Plan Should Include Flashcards, test questions and answers

Question 1

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every one to two hours? 1 Maintain comfort 2 Prevent pressure ulcers 3 Prevent flexion contractures of the extremities 4 Improve venous circulation in the lower extremities

Answer

2 Prevent pressure ulcers
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Question 2

A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include

Answer

recommending a heart-healthy diet
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Question 3

One section of the competitors analysis of a formal marketing plan should include all of the following, except

Answer

the competitiveness of plans such as warranty and repair policies
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Question 4

A young boy has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which of the following? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.

Answer

a. Recommend genetic counseling. Rationale: Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring.
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Question 5

A young boy has just been diagnosed with pseudohypertrophic (Duchenne’s) muscular dystrophy. The management plan should include:

Answer

Recommending genetic counseling. Pseudohypertrophic (Duchenne’s) muscular dystrophy is inherited as an X-linked recessive gene. Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy. Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.
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Question 6

The verbal report you receive from the Post Anesthesia Care Unit (PACU) nurse should include: Select all that apply (there are 6 correct answers). Hint the name of the surgical procedure Mr. Hale had Correct Knowing the procedure the patient had is critical. Your surgical care plan should include standards of care relevant to the surgical procedure, individualized for Mr. Hale. Mr. Hale’s relevant health history Correct Comprehensive medical information is collected on every patient prior to surgery. Relevant data in a concise format should be communicated to nurses in all areas. Relevant information from the patient’s history includes the patient’s age, allergies, medication use, and major health problems (including substance abuse history). Any identified latex sensitivity should also be communicated. Latex-sensitive patients require use of latex-safe equipment, and use of nonlatex gloves by caregivers. The PACU nurse tells you about Mr. Hale and his history of diabetes. A recent fingerstick glucose reading was 142 mg/dl. Mr. Hale’s fluid status and IV therapy Correct Fluid balance is a critical assessment postoperatively. Fluids are generally restricted preoperatively and fluid loss is common during surgery. Fluids are generally administered during and after surgery to correct deficits and maintain fluid balance. Knowledge of efforts to maintain fluid balance during and after surgery is critical. Urine output also provides information about fluid status and should be reported. The PACU nurse reports that Mr. Hale received one unit of packed red cells during surgery. In PACU, Lactated Ringer’s infused at 125 mL per hour, and continues to infuse. Mr. Hale does not have a Foley catheter and has not voided. information about any tubes or drains Correct Tubes and drains need ongoing assessment and care. Tubes present should be determined when a patient is received from PACU. The PACU nurse reports that Mr. Hale has a vented nasogastric (NG) tube to be connected to suction. NG tube drainage has been bloody, and 75 mL has drained since surgery. Mr. Hale does not have a Foley catheter and he has not voided. information about anesthesia and drugs that were administered Correct Knowing about anesthetics and medications that were administered will enable you to determine drug-specific assessments and interventions, and also to plan for Mr. Hale’s pain control. The PACU nurse reports that Mr. Hale had general anesthesia. In PACU, morphine sulfate 2 mg IV was given just prior to bringing Mr. Hale to the Surgical Unit. At that time, Mr. Hale complained of incisional pain, rated as 7 on a scale of 1-10. Morphine provided relief of pain. In PACU, because the depressant effects of anesthetics are generally still in effect, a small dose of a narcotic analgesic usually achieves analgesia. the condition of Mr. Hale’s surgical incision Correct The condition of the surgical incision should be reported, including type of wound closure and any dressing. Any bleeding or other drainage at the incision should also be reported. The PACU nurse tells you that Mr. Hale has a midline incision with staples. A gauze dressing applied over the wound is intact, with a quarter-size area of bloody drainage circled. Mr. Hale’s religious preference Ordinarily, a patient’s religious preference is not included in a verbal report when a patient is admitted from PACU. This information should be accessible, however, in the patient’s medical record.

Answer

You assess Mr. Hale. The most critical, high-priority assessment to be done is: Hint operative site Assessment of the operative site is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU). skin integrity Assessment of skin integrity is important. However, another assessment should be done first. pulse Pulse assessment is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU). airway Correct The nurse’s initial priority when admitting a patient to the Surgical Unit is to determine and insure the adequacy of the patient’s airway and breathing. The patient’s airway should be assessed for patency. Respiratory rate, rhythm, and quality should be determined. Breath sounds should be auscultated as soon as possible. Mr. Hale is breathing on his own at 16 regular, deep breaths per minute. You know that to meet criteria for discharge from the Post Anesthesia Care Unit (PACU), Mr. Hale had a SpO2 of 94-100% on room air for a minimum of five minutes. SpO2 measures O2 saturation noninvasively by means of pulse oximetry. blood pressure BP assessment is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU).
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