Prioritizing Care Level 1 & 2

The registered nurse is caring for a client in the emergency department. Which conditions of the client made the nurse stabilize the cervical spine as the primary nursing intervention? Select all that apply.

Correct1

Flail chest

Correct2

Head injuries

Correct3

Facial chemical burns

4

Renal colic pain

5

Blunt abdominal pain

Immediate care for a client with a head injury and facial chemical burns is stabilization of the cervical spine because the client may suffer severe respiratory distress. Cervical spine trauma should be suspected in any client with face, head, or neck trauma and significant upper chest injuries, such as in flail chest. The nurse should stabilize the cervical spine and or immobilize during assessment of the airway. Stabilization of the cervical spine may not be required in a client with renal colic pain or with blunt abdominal pain because the clients may not experience respiratory distress.

Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply.

Correct1

Collaboration

Incorrect2

Care planning

3

Communication

Correct4

Clinical judgment

Correct5

Cultural competency

The Synergy Model describes eight nurse competencies, which include collaboration, clinical judgment, advocacy and moral agency, caring practices, facilitation of learning, systems thinking, response to diversity (cultural competency), and clinical inquiry. Care planning and communication are skills that every nurse should demonstrate regardless of the care delivery system being implemented.

disaster triage tag system

black - deceased

red - immediate

yellow - delayed (can wait)

green - minor

Which member of the healthcare team, when using the team nursing approach, is responsible for prioritizing client care?

Correct1

Team leader

2

Charge nurse

3

Licensed practical nurse

4

Unlicensed assistive personnel

When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide client care to a small group of clients, including the prioritization of client care. The charge nurse is responsible for assigning team members to each team leader. The licensed practical nurse and the unlicensed assistive personnel will receive their assigned tasks and client care from the team leader.

A client with severe burns and injuries from a bomb blast is admitted in the emergency unit. Which triaging priority is preferable for the client?

Correct1

Class I

Incorrect2

Class II

3

Class III

4

Class IV

A client with severe burns and injuries due to a bomb blast requires emergent treatment to prevent life-threatening complications. Therefore the client should be considered for class I triage. Clients belonging to class II have major injuries that require normal treatment. Clients belonging to class III have minor injuries that do not require immediate treatment. Clients belonging to class IV are not allotted treatment because they are expected to die.

What term began to be used in the 1960s to describe case management?

1

Process control

2

Risk management

3

Quality improvement

Correct4

Utilization management

In the 1960s, insurers began to use nursing case management (NCM) as a strategy to manage the needs of complex clients who require coordination over the course of treatment. Acute care hospitals used nurses in this role under the term "utilization management." Process control is not a recognized term for client management. Risk management is a process to manage safety. Quality improvement is a process of ensuring high quality safe client care.

Which health care providers should be considered when filling a position as case manager for a community health care center? Select all that apply.

Correct1

Social worker

Correct2

Registered nurse

3

Physician assistant

4

Respiratory therapist

5

Certified nursing assistant

Social workers and nurses may work as case managers, bringing with them their discipline-specific skills and knowledge. A physician assistant is not identified as being appropriate for case management. The respiratory therapist's scope of practice is limited to respiratory function. The certified nursing assistant does not have adequate education to support the total client's needs in the case management model.

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?

1

Call the laboratory to repeat the test.

Correct2

Take vital signs and notify the healthcare provider.

3

Inform the cardiac arrest team to place them on alert.

4

Take an electrocardiogram and have lidocaine available.

Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The healthcare provider should be notified because medical intervention may be necessary. A repeat laboratory test will take time and probably reaffirm the original results; the client needs immediate attention. The cardiac arrest team is always on alert and will respond when called for a cardiac arrest. Taking an electrocardiogram and having lidocaine available are insufficient interventions.

Which is a theme in the design of "Transforming Care at the Bedside"?

1

Validity

Correct2

Reliability

3

Cost-effectiveness

Incorrect4

Evidence-based practice

In the Transforming Care at the Bedside model, reliability is a theme that ensures the care provided for moderately sick clients who are hospitalized is safe, reliable, effective, and equitable. Validity, cost-effectiveness, and evidence-based practice are not themes within the design of "Transforming Care at the Bedside".

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority?

1

Applying dry dressing

Incorrect2

Evaluating chest expansion

Correct3

Providing adequate oxygen supply.

4

Applying direct pressure on a bleeding site

The nurse should prioritize care while caring for a client with trauma in the emergency department. Evaluation of chest expansion, respiratory effort, and an evidence of chest wall trauma helps to assess breathing, a primary survey. The highest priority intervention is to establish a patent airway by providing adequate oxygen supply, thereby reducing the brain injury and progression to anoxic brain death. Direct application of pressure on the bleeding site with thick, dry dressing material helps to reduce external hemorrhage.

A student nurse is learning Gardner's Tasks of Leading and Managing. Which position of the health care team has the managing function of priority setting, according to Gardner?

Correct1

Clinical position

2

Executive position

3

Following position

4

Management position

The clinical position is that of the health care provider. The clinical position makes plans for priority setting and decision-making for prioritizing care in respect with the health condition of the clients. The executive position consists of registered nurses who delegate tasks for different assistants. The following position assists the organizational heads to achieve effective outcomes in prioritizing care. Nursing assistants, licensed practical nurses, and unlicensed nursing personnel are under the following position. The management position consists of the nursing manager and charge nurses who manage the condition for delegating proper tasks according to the priorities given by the health care provider.

Which health care provider would best help a homeless client receive needed medication for a communicable disease?

Correct1

Navigator

2

Case manager

3

Primary nurse

4

Unlicensed assistive personnel

The navigator role was conceived to reduce barriers to care for vulnerable clients who may cope with delays in access, diagnosis, treatment, and/or fragmented and uncoordinated care. A homeless person would be appropriately cared for by a navigator. The case manager, primary nurse, or unlicensed assistive personnel (UAP) would not be appropriate to aid the homeless client receive medication for a communicable disease.

Which leadership skill is least likely to be utilized when the case method of care delivery is used?

Correct1

Delegation

Incorrect2

Collaboration

3

Communication

4

Time management

No aspect of nursing care is delegated when the case method of care delivery is used, thus eliminating the need for supervising others. The nurse will collaborate and communicate with the client, family, and other care providers when providing care through the case method. Time management is essential with the case method because all activities and tasks are to be completed during the nurse's period of work.

What aspect of total client care needs to be taken into consideration if used on a 24-bed care area?

Correct1

Cost of nurses

Incorrect2

Training needs

3

Documentation

4

Time commitment

Since total client care is provided by a registered nurse (RN) it can be very expensive and not realistic to use a highly skilled and extremely knowledgeable professional nurse to provide all the care required in a unit of 24 clients. There are no particular issues with training, documentation, or time commitment with total client care.

Which type of clients are often referred to as the "walking wounded" in a mass casualty scene?

1

Red tagged clients

2

Black tagged clients

Correct3

Green tagged clients

4

Yellow tagged clients

Green tagged clients have minor injuries that can be managed in a delayed fashion, and they can evacuate themselves from the mass casualty scene and go by private vehicle. Therefore they are termed the "walking wounded" clients. Red tagged clients need immediate intervention because they have an immediate threat to life. Black tagged clients are those who are considered as dead or about to die. Yellow tagged clients also have major injuries that need treatment within 30 minutes to 2 hours and are not considered "walking wounded" clients.

The nurse is caring for a client who sustained a soft tissue injury while playing sports. Following an assessment of the extent of the injury, what should be the order of nursing interventions according to priority?

Correct

1.

Assessing neurovascular status

Correct

2.

Elevating the involved limb

Correct

3.

Applying a compression bandage

Correct

4.

Obtaining x-rays of the extremity

The client with a soft tissue injury should first assess the extent of the injury and determine the neuromuscular status of the client. Next intervention is elevating the involved limb. Then the nurse should apply compression bandage to the affected limb. Then the client's diagnostic report such as x-ray should be obtained to provide required treatment.

What should the associate nurse use to provide client care within the primary nursing delivery model?

Correct1

Plan of care

2

Nurse's notes

3

Physician's orders

4

Direction from the charge nurse

The associate nurse provides care using the plan of care developed by the primary nurse. The nurse's notes and physician's orders will not provide adequate information to provide client care. The charge nurse will not provide direction for client care within primary nursing.

What is a high priority assignment in an emergency department when a nurse is providing care for clients during a mass casualty?

1

Resolving stock availability problems

Correct2

Taking inventory and restocking supplies

3

Debriefing to promote effective coping strategies

Incorrect4

Outlining emergency expectations and arrangements

A high priority assignment in an emergency department during a mass casualty is taking inventory and restocking supplies. Collaboration between the emergency department and the central supply department is essential for resolving stock availability problems. Debriefing teams provide sessions for small groups of staff to promote effective coping strategies. Outlining emergency expectations and arrangements should be part of the hospital's overall emergency preparedness plan.

Which delivery system was developed to provide care through others as an adaptation to functional nursing?

Correct1

Team

2

Primary

3

Case management

4

Differentiated practice

The hallmark of team nursing is "care through others," which was designed as an adaptation to functional nursing. Primary nursing is an adaptation to the case method. Case management is the process of coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes. Differentiated practice consists of models of care delivery that are differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.

Which statement best describes a fundamental aspect of the clinical nurse leader (CNL)?

1

Schedules staff to cover work shifts

Correct2

Evaluates care for evidence-based approaches

3

Serve as a liaison between team leaders and other care providers

4

Meets with unlicensed assistive personnel (UAP) to review tasks

A fundamental aspect of the role of a clinical nurse leader (CNL) is to evaluate care for evidence-based approaches. The nurse manager would schedule staff to cover work shifts. The charge nurse functions as a liaison between the team leaders and other healthcare providers. The team leader or charge nurse would meet with unlicensed assistive personnel (UAP) to review tasks.

A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis?

Correct1

Preventing falls

2

Monitoring electrolytes

3

Administering antiemetics

4

Adjusting the diuretic therapy

A client with alkalosis has hypotension and muscle weakness, which increases the risk for injury due to falls; therefore, to prevent injury, the priority nursing care is to prevent falls. Monitoring electrolytes daily until they return to normal is not the priority nursing care. Antiemetics are prescribed for vomiting and are given low priority. Once the client is protected from the risk of injury, diuretic therapy is adjusted.

Which would the nurse claim is a cardiovascular manifestation of alkalosis?

1

Anxiety

Incorrect2

Seizures

3

Hyperreflexia

Correct4

Increased digitalis toxicity

Increased digitalis toxicity is one of the cardiovascular manifestations of alkalosis. Anxiety and seizures are central nervous system manifestations of alkalosis. Hyperreflexia is a neuromuscular manifestation of alkalosis.

The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio. Which finding is indicative of fetal lung maturity?

Incorrect1

1:1

2

1.4:1

3

1.8:1

Correct4

2:1

The detection of the presence of pulmonary surfactants, surface-active phospholipids, in amniotic fluid has been used to determine the degree of fetal lung maturity, or the ability of the lungs to function after birth. Lecithin (L) is the most critical alveolar surfactant required for postnatal lung expansion. It is detectable at approximately 21 weeks and increases after week 24. Another pulmonary phospholipid, sphingomyelin (S), remains constant in amount. Therefore the measure of lecithin in relation to sphingomyelin, or the L/S ratio, is used to determine fetal lung maturity. When the L/S ratio reaches 2:1, the fetus' lungs are considered mature.

The nurse determines that a client's placenta has separated during the third stage of labor. Which clinical finding supports the nurse's conclusion?

Correct1

A gush of blood

2

Bogginess of the uterus

3

Shrinkage of the uterus

4

An abrupt drop in blood pressure

There is a gush of blood when the placenta separates from the uterine wall, before the physiologic clamping of the vessels at the placental site occurs. The uterus contracts and becomes firm, not boggy, when the placenta separates because of the influence of endogenous oxytocin. The uterus appears to increase, not decrease, in size when the placenta separates. The uterus changes from round to an egg shape as the placenta moves into the lower uterine segment. The blood pressure returns to prenatal status shortly after birth; the decrease is gradual and unrelated to placental separation.

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. Which additional information about the fetus will examination of the amniotic fluid reveal at this time?

1

Lung maturity

2

Type 1 diabetes

3

Cardiac anomaly

Correct4

Neural tube defect

Alpha-fetoprotein in amniotic fluid is increased in the presence of a neural tube defect. Lung maturity cannot be determined until after 35 weeks' gestation. Neither diabetes nor cardiac disorders can be detected with the use of amniocentesis.