SELECT THE RIGHT ANSWER

QUES :

The nurse is preparing to perform a moist-to-dry dressing change on a patient with a large dehisced surgical wound of the abdomen. The nurse begins to organize the supplies and knows to prioritize which nursing intervention?

Select one:

a. Gather all the needed dressing and treatment supplies.

b. Protect the patient’s bedding using waterproof pads.

c. Ensure privacy during the dressing change.

d. Administer pain medication before the dressing change.

QUES :

The nurse is performing skin check rounds on the stroke rehabilitation unit. While assessing a patient’s skin, the nurse notices an unstageable pressure injury on the left heel covered with a layer of dark, dry eschar. Which intervention is the appropriate next action?

Select one:

a. Obtain an order for enzymatic debridement.

b. Obtain an order for moist-to-dry debridement interventions.

c. Complete a vascular assessment to determine if debridement is appropriate.

d. Document the presence of the wound and notify the practitioner.

QUES :

A 52-year-old person with diabetes presents for ankle–brachial index (ABI) assessment. The left leg is dusky red and cool to touch while the right leg appears normal. The person has no sensation from the knees and reports no pain. ABI calculation is 1.1 on the left side and 1.3 on the right side. What is the correct interpretation?

Select one:

a. ABI is normal but clinical indications are inconsistent; further testing is recommended.

b. ABI is low; client should be referred for vascular surgery.

c. ABI is normal; no further action required.

d. ABI is elevated; client should be referred for toe–brachial index.

QUES :

The patient’s postoperative wound drain was removed yesterday. Today, the nurse notes increased drainage on the dressing, pain at the wound site, and a low-grade fever. What should the nurse conclude from these findings?

Select one:

a. These signs and symptoms suggest an infection at the wound site.

b. These changes in wound drainage require replacement of the wound drain.

c. These changes indicate a normal postoperative wound healing process.

d. These changes indicate a normal postoperative wound healing process.

Mrs. C, is a 79-year-old woman is newly admitted to the geriatric rehabilitation unit on 11/06/2020 after having a hip replacement two days ago (11/4/2020).

Her medical history includes high blood pressure, type II diabetes and osteoporosis and mild dementia. She is complaining of 8/10 pain, poor appetite and states she is very nervous about physical therapy “breaking her new hip.” She is refusing her morning bath and ADL’s stating “my daughter will help me when she gets here”. Mrs. C. was noted to be dizzy when out of bed with physical therapy and nursing assistance yesterday (11/05/20). Upon examination you note the following: blood pressure is within normal limits, pulse 108 BPM. Respiratory rate is 22. It is 11:00am and she has not voided, she took only a few sips of water, refusing breakfast. She has had no visitors since her admission.

I. What additional information related to Mrs. C.’s condition & concerns should be included in your initial nursing history and assessment? (1 point)

II. Formulate three nursing diagnosis for Mrs. C. (1 point)

1. Physiological

2. Psychosocial

3. Safety

4. Patient education

III. Develop an ISBAR report addressing one of the patient concerns identified within the scenario as a communication report to a selected health care team member. (1 point)

IV. Identify members of the multidisciplinary team that you would want to include in caring for Mrs. C. (Provide rationale). (1 point)

Sample (I)SBAR Format (Refer to pages 474-477)

Identity/Introduction: Communicate who you are, where you are, and why you are communicating.

Situation or Problem: Communicate is going on with the patient. Brief summary

Explain in details diagnosis process and different treatment strategies of Migraine?

In Your Words

Based on CHAPTER 11 Healthcare Law- Basics of the U.S. Health Care System (4th Edition), please provide an explanation of the following concepts in your own words as they apply to healthcare law.

Criminal law:

________________________________________________________

________________________________________________________

Civil law:

________________________________________________________

________________________________________________________

Battery:

________________________________________________________

________________________________________________________

Defensive medicine:

________________________________________________________

________________________________________________________

Torts:

________________________________________________________

________________________________________________________

Affirmative action plan:

________________________________________________________

________________________________________________________

Qui tam:

________________________________________________________

________________________________________________________

Standard of care:

________________________________________________________

________________________________________________________

Job lock:

________________________________________________________

________________________________________________________

Privacy rule:

________________________________________________________

________________________________________________________

Current Events

Perform an Internet search and find a current events topic over the last 3 years that is related to this chapter 11 Healthcare Law - Basics of the U.S. Health Care System (4th Edition). Provide a summary of the article and the link to the article and explain how the article relates to the chapter.

Numerous factors affect the rate of absorption of a drug in an individual. Identify and explain the impact of at least three of these factors.

The decision to use a particular drug formulation is based on many factors, including onset of action, physician/patient preferences, and the available routes of administration. Describe one to two instances where an injectable route of administration might be preferred over an oral route. Identify the advantages to using an injectable route in those scenarios.

Define adverse, allergic, and anaphylactic shock reactions. Compare and contrast an allergic reaction from an anaphylactic shock. What pharmaceuticals are used to treat these conditions?

47. A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse includes in the teaching?

1. Hypotension
2. Increased temperature
3. Decreased heart rate
4. Lethargy

48. A nurse is caring for a female client who is receiving total parenteral nutrition without fat emulsion. Which of the following findings should the nurse report?

1. Bowel sounds absent in lower quadrants
2. Crackles in the bilateral lung bases
3. Weight gain of 1.3 kg (3 lb) over the past 7 days
4. Triglyceride 110 mgidl

49. A nurse is planning care for a client who has full thickness burns on the lower extremities. Which of the following interventions should the nurse include?

1. Provide a diet of fresh fruits and vegetables for the client.
2. Apply new gloves when alternating between wound care sites.
3. Limit visitation time for the client's children to 40 min per day.
4. Clean the equipment in the client's room once per week.

50. A nurse is teaching a client how to use a quad cane for ambulation following a right-hemispheric stroke. Which of the following client actions indicates an understanding of the teaching?

1. Client moves the cane 2 feet ahead
2. Client takes a step before advancing the cane
3. Client holds the cane with the left hand
4. Client advances the weaker leg forward first

State the Etiology, Prognosis, and Complications for Acute stress disorder and Fractures.

47. A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?

1. Age 46 years
2. Diet high in fiber
3. BMI of 24
4. History of Crohn's disease

48. A nurse is providing discharge teaching to a client who will be self-administering insulin at home. Which of the following information should the nurse include regarding needle disposal?

1. "Place your storage container in a recycle bin when it is full."
2. "Remove the needle from the syringe before you place it in the trash."
3. "Secure the cap tightly over the needle before you discard it."
4. "You can discard needles in an empty bleach bottle with a lid."

49. A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings indicates that the client is experiencing hypoglycemia?
50. Abdominal cramping
51. Increased perspiration
52. Dehydration
53. Fruit odor to breath
54. A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following

actions should the nurse take?

1. Familiarize themselves with commonly used signed language.
2. Ask a family member to be present during the admission.
3. Obtain a board that uses colored pictures as communication.
4. Request an interpreter during the initial assessment.

51. A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?
    1. Auscultate breath sounds.
    2. Examine the surgical incision for drainage.
    3. Measure the client's core body temperature.
    4. Palpate pulses distal to the graft donor site.

47. A nurse is caring for a client following a below-the-knee amputation. The client states, "My life is over." Which of the following responses should the nurse make?

1. Would you like to meet with another client who is an amputee?"
2. "Why do you think your life is over?"
3. "You are upset. We can talk about this later."
4. "Most people can adjust following this surgery."

48. A nurse in the PACU is assessing a client who is postoperative following general anesthesia. Which of the following findings is the priority to address?

1. Indistinct, rambling speech
2. Piloerection of the skin
3. Decreased body temperature
4. Vomiting upon arousal

49. A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

1. Collect information about the irritant that caused the injury.
2. Administer proparacaine eyedrops into the affected eye.
3. Instill 0.9% sodium chloride solution into the affected eye.
4. Place a strip of pH paper onto the cul-de-sac of the affected eye.

50. A nurse is providing Instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

1. "You will need cryotherapy for 1 to 2 weeks."
2. You will need to take an antiviral medication for 6 months."
3. You will need three follow-up blood tests within a 24-month period."
4. "You will need to be monitored for 15 minutes after receiving each medication dose."

What is cultural broking? Who are cultural brokers, and how do they impact patient/ provider services? How are you practicing cultural broking? In what ways can you improve your service to patients?

47. A nurse is planning care for a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse include in the plan of care?

1. Remind the client to use a cane on his left side while ambulating.
2. Position the bedside table on the client's left side.
3. Provide the client with a short-handled reacher.
4. Place a plate guard on the client's meal tray.

48. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?

1. Administer IV fluids to the client.
2. Prepare the client for an intravenous pyelogram.
3. Initiate beta blocker therapy.
4. Insert a urinary catheter.

49. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

1. Discard the radioactive device in the client's trash can.
2. Instruct visitors to remain 3 feet from the client.
3. Limit time for visitors to 2 hr per day.
4. Keep so led bed linens in the client's room.

50. A nurse is reviewing medications taken at home with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

1. "I should take my daily aspirin on an empty stomach."
2. "I should withhold my metoprolol if my heart rate is above 100 beats per minute."
3. "I should place a nitroglycerin tablet under my tongue every 10 minutes for up to four doses."
4. "I should lie down before taking a dose of isosorbide dinitrate."

What are the strengths, limitations, and conclusions to the John Hopkins evidence-based practice nursing model?