NURS_347_01_SP25_Exam 3
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A client is agitated, combative, and pulling at their intravenous line and urinary catheter. For patient safety, restraints are applied. Which statement made by the nurse is inaccurate?
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"An alternative to restraints is moving the patient to a visible room near the nurse's station."
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"Restraints should always be used as a last resort for safety of the patient and staff."
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"Restraints can initially be applied by a nurse and requires an order by the physician within 72 hours."
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"A chemical restraint constitutes the use of medications for patient safety."
Explanation
Correct Answer: (C) "Restraints can initially be applied by a nurse and requires an order by the physician within 72 hours."
This statement is inaccurate because while a nurse may apply restraints in an emergency situation to ensure immediate patient safety, a physician's order must be obtained within 1 hour, not 72 hours. The Joint Commission and facility policies mandate that a licensed provider evaluate the patient and provide a written order for restraints within a very short timeframe after emergency application. The 72-hour timeframe stated in option C is dangerously incorrect and represents a serious violation of restraint standards.
Why the other options are incorrect:
A. Moving an agitated patient to a visible room near the nurse's station is a recognized and appropriate least-restrictive alternative to restraints, allowing for closer monitoring without physical restriction.
B. Restraints being used as a last resort is a true and accurate statement. Restraints are only appropriate when all other less-restrictive interventions have been considered or attempted.
D. Chemical restraints referring to the use of medications to control behavior for patient safety is an accurate definition. Medications such as sedatives used to restrain a patient's movement or behavior are classified as chemical restraints.
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on the evaluation, which of the following actions should the nurse take, according to the nursing process?
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Reassess the client to determine the reasons for inadequate pain relief.
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Teach the client about the plan of care for managing pain.
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Wait to see whether the pain lessens during the next 24 hours.
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Change the plan of care to provide different pain relief interventions.
Explanation
Correct Answer: (A) Reassess the client to determine the reasons for inadequate pain relief.
According to the nursing process, when evaluation reveals that a desired outcome has not been met, the nurse must return to the assessment phase to identify why the current plan is ineffective before making changes. Reassessing the client allows the nurse to gather new data about the nature, location, intensity, and contributing factors of the unrelieved pain, which will then guide appropriate modifications to the care plan. Acting without reassessment could lead to inappropriate or ineffective interventions.
Why Other Options are Incorrect:
B. Teaching the client about the pain management plan is an implementation step, not the appropriate response when an outcome has not been achieved. Reassessment must come first to identify why pain relief is inadequate.
C. Waiting another 24 hours to see if pain lessens is inappropriate and unsafe. Unrelieved pain by the second postoperative day requires immediate reassessment and intervention, not a passive wait-and-see approach.
D. Changing the plan of care is appropriate but must come after reassessment. Modifying interventions without first identifying the reason for failure may not address the actual problem and could be harmful.
A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. What action does the nurse suggest they prioritize?
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Preventing exposure to temperature extremes
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Ensuring proper function of fire alarms
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Maintaining clutter free rooms and hallways
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Screening for partner or elder abuse
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Ensuring any fire arms are secured
Explanation
Correct Answer: (D) Screening for partner or elder abuse
Elder abuse is a widespread and often underreported problem in long-term care settings. Older adults are particularly vulnerable due to physical frailty, cognitive decline, and dependence on caregivers. An interprofessional safety committee focused specifically on protecting older adults from injury and trauma should prioritize screening for elder or partner abuse, as this directly addresses intentional harm that may go undetected without systematic screening protocols in place.
Why the other options are incorrect:
A. Preventing exposure to temperature extremes is important for older adults but is a general environmental safety concern, not the most targeted action for an interprofessional committee focused on injury and trauma prevention in this population.
B. Ensuring proper function of fire alarms is a general facility safety measure applicable to all patients and staff, not specific to protecting older adults from injury and trauma.
C. Maintaining clutter free rooms and hallways helps prevent falls but is a standard environmental measure rather than the priority focus of an interprofessional trauma-focused safety committee.
E. Ensuring firearms are secured is a relevant safety concern in community settings but is less applicable in a long-term care facility environment.
increased / decreased
intravascular / intracellular
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increased
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decreased
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intravascular
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intracellular
Explanation
Correct Answer: (1) Decreased (2) Intravascular
Hypovolemia refers to an abnormally low volume of blood or fluid in the body. It specifically results in decreased volume in the intravascular compartment, meaning there is less fluid circulating within the blood vessels. This can occur due to hemorrhage, excessive fluid loss from vomiting, diarrhea, or burns. The intravascular space is the first compartment affected, leading to reduced blood pressure, increased heart rate, and poor tissue perfusion.
Why the other options are incorrect:
Increased is incorrect because hypovolemia by definition means a reduction, not an increase, in fluid volume. Intracellular is incorrect because hypovolemia primarily affects the intravascular space first, not the fluid within the cells.
It is 2 pm and a patient who is 2-days postoperative reports to the nurse, "I do not want to get out of bed because I have pain from the surgery. I will walk tomorrow with a new nurse." Which intervention from the nurse is most appropriate?
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Educate the patient on the importance of early ambulation to prevent surgical complications
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Per the patient's request, ask the nurse assigned for tomorrow's shift to ambulate with the patient
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Encourage the patient to ambulate today and administer pain medication after ambulation
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Reassure the patient that pain is normal and document "Patient refuses, will try again in 48 hours"
Explanation
Early postoperative ambulation is a critical component of surgical recovery that prevents serious complications including deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia, and ileus. The nurse's priority is to educate the patient about why ambulation is essential so the patient can make an informed decision. Addressing the patient's knowledge deficit regarding the importance of early mobility is the most therapeutic and appropriate first intervention when a patient is refusing ambulation due to pain concerns.
Why the other options are incorrect:
B. Deferring ambulation to the next shift nurse respects the patient's request but delays a medically necessary intervention. At two days postoperative, ambulation should not be postponed, as the risks of immobility accumulate rapidly.
C. Encouraging ambulation and then administering pain medication after is incorrect in sequencing. Pain medication should ideally be given before ambulation so that the patient can tolerate and participate in the activity more effectively, not after the exertion is already complete.
D. Reassuring the patient that pain is normal and documenting a 48-hour delay is inappropriate and potentially harmful. Waiting 48 hours to attempt ambulation again significantly increases the patient's risk of preventable postoperative complications and does not reflect adequate nursing advocacy or standard of care.
A community health nurse is providing education on child safety. Who does the nurse identify as the highest risk for choking and suffocation?
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A 3-year-old eating cheerios for a snack
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A toddler playing with his older brother's wooden blocks
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A 4-year-old drinking a glass of milk
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An infant sleeping in the prone position
Explanation
Correct Answer: (D) An infant sleeping in the prone position
Infants sleeping in the prone, or face-down, position are at the highest risk for suffocation. This position is the leading risk factor for Sudden Infant Death Syndrome (SIDS) because infants lack the neck strength and motor control to reposition themselves if their airway becomes obstructed by the mattress or bedding. The safe sleep guideline universally recommended is to always place infants on their backs to sleep on a firm, flat surface.
Why Other Options are Incorrect:
A. A 3-year-old eating cheerios carries some choking risk, but cheerios are small, lightweight, and dissolve easily, making them one of the safer snack options for young children. The risk is significantly lower compared to an infant in the prone position.
B. A toddler playing with wooden blocks poses a risk only if the blocks are small enough to be swallowed. Standard wooden blocks are typically too large to be a choking hazard, though supervision is always recommended.
C. A 4-year-old drinking milk presents minimal choking or suffocation risk under normal circumstances. Liquid aspiration is possible but far less immediately life-threatening than an infant sleeping face-down.
Mrs. Phillips asks to go to the bathroom when the nurse begins the admission process. Which safety intervention must the nurse perform first?
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Arrange furniture so that the client has something to hold on to.
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Assess for need for assistance with ambulation
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Apply socks to the client's feet.
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Put the client's bedside rails up.
Explanation
Correct Answer: (B) Assess for need for assistance with ambulation
Before any physical intervention is implemented, the nurse must first assess the patient's ability to ambulate safely. Mrs. Phillips has a significant past medical history including a previous fall resulting in a fractured wrist, hypertension, and myocardial infarction, all of which are risk factors for falls and mobility impairment. Assessment is always the first step of the nursing process. Determining whether the patient needs assistance, a walker, or full support before she attempts to walk to the bathroom is the priority action to prevent injury.
Why Other Options are Incorrect:
A. Arranging furniture to provide support is a helpful environmental modification but should only be implemented after the nurse has assessed the patient's actual mobility status and level of assistance needed. Acting without assessment may not address the patient's true needs.
C. Applying socks to the client's feet is a fall prevention measure but is a secondary intervention. It should follow the assessment of the patient's ambulation needs rather than precede it. Non-slip socks alone do not address whether the patient can walk safely or needs assistance.
D. Putting the bedside rails up is relevant when the patient is in bed, but Mrs. Phillips is requesting to get up and go to the bathroom. Raising rails would not facilitate safe ambulation and does not address the immediate safety need of getting her to the bathroom safely.
A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select All That Apply
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Assess medication for side effects of sleep pattern disturbances.
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Arrange for assessment for depression and treatment.
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Discourage napping during the day.
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Administer diuretics in the morning.
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Encourage patient to engage in some type of physical activity during the day.
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Decrease fluids during the evening.
Explanation
Correct Answer: (A, B, C, D, E, F) — All options are correct
All listed interventions are appropriate nursing actions for a patient with disturbed sleep pattern related to initiation of sleep. Certain medications can interfere with sleep, so assessing for side effects is essential. Depression is a common cause of sleep disturbances in older adults and warrants evaluation. Daytime napping reduces sleep drive at night. Administering diuretics in the morning prevents nighttime urination that disrupts sleep. Physical activity during the day promotes better sleep onset at night. Reducing fluid intake in the evening decreases the likelihood of nocturia, which commonly interrupts sleep in older adults.
Why the other options are incorrect:
There are no incorrect options in this question as all interventions A through F are evidence-based nursing actions appropriate for managing disturbed sleep pattern in an older adult.
Which percent of total body fluid is contained in the intravascular and interstitial space?
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45%
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30%
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50%
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70%
Explanation
Correct Answer: (B) 30%
Total body fluid is divided into intracellular fluid, which makes up approximately 70% of total body fluid, and extracellular fluid, which makes up approximately 30%. The extracellular fluid compartment includes both the intravascular space (plasma within blood vessels) and the interstitial space (fluid surrounding cells). Therefore, the intravascular and interstitial spaces together contain approximately 30% of total body fluid.
Why Other Options are Incorrect:
A. 45% does not accurately represent the proportion of extracellular fluid in the body and does not correspond to a standard fluid compartment distribution value.
C. 50% overestimates the extracellular fluid compartment. The majority of body fluid, approximately 70%, is intracellular, leaving only about 30% in the extracellular compartments.
D. 70% represents the intracellular fluid compartment, not the intravascular and interstitial spaces combined.
A. Increase venous return
B. Promote respiratory function
C. Provide diversional activities
D. Maintain functional abilities
Explanation:
Correct Answer: (A) Increase venous return
Leg exercises after surgery, such as ankle pumps, foot circles, and leg lifts, are primarily performed to increase venous return by activating the calf muscle pump. This helps push blood from the lower extremities back toward the heart, preventing venous stasis, which is a major risk factor for deep vein thrombosis (DVT) and pulmonary embolism in postoperative patients. Promoting circulation through leg exercises is a critical component of postoperative care.
Why Other Options are Incorrect:
B. Promoting respiratory function is the goal of deep breathing and coughing exercises, not leg exercises. Respiratory exercises prevent atelectasis and pneumonia, while leg exercises specifically target circulatory complications.
C. Providing diversional activities is not a clinical rationale for postoperative leg exercises. Leg exercises are a therapeutic intervention with a specific physiological purpose, not a method of keeping the patient occupied or entertained.
D. Maintaining functional abilities is a general goal of early mobility and rehabilitation but is not the primary or most specific rationale for performing leg exercises in the immediate postoperative period.
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Increase venous return
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Promote respiratory function
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Provide diversional activities
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Maintain functional abilities
Explanation
Correct Answer: (A) Increase venous return
Leg exercises after surgery, such as ankle pumps, foot circles, and leg lifts, are primarily performed to increase venous return by activating the calf muscle pump. This helps push blood from the lower extremities back toward the heart, preventing venous stasis, which is a major risk factor for deep vein thrombosis (DVT) and pulmonary embolism in postoperative patients. Promoting circulation through leg exercises is a critical component of postoperative care.
Why Other Options are Incorrect:
B. Promoting respiratory function is the goal of deep breathing and coughing exercises, not leg exercises. Respiratory exercises prevent atelectasis and pneumonia, while leg exercises specifically target circulatory complications.
C. Providing diversional activities is not a clinical rationale for postoperative leg exercises. Leg exercises are a therapeutic intervention with a specific physiological purpose, not a method of keeping the patient occupied or entertained.
D. Maintaining functional abilities is a general goal of early mobility and rehabilitation but is not the primary or most specific rationale for performing leg exercises in the immediate postoperative period.
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