Saunders Flashcards


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Strategy ~ Comparable or ALike
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1

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

1.Hypertension

2.Hyperlipidemia

3.Substance abuse disorder

4.Post-traumatic stress disorder

4. PTSD

Note the strategic word, prioritize. This phrase indicates that although all options may be important, one option is a priority due to safety considerations. Also note that options 1 and 2 are comparable or alike and therefore can be eliminated. Although substance abuse may be a concern, PTSD is the priority.

2

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

1."I will sign as a witness to your signature."

2."You will need to find a witness on your own."

3."Whoever is available at the time will sign as a witness for you."

4."I will call the nursing supervisor to seek assistance regarding your request."

4."I will call the nursing supervisor to seek assistance regarding your request."

Test-Taking Strategy(ies):
Note the strategic words, most appropriate. Options 1 and 3 are comparable or alike and should be eliminated first. Option 2 is eliminated because it is a nontherapeutic response.

3

Which identifies accurate nursing documentation notation(s)? Select all that apply.

1.The client slept through the night.

2.Abdominal wound dressing is dry and intact without drainage.

3.The client seemed angry when awakened for vital sign measurement.

4.The client appears to become anxious when it is time for respiratory treatments.

5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1,2,5

Focus on the subject, accurate documentation notations. Eliminate options 3 and 4 because they are comparable or alike and include vague terms (seemed, appears).

Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable, because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.

4

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

1."Oh, really? I will discuss this situation with your son."

2."Let's talk about the ways you can manage your time to prevent this from happening."

3."Do you have any friends who can help you out until you resolve these important issues with your son?"

4."As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

4

Test-Taking Strategy(ies):
Note the strategic words, most appropriate. Focus on the data in the question and note that an older woman is receiving physical abuse by her son. Recall the nursing responsibilities related to client safety and reporting obligations. Options 1, 2, and 3 should be eliminated because they are comparable or alike in that they do not protect the client from injury.

5

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

1.Contact the nursing supervisor.

2.Administer the dose prescribed.

3.Hold the medication until the PHCP can be contacted.

4.Administer the recommended dose until the PHCP can be located.

1. Contact the nursing supervisor.

Test-Taking Strategy(ies):
Eliminate options 2 and 4 first because they are comparable or alike and are unsafe actions. Holding the medication can result in client injury. The nurse needs to take action. The correct option clearly identifies the required action in this situation.

6

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

1.Finish the bed bath and then administer the pain medication to the other client.

2.Ask the AP to find out when the last pain medication was given to the client.

3.Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.

4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

Note the strategic words, most appropriate, and use principles related to priorities of care. Options 1 and 3 are comparable or alike and delay the administration of pain medication, and option 2 is not a responsibility of the AP. The most appropriate action is to plan to administer the medication.

7

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

1.A client requiring a colostomy irrigation

2.A client receiving continuous tube feedings

3.A client who requires urine specimen collections

4.A client with difficulty swallowing food and fluids

3.A client who requires urine specimen collections

Note the strategic words, most appropriate, and note the subject, an assignment to the AP. Eliminate option 4 first because of the words difficulty swallowing. Next, eliminate options 1 and 2 because they are comparable or alike and are both invasive procedures and as such an AP cannot perform these procedures.

8

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

1.Weight loss and dry skin

2.Flat neck and hand veins and decreased urinary output

3.An increase in blood pressure and increased respirations

4.Weakness and decreased central venous pressure (CVP)

3.An increase in blood pressure and increased respirations

Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease.

9

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

1.Twitching

2.Hypoactive bowel sounds

3.Negative Trousseau's sign

4.Hypoactive deep tendon reflexes

1. twitching

Note that the three incorrect options are comparable or alike in that they reflect a hypoactivity. The option that is different is the correct option.

10

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

1.Urinary output

2.Wound drainage

3.Integumentary output

4.The gastrointestinal tract

Integumentary output

Note that the subject of the question is insensible fluid loss. Note that urination, wound drainage, and gastrointestinal tract losses are comparable or alike in that they can be measured for accurate output. Fluid loss through the skin cannot be measured accurately; it can only be approximated.