Test 2 Flashcards
(207 cards)
A client with impaired mobility is within one week of being discharged from the hospital. which is the best example of a discharge goal for the client? The client will:
a. Understand range-of-motion exercises
b. Be taught range-of-motion exercises
c. Transfer independently to a chair
d. Be kept clean and dry
C. Transfer independently to a chair
This is a client-centered goal and measurable
A nurse is transferring a client from a bed to a wheelchair. What should the nurse do to quickly assess the client’s tolerance to the change in position?
a. Obtain a blood pressure
b. Monitor for bradycardia
c. Determine if the client feels dizzy
d. Allow the client time to adjust to the change in position
C. Determine if the client feels dizzy
Feeling dizzy is a subjective response to orthostatic hypotension. Obtaining feedback from the client provides a quick evaluation of the client’s tolerance of the transfer.
A nurse concludes that a client has the potential for impaired mobility. Which assessments reflect risk factors that support this conclusion? (Select all that apply)
a. Joint pain
b. Exertional fatigue
c. Sedentary lifestyle
d. Limited range-of-motion
e. Increased respiratory rate
A. Joint pain
D. Limited range-of-motion
Joint pain may prevent the client from moving about, leading to contractures resulting in impaired mobility.
Limited range-of-motion is associated with contracture formation and impaired mobility.
To prevent pressure ulcers, which intervention should Abby include in Mr. Rogers plan of care?
a. Reposition Mr. Rogers at least twice every shift.
b. Vigorously massage the bony prominences to induce blood flow.
c. Post a turning schedule at Mr. Rogers’ beside.
d. Log roll Mr. Rogers when turning.
C. Post a turning schedule at Mr. Rogers’ beside.
A turning schedule will help ensure Mr. Rogers is repositioned in a timely manner which will help prevent skin breakdown.
Upon review of the care for a patient with restricted mobility, Abby learns that the most significant hazard to the immobilized patient is:
a. foot drop
b. myocardial ischemia.
c. deep vein thrombosis.
d. orthostatic hypotension.
C. deep vein thrombosis
Patients with decreased mobility are at risk for deep vein thrombosis, which can lead to life-threatening pulmonary embolism.
Abby plans to assist Mr. Rogers into a wheelchair. As they prepare to make the transfer, Abby correctly instructs Mr. Rogers to:
a. hold on to the IV pole when rising from the bed.
b. push up from the bed using his arms on the count of three.
c. hold onto the side rails at the bottom of the bed before standing.
d. place his feet behind Abby’s feet.
B. Push up from the bed using his arms on the count of three
Mr. Rogers should be instructed to push up from the bed using his arms on the count of three
A primary health-care provider orders active range-of-motion exercises. What nursing action is unique to providing active range-of-motion exercises?
a. Assisting the client who is able to complete the exercise through all planes of movement
b. Encouraging the client to perform the exercises independently
c. Providing a warm bath before the exercises
d. Demonstrating how to do the exercises
B. Encouraging the client to perform the exercises independently
Active range-of-motion exercises require the client to complete the exercises independently. Active range-of-motion exercises require muscle contraction that eventually improves muscle strength.
Sam speaks about sleep pattern changes that occur in the elderly population include:
a. longer daytime naps.
b. sleeping until late morning.
c. decreased time in deep sleep.
d. diminished sleep latency.
C. decreased time in deep sleep.
A normal part of aging is a decreased amount of time in deep sleep. This can lead to increased fatigue during the daytime, which may lead to more daytime napping.
Sam knows that Mrs. Simms understands education about promoting restful sleep when she says:
a. “I’ll make a list of things I need to do tomorrow and put it at my bedside to look at before I go to sleep.”
b. “I put flannel sheets on my bed to help me stay warm at night.”
c. “I’ll do some exercise before bedtime so I will be worn out and tired.”
d. “I will stop taking my water pill because it makes me get up in the middle of the night to go to the bathroom.”
B. “I put flannel sheets on my bed to help me stay warm at night.”
An environment that is comfortable for the patient induces sleep.
At 0200 Sam finds Mrs. Simms sitting in the chair beside her bed. She tells Sam she is unable to sleep. What is Sam’s best response?
a. Assist Mrs. Simms back to bed.
b. Ask Mrs. Simms about strategies she has used successfully in the past to fall asleep.
c. Offer Mrs. Simms a glass of warm milk and give her a back rub.
d. Call the physician to obtain and order for a hypnotic.
B. Ask Mrs. Simms about strategies she has used successfully in the past to fall asleep
Sam can plan nursing interventions based on successful strategies Mrs. Simms has used in the past to help her fall asleep.
Mrs. Simms tells Sam she hasn’t slept well for a least a month. She complains of waking up tired each morning. Which question would provide Sam with the best information about factors that may be contributing to Mrs. Simms sleep problem?
a. How old are you?
b. What are you doing now to improve your sleep?
c. What has your family noticed about your sleep?
d. What brought this on?
D. What brought this on?
The cause of insomnia can usually be identified. “What brought this on?” addresses the contributing factors to the problem.
A client is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic open-ended question the nurse can ask about the quality of the client’s sleep?
a. “How would you describe your sleep?”
b. “Do you consider you sleep to be restless or restful?”
c. “Is the number of hours you sleep at night good for you?”
d. “Does your bed partner complain about your sleep behaviors?”
A. “How would you describe your sleep?”
This open-ended question requires client’s to explore the topic of sleep as it relates specifically to their own experiences
What are some examples of regulatory and accreditation agencies that took initiatives on safety?
The Joint Commission & Centers for Medicare/Medicaid Services
2018 Patient Safety Goals
Goal1: Identify patients correctly
Goal 2: Improve staff communication
Goal 3: Use medications safely
Goal 6: Use alarms safely
Goal 7: Prevent infection
Goal 15: Identify patient safety risks
Prevent mistakes in surgery
what does the national quality forum do?
-Improve the quality of healthcare in America
- they endorse national consensus standards for measuring and report safety performance publicly
- identify serious reportable events and never events
what is a culture of safety?
- acknowledges risk
- pursues safety
- fosters a blame free environment
- focus on performance improvement
What does QSEN do?
emphasizes the need for:
-continuous improvement
-minimizing of risks
-knowledge
-skills
-safety promoting attitudes
what does providing a safe environment include?
- meeting basic human needs
- reducing physical hazards
- reducing transmission of pathogens
what are some examples of basic human needs?
oxygen, comfortable temperature, and nutrition
Physical Hazards
-Fires
-Falls
-Disasters
-Pollution
-Poison
-Motor vehicle accidents
what are some factors influencing patient safety?
- lifestyle
- impaired mobility
- sensory impairment
- cognitive impairment
- safety awareness
Risk In Healthcare: Fall Risks
Intrinsic Factors- Related to patients (ex. immobility)
Extrinsic Factors- related to environment
Risk In Healthcare: Chemical Exposure
Helps you understand risk -material safety data sheets
Risk In Healthcare: Patient-inherent accidents
accidents other than falls (fingers stuck in drawers)
