PN Fundamentals NGN

The correct answer is D: You can decline to have certain medical procedures performed in your living will.

Rationale: Advance directives are legal documents that outline a person's wishes regarding medical treatment in the event they become incapacitated and are unable to communicate those wishes. The living will, which is a component of advance directives, allows a person to specify which medical procedures or life-sustaining treatments they would or would not want if they are in a terminal condition or permanently unconscious.

Why the other options are incorrect:

A. You must have advance directives in place in order to refuse recommended treatment.

This statement is not accurate. While advance directives provide guidance for healthcare providers in situations where the patient cannot communicate their preferences, a person can refuse treatment at any time, even without an advance directive. Refusing treatment is a fundamental right, and an advance directive is not required to exercise that right.

B. An attorney is needed in order for you to name a designee in your health care proxy. 

This statement is incorrect. An attorney is not required to name a designee in a health care proxy. Most states allow individuals to designate a health care proxy (or durable power of attorney for health care) without legal assistance. A health care proxy simply requires the individual to designate a trusted person to make healthcare decisions on their behalf if they are unable to do so themselves.

C. A living will can be an oral statement that you agree upon with your provider.

This statement is incorrect. A living will must be a written document. While individuals may discuss their healthcare preferences with their provider, an oral statement alone is not legally binding as a living will. To be effective, a living will must be documented in writing, signed, and witnessed according to state laws.

In summary: D is the correct answer because a living will allows individuals to specify the medical treatments they wish to receive or decline, making it a suitable document for expressing preferences about medical procedures.

The correct answer is B: Dorsalis pedis.

Explanation of the correct answer:

B. Dorsalis pedis

The dorsalis pedis pulse is located on the top (dorsum) of the foot. To palpate it, the nurse should place the fingers of one hand gently on the top of the foot, just lateral to the extensor tendon of the big toe. This pulse is part of the arterial system of the foot and can be used to assess the circulation in the lower extremity, especially in individuals who might have conditions like peripheral artery disease (PAD) or diabetes, which can impair circulation.

How to find the dorsalis pedis pulse:

The nurse should ask the client to relax their foot. Then, using their index and middle fingers, gently palpate the top of the foot, slightly lateral to the big toe's tendon. The pulse should be strong and regular, indicating good circulation to the foot.

Why the other options are incorrect:

A. Posterior tibial

The posterior tibial pulse is located on the inside (medial side) of the ankle, just behind the medial malleolus, which is the bony prominence on the inner ankle. To palpate this pulse, the nurse should place their fingers just behind the ankle bone. The posterior tibial pulse is used to assess blood flow to the foot and lower leg but is not located on the top of the foot.

How to find the posterior tibial pulse:

The nurse should palpate the inner side of the ankle, just behind the medial malleolus, and press gently to feel the pulse. This is another important pulse used for circulation assessments, but it is not on the top of the foot.

C. Popliteal

The popliteal pulse is located behind the knee in the popliteal fossa. This pulse can be difficult to palpate, especially in obese patients, and is assessed when the knee is slightly bent to relax the muscles in that area. It is crucial for evaluating blood flow to the lower extremity but is not located on the top of the foot.

How to find the popliteal pulse:

The nurse should ask the client to lie down with their knee slightly bent. Place the fingers behind the knee in the popliteal fossa and gently palpate. This pulse is important for circulation to the lower leg and foot but does not appear on the foot itself.

D. Brachial

The brachial pulse is located on the inner aspect of the upper arm, just above the elbow crease. It is most commonly used when measuring blood pressure or assessing circulation to the arm. It is not located anywhere near the foot.

How to find the brachial pulse:

To palpate the brachial pulse, the nurse places their fingers on the inner side of the upper arm, just above the elbow. This pulse is used in blood pressure measurements but is not relevant to the foot or its circulation.

Summary:

The dorsalis pedis pulse is located on the top of the foot, specifically lateral to the tendon of the big toe. This pulse is used to assess circulation in the lower extremity, making it the correct answer in this case.

The posterior tibial pulse is found behind the medial malleolus (inside of the ankle), the popliteal pulse is found behind the knee, and the brachial pulse is found in the upper arm, none of which are located on the top of the foot.

Understanding the locations of these pulses helps in evaluating the blood flow to different parts of the body, which is critical for managing conditions that affect circulation.

Correct Answer: C. Begin range of motion exercises

Why C is correct:

Footdrop, which is a condition where the foot drags or cannot be lifted properly, is often caused by prolonged immobility, muscle weakness, or nerve damage. One of the most effective ways to prevent footdrop is to maintain and improve muscle strength and joint flexibility. Range of motion (ROM) exercises help to maintain joint mobility and muscle strength, preventing the contractures and stiffness that can lead to footdrop.

Why Other Options Are Wrong:

A. Use a gait belt during ambulation While using a gait belt can assist in ambulation and ensure safety, it does not directly address the prevention of footdrop. Gait belts are primarily used for assisting in mobility and preventing falls, rather than maintaining muscle and joint function to prevent footdrop.

B. Elevate the feet while in bed Elevating the feet while in bed may be helpful in improving circulation and reducing edema, but it does not prevent or treat footdrop. Footdrop prevention requires specific exercises to maintain muscle strength and joint movement.

D. Apply compression stockings Compression stockings are used to improve venous circulation and prevent deep vein thrombosis (DVT) or edema, but they do not address the muscle weakness or joint immobility that contribute to footdrop.

Summary:

To reduce a client's risk for footdrop, it is crucial to implement range of motion exercises. These exercises help maintain the flexibility and strength of the muscles and joints, reducing the risk of footdrop. Other actions like using a gait belt, elevating the feet, or applying compression stockings are helpful for different concerns but do not directly prevent footdrop.

Correct Answer: Evaluate the room environment.

Explanation:

The priority nursing action when an older adult client reports an inability to fall asleep is to evaluate the room environment. Sleep disturbances can be caused by factors such as noise, light, temperature, or an uncomfortable bed. For older adults, sleep hygiene becomes especially important, and ensuring a conducive environment for sleep is the first step in managing insomnia. The PN should check if the room is too bright or noisy, ensure that the temperature is comfortable, and determine if the bed or linens are uncomfortable. By assessing the environment first, the nurse can eliminate simple environmental factors that may be disturbing the client’s sleep. Adjusting these factors before resorting to pharmacologic interventions or reassurances ensures a more holistic approach to solving the issue.

Why the other options are wrong:

Provide a PRN hypnotic medication:

While it may seem appropriate to offer medication, pharmacological intervention should not be the first step. In older adults, sleep medications can have side effects, such as confusion, dizziness, or increased risk of falls. Moreover, using medications without addressing the underlying environmental causes of sleep disturbance can lead to dependency or ineffectiveness. The first priority is non-pharmacological measures, such as evaluating and adjusting the environment, before considering medication.

Reassure the client that it is still early:

Reassuring the client that it is still early does not address the root cause of their inability to sleep. Simply telling the client it is early may be perceived as dismissive and may not help the client understand or resolve their current frustration with not being able to fall asleep. The PN should first evaluate the environment and determine if there are any barriers to sleep.

Close the door to the client's room:

While closing the door might reduce noise or light from the hallway, it is not the most comprehensive action. Closing the door may not be sufficient if there are other factors in the room, such as uncomfortable lighting, temperature, or an uncomfortable mattress. It’s essential to evaluate the entire room environment to identify potential sleep disturbances, not just focus on closing the door.

Summary:

The most important first step when a client reports difficulty sleeping is to assess the room environment. This includes checking for factors such as noise, light, and comfort. Once the environment has been evaluated and adjusted, the PN can then consider other interventions, such as medication, if needed, but these should only be used after addressing non-pharmacological causes of sleep disturbances.

The correct answer is C: decrease the rate of feeding.

Explanation of the correct answer:

C. Decrease the rate of feeding

The presence of hyperactive bowel sounds (greater than 30 bowel sounds per minute) may indicate that the client is experiencing increased gastrointestinal motility, which can be a sign of feeding intolerance, diarrhea, or potential malabsorption. When administering continuous enteral feedings, it’s essential to monitor for tolerance. If bowel sounds are excessively active and the client shows other signs such as cramping, bloating, or loose stools, the nurse should consider slowing the rate of feeding to allow for better absorption and reduce GI stress. Slowing the rate can help prevent complications like dumping syndrome or diarrhea.

Why the other options are incorrect:

A. Replace the NG tube

There is no indication that the NG tube is malfunctioning or misplaced. Hyperactive bowel sounds are related to GI activity, not the tube’s position. Tube replacement would only be warranted if there were evidence of displacement, blockage, or damage.

B. Place the client in Sims' position

While positioning can aid in comfort or facilitate drainage in some situations, Sims’ position is not standard for managing feeding intolerance. The preferred position for enteral feedings is semi-Fowler's (head of bed elevated 30–45°) to reduce the risk of aspiration.

D. Check the client’s blood glucose

Blood glucose monitoring is important in clients receiving enteral nutrition, especially if they are diabetic or receiving high-glucose formulas. However, hyperactive bowel sounds are not directly caused by blood glucose levels and do not warrant a glucose check as the immediate response.

Summary:

In the presence of hyperactive bowel sounds during continuous NG tube feeding, the most appropriate intervention is to decrease the feeding rate. This helps prevent GI complications and promotes better digestion and nutrient absorption.

Correct Answer: Check the medical record to verify the medication's name and strength.

Explanation of the Correct Answer:

 When a client expresses uncertainty about the medication being administered, the first step is to verify the medication. This ensures that the right drug is being given at the correct dose and that there has been no mix-up in the medication administration process. The medical record will indicate the correct medication and its prescribed strength. Verifying the medication before any further actions can prevent medication errors. 

Why the Other Options Are Incorrect:

Reassure the client that the blue tablet is the correct medication.

While it may be true that the blue tablet is correct, the PN should not simply reassure the client without verifying the medication first. It is important to confirm the medication to avoid potential errors.

Explain that the tablets are from different manufacturers.

This explanation may be true, but it is not the first step. The PN should verify the medication before assuming the discrepancy is due to different manufacturers. Clients should never be reassured without proper verification.

Withhold the medication and notify the healthcare provider.

While this may be appropriate if a medication error is confirmed, it is premature to take this action before verifying the medication. The first action is always to check the medical record to clarify the situation.

Summary:

The PN should first verify the medication in the medical record to ensure the correct drug and dose are being administered. This is the safest and most accurate approach to resolve any concerns raised by the client

Correct Answers are:

Intensive Care Unit

Oncology Treatment Center

Burn Center.

Explanation of the correct answers:

 Intensive Care Unit (ICU)

The ICU is an example of tertiary care. Tertiary care refers to specialized and highly complex care provided in hospitals or specialized centers. The ICU provides intensive, life-saving care for clients with severe health conditions that require continuous monitoring and advanced medical interventions, making it a clear example of tertiary care.

Oncology Treatment Center

Oncology Treatment Centers are part of tertiary care. These centers provide specialized care for patients with cancer, offering advanced treatment options such as chemotherapy, radiation therapy, and surgical interventions. The care provided is highly specialized and focused on specific, complex health conditions like cancer, which is characteristic of tertiary care

 Burn Center

A Burn Center also falls under tertiary care. These centers provide specialized treatment for individuals with severe burn injuries, including reconstructive surgeries and advanced wound care. Tertiary care facilities often treat patients who require highly specialized services due to the complexity or severity of their condition, such as burns.

Why the other options are incorrect:

Cardiac Rehabilitation

Cardiac Rehabilitation is considered secondary care, not tertiary care. It focuses on the recovery and rehabilitation of patients who have experienced heart-related issues, such as heart attacks or surgeries. It involves therapy and lifestyle changes to prevent further complications. While it provides specialized care for heart patients, it is not as complex or acute as tertiary care, which focuses on treatment for more severe, specialized, or rare conditions.

Home Health Care

Home Health Care is considered primary or secondary care, depending on the specific services provided. It involves healthcare services provided in a patient's home, typically for ongoing management of chronic conditions or post-acute care, such as wound care, physical therapy, or nursing visits. It does not involve the specialized, complex interventions characteristic of tertiary care.

Summary:

Tertiary care includes highly specialized services and treatment for severe or complex conditions that require expert intervention and resources. The ICU, oncology treatment centers, and burn centers are examples of settings that provide this level of care. Other options like cardiac rehabilitation and home health care provide less specialized services and therefore do not fit within tertiary care.

The correct answer is D: I should get out of bed if I don't fall asleep within an hour of lying down.

Explanation of the correct answer:

D. I should get out of bed if I don't fall asleep within an hour of lying down.

This statement aligns with one of the key behavioral strategies for managing insomnia, known as stimulus control therapy. The goal of this strategy is to break the association between the bed and wakefulness. If a client cannot fall asleep after lying in bed for an extended period, it is recommended that they get up and engage in a quiet, relaxing activity outside the bedroom until they feel sleepy. This helps to prevent the bed from becoming a place associated with anxiety and frustration, which can worsen insomnia.

Why the other options are incorrect:

A. I should turn on the ceiling fan to block out unwanted noise.

While environmental factors like noise can affect sleep quality, simply turning on a fan may not be the best strategy. It’s generally recommended to keep the sleep environment quiet and dark. If noise is a consistent issue, using earplugs or a white noise machine would be more effective. Turning on a fan may not always block out noise sufficiently and can potentially introduce more distractions.

B. I will limit my daily nap to 45 minutes.

Napping for too long during the day can interfere with nighttime sleep, and 45 minutes may be too long for some individuals. The ideal nap duration is typically 20-30 minutes, as longer naps can reduce sleep pressure, making it harder to fall asleep at night. While limiting naps is a good practice, 45 minutes is generally considered too long.

C. I will drink a cup of green tea at bedtime to help me sleep.

Green tea contains caffeine, which is a stimulant and can interfere with sleep, particularly if consumed close to bedtime. Although herbal teas like chamomile or valerian root are commonly used to promote relaxation and improve sleep quality, green tea is not suitable for bedtime due to its caffeine content. The best approach would be to avoid caffeine in the evening.

Summary:

The most effective approach to managing insomnia is to follow stimulus control therapy, which involves getting out of bed if unable to fall asleep within an hour. This helps break the association between the bed and wakefulness. The other statements reflect strategies that may not be as effective, such as relying on a ceiling fan for noise control, taking long naps, or consuming caffeinated beverages before bedtime.

The correct answer is A: I will be sure to keep the crutch dips dry.

Explanation of the correct answer:

A. I will be sure to keep the crutch dips dry.

This statement shows an understanding of the proper use of crutches. Crutch dips (the areas where the crutches rest against the underarms) should always be kept dry to prevent skin irritation, pressure sores, and discomfort. Keeping these areas dry ensures that the crutches are comfortable and do not cause injury to the skin.

Why the other options are incorrect:

B. I will hold a crutch in each hand when sitting down.

When sitting down, the client should not hold a crutch in each hand. Instead, the client should hold both crutches in one hand (usually the hand opposite to the injured leg) while using the other hand to assist in sitting down. Holding both crutches when sitting down could cause instability and make it harder to sit properly.

C. I will place my weight on my underarms.

The correct way to use crutches is to avoid placing weight on the underarms. Placing weight on the underarms can cause nerve damage, skin breakdown, and pressure sores. The client should place weight on their hands, specifically the hand grips, while keeping the weight off the underarms to prevent discomfort and injury.

D. I will lead with my right leg when going up stairs.

The client should lead with the good leg (the uninjured leg) when going up stairs. The pattern for using crutches on stairs is: "good leg up, bad leg down." The right leg (injured leg) should be placed last when going up stairs, as the injured leg should be brought up after the good leg. This helps maintain balance and stability.

Summary:

The correct statement is that the client will keep the crutch dips dry to prevent skin irritation and discomfort. The other options involve incorrect techniques for crutch use, which could lead to injury or instability during movement.