NURSING PRACTICE 4 Situation 1 - Because of the serious consequences of severe burns management requires a multi disciplinary approach. You have important responsibilities as a nurse. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst into flames. The most effective way to extinguish the flames with as little further damage as possible is to: a. log roll on the grass/ground b. slap the flames with his hands c. remove the burning clothes d. pour cold liquid over the flames CORRECT ANSWER: A RATIONALE: Stop, drop and roll is a simple fire safety technique taught to children, emergency services personnel and industrial workers as a component of health and safety training. Primarily, it is a method to extinguish a fire on a person's clothes or hair without, or in addition to, the use of conventional firefighting equipment. In addition to extinguishing the fire, stop, drop and roll is an effective psychological tool, providing those in a fire situation, particularly children, with a routine that can be used to focus on in order to avoid panic. Stop, drop and roll consists of three components. · Stop Stop - The The fir fire e vic victi tim m mus must t sto stop p sti still ll. . Ceas Ceasin ing g any any mov movem emen ent t whi which ch may may fan fan the flames or hamper those attempting to put the fire out. · Drop Drop - The The fire fire vict victim im must must 'dro 'drop' p' to the the gro groun und, d, lyin lying g dow down n if if pos possi sibl ble. e. · Roll Roll - The The fire fire vict victim im must must roll roll on the the gro groun und d in in an an eff effor ort t to to ext extin ingu guis ish h the fire by depriving it of oxygen. If the victim is on a rug or one is nearby, they can roll the rug around themselves to further extinguish the flame. The effectiveness of stop, drop and roll may be further enhanced by combining it with other firefighting techniques,including the use of a fire extinguisher, dousing with water, or fire beating. 2. a. b. c. d.
Once the flames are extinguished, it is most important to: cover Sergio with a warm blanket give him sips of water calculate the extent of his burns assess Sergio's breathing
CORRECT ANSWER: D RATIONALE: Thermal burns are caused by exposure to flames, hot liquids, steam or hot objects. Like this one, 1st priority should go to the assessment of breathing if there are no airway problems, possibility of inhalation of the smoke from the flames may cause smoke poisoning from by products of combustion. A localized inflammatory reaction may occur, causing a decrease in bronchial ciliary action and a decrease in surfactant. A compromised breathing may later on lead to respiratory complications. Assess for mucosal edema in the airways, after several hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop, ARDS can result.(Source: Saunders Comprehensive Review for the NCLEX-RN exam 3rd Edition, p. 545) OPTION A: covering Sergio with a warm blanket will not benefit the situation since it can only increase heat and compromise comfort that should be provided for Sergio. OPTION B: Although giving sips of water may help in the drying of the mucosa of the patient, it is first essential to assess the airway and breathing of the patient as mucosal edema may be present and sips of water may result to aspiration.
OPTION C: Calculating the extent of the burn may be done after assessment of the ABC’s which is very essential in providing care to the patient. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right lower extremities. His wife asks what that means. Your most accurate response would be: a. Structures beneath the skin are damaged b. Dermis is partially damaged c. Epidermis and dermis are both damaged d. Epidermis is damaged CORRECT ANSWER: D RATIONALE: Superficial partial thickness: These burns are superficial with injury to the epidermis. These are first-degree burns and are characterized by erythema, edema, and pain; slight fluid loss, especially if less than 15% of the body is involved. Superficial partial-thickness burns heal spontaneously within 2-3 weeks, usually without scarring. Injured area is sensitive to cold air. Grafts may be used if healing process is prolonged. SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition,p. 544) OPTION A: is true for Deep Full-thickness burns as it involves injury to the muscle and bone. OPTION B: is true for Deep Partial-thickness burns as it involves the epidermis and superficial dermis causing erythema, pain, vesicles with oozing; fluid loss slight to moderate. OPTION C: is true for Full-thickness (3rd Degree) burn affects the epidermis, entire dermis and at times the subcutaneous tissue, resulting in charred or pearly white, dry skin and absence of pain; fluid loss usually severe, especially if more than 2% of body surface is involved. (SOURCE: Mosby Comprehensive Review of Nursing for the NCLEX-RN exam 18th edition, p. 169.) 4. a. b. c. d.
During the first 24 hours after thermal injury, you should assess Sergio for hypokalemia and hypernatremia hypokalemia and hyponatremia hyperkalemia and hyponatremia hyperkalemia and Hypernatremia
CORRECT ANSWER: C RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues. Since most of the potassium in the body is contained in muscle, a severe trauma that crushes muscle cells results in an immediate increase in the concentration of potassium in the blood. Hyperkalemia result from severe burns for the 1st 24 hours. Hyponatremia in burns occur due to low plasma osmolarity. (SOURCE: Silvestri Saunders Online Review Course,Fluid and Electrolyte Imbalance, p. 18) 5. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities two days ago, begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy is developing: a. Cerebral hypoxia b. Hypervolemia c. Metabolic acidosis d. Renal failure .
CORRECT ANSWER: A RATIONALE: Rarely do burn-injured clients suffer neurologic damage. The client with a major burn injury is most often awake and alert on admission to the hospital. If alteration in level of consciousness manifests, the client may be suffering from hypoxemia or hypovolemia and needs further assessment for identifying the origin of these changes. It is most often related to impaired perfusion to the brain, hypoxia/hypoxemia (as in a closed space fire), inhalation injury (as from exposure to asphyxiate or other toxic materials from the fire). Major burn injuries that may cause severe fluid loss can lead to a decrease in blood pressure, causing decreased cerebral perfusion, followed by impaired oxygenation to the brain. Neurologic manifestations may include headache, dizziness, memory loss, confusion or loss of consciousness, disorientation, visual changes, hallucinations, combativeness and coma. (SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1441 Situation 2 - You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implications. 6. You are on night duty in the surgical ward. One of our patients Martin is prisoner who sustained an abdominal gunshot wound. He is being guarded by policemen from the local police unit. During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hurt Martin. He denied the matter. Which among the following activities will you do first? a. Write an incident report b. Call security officer and report the incident c. Call your nurse supervisor and report the incident: d. Call the physician on duty CORRECT ANSWER: A RATIONALE: The incident report is used as a means of identifying risk situations and improving client care. Specific documentation guidelines are followed in completion of the incident report. The criteria’s to formulating an incident report are as follows: · Accid cident ental omiss ission ion of order dered the therap rapies · Circ Circum umst stan ance ces s tha that t led led to inju injury ry or a ris risk k for for clie client nt inju injury ry · Client falls · Medication ad administration er errors · Needlestick injuries · Proc Proced edur uree-re rela late ted d or equi equipm pmen entt-re rela late ted d acci accide dent nts s · A visitor ha having sy symptoms of an an il illness (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 57) 7. The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the: a. error will result in suspension b. incident report is a method of promoting quality care and risk management c. incident will be reported to the board of nursing d. incident will be documented in the personnel file. CORRECT ANSWER: B
RATIONALE: Documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse’s error will not result in suspension nor will it be documented in the personnel file. The situation and the error presented in the question are not a reason for notifying the board of nursing. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 62) 8. The nurse hears a client call for help. The nurse hurries down the hallway to the client’s room and finds the client lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse notifies the physician of the incident and completes an incident report. Which of the following would the nurse document on the incident report? a. the client was found lying on the floor b. the client climbed over the side rails c. the client fell out of bed d. the client became restless and tired to get out of bed CORRECT ANSWER: A RATIONALE: The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injury experienced by those involved, and the outcome of the situation. Option A is the only option that describes the facts as observed by the nurse. Options B, C, and D are interpretations of the situation and not factual data as observed by the nurse. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 63) 9. You are on duty in the medical ward. The mother of your patient who is also a nurse came running to the nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do first? a. Start basic life support measures b. Call for the Code c. Bring the crash cart to the room d. Go to see Fiolo and assess for airway patency and breathing problems CORRECT ANSWER: D RATIONALE: The purpose of primary assessment in cardiopulmonary arrest is to immediately identify any client problem that poses a threat, what could have caused the arrest. Airway clearance and breathing should be assured before anything else after which, immediate interventions such as CPR and advanced life support must be instituted to aid in preserving the client’s life. OPTIONS A-C: these are the following interventions that are done after a primary assessment of the ABC’s had been made. (SOURCE: Med.-Surg. Nursing by Black and Hawk, 7th edition, vol.2, p.2485) 10. A client is brought to the emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury, multiple fractures, and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action? a. call the police to identify the client and locate the family b. obtain a court order for the surgical procedure. c. ask the emergency medical services team to sign the informed consent d. transport the victim to the operating room for surgery
CORRECT ANSWER: D RATIONALE: Generally, in only 2 instances is an informed consent of an adult client not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining an informed consent would result in injury or death o the client. The 2nd instance is when the client waives the right to give informed consent. OPTION 2, will delay emergency treatment and option 3 is inappropriate. Although option 1 may be pursued, it is not the best action. Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures and other modes of treatment are done to ensure quality of life. You are assigned in the Cancer institute to care of patients with this type of cancer. 11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer. a. Barium enema b. Carcinoembryonic antigen c. Annual digital rectal examination d. Proctosigmoidoscopy CORRECT ANSWER: C RATIONALE: Early detection through routine screening is the key to decreasing mortality. It is recommended that people with an average risk for colon cancer be screened annually for digital rectal examinations and Fecal occult blood tests begin at 40 years of age withy sigmoidoscopy every 3-5 years beginning at 50 years of age. 12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study? a. carcinoembryonic antigen b. incisional biopsy of the colon c. stool hematologic test d. abdominal computed tomography (CT) test CORRECT ANSWER: B Rationale: Incisional biopsy; a selected part of the lesion is removed. This form of biopsy is commonly completed During endoscopic examination. The Frozen Method procedure is used to assess for malignant cells from tissue samples. Frozen sections are used for rapid microscopic diagnosis. A thin slice of tissue is cut from the frozen specimen and examined. The procedure requires 10-15 minutes. The pathologist can determine whether malignancy is present and whether the entire tumor has been removed by looking for a margin of tumor-free tissue. SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, Vol.1, p. 106) 13. The foll followi owing ng are are risk risk fact factors ors for colo colorec rectal tal canc cancer, er, EXC EXCEPT EPT: : a. inflammatory bowels b. low fat, high fiber diet c. smoking d. genetic factors-familial adenomatous polyposis CORRECT ANSWER: B RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the development of cancer of the large bowel. Studies on bulk in stool and the rate of transit of fecal matter have so far given mixed results. Some researchers propose that metabolic and bacterial end products are carcinogenic and that constipation allows a longer contact with the bowel wall, thus raising the probability that
cancer will develop. Increasing fiber in the diet may reduce exposure to carcinogens by speeding stool transit through the intestines. (SOURCE: Med-Surg. Nsg Black and Hawk 7th edition, Vol.1 p. 831) 14. Sympto Sym ptoms ms a asso ssocia ciated ted with with can cancer cer of the the col colon on inc includ lude: e: a. constipation, ascites and mucus in the stool b. diarrhea, heartburn and eructation c. blood in the stools, anemia, and pencil-shaped, stools d. anorexia, hematemesis, and increased peristalsis CORRECT ANSWER: C RATIONALE: Symptoms include the following: Blood in stools, anorexia, vomiting, and weight loss, malaise, Anemia, abnormal stools. Ascending colon tumor: Diarrhea, Descending Colon tumor: constipation or some diarrhea, or flat, ribbonlike stool resulting from a partial obstruction. Rectal Tumor: alternating constipation and diarrhea, guarding or abdominal distention, abdominal mass (a late sign), Cachexia (a late sign). (source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p.592) 15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to: a. promote rest of the bowel by minimizing peristalsis b. reduce the bacterial content of the colon c. empty the bowel of solid waste d. soften the stool by retaining water in the colon CORRECT ANSWER: B RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug, primarily for the treatment of asymptomatic mengococcal carrier, can be used as alternative for penicillin in rheumatic fever. Neomycin, kanamycin sulfate, erythromycin, & succinylsulfathiazole (Sulfasuxidine) are used pre-operatively to reduce bacterial number in the GI tract. (Source: Nursing Drug Handbook 2006, 26th Edition, p. 131) Sulfasuxidine and other antiseptics and antibiotics, as prescribed to decrease the bacterial content of the colon to reduce the risk of infection from the surgical procedure. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 592) Situation 4 - ENTEROSTOMAL THERAPY is now considered especially in nursing. You are participating in the OSTOMY CARE CLASS. 16. You plan to teach Fermin how to irrigate the colostomy when: a. The perineal wound heals and Fermin can sit comfortably on the commode b. Fermin can lie on the side comfortably, about the 3rd postoperative day c. The abdominal incision is close and contamination is no longer a danger d. The stool starts to become formed, around the 7th postoperative day CORRECT ANSWER: C RATIONALE: Carefully assess the client’s physical condition, emotional and mental attitudes toward the colostomy before attempting to teach ostomy self-care. Pace the teaching to the client’s level of acceptance of the colostomy and ability to manage it. Teach the client how to apply the pouch to the stoma correctly. The client first should be taught how to examine the stoma. A healthy stoma and abdominal incision is a very good indicator that client is now ready for ostomy care teaching. (SOURCE: Med-Surg. Nsg. by Black and Hawk, 7th edition, vol.1, p. 837) 17. When preparing to teach Fermin how to irrigate his colostomy, you should plan to do the procedure:
a. b. c. d.
When Fermin would have normal bowel movement At least 2 hours before visiting hours After breakfast After Fermin accepts alteration in body image
CORRECT ANSWER: C RATIONALE: A suitable time for the irrigation is selected that is compatible with the patient’s posthospital pattern of activity (preferably after a meal). Irrigation should be performed at the same time each day. (SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064) 18. When observing a rectum demonstration of colostomy irrigation, you know that more teaching is required if Fermin: a. Lubricates the tip of the catheter prior to inserting into the stoma b. Hands the irrigating bag on the bathroom door doth hook during fluid insertion c. Discontinues the insertion of fluid after only 500 ml of fluid had been insertion d. Clamps off the flow of fluid when feeling uncomfortable CORRECT ANSWER: C RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate evacuation, Volume may be increased with subsequent irrigations to 500, 1000, up to 1, 500 mL as needed by the patient for effective results. Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Water should flow in over 5 to 10 minute period. (SOURCE: Brunner and Suddarth’s Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064) 19. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact my physician and report: a. If I have any difficulty inserting the irrigating tube into the stoma." b. If I notice a loss of sensation to touch in the stoma tissue." c. The expulsion of flatus while the irrigating fluid is running out." d. When mucus is passed from the stoma between irrigation." CORRECT ANSWER: A Rationale: Any difficulty in the insertion of the irrigating tube into the stoma may mean an obstruction to the system. 20. You would know after teaching. Fermin that dietary instruction for him is effective when he states, "It is important that I eat: a. Soft foods that are easily digested and absorbed by my large intestine." b. Bland food so that my intestines do not become irritated." c. Food low in fiber so that there is less stool." d. Everything that I ate before the operation, while avoiding foods that cause gas." CORRECT ANSWER: A RATIONALE: As such there is no specific diet plan for Ostomy patients. The main point is that you should be able to tolerate the food you are eating. Still certain foods you need to avoid or include in your diet so as to maintain a good health after Ostomy. Below is the list of food you need to keep in consideration: · Food Food r res esul ulti ting ng i in n thic thicke kene ned d stoo stools ls ( (Lo Loww-Fi Fibe ber) r): : Appl Apples esau auce ce, , Pean Peanut ut b but utte ter, r, boiled milk, Tapioca, Rice, Cheese, Bananas, and Pretzels. · Food Food res resul ulti ting ng in soft soft stoo stools ls (Hig (High h Fib Fiber er): ): Red Red win wine, e, Beer Beer, , Cof Coffe fee, e, Prun Prune e
juice, Fresh vegetables, Fruits and Food with high fiber content. · Food Foods s resu result ltin ing g in inc incom ompl plet ete e dige digest stio ion: n: B Bro rocc ccol oli, i, C Cab abba bage ge, , Raw Raw carr carrot ots, s, R Raw aw onions, Pineapple, Beans, Spinach, Potato skins, Corn, Coconut, Celery, Whole grains, Nuts, Raisins, Popcorn, Raw fruits, Chinese vegetables, Seeds and Skins. · Food Foods s caus causin ing g odor odor: : Cabb Cabbag age, e, B Bea eans ns, , Aspa Aspara ragu gus, s, O Oni nion ons, s, Garl Garlic ic, , Eggs Eggs, , Fish Fish, , Alcohol and Vitamins. · Food Foods s caus causin ing g gas: gas: R Raw aw a app pple le, , Cabb Cabbag age, e, B Bro rocc ccol oli, i, O Oni nion ons, s, T Tur urni nip, p, C Cor orn, n, N Nut uts, s, Milk, Beer, Carbonated beverages, iced beverages and Chewing gums. · Food Foods s cau causi sing ng diar diarrh rhea ea: : Fri Fried ed food foods, s, high highly ly spic spicy y foo food, d, Legu Legume mes, s, Grap Grape e juice, Apple juice, Prune juice, Green beans, Spinach, Raw fruits, Cabbage and Milk. SOURCE: Ostomy Nutrition Guide booklet page 1-5 Situation 5 - Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications. 21. Randy Randy has chest chest tubes tubes attac attached hed to a pleural pleural drainage drainage system. system. When caring caring for for him you should: a. empty the drainage system at the end of the shift b. clamp the chest tube when suctioning c. palpate the surrounding areas for crepitus d. change the dressing daily using aseptic techniques CORRECT ANSWER: C RATIONALE: Assessment actions to check for signs of extended pneumothorax or hemothorax should be performed such as palpating surrounding areas for crepitus. It may also be an indication for a chest tube complication known as subcutaneous emphysema. Subcutaneous emphysema occurs when air gets into tissues under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other penetrations, or blunt trauma. Air can also be found in between skin layers on the arms and legs during certain infections, including gas gangrene. Subcutaneous emphysema can often be seen as a smooth bulging of the skin. When a health care provider feels (palpates) the skin, it produces an unusual crackling sensation as the gas is pushed through the tissue. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN, 3rd edition, p. 242) 22. Fanny came in from PACK after pelvic surgery. As Fanny's nurse you know that the sign that would be indicative of a developing thrombophlebitis would be: a. a tender, painful area on the leg b. a pitting edema of the ankle c. a reddened area at the ankle d. pruritus on the calf and ankle CORRECT ANSWER: A RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall as a result of the inflammation of the vessel wall. It has 3 Types: Superficial, Femoral, and Pelvic. Assessment findings for a developing Superficial Thrombophlebitis are tenderness and pain in the affected lower extremity. Also includes the following symptoms: warm and pinkish red color over the thrombus area, palpable thrombus that feels bumpy and hard. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p.329) 23. To prevent recurrent attacks on Terry who has acute glomerulonephritis, glomerulonephrit is, you should instruct her to: a. seek early treatment for respiratory infections b. take showers instead of tub bath
c. continue to take the same restrictions on fluid intake d. avoid situations that involve physical activity CORRECT ANSWER: A RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or tonsillitis 2 – 3 weeks before symptoms. Usually a streptococcal infection may precede it. It is very important to seek treatment for respiratory infections existing to stop the progress of the disease. And it is usually with untreated respiratory infections (Group A β-hemolytic streptococcus) that this sequelae develop. OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria from entering the urethra, however is indicated for UTI. OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is more of an intervention rather than a preventive measure for recurrence. OPTION D: Avoiding physical activity is also an intervention for Glomerulonephritis. 24. Herbert has a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged, what should you teach him first? a. Recognize that prompt closure of the tracheal opening may occur b. Keep calm because there is no immediate emergency c. Reinsert another tubing immediately d. Notify the physician at once CORRECT ANSWER: D RATIONALE: If the patient verbalizes his concerns regarding dislodgement it would mean then that the patient has not been well educated about the process of having a laryngectomy. It is stated that the patient is now for discharge and it is expected that by this time the patient should be having all the information he has to know regarding the laryngectomy. Preoperative teaching is done so that patient will be able to correct misconceptions and fears about the reason for having the surgery, nature of the surgical procedure. Postoperatively, the nurse reviews equipment and treatments for care with the patient, patients’ family. It means that after essential information and teaching had been offered, patient still lack the knowledge and confidence to carry out self care and important procedure considerations. (SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing 10th Edition, p. 510-511) 25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain: a. supplementary oxygen b. ventilation exchange c. chest tube drainage d. blood replacement CORRECT ANSWER: A RATIONALE: After surgery, the vital signs are checked frequently. Oxygen is administered via a mechanical ventilator, nasal cannula, or mask for as long as necessary. A reduction in lung capacity requires a period of physiologic adjustment, and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema. OPTION B and C: ventilation exchange may also be important as it is the goal of the surgery to promote a better gas exchange and oxygenation. Chest Tube drainage is already a precursor of the surgery as it is needed to facilitate recuperation of lung expansion functions and avoid further complications such as pneumothorax and hemothorax.
OPTION D: Blood replacement is a standing order in cases that bleeding problem may arise within the surgical procedure. (SOURCE: Brunner and Suddarth’s Textbook of Med.-Surg. Nursing 10th edition, vol.1 p. 628) Situation 6 - Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care. 26. Honrad, Honrad, who has been complain complaining ing of anore anorexia xia and feeling feeling tired, tired, devel develops ops jaundice. After a workup he is diagnosed of having Hepatitis A. His wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be: a. "Don't worry your husband's type of hepatitis is no longer communicable" b. "Gamma globulin provides passive immunity for Hepatitis B" c. "You should contact your physician immediately about getting gamma globulin." d. "A vaccine has been developed for this type of hepatitis" CORRECT ANSWER: D RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM, IgG, IgA, IgD, and IgE, which are essential in the body’s defense against microorganisms. Household and personal contacts of clients with HAV should be given immune globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and after exposure. However a specific vaccine had been developed for Hepatitis A which is the inactivated hepatitis A vaccine (active), which is given two doses of at least 6 months apart for persons who reside in a community that has a high rate of hepatitis A virus infection, who are at risk because of foreign travel, or who have chronic liver disease. (SOURCE: Med.-Surg. Nsg. By Black and Hawk, 7th edition, vol.1, p. 427, Vol.2 p. 2241) 27. Voltaire develops a nosocomial respiratory tract infection. He asks you what that means. a. "You acquired the infection after you have been admitted to the hospital." b. "This is a highly contagious infection requiring complete isolation." c. "The infection you had prior to hospitalization flared up." d. "As a result of medical treatment, you have acquired a secondary infection." CORRECT ANSWER: A RATIONALE: Nosocomial Infections also are referred to as infections. Such infections are infections acquired in a care facility that were not present or incubating at the admission. The hospital environment provides exposure to organisms that the client has not been exposed to in the client has not developed resistance to these organisms. Comprehensive Review for the NCLEX-RN exam, 3rd edition,
hospital-acquired hospital or other health time of a client’s a variety of virulent past; therefore the (SOURCE: Saunders p. 180)
28. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is: a. stomatitis b. hepatitis c. dysrhythmia d. infection CORRECT ANSWER: D RATIONALE: It is most important to watch out for signs of infection because a
patient in TPN is most prone to infection because of an open venous access that can be easily contaminated; furthermore, microorganisms can easily find its way to enter the body through the bloodstream. A strict aseptic technique must be used because the TPN solution has a high concentration of glucose, which is a medium for bacterial growth. Signs of an infection are as follows: Chills, elevated WBC count, erythema or drainage at the insertion site, and fever. Assess IV site for redness, swelling, tenderness, or drainage. Change IV tubing every 24 hours or according to agency protocol. If signs of infection occur at the site, the following must be done: · · ·
IV line line must must be remo remove ved d and and rest restar arte ted d a at t a diff differ eren ent t s sit ite e Remo Remove ve the the tip tip of the the IV IV cat cathe hete ter r and and sen send d it it to to the the labo labora rato tory ry for for cul cultu ture re Prepare the client for blood cultures
29. A solution used to treat Pseudomonas wound infection is: Dakin's solution Half-strength hydrogen peroxide Acetic acid Betadine CORRECT ANSWER: C RATIONALE: Acetic Acid is effective for irrigating, cleansing, and packing wounds infected by Pseudomonas Aeruginosa. Healthy skin surrounding the wound must be protected with a petroleum barrier because acetic acid excoriates the skin. (Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 566)The use of acetic acid to treat Pseudomonas aeruginosa in superficial wounds dates back to 1916 when it was discovered that a 1% solution applied to war wounds led to elimination of this organism then called Bacillus pyocyaneas. In 1992 a prospective study involving the use of 5% acetic acid was undertaken in 9 patients. No patients complained of discomfort after the soaks which were applied daily. Two wounds lost Pseudomonas species within 2 days and a further four within one week. Only one patient remained contaminated after three weeks. Following eradication of the organism, healing occurred rapidly. Milner-S;Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns - (letter);The Lancet;Vol 340 (1992):61. It is possible the application of acetic acid may confer other benefits to the healing process as well as the removal of bacteria. Acidification of a wound would also increase the pO2 and reduces the histotoxicity of ammonia which may be present (Ammonia is less toxic in an acid environment). OPTION A: Dakin’s Solution or more commonly known as Bleach is a chloride solution that loosens, dissolves, and deodorizes necrotic tissue and blood clots. The solution must not be in contact with healing or normal tissue. OPTION B: Half strength hydrogen peroxide is a 3% solution has effervescent action that releases gas and breaks up necrotic tissue. However, it is not used to pack wounds because it decomposes too rapidly. OPTION D: Betadine is a brand name of povidone-iodine which is a water-soluble complex of iodine with polyvinylpyrrolidone (PVP), with from 9.0% to 12.0% available iodine, calculated on a dry basis[1].It is used in hospitals for cleansing and disinfecting the skin, preparing the skin preoperatively and treating infections susceptible to iodine.It works through disruption of pathogen cell walls. 30. Which of the following is most reliable in diagnosing a wound infection? a. Culture and sensitivity b. Purulent drainage from a wound c. WBC count of 20,000/pL d. Gram stain testing CORRECT ANSWER: D
RATIONALE: The Gram-Stain is the most important of all bacteriologic differential stains to diagnose a wound infection. It divides bacteria into two physiologic groups: Gram – and Gram + organisms, thus determining the type of medication to be given to the patient. Infectious diseases or processes can be diagnosed by detection of an immunologic response specific to an infecting agent in a patient’s serum. Normal humans produce both IgM ( first-response antibodies) and IgG (antibodies that may persist long after an infection) to most pathogens. (Frances Fischbach’s A manual of Laboratory and Diagnostic Tests 7th edition, p. 500) Situation 7 - As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented. 31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted and an I.V. infusion was started. As a nurse assigned to Wendy what will he your priority goal? a. Prevent skin breakdown b. Preserve muscle function c. Promote urinary elimination d. Maintain a patent airway CORRECT ANSWER: D RATIONALE: In a pt. that has a GCS of 6, it is very essential that airway must be maintained since deficient O2 delivery to the brain can cause irreversible brain damage in only 6 minutes. Taking into consideration the ABC’s of emergency and medical management Airway must be established first followed by Breathing, and last is circulation. If patient have already manifestations of brain injury, patient may fail to initiate his own breathing and thus airway patency can be compromised resulting to a more severe condition. (SOURCE: Brunner and Suddarth’s Textbook of Medical Surgical Nursing Vol.1 10th Edition, p. 201-202) 32. Knowing that for a comatose patient hearing is the best last sense to be lost, as Judy's nurse, what should you do? a. Tell her family that probably she can't hear them b. Talk loudly so that Wendy can hear you c. Tell her family who are in the room not to talk d. Speak softly then hold her hands gently CORRECT ANSWER: D RATIONALE: It is important to get the attention of the client before beginning to speak despite it’s inability to respond or to react, nurse must move close to the client and speak slowly and clearly, talking in lower tones is advised as shouting may not help and may only disturb other clients inside the unit. Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p. 910-911) 33. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparersis secondary to stroke? a. Place June on an upright lateral position b. Perform range of motion exercises c. Apply antiembolic stocking d. Use hand rolls or pillows for support CORRECT ANSWER: B RATIONALE: Hemiparesis is the partial paralysis of one side of the body. It is
generally caused by lesions of the corticospinal tract, which runs down from the cortical neurons of the frontal lobe to the motor neurons of the spinal cord) and is responsible for the movements of the muscles of the body and its limbs. ROM exercises are the highest priority of all the interventions because for a patient with hemiparesis, rehabilitation and restoration of functional capability is very important. ROM exercises may be done with assistance or guidance of a physical therapist and a rehabilitation nurse. Exercise when performed correctly assists in maintaining and building muscle strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance and promoting relaxation. Some disabilites, such as spinal cord injury, acute brain injury, and other conditions that cause muscle weakness or hemiparesis require extended periods in the recumbent position, thus may be assisted to an alternative 90-degree position such as a reclining wheelchair with elevated leg rests. (SOURCE: Brunner and Suddarths textbook for Medical Surgical Nursing Vol.1, 10th edition, p.163) 34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic by doing which of the following? a. honoring her request for a television b. placing her bed near the window c. dimming the light in her room d. allowing the family unrestricted visiting privileges CORRECT ANSWER: C RATIONALE: Prior to surgery it is important that medical management be maintained, includes: maintaining cerebral perfusion pressure, controlling ICP, minimizing effects of vasospasm. The client with intracranial aneurysm is at great risk for the development of increased ICP. (Normal ICP 0-15mmHg). A therapeutic nursing management is to decrease environmental stimuli which can increase ICP. Dim all lights Speak softly Touch gently and only when needed Space all interventions Limit noxious stimuli such as suctioning to only as needed OPTIONS A, B and D are distractive and are examples of environmental stimuli that may aggravate the condition of the patient.(Source: Med.-Surg. Nsg. By Black and Hawk 7th edition Vol.2, p.2095) 35. When performing a neurological assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he: a. probably has meningitis b. is going to be blind because of trauma c. is permanently paralyzed d. has received a significant brain injury CORRECT ANSWER: D RATIONALE: Fixed, Dilated pupils (unilateral or bilateral) or midposition fixed pupils indicate an upper midbrain involvement of brain injury. . (SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition Vol.2,p. 2055) Situation 8 - With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients.
There are frequently encountered situations and issues relevant to the older, patients. 36. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging. a Ineffective airway clearance b. Decreased alveolar surface area c. Decreased anterior-posterior chest diameter d. Hyperventilation CORRECT ANSWER: B RATIONALE: A 70-year-old expends 70% of the total elastic work of breathing on the chest wall compared with 40% for a 20-year-old. While there is great variation between individual and genders, there are age-related decrements of respiratory muscle strength and endurance of approximately 20% by the age of 70 years. Beginning in early adulthood, there is a progressive enlargement of the alveolar ducts and respiratory bronchioles. The effect of the enlargement of the terminal respiratory units is a decrease of functional alveolar surface area by 15% by the age of 70 years. The decrease in alveolar surface area reduces alveolar surface tension with consequential negative effect on alveolar gas exchange and forced expiratory flow. 37. The older patient is at higher risk for in incontinence because of: a. dilated urethra b. increased glomerular filtration rate c. diuretic use d. decreased bladder capacity CORRECT ANSWER: D RATIONALE: Aging causes a number of changes in urinary tract physiology, all of which can affect continence. These changes include: A decrease in bladder elasticity, which decreases bladder capacity and requires the older adult to void more frequently A decrease in the strength of the detrusor muscle, resulting in incomplete bladder emptying An increase in spontaneous detrusor muscle contractions A decrease in the ability to postpone urination A decrease in urethral closing pressure 38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate: a. dementia b. a visual problem c. functional decline d. drug toxicity CORRECT ANSWER: B RATIONALE : Visual information is of particular importance to maintaining balance. The visual systems most involved are the optokinetic and pursuit systems. The optokinetic system is the motor impulse responsible for moving the eyes when the head moves, so that the field of vision remains clear. The pursuit system allows a person to focus on a moving object while the head remains stationary. Both of these systems feed information about the person's position relative to the surroundings to the brainstem. A specific type of eye movement called nystagmus, which is repetitive jerky movements of the eye, most often in the horizontal direction, may cause dizziness. Nystagmus may indicate that neurologic signals from the optokinetic or pursuit systems are not in agreement with the other
balance information received by the brain. If the eyes do not move in parallel or if the upper eyelid covers more than a tiny portion of the iris, note the conditions as abnormal findings. (SOURCE: Med.-Surg. Nsg. by Black and Hawk 7th edition, vol.2, p. 1924) 39. Cardiac ischemia in an older patient usually produces: a. ST-T wave changes b. Very high creatinine kinase level c. chest pain radiating to the left arm d. acute confusion CORRECT ANSWER: C RATIONALE: A classical manifestation of Myocardial ischemia is angina that can develop quickly or slowly. Some ignore the chest pain, thinking that it will go away or that it is indigestion. Its location is usually retrosternal or slightly to the left of the sternum, as reported by 90% of incidents. The pain usually radiates to the left shoulder and upper arm and may then travel down the inner aspect of the left arm to the elbow, wrist, and 4th-5th finger. (SOURCE: Med.Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1703) 40. The nurse is providing medication instructions to an older adult who is taking digoxin (Lanoxin) daily. The nurse bears in mind that which age-related body changes could place the client at risk for digoxin toxicity? a. decreased cough efficiency and decreased vital capacity b. decreased lean body mass and decreased glomerular filtration rate c. decreased salivation and decreased gastrointestinal motility d. decreased muscle strength and loss of bone density CORRECT ANSWER: B RATIONALE: The older client is at risk for medication toxicity because of decreased lean body mass and age-associated decreased glomerular filtration rate. Although options A, C and D identify age-related changes that occur in the older client, they are not associated specifically with this risk. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 394)
Situation 9 - A "disaster" is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody's business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency program and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all type of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector. 41. Which of the four phases of emergency management is defined as "sustained action that reduces or eliminates long-term risk to people and properly from natural hazards and the effect"? a. Recovery b. Mitigation c. Response d. Preparedness CORRECT ANSWER: B RATIONALE: Mitigation - actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of one · Invo Involv lves es dete determ rmin inin ing g com commu muni nity ty haza hazard rds s and and risk risks s (ac (actu tual al and and pot poten enti tial al
threats) for the occurrence of a disaster · Invo Involv lves es i ide dent ntif ifyi ying ng a ava vail ilab able le c com ommu muni nity ty r res esou ourc rces es a and nd c com ommu muni nity ty-h -hea ealt lth h personnel · Invo Involv lves es dete determ rmin inin ing g the the reso resour urce ces s ava avail ilab able le for for car care e of of infa infant nts, s, olde older r clients, the disabled, and those with chronic health problems Recovery: Includes actions taken to return to normal after the disaster. Includes prevention of debilitating effects and restoration of personal, economic, and environmental health and stability to the community Response: Involves putting disaster-planning services into action and enumerating the actions needed to save lives and prevent further damage. Primary concerns include the safety and physical and mental health of both the victims and the members of the disaster-response team Preparedness: Includes plans for rescue, evacuation, and care of disaster victims · Incl Includ udes es pla plans ns f for or t tra rain inin ing g disa disast ster er p per erso sonn nnel el a and nd g gat athe heri ring ng r res esou ourc rces es, , equipment, and other materials needed for dealing with the disaster · Incl Includ udes es ide ident ntif ific icat atio ion n of spe speci cifi fic c resp respon onsi sibi bili liti ties es for for var vario ious us dis disas aste terrresponse personnel · Esta Establ blis ishe hes s a comm commun unit ity y disa disast ster er pla plan n and and an effe effect ctiv ive e publ public ic-c -com ommu muni nica cati tion on system · Invo Involv lves es sett settin ing g u up p a an n e eme merg rgen ency cy medi medica cal l s sys yste tem m a and nd a p pla lan n f for or its its activation · Incl Includ udes es chec checki king ng prop proper er func functi tion onin ing g of emer emerge genc ncy y equi equipm pmen ent t · Invo Involv lves es maki making ng anti antici cipa pato tory ry prov provis isio ions ns and and set setti ting ng up a loc locat atio ion n for for distribution of food, water, clothing, shelter, other supplies, and medicine · Incl Includ udes es chec checki king ng supp suppli lies es on a reg regul ular ar basi basis s and and rep reple leni nish shin ing g tho those se that that have become outdated · Incl Includ udes es prac practi tici cing ng comm commun unit ity y dis disas aste ter r pla plans ns (moc (mockk-di disa sast ster er dril drills ls) ) SOURCE: Saunders Comprehensive Review for the NCLEX-RN Exam, 3rd Edition, p. 7374) 42. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included. a. Tertiary prevention b. Primary prevention c. Aggregate care prevention d. Secondary prevention CORRECT ANSWER: A RATIONALE: Tertiary prevention combats the complications of disaster. Primary prevention of disaster is possible through technical, organizational and judicial means Secondary prevention implies the optimal management of disaster itself. Aggregate care prevention: 43. During the disaster you see a victim with a green tag, you know that the person: a. has injuries that are significant and require medical care but can wait hours will threat to life or limb b. has injuries that are life threatening but survival is good with minimal intervention c. indicates injuries that are extensive and chances of survival are unlikely even with definitive care d. has injuries that are minor and treatment can be delayed from hours to days
CORRECT ANSWER: D RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated. They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (examples: broken bones without compound fractures, many soft tissue injuries). Option A:Yellow Tag: Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances). OPTION B: Red Tag: They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. OPTION C: Black Tag: They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be taken to a holding area and given painkillers as required to reduce suffering. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition p.75) 44. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment: a. Immediate b. Emergent c. Non-acute d. Urgent CORRECT ANSWER: D RATIONALE: Urgent Category are conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living. Usually victim must be treated within 30-60 minutes. These are patients who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention. Some examples of conditions that can be treated at urgent care include: accidents and falls, broken bones, breathing difficulties, severe abdominal pain, bleeding/cuts, high fever and vomiting/diarrhea/dehydration. Immediate - are used to label those who cannot survive without immediate treatment but who have a chance of survival. patients who have a trauma score of 3 to 10 (RTS) and need immediate attention. they need advanced medical care at once or within 1 hour. These people are in critical condition and would die without immediate assistance. They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. Examples: Talking, not walking (severe distress with dyspnea, twitching, and/or nausea and vomiting);moderate-to-severe effects in two or more systems (eg, respiratory, gastrointestinal, muscular);circulation intact Emergent – Clients with life-threatening injuries, who need immediate attention and continuous evaluation, yet have a high probability of survival once their condition is stabilized. Examples: clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, or acute neurological deficits and those who have sustained chemical splashes to the eye. Non-acute – Clients with local injuries who do not have immediate complications and who can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Examples: clients with minor
lacerations, sprains, or cold symptom (SOURCE:Saunders Comprehensive Review for the NCLEX-RN exam 3rd edition, p.74-75) 45. Which of the following terms refer to a process by which the individual receives education about recognition of stress reactions and management strategies for handling stress which may be instituted after a disaster? a. Critical incident stress management b. Follow-up c. Debriefing d. Defusion CORRECT ANSWER: A RATIONALE: It is an adaptive short term helping process that focuses solely on an immediate and identifiable problem to enable the individual/s affected to return to their daily routine(s) more quickly and with a lessened likelihood of experiencing post-traumatic stress disorder. Critical Incident Stress Management is designed to help people deal with their trauma one incident at a time by allowing the individual to talk about the incident when it happens without judgment or criticism. Follow-up can be held weeks or months later if needed to address any unresolved issues Debriefings are usually the second level of intervention for those directly affected by the incident and often the first for those not directly involved. Defusings are limited only to individuals directly involved in the incident and are often done informally, sometimes at the scene. They are designed to assist individuals in coping in the short term and address immediate needs Situation 10 - As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon, 46. While eating his meal, Matthew accidentally dislodges his IV line and bleeds. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with: a. Acetone b. Alcohol c. Ammonia d. Bleach CORRECT ANSWER: D RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated cautiously. Gloves shall be worn when cleaning up blood spills or other bodily fluid spills. These spills shall be disinfected with a ten percent bleach solution or an approved cleansing solution. Bleach primarily is used to disinfect blood spills on various surfaces, they are composed of various chemical components one of which is Sodium Hypochlorite. A 1 in 5 dilution of household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria and some viruses, and is often the disinfectant of choice in cleaning surfaces in hospitals. The solution is corrosive, and needs to be thoroughly removed afterwards, so the bleach disinfection is sometimes followed by an ethanol disinfection. 47. The nurse manager has implemented a change in the method of the nursing delivery system from functional team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following would be the best approach in dealing with
the nursing assistant? a. ignore the resistance b. exert coercion with the nursing assistant. c. provide a positive reward system for the nursing assistant d. confront the nursing assistant to encourage verbalization of feelings regarding the change. CORRECT ANSWER: D RATIONALE: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option A will not address the problem. Option B may produce additional resistance. Option C may provide problem solving measures. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.78) 48. Part of your responsibility as a member of the diabetes core group is to get referrals from the various wards regarding diabetic patients needing diabetes education. Prior to discharge today 4 patients are referred to you. How would you start prioritizing your activities? a. Bring your diabetes teaching kit and start your session taking into consideration their distance from your office b. Contact the nurse-in-charge and find out from her the reason for the referral c. Determine their learning needs then prioritize d. involve the whole family in the teaching class CORRECT ANSWER: C RATIONALE: Learning need is a desire or a requirement to know something that is presently unknown to the learner. A comprehensive assessment of learning needs incorporates data from the nursing history and physical assessment and addresses the client’s support system. It also considers client characteristics that may influence the learning process: readiness to learn, motivation to learn, and reading or comprehension level, for example. Assessment of learning need is done first before developing a teaching plan. OPTION D may be done at later part of learning. 49. The nurse is working in a long-term care facility and is administering medications to assigned clients. A client refuses to take the prescribed medication, and the nurse threatens the client and tells the client that if the medication is not taken orally, then restraints will be applied and the medication will be given by injection. This statement by the nurse constitutes which legal tort? a. invasion of privacy b. negligence c. assault d.battery CORRECT ANSWER: C RATIONALE: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one’s body. Negligence involves actions below the standards of care. Invasion of privacy occurs with unreasonable intrusion into the individual’s private affairs. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.64) 50. The nurse is reviewing the critical paths of the clients on the nursing unit.
In performing a variance analysis, which of the following would indicate the need for further action and analysis? a. a client’s family attending a diabetic teaching session b. canceling physical therapy sessions on the weekend c. normal vital signs and absence of wound infection in a postoperative client d. a client demonstrating accurate medication administration following teaching CORRECT ANSWER: B RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.76)
