Safety
A nurse is caring for a patient with Parkinson's disease who is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?
What is aspiration. (When a person has difficulty swallowing, food or fluid can pass into the trachea and be inhaled into the lungs rather than swallowed down the esophagus. This can result in choking, partial or total airway obstruction, or aspiration pneumonia).
The primary reason why the nurse should avoid glued-on artificial nails is because they?
What is the provide crevices in which microorganism can grow (Especially if they become cracked, broken, split.)
What is the primary goal of the assessment phase of the nursing process?
What is collect data.
An unconscious patient begins vomiting. In which position should the nurse place the patient?
What is the side-lying position? (This position prevents the tongue from falling into the back of the oropharynx, allowing the vomitus to flow out of the mouth by gravity and thus preventing aspiration.)
A nurse is concerned about a patient's ability to withstand exposure to pathogens. What blood component should the nurse monitor?
What are neutrophils (Neutrophils are the most numerous leukocytes (white blood cells), are a primary defense against infection because they ingest and destroy microorganisms (phagocytosis). When the leukocyte count is low, it indicates a compromised ability to fight infection.)
Which human response identified by the nurse is an example of objective data?
a. Irregular radial pulse of 50 bpm
b. Pain 5/10
c. Shortness of Breath
d. Dizziness
What is A: Irregular pulse of 50 bpm (Objective data is measurable and checkable.)
What is the last step in making an occupied bed that the nurse should teach an assistant?
What is the bed should be in the lowest position (This positioning of the bed is safer because a greater risk for injury occurs when the mattress of the bed is further from the floor.)
A nurse identifies that a patient has an inflammatory response. Which localized patient response supports this conclusion?
What is erythema (Local trauma or infection stimulates capillary permeability and blood flow to the local area. Th increase of blood flow to the area causes redness.)
What is the primary reason a nurse performs an admission assessment of a newly admitted patient?
a. Diagnose is patient is a fall risk
b. Ensure patient's skin is intact
c. Establish a therapeutic relationship
d. Identify important data
What is c: identify important data (Data must be collected and then analyzed to determine significance and grouped into meaningful clusters before a plan of care can be made.)
What clinical manifestation indicated that a further nursing assessment is necessary to determine if the patient is having difficulty swallowing?
What is debris in the buccal cavity (Stasis of food in the oral cavity indicates that the patient is not swallowing ingested food completely. Food collects in the buccal cavity because the area between the teeth and cheek forms a pocket that traps the food.)
A patient's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this patient?
What is contact precautions (Clostridium difficile or C diff. is contracted by direct contact and also requires soap and water only before and after patient care.)
A nurse is interviewing a patient. Which patient statement is an example of objective data?
a. "I am hungry"
b. "I feel very warm"
c. "I ate half my lunch"
d. "I have the urge to urinate"
What is c: the amount of food eaten (The nurse can measure and document the percentage.)
What time of day is of most concern for the nurse when trying to protect a patient with dementia from injury?
What is at night (Patients with dementia often continue to experience confusion and agitation at night. Due to less light, less activity, fewer caregivers, and fewer orienting stimuli. Patients who are confused or agitated are at increased risk for injury because they may not comprehend cause and effect and, therefore, lack the ability to make safe judgement.)
What patient information collected by the nurse reflects a systemic response to a wound infection?
What is hyperthermia (Hyperthermia is a common systemic response to infection. With hyperthermia, microorganisms or endotoxins stimulate phagocytic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever.)
The nurses assesses a patient and collects a variety of data. Identify the human responses that are subjective (SELECT ALL THAT APPLY)
a. Nausea
b. Jaundice
c. Dizziness
d. Diaphoresis
e. Hypotension
What is A & C (Nausea and Dizziness can not be measured because it is experience only by the patient.)