Flashcards in Skills CH 2~38~39~40 questions Deck (22):
Which of the following is part of the standard admission procedure? (Select all that apply.)
A) Explanation of patient’s rights and elements of advance directives
B) Orientation to policies and procedures of relevant health care agency
C) Assessment of patient’s health care problems and needs
D) Preliminary testing and screening (specific for each agency and for each patient’s condition)
E) Development of an individualized plan of care
A, B, C, D, E
All are common procedures used in standard hospital admissions. (REF: p. 13)
EMTALA defines an appropriate transfer as including which of the following preparations? (Select all that apply.)
A) Informing the patient of the risks and benefits of the transfer
B) Obtaining the patient's written consent for transfer
C) Having the transferring hospital provide medical treatment within its capacity
D) Having available space but personnel at the receiving institution who are not qualified to treat the patient
A, B, C
EMTALA is a federal law intended to protect patients from being transferred against their wishes; it thus defines how an appropriate facility-to-facility transfer is accomplished. An appropriate transfer includes the following: informing the patient of the risks and benefits of the transfer; obtaining the patients written consent for transfer; having the transferring hospital provide medical treatment within its capacity; having available space and personnel qualified to treat the patient at the receiving institution and agree to accept transfer of the patient and to provide treatment; making copies of all relevant medical records, including a transfer form sent by the transferring institution to the receiving facility; and transporting the patient using qualified personnel and appropriate transportation equipment (e.g., ambulance with advanced cardiac life support [ACLS] vs. basic life support [BLS]). (REF: p. 19)
Patients who fall in the hospital typically are those who:
A) Are unfamiliar with surroundings.
B) Take one medication.
C) Have chronic illness.
D) Use an assistive device.
Patients who fall in the hospital typically are those who have been recently admitted and are unfamiliar with surroundings, have acute illness, or take four or more medications. (REF: p.17- 18)
The Resident Assessment Instrument (RAI) consists of the minimum data set (MDS), resident assessment protocols, and _____________________ as specified in state operations guidelines.
Two essential components of successful transfer to a long-term care facility are __________________________________ that are accurately communicated.
medication lists and advance directives
The patient asks the nurse why he has a drain in his abdomen after surgery. Which response by the nurse is most accurate?
A) “The drain removes abdominal fluids to reduce stress on the suture line.”
B) “You have a drain to prevent any swelling of the surgical area.”
C) “The drain allows the antibiotics that were instilled in the wound to drain.”
D) “The drain removes fluid from the surgical area to promote healing.”
The drain removes any accumulation of drainage from the wound bed, and this promotes wound healing. The answer is truthful and uses no technical words. (REF: p. 935)
A patient with a large abdominal incision is being discharged. Which statement by the patient indicates that teaching by the nurse has been effective?
A) “Now that my incision is without staples, it is healed and strong.”
B) “As long as I don’t have pain, I can do just about anything I want.”
C) “I don’t have to worry about further drainage, now that the staples are out.”
D) “I need to avoid lifting anything heavy for at least several weeks.”
Lifting heavy objects can cause a strain on the suture line and must be avoided for several weeks. An incision without staples is still healing and will not contain strong tissue, thus it could still be vulnerable to damage. Drainage would be minimal but could still occur. (REF: p. 935)
While removing the patient’s staples, the nurse notices that the incision starts to open larger than the width of two staples. Which action should the nurse initially take?
A) Place several Steri-Strips to close the open area.
B) Remove one more staple to see whether the open area enlarges.
C) Notify the health care provider of the opening in the wound.
D) Palpate the edges of the wound.
Steri-Strips would be applied first to prevent any further opening of the incision. The patient’s physical needs must be met first. The health care provider would be notified, and the wound status documented. No further staples should be removed at this time. The staples may need to remain in longer. (REF: p. 934)
A patient needs to have his abdominal wound irrigated. Which part of the procedure may the nurse delegate to nursing assistive personnel (NAP)?
A) Documenting the description of the wound
B) Packing the wound with sterile gauze pads
C) Taping the dressing once the wound is covered
D) Performing wound irrigation
Nursing assistive personnel cannot have wound irrigation delegated to them. Because they may cleanse chronic wounds using clean technique, the NAP would be able to tape the dressing after the irrigation, once it has been covered by the nurse. (REF: p. 926)
An older diabetic patient with a lot of abdominal fat underwent abdominal surgery 4 days ago involving an 8-inch vertical incision. The nurse would be most concerned if which observation of the incision was made?
A) The incision line is slightly pink and elevated where the staples are located.
B) Serosanguineous drainage has increased since 2 days ago.
C) The incision line has a light crust on it.
D) The patient’s pain level has changed from “5” yesterday to “2” today.
An increase in serosanguineous drainage is an early indication that the wound is not healing as expected, and that dehiscence could occur. The patient is obese, is advanced in age, and has diabetes—all of which are stressors that could cause a negative outcome. (REF: p. 924 )
Normal wound healing requires a physiologic wound environment that includes which of the following? (Select all that apply.)
A) Control of bacterial burden
B) Adequate moisture
C) Temperature control
D) Tissue eschar
A healthy physiologic wound environment includes adequate moisture, control of temperature, pH, and bacterial burden to promote healing. Eschar or necrotic tissue forms in deep infected wounds. (REF: p. 942)
A patient developed a 2-cm stage I pressure ulcer over the sacrum. A transparent dressing has been in place for 2 days. The nurse on the evening shift notices that the skin under the dressing appears broken. The patient complains of tenderness when the nurse palpates the skin. The nurse also notices drainage under the transparent film. What action should the nurse take in this situation?
A) Remove the dressing and obtain an order for a wound culture.
B) Record observations and keep the dressing in place.
C) Increase the frequency of changing the transparent dressing.
D) Consider irrigating the wound.
The wound has advanced from a stage I to a stage II ulcer and shows signs of infection. Removal of the dressing is necessary. A wound culture will determine the type of bacteria growing in the wound. It would also be appropriate to consider using a different type of dressing. Irrigation is likely not necessary for a stage II pressure ulcer. (REF: p. 956, 958)
A patient was originally in the intensive care unit and has been moved out to the general surgery unit. The patient is obese and has an 8-inch abdominal incision. The nurse makes rounds and begins to check the patient’s dressing when the patient tells the nurse, “I think I felt something just give way in my belly.” The nurse removes the gauze dressing over the incision and sees that the wound has Serosanguineous. What should be her next step?
A) Notify the patient’s health care provider.
B) Check the patient’s blood pressure and heart rate.
C) Cover the wound with gauze moistened in sterile saline.
D) Instruct the patient to lie on the right side.
The first step is to cover the wound with gauze moistened in saline to protect the wound. The nurse should then have the patient lie still without turning. It is important to monitor vital signs and notify the health care provider. (REF: p. 952)
A patient with a large surgical wound that is healing by secondary intention has an order for the wound to be packed with gauze that has been moistened in saline. Which of the following steps in packing a wound is incorrect?
A) Pack the wound gently.
B) Cover moist gauze packing with dry sterile gauze.
C) Avoid placing gauze into the sinus tract or an undermined area of the wound.
D) In the case of a deep wound, wear sterile gloves.
It is important to be sure that any dead space from sinus tracts, undermining, or tunneling is loosely packed with gauze. Loose packing facilitates wicking of drainage. A dry cover gauze pulls moisture from the wound. It is necessary to wear sterile gloves when packing a deep wound. (REF: p. 946)
An injured football player asks how a cold pack makes his sports injury feel better. Which explanation by the nurse is most appropriate?
A) “It blocks the nerve impulses from the brain to the injured area.”
B) “It decreases the blood flow, which reduces fluid accumulation that causes swelling.”
C) “It overrides the pain sensation, causing a systemic anesthetic response.”
D) “It increases the release of endorphins, and this causes a decrease in pain receptor activity.”
Clearly explaining exactly how the use of cold works is most helpful to the patient. Cold causes a local effect, not a systemic one. The other options contain incorrect information. (REF: p. 986)
A patient with a severe head injury has a severely elevated temperature. Which of the following is the best rationale for placing the patient on a hypothermia blanket?
A) A hypothermia blanket reduces body temperature through conduction.
B) A hypothermia blanket is believed to be neuroprotective and reduces or moderates negative neurologic outcomes.
C) A hypothermia blanket in the automatic setting continually monitors the patient’s temperature.
D) A hypothermia blanket maintains the target temperature by raising or lowering the temperature of the circulating water.
Although all of these answers regarding the hypothermia blanket are correct, the reason for its use in a patient with a head injury is to reduce or prevent any negative neurologic outcomes. (REF: p. 989)
In addition to assessment of the patient’s vital signs and neurologic status, what baseline assessment is needed before the patient with an acute head injury is placed on a hypothermia blanket?
A) Respiratory status
B) Urinary status
C) Skin integrity
D) Mucous membranes
Application of the hypothermia blanket places the patient’s skin in contact with a cooling surface. Although a bath blanket is used to prevent direct contact of the skin with the cooling surface, there remains a risk to skin integrity for the tissues most directly in contact with the blanket. Baseline data provide information to help the clinician determine whether the patient’s skin is damaged or a pressure ulcer is developing as a result of the hypothermia. (REF: p. 990)
A new mother who had a vaginal birth is going to have a sitz bath. In addition to assessing her comfort level, you obtain vital signs. What is the best rationale for obtaining the vital signs?
A) Monitoring pain levels
B) Providing a baseline for response to therapy
C) Documenting circulatory fluid volume
D) Monitoring impact of vasoconstriction from the sitz bath
A sitz bath causes vasodilation and the person’s blood pressure may drop during the treatment. Obtaining vital signs before the bath provides a baseline in case a change in blood pressure occurs. Although pain affects vital signs, the change in vital signs does not monitor the pain level. Sitz baths cause vasodilation, not constriction, which occurs during cold application. (REF: pp. 980, 982)
A patient has a moist compress with a water flow pad (aquathermia) applied over the compress for 20 minutes. Which of the following are appropriate steps to take when using this equipment? (Select all that apply.)
A) Place plastic wrap between the compress and the device.
B) When needed, fill the reservoir with distilled water.
C) Apply directly over the compress.
D) Apply towel or bath blanket over the device.
Distilled water in the reservoir maintains a constant preset temperature of the device. Placing a bath blanket or towel around the devices reduces the risk of injury to underlying skin from burns. Plastic wrap is not used because it conducts heat and increases the risk of injury. Applying the water flow device directly over the compress also increases the risk of burn injury to adjacent skin and tissues. (REF: p. 981)
In which of the following steps of the admission can the admission personnel participate? (select all that apply)
1) Explaining information about a patients rights to health care services
2) Attaching a ID band after verifying that the information is correct
3) Reviewing the details of a patients advance directive for clarity
4) Explaining how HIPPA is enforced in the agency
5) Printing a patients allergies on the allergy band before attaching it to the patient
6) Helping a patient know what is included in the basic admission process
Who is responsible for developing a patients discharge plan?
1) The primary nurse
2) The medical social worker?
3) The nurse caring for the patient longest
4) The patients health care team