client admitted for diabetes mellitus with a blood glucose of 140 mg/dL. C. A client admitted for a left femur fracture with new-onset confusion. D. A client admitted for dehydration with a BP of 105/77 mm Hg.

Answer and Explanation

Choice A:

A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B:

A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C:

A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D:

A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

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Question 2:

The nurse is reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?

A. A hematocrit of 33.4%. B. A white blood cell count of 15.5 x10/uL. C. A platelet count of 386,000 mm³. D. A hemoglobin of 12.2 g/dL.

Answer and Explanation

Choice A:

A hematocrit level of 33.4% is slightly below the normal range, which may indicate mild anemia. While this is important to monitor, it is not as urgent as a high white blood cell count, which could indicate an infection. Mild anemia can typically be managed perioperatively without significant risk.

Choice B:

A white blood cell count of 15.5 x10/uL is significantly elevated and suggests an active infection or inflammatory process. Before proceeding with surgery, it is crucial to identify and treat any infections to prevent postoperative complications, such as sepsis. This value is the most critical to report to the healthcare provider to ensure the safety of the surgical procedure.

Choice C:

A platelet count of 386,000 mm³ is within the normal range and does not indicate any immediate risk of bleeding or clotting disorders. Thus, this value does not necessitate urgent reporting before surgery.

Choice D:

A hemoglobin level of 12.2 g/dL is at the lower end of the normal range, indicating borderline anemia. Although it is important to consider, it does not present as immediate a concern as a potential infection. The surgery can generally proceed with closer monitoring of the client's hemoglobin levels.

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Question 3:

A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

A. Red B. Green C. Black D. Yellow

Answer and Explanation

Choice A:

The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening. Therefore, the red category is not applicable.

Choice B:

The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring.

Choice C:

The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category. Therefore, this category is not suitable for the client's condition.

Choice D:

The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.

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Question 4:

The nurse is caring for a hospitalized client who is found lying on the floor next to the bed. After completing the client assessment and notifying the provider, the nurse completes a hospital incident report. Which statements represent correct documentation that should be included in the report? (Select all that apply)

A. The client fell out of bed. B. The client's vital signs are blood pressure 165/78, pulse 78, and respirations 16. C. No bruises or injuries noted on the client. D. The client apparently climbed over the side rails unwitnessed. E. The health care provider was notified that the client was found on the floor next to the bed.

Answer and Explanation

Choice A:

The statement "The client fell out of bed" is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions. Therefore, this statement should not be included in the incident report.

Choice B:

Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.

Choice C:

Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.

Choice D:

The statement "The client apparently climbed over the side rails unwitnessed" includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.

Choice E:

Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.

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Question 5:

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

A. Obtain a routine urine sample from a newly-admitted client. B. Pass fresh water to clients on the unit. C. Transport a client to the radiology department for an x-ray. D. Take an arterial blood gas (ABG) specimen to the laboratory.

Answer and Explanation

Choice A:

Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive.

Choice B:

Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed.

Choice C:

Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status.

Choice D:

Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.

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Question 6:

The newly hired nurse educator for the emergency department is reviewing the hospital disaster plan and policies and finds that it has not been reviewed with the staff for 3 years. Which finding would be most important for the nurse educator to address related to the disaster plan?

A. Stockpiles of medications and resuscitation equipment may be depleted. B. Resources within the hospital are likely to have changed. C. New staff is unlikely to have training and practice in using the plan. D. Surrounding communities are at an increased risk for technologic disasters.

Answer and Explanation

Choice A:

Depleted stockpiles of medications and resuscitation equipment is a critical concern during a disaster, as it can directly impact the ability to provide care. However, this can typically be addressed by restocking and checking inventory regularly. It is not as immediately crucial as ensuring that all staff are trained and prepared to execute the disaster plan.

Choice B:

Changes in hospital resources, such as personnel and infrastructure, can affect the execution of a disaster plan. While this is significant, the most pressing issue is ensuring that the new staff, who may be unfamiliar with the disaster protocols, are adequately trained and ready to respond effectively in an emergency.

Choice C:

New staff lacking training and practice in using the disaster plan is the most important finding to address. In a disaster, the ability to implement the plan swiftly and effectively can save lives. Untrained staff may not know their roles, how to use equipment, or the procedures to follow, leading to chaos and ineffective response. Therefore, it is crucial to ensure all staff are familiar with and have practiced the disaster plan.

Choice D:

The risk of technologic disasters in surrounding communities is important to consider in the disaster plan. However, the immediate priority within the hospital is to ensure staff are trained and prepared to handle any disaster scenario. Without proper training, even the best-planned responses to technologic disasters may fail.

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Question 7:

The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?

A. Administering tube feedings to a quadriplegic client. B. Assisting with bowel training by placing the client on the bedside commode. C. Observing the client demonstrating a self-catheterization technique. D. Teaching Crede's maneuver to a client needing to void.

Answer and Explanation

Choice A:

Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B:

Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C:

Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D:

Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

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Question 8:

The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)

A. The acuity level of the clients. B. The clustering of the rooms on the unit. C. Client needs and the staff's needs and abilities. D. The number of anticipated client discharges. E. Specific requests from the staff.

Answer and Explanation

Choice A:

The acuity level of the clients is a critical factor to consider when planning staff assignments. Clients with higher acuity levels require more intensive care and monitoring, necessitating a greater allocation of resources and experienced staff. By considering client acuity, the charge nurse can ensure that the most critical patients receive the appropriate level of care and attention, while also balancing the workload among the nursing staff.

Choice B:

The clustering of the rooms on the unit can significantly impact the efficiency of care delivery. By grouping clients in close proximity, the nurse can minimize the time and effort spent moving between rooms, thus enhancing the ability to respond quickly to client needs. This consideration helps to optimize workflow and improve overall patient care by reducing potential delays.

Choice C:

Considering both client needs and the staff's needs and abilities ensures that the right personnel are assigned to the appropriate tasks. Matching staff competencies with client requirements maximizes the effectiveness of care delivery. Additionally, taking into account staff preferences and skills can improve job satisfaction and performance, ultimately benefiting the clients.

Choice D:

The number of anticipated client discharges is an important logistical factor that can affect the day's workflow. Planning for discharges allows the charge nurse to allocate resources for discharge planning, patient education, and follow-up care. It also helps in managing bed availability and preparing for incoming admissions, ensuring a smooth transition for both clients and staff.

Choice E:

Specific requests from the staff can include preferences for certain shifts, working with particular patients, or avoiding specific tasks. While it may not always be possible to accommodate all requests, considering them when feasible can improve staff morale and cooperation. Addressing staff preferences helps to create a positive work environment, leading to better teamwork and patient outcomes.

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Question 9:

The nurse is teaching a class on bioterrorism. What is the scientific rationale for designating a specific area for decontamination?

A. It provides a centralized area for stocking the needed supplies. B. It prevents secondary contamination to the health-care providers. C. It designates an area where bioterrorism clients can receive care. D. Showers and privacy can be provided to the client in this area.

Answer and Explanation

Choice A:

Providing a centralized area for stocking the needed supplies is important for logistical reasons, ensuring that all necessary materials are readily available. However, this is not the primary scientific rationale for designating a specific decontamination area. The primary focus is on preventing contamination and ensuring safety.

Choice B:

Preventing secondary contamination to health-care providers is the most crucial reason for designating a specific area for decontamination. This measure is vital to avoid spreading hazardous substances to others and ensuring the safety and effectiveness of the decontamination process. By containing the contamination in a controlled area, health-care providers can minimize the risk of exposure and cross-contamination.

Choice C:

Designating an area where bioterrorism clients can receive care is important, but it is not the primary rationale for having a specific decontamination area. While care and treatment are critical, the main goal of the decontamination area is to remove contaminants and protect health-care providers and other patients from exposure.

Choice D:

Providing showers and privacy to the client in the decontamination area is beneficial for the comfort and dignity of the client. However, this is not the main scientific rationale for having a designated decontamination area. The primary reason is to control and contain contamination and prevent it from spreading.

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Question 10:

A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?

A. Fidelity B. Autonomy C. Justice D. Veracity

Answer and Explanation

Choice A:

Fidelity refers to the principle of keeping promises and being faithful to one's commitments. It involves loyalty and maintaining trust in the nurse-client relationship. While fidelity is important, it is not the most relevant principle in the context of respecting a client's decision to discontinue treatment.

Choice B:

Autonomy is the ethical principle that recognizes an individual's right to make their own decisions and choices regarding their healthcare. Respecting a client's autonomy means acknowledging their right to refuse or discontinue treatment, even if the healthcare team disagrees with their decision. In this case, continued treatment against the client's wishes would violate their autonomy.

Choice C:

Justice refers to the principle of fairness and equality in the distribution of resources and care. It involves ensuring that all clients receive equitable treatment. While justice is a key ethical principle, it is not the primary issue when considering the client's wish to discontinue ventilator support.

Choice D:

Veracity refers to the principle of truthfulness and honesty in communication with clients. It involves providing accurate and complete information to enable clients to make informed decisions. While veracity is essential, it does not directly address the issue of respecting the client's decision to discontinue treatment.

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