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Brunner and Suddarth's Textbook of Medical-Surgical Nursing14th EditionJanice L Hinkle, Kerry H Cheever 440 solutions The nurse in an ambulatory surgical center checks the vital signs of patients in the preoperative period. What would the vital signs indicate? -Patient's stability Rationale: In the preoperative period, the nurse checks for the patients vital signs to ensure health and stability. They also serve as a baseline for intraoperative assessment. The vital signs do not indicate correction of abnormalities. The vital signs do not assess the fear and stress of the patient. Which statement is true regarding the intraoperative surgical phase? -This phase requires careful preparation for the care of the patient. Rationale: The intraoperative surgical phase requires careful preparation for the care of the patient during the surgical procedure. Personnel in the operating room are at risk of injuries in this phase. Personnel involved in this phase should wear laser-protective eyewear or shields for protection from injuries to the skin and the eyes from contaminated body fluids. Personnel in the operating room may come in contact with contaminated fluids. The nurse is evaluating the need for the use of restraints when managing a patient with delirium. Which condition must be met before the nurse may use restraints? -The safety of the patient is at risk. Rationale: Restraints are not always recommended and should be used only in select cases. The three conditions that must be met before the use of restraints include (1) their use is necessary to ensure the safely of the patient or other patients, (2) a provider prescription is written with a start and end time and reviewed according to institution policy, and (3) all other attempts to provide for patient safety have failed. When the patient is improving, there is typically no need for restraints. Patients have the right to refuse investigations and procedures, and the nurse cannot restrain them for doing so. Such restraint may be considered false imprisonment. Which reason would support the use of patient restraints? -Confusion and disorientation Rationale: Physical restraints are used (temporarily) when a patient is confused and disoriented to prevent the risk of falls. Some patients are extremely irritated because they are connected to many medical devices, such as electrocardiogram (ECG) leads, a pulse oximeter, and intravenous (IV) lines. When patients tend to remove the devices repeatedly, the nurse should use restraints to prevent the removal of such devices Physical restraints should not be used if the patient is verbally aggressive to the nurse, but the nurse should make the patient realize that the behavior is inappropriate. The nurse can raise the side rails of the bed for prevention of falls in a sedated patient. When used in this way, the rails are not considered a restraint. Restraints are not needed in preparing the patient for a physical assessment.
Which reason would justify the use of restraints on a disoriented patient? -Helps reduce the risk of patient injury from falls Rationale: Restraints are a means to maintain patient safety. Nurses use restraints to protect patients who are confused, disoriented, repeatedly fall, or try to remove medical devices such as IV infusions or oxygen equipment. A disoriented patient can harm others and should be restrained. A restraint is not used to control the patient or to discontinue care. Which statement made by the nursing student regarding the use of physical restraints indicates effective learning? -"They reduce the risk of patient injury from falls." Rationale: Restraints are used temporarily to keep patients safe. They can be used to help reduce the risk of patient injury from falls. Restraints can also prevent interruption of therapy, such as traction, and prevent the removal ... Which statement is true regarding the use of patient restraints? -Restraints are a part of the patients prescribed medical treatment and plan of care. Rationale: If restraints are to be used, they must be a part of a patient's prescribed medical treatment and plan of care. Restraints are not ordered prn. The use of restraints involves a psychological adjustment for both the patient and the family, not just the family. Informed consent from family members is required before using restraints only in long-term care facilities, not in acute care settings. Which restraint would the nurse use to prevent nerve injury? -Elbow Rationale: An elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa. A belt restraint is used to maintain the center of gravity and prevents patients from rolling off stretchers or sitting up while on stretchers as well as from falling out of bed. Mitten restraints prevent patients from dislodging invasive equipment, removing dressings, or scratching. Extremity restraints maintain immobilization of extremities to protect patients from falling or accidental removal of therapeutic devices. Which patient would need a temporary restraint? -Confused patients Rationale: Confused patients are prone to falls and injuries if not restrained. Patients who repeatedly fall are at an increased risk of becoming injured and should be restrained. Patients who try to remove medical devices should be restrained to prevent them from removing medical devices. Alert patients are generally cooperative and bale to communicate and therefore do not require restraints. Accommodating patients are cooperative and do not require restraints. Which task related to the use of patient restraints can be delegated to assistive personnel (AP)? -Checking on a restraint Rationale: Routinely applying or checking on a restraint can be delegated to appropriately trained AP. Assessing a patient's behavior, determining the need and for restraints, orienting the patient to the environment, and determine the need and appropriate use of restraints must be performed by the nurse and cannot be delegated to AP. Which complication would the nurse be aware of when using physical restraints? -Constipation Rationale: Constipation can result from immobility. Incontinence can be caused by the inability to get out of bed in time to use the toilet. Pressure injuries can result from pressure of bony prominences caused by immobility. Increased appetites is generally not a complication and may not be related to the use of restraints. Improved alertness is a good sign and is not a complication of the use of restraints. The nurse is reviewing the manufacturer's instructions for restraint application before entering the patient's room. Which step in the nursing process is the nurse demonstrating? -Assessment Rationale: The basic step involved in this situation is assessment. Assessment involves the nurse reviewing the manufacturers instructions for restrain application before eating the patients room so that the nurse can be familiar with all the devices used for the patient. Planning involves gathering equipment and performing hand hygiene to reduce transmission of microorganisms. Evaluation occurs after application and involves observing the patient for signs of injury and checking vital signs. Implementation involved adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application. Which action by a registered nurse would result in both criminal and administrative sanctions against the nurse? -Taking or selling controlled substances Rationale: The inappropriate use of controlled substances is prohibited by every Nurse Practice Act. A physical restraint can be applied only on the written prescription of a health care provider based on The Joint Commission and Medicare guidelines. Refusing to provide health care information to a patient's child, reporting suspected abuse and neglect of children, and administering the wrong medication to a patient would not result in both criminal and administrative sanctions against the nurse. In which situation is the nurse allowed to use physical restraints? -The health care provider has given a written prescription. Rationale: The nurse can use physical restraints on a patient only if the health care provider has given a prescription to do so or to ensure the safety of other patients. If the patient is irritated the nurse should use other measures of restraining the patient, such as counseling. Patients exhibiting suicidal ideation should be monitored closely and should receive psychotherapy. The nurse should not restrain the patient just because family members have asked the nurse to do so. The hospital administrators warn the nurse about being negligent while providing care. Which reason for the warning is most appropriate? -The nurse has given an excessive does of a hepatotoxic drug to a patient with liver failure. Rationale: Giving an excessive does of a hepatotoxic drug to a patient with liver failure is an example of a negligent act by the nurse. Threatening the patient with the use of physical restraints is an example of assault by the nurse, not a negligent act. Publishing the wrong assessment findings of a patient in a scientific journal is an example of demotion of character tort but is not considered as negligence in providing care. Informing the spouse regarding the patients diagnosis without the patients consent is an example of invasion of privacy; it is not considered an act of negligence. Which statement is true about discharge planning? -Start discharge planning at admission. Rationale: True statements about discharge planning include start discharge planning at admission and involve family members. Discharge planning begins the moment a patient enters the health care system. It is beneficial to involve the family in planning care so that the care can be continued at home. Discharge planning should not be delayed until 48hrs after admission. It starts as soon as the patient is admitted to the hospital. The discharge planning is not dependent on prescriptions from the health care provider; it can be initiated by the nurse. The discharge planning does not depend on the patients willingness. Which option is a nursing-sensitive indicator that the nurses can use to measure patient safety and quality for the unit? -Total nursing hours per patient day. Rationale: Nursing-sensitive outcomes include total nursing hours per patient day and the job satisfaction rate for RNs. Nursing-sensitive outcomes are patient outcomes and nursing workforce characteristics that are directly related to nursing care. Number of antibiotics administered, total number of pt dismissed per day, and number of emergency department admission per year are not nursing-sensitive outcomes; they are medical-initiated outcomes. Which statement requires the manager to advise the nurse on the correct techniques of documentation and informatics used in a hand-off report? -The patient is extremely uncooperative and
grumbles all the time. Rationale: The hand-off report should be free of any personal and derogatory statements regarding the patient. The patient's condition is recorded specifically as opposed to giving generalized statements that the patient feels good or better. Biographical details already mentioned in the medical record need to be reported on the hand-off report; these include age, race, or admission dx. Only essential information should be provided, such as the patients name, gender, and nursing diagnosis. Any improvement or decline in the patients condition is recorded (ex. the patient is free of pain, had a good sleep, or could not sleep.) Which parameter indicates a high quality of nursing care provided in the care unit? -The low rate of hospital-acquired infections Rationale: A low rate of hospital-acquired infections indicates that the quality of nursing care is high. A high number of patient falls and high number of patients developing pressure injuries indicate subpar nursing care, not a high quality of nursing care. The low rate of patient admissions is not related to the quality of nursing care provided, but is more medical-focused than nursing-focused. Which approach would the nurse use to begin a conversation about the goals of care for end of life? -Ask the patient to identify beliefs about the goals of care. Rationale: To begin a conversation, the nurse would ask the patient to identify beliefs about the goals of care. By first determining what the patient believes is best, the nurse can then discuss that option in more detail and give realistic ways of reaching the desired goal. Although encouraging family members us appropriate, encouraging them to think more positively is not. The nurse must support the family as they grieve. The nurse would not avoid the discussion because it is within the realm of nursing; it is not just medical. Initiating a discussion about advance directives with the patient, family, and health care team should first be done upon admission to the agency and should be with the patient first, then later with the family members and health care team. The nurse is conducting an interview of a patient after admission. Which datum should the nurse document as subjective datum? -Nausea Rationale: Subjective date refers to information that a patient provides that is not necessarily observable or measurable. The patient who feels nauseous or light-headed or has discomfort in the stomach are examples of subjective data. A temp of 100 and blood pressure of 120/80 are objective data; these can be assessed and measured by the nurse. A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; partial pressure of carbon dioxide (PaCO2), 21 mm Hg; partial pressure of oxygen (PaO2), 92 mm Hg; and bicarbonate (HCO3-), 8 mEq/L. Which condition do those laboratory values indicate? -Metabolic acidosis Rationale: The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation. Which action would the nurse implement for discharge planning? -Develop a plan for further care. Rationale: Developing a plan for further care, coordinating a smooth transition from the hospital to another health care level, and anticipating and identifying patient needs are actions the nurse would take for discharge planning. Discharge planning is an an important nursing activity that requires critical thinking. When planning a discharge, the nurse develops a plan for further care of the patient ensuring that there is a smooth transition from the hospital to another level of health care such as nursing home. The nurse anticipates and identifies the patients needs so that the plan includes the care needed once the patient leaves the hospital setting. Referralls are important in ensuring that all the patients needs are met and should be included, not excluded. Discharge planning starts as soon as the patient is admitted, not after discharge instructions are given. The nurse is preparing a discharge summary for the patient with diabetes being discharged home on insulin. Which information would the nurse provide in the discharge summary? -The contact information of the health care provider Rationale: Proper discharge planning is important to prepare patient for an effective and timely discharge from a health care institution. This is necessary to facilitate cost savings and ensure reimbursement. Contact information of the health care providers is documented to help the patients contact them when needed. Step-by-step instructions about the procedures should be provided so the patient can refer to them while doing self-care procedures. Warning signs and symptoms that require the health care provider's attention should be documented in the discharge summary. Detailed biographical information of the patient and all the investigations done during the period of hospitalization are not required to be documented in a discharge summary. Which information would the nurse include in patient discharge summary forms? -Dietary
restrictions Rationale: At the time of discharge, a patient should be provided with a discharge summary form I which home care is noted. Dietary restrictions, follow-up care, and emergency contact numbers should be included in the discharge summary forms. Preoperative instructions are given before surgical procedures. Acuity records determine hours of care and staff required to care for the patient. Which topic would the nurse include in the discharge plan? -Necessary follow-up care Rationale: Discharge topics include necessary follow-up care, counseling regarding nutrition and diet, and correct and effective use of medications. The nurse prepares a discharge plan for a patient to ensure continuity of care. The plan includes necessary rehabilitation techniques to support adaptation to the environment. The nurse provides counseling regarding nutrition and diet to help the patient lead a healthy life. The plan also includes information about safe and effective use of medications. The patients medical history and reports of diagnostic test are documented in the patient electronic health record, not in the discharge planning. At which point would the nurse begin discharge planning for the patient? -The time the patient enters the health care system Rationale: Discharge planning begins when the patient enters the health care system. The nurse should start planning the care, patient education, home care services, and participation in community support groups if needed. Discharge planning is performed even before the patient starts taking medication, completes the treatment plan, or has a definitive diagnosis confirmed. This ensures that holistic care is provided to the patient. Which member of the nursing team is MOST likely to use transformational leadership for team development? -Nurse manager Rationale: Using relational leadership styles such as transformational leadership for team development is a leadership quality exhibited by the nurse manager. This helps create a positive environment among the RNs and other staff, such as LPNs and assistive personnel. This form of leadership is more appropriately used by a nurse manager than an RN, an LPN, or assistive personnel. Which information would the nurse include in patient discharge summary?The six primary content areas to be contained in a discharge summary, as mandated by The Joint Commission, are: reason for hospitalization, significant findings, procedures and treatment provided, patient discharge condition, patient and family instructions, and attending physician signature.
Which information would the nurse include in patient discharge summary forms Select all that apply?A written transition plan or discharge summary is completed and includes diagnosis, active issues, medications, services needed, warning signs, and emergency contact information. The plan is written in the patient's language.
Which information would the nurse include in a discharge plan quizlet?Which topic would the nurse include in the discharge plan? Rationale: Discharge topics include necessary follow-up care, counseling regarding nutrition and diet, and correct and effective use of medications.
Which information with the nurse include in a handoff report at the end of shift?It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
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Which information would the nurse include in patient discharge summary forms quizlet?
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