Vanyo Exam one Flashcards


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1

Which would represent an attainable goal for an obese client who works at a fast food restaurant wanting to lose weight?

A. Quit working

B. Workout 3 hours a day

C. Get a gym membership

D. List affordable but healthy meal options

Answer: D

Rationale: According to our page 2343 of our text client goals should be realistic and attainable for client. Quitting his/her job would likely be unrealistic and likely not beneficial for the goal of losing weight. Working out 3 hours a day is far above what most associations recommend and for most working individuals unrealistic. Getting a gym membership might be beneficial, but this might be difficult for someone with a low income. The only one that qualifies as realistic and attainable is D. Listing affordable but healthy meal options is the only option that meats the realistic and attainable requirement for writing a goal.

2

Which patient would you visit first?

A. Patient with broken finger

B. Patient with head injury who just stopped breathing

C. Patient needing oral care

D. Patient pressing call bell for the 8th time in the last hour for ice chips

Answer: B

Rationale: According to pg 2366 high priority patients are those with life-threatening problems. The only patient with a life-threatening problem above is the patient with a head injury who just stopped breathing. This patient is showing signs of ineffective breathing pattern, which could lead to death without intervention.

3

Nurse is going to enter room of patient with MRSA, what is the nurse’s first priority?

a. Don PPE

b. Ensure the rooms thermostat is set to 70 degrees Fahrenheit

c. Perform hand hygiene

d. Check if room is a droplet precaution and eye protection is needed.

Answer: C

Rationale: “The most effective preventative measure against spreading infections in the hospital setting is consistent and appropriate hand hygiene.” (Nursing, 2015)

Nursing: a concept-based approach to learning. (2nd ed., Vol. 1, page 958). (2015). Pearson.

4

Four patients arrive at the emergency room, which patient should be seen first?

a. A 16 year-old female complaining of severe abdominal cramping.

b. A six year-old boy who’s wheezing and his oxygen saturation is 75%

c. A 42 year-old male a temperature of 101 *F who is coughing

d. A 30 year-old female with a gunshot wound in her right shoulder.

Answer: B

Rationale: “Inadequate levels of oxygenation can affect the acid-base balance. Decreased levels of oxygen can lead to a condition known as respiratory acidosis.” (Nursing, 2015)

Nursing: a concept-based approach to learning. (2nd ed., Vol. 2, page 2702). (2015). Pearson.

5

An elder client comes into the emergency department with symptoms of a cough and fever. Nurse Jackie obtains his vitals, listens to his lung and heart sounds, and asks client to rate his pain on a scale of 0-10. Which step in the clinical decision making process is nurse Jackie making?

A. Assessment

B. Diagnosis

C. Planning

D. Evaluation

Answer A

6

A patent walks into his Doctors appointment and is complaining of shortness of breath. The nurse looks through the patient’s documentation and notices the patient has a diagnosis of COPD. What would the priority nursing diagnosis be?

A. Risk for acid base imbalance

B. Risk for bleeding

C. Impaired skin integrity

D. Risk for infection

Answer A

7

A patient has chronic kidney failure and is being admitted with pulmonary edema. Which is a priority nursing intervention?

a) Teach importance of dialysis appointments

b) Monitor serum potassium levels

c) Assess lung sounds and oxygen saturation level

d) Promote independence in activities of daily living

Answer C

8

Which patient needs immediate nursing intervention? The patient who:

a) has epigastric pain after eating.

b) has a rigid, board-like abdomen.

c) has ribbon-like stools.

d) complains of anorexia and periumbilical pain.

Answer B

9

In the emergency room there is Patient a, patient b, patient c, and patient d. Which

would the nurse’s highest priority?

A) Patient with peripheral edema and numbness in lower extremities

B) Patient 2 days postoperative complaining of pain at incision site, 5 out of 10

C) Patient with COPD complaining of SOB with pulse oximetry of 87%

D) Patient with superficial abrasion to left arm in stable condition

Answer: C

10

Patient is exhibiting signs of allergic reaction. Which manifestation would the nurse treat first?

A) Swollen tongue obstructing patient’s airway

B) Raised red hives on patient’s limbs

C) Increased level of anxiety

D) Pain level 4 out of 10

Answer: A

11

Mr. Smith has type 1 diabetes mellitus. He knows that when he shows signs of hypoglycemia he should immediately:
A. Inject his insulin as soon as possible

B. Consume 15 grams of rapid acting sugar followed by the 15/15 rule

C. Perform a brief, quick 15 minute exercise to raise blood glucose

D. Inject Lantus and Humulin R together for faster homeostasis

The answer is B. The patient should immediately consume 15 grams of rapid acting glucose such as glucose tablets, half cup of fruit juice, skim milk, hard candies, marshmallow, sugar, or honey. If after 15 minutes later and blood glucose is still low the individual should consume 15 more grams of carbohydrates. This can continue till blood glucose returns to normal. Also, Lantus should never be mixed with any other insulin. Plus insulin will only cause blood sugar to go lower.

12

Signs and symptoms are linked to the etiology by the phrase:

A. Subjective

B. Objective

C. Primary & secondary

D. As evidenced by

The answer is D as these are physiological responses to an illness or imbalance and seen by the nurse.

13

Which of the following should the nurse delegate to the licensed practical nurse (LPN)? Select all that apply.
A - Administering a piggyback IV medication
B - IM medication administration
C - Initiating a primary IV medication
D - Oral medication administration
E - Urinary catheterization

Answers - A, B, D, E
LPNs can administer PO, IM, SQ or IV medication and begin a urinary catheterization. LPNs cannot initiate a primary IV medication; an RN must accomplish this task.

14

Four patients all require the attention of the nurse. Who should the nurse see first?
A - A 12-year-old with asthma asking to ambulate
B - A 15-year-old post-op patient complaining of continuous, achy pain
C - A 16-year-old with pneumothorax complaining of shortness of breath
D - An 8 year-old waiting to be discharged

Answer - C
A patient with a pneumothorax who is experiencing shortness of breath needs immediate attention to prevent respiratory failure or other negative outcomes. The patient with compromised oxygenation should be the priority.

15

A nurse enters the room of a patient with COPD. The nurse quickly assesses that the patient is short of breath, she also assesses that the patient’s O2 sat is at 85%. Immediately, the nurse assists the patient to a sitting position on the side of the bed and instructs him to lean over the bedside table. She also instructs him to take slow, deep breaths in through his nose and out through pursed lips. Which part of the nursing process is being demonstrated?

Planning

Evaluation

Diagnosis

Implementation

Answer: D Rationale: The nurse acts within her scope of practice to implement leaning over the bedside table and teach pursed lip breathing as a strategy to overcome the COPD patient’s ineffective breathing pattern. The nurse does not plan by making a broadly stated goal. Evaluation of the success of the nursing interventions would be the next step (after implementation) that the nurse would take. The nurse does not present a diagnosis for the patient.

16

Which nursing diagnosis takes highest priority for client with hypothyroidism?

a.Risk for imbalanced nutrition: Less than body requirements related to TH excess

b.Disturbed body image related to weight loss

c. Risk for imbalanced nutrition: More than body requirements related to TH deficiency

d. Risk for heat intolerance

Answer: C Rationale: All of the other options are related to hyperthyroidism, so by process of elimination, the answer is C.

17

An RN is caring for 4 clients. Which client should be seen first?
a. 48-old male with a breathing rate of 32
b. 12-old female reporting abdominal pain level of 7
c. 18-old female with a 101° F temperature
d. 54-old male with a blood glucose of 220 mg/dL

Answer is A. The client with the fever is not in danger with a temperature of 101° F. A blood glucose of 220 mg/dl is high, but again it is not a high priority problem. A child reporting an abdominal pain level of 7 is concerning, but with no other indication of a serious problem this ailment is not of critical urgency. A breathing rate of 32 while resting takes priority over the others as it is a compromise of the ABC’s of patient care, and could possibly worsen to become life-threatening.

18

A patient was admitted to the hospital with cirrhosis and has developed ascites and edema. What is the priority nursing intervention for this patient?

a. Inform the patient of the effects alcohol has on the liver

b. Restrict the patient’s sodium intake

c. Balance fluid volume, assess and measure the ascites

d. Call the physician

Answer is C. Restricting the patient’s sodium could make the ascites and edema worse. Calling the physician at this point is unwarranted. Informing the patient of the effects of alcohol will not improve the patient’s condition. Balancing the patient’s fluid volume will begin to reduce the ascites and edema, and assessing and measuring the ascites will give the nurse a base reading to gauge the effectiveness of treatment as time progresses.

19

Which of the following characteristics is not a common attitude of critical thinkers?
a) perseverance
b) adaptability
c) independence
d) integrity

Answer B Adaptability, which is a characteristic of verbal communication. Spoken messages must be altered in response to behavioral cues from the patient. (Page 2317, Table 36-1)

20

A nurse is caring for 9 year old Amber who has ineffective respirations following abdominal surgery. Amber's doctor ordered the patient to use an incentive spirometer. Amber is frightened by the equipment and tires quickly during the treatment. The nurse offers Amber a bottle of bubbles knowing that her respiratory effort in blowing bubbles will promote alveolar expansion and suggests she blow bubbles between incentive spirometry treatment. In what way is the nurse applying her critical thinking skills?
a. Intellect
b. inquiry
c. creativity
d. reasoning

Correct answer: c, pg. 2318, creativity means finding unique solutions to unique problems when traditional interventions are not effective.

21

A pediatric nurse is coming on shift, which patient should be assessed first?

A distressed five year old boy

A nine year old with a broken leg who rates their pain at a 6 out 10

A four year old patient with observed retractions

A two year old patient anticipating discharge

Rationale: Correct answer is C. The priority patient would be the one showing signs of respiratory distress. Accessory muscle use in pediatric patients is a sign of respiratory distress.

22

A 23-year-old female patient who is two hours post caesarian section is reporting her pain as an 8 out 10 on the pain scale. What is the priority intervention?

a. Call the physician

Ask the patient to describe their pain

Administer PRN pain medication

Reposition the patient

Answer C. Rationale: The patient’s pain is the priority. There is already a standing order for the medication so calling the physician is unnecessary and asking them to describe the pain is not the priority. Repositioning the patient may help but administering their medication is more important.

23

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse?

Encourage ambulation and administer bronchodilators and steroids as ordered.

Position in high Fowler's position and administer bronchodilators as ordered.

Position in Fowler’s position, initiate oxygen, and administer bronchodilators as ordered.

Place in supine position, initiate oxygen, and administer bronchodilators as ordered.

c

24

The nurse is caring for four patients. After reviewing the results of their arterial blood gases, which patient would require priority intervention?

A. pH 7.35, PaCO2 40, HCO3 24

B. pH 7.25, PaCO2 35, HCO3 18

C. pH 7.42, PaCO2 40, HCO3 22

D. pH 7.45, PaCO2 45, HCO3 28

B

25

The nurse is preparing for the suctioning of the airway of a client who has an endotracheal tube. In order of priority, which actions should the nurse take in order to perform this sterile procedure?

1.Hyperoxygenate the client before and after each time the airway is entered for suctioning and wait 1 minute before suctioning again.

2. Apply sterile gloves and with the non-dominant hand attach the suction catheter to the suctioning tube.

3. Place the client in semi-Fowler position to promote deep breathing, maximum lung expansion, and productive coughing.

4. Turn on suction, and set the pressure between 80 mmHg -120 mmHg.

5. Insert catheter until resistance is met, and then apply intermittent suction and slowly withdraw the catheter.

Answer: 3,4,2,1,5 Rationale?

26

Question 1: A patient requests that a nurse who was working on a previous shift not beallowed to provide the patient's care again. What is the most appropriate action by thenurse?
1. Notify the Human Resources Department

2. Document the issue on an incident report

3. Address patient's concern with the charge nurse.

4. Explain to the patient that the nurse was just having a bad day.

Answer is 3. Rationale: A personality conflict may need to be addressed, but may not
concern abuse or neglect. Therefore notifying the charge nurse to look into it would bethe best option. Bypassing the patient's feelings or assuming anything for or makingexcuses to the patient can result in a loss of trust and/or respect from the client, and isnot practicing according to professional standards.

27

A client with bulimia nervosa tells the nurse that they do not agree with theirparents on anything. Which is the best method to address this problem the next time thefamily comes for a meeting?
1. Focus on conflict resolution skills

.2. Establish an internal locus of control.

3. Construct a multi-generational genogram.

4. Discuss age-specific developmental problems.

Answer is 1. Rationale: The nurse should teach the family conflict resolution skills to
decrease conflict and promote family harmony. Establishing a plan to promote internalcontrol, or constructing a genogram will not help the family solve conflicts. Discussion ofage-specific developmental problems won't promote conflict resolution or familyharmony.

28

A charge nurse notices that some of the nurses on the floor have been struggling toget along. What are some measures she can take to reduce future conflict between thenurses? Select all that apply:
a. Clearly define roles for all team members

b Acknowledge the nurses' accomplishments

c.Encourage frequent and open feedback

dReduce her own stress

Answer: a, b, c, d Rationale: One of the main causes of conflict in the workplace is role boundaries, so it is
important for the charge nurse or nurse leader to make sure roles are understood. Byacknowledging the nurses' accomplishments you let the nurse know that you appreciatethe good job they are doing, which encourages them to keep doing it. Lack ofcommunication can lead to misunderstandings and conflict, so encouraging frequentfeedback helps facilitate better communication. The charge nurse cannot help her teamif she is stressed to begin with.

29

Martha is a young Unit Manager of the Pediatric Ward. Most of her staff nurses aresenior to her, very articulate, confident and sometimes aggressive. Martha feelsuncomfortable believing that she is the scapegoat of everything that goes wrong in herdepartment. Which of the following is the best action that she must take?
A. Identify the source of the conflict and understand the points of friction

B. Disregard what she feels and continue to work independently

C. Seek help from the Director of Nursing

D. Quit her job and look for another employment

Answer: A. Rationale: This question is involving a problem solving approach,addressing the root cause of the situation.

30

Three nurses where put in charge of creating a plan of action that should befollowed when it comes to treating pressure ulcers on patients that have been immobile.The nurses have met 3 times previously to discuss the plan of action and have alreadyselected roles when it comes to the plan of action and collaboration between the nurseshas already begin. What stage of group process are the nurses currently in?
A. Forming

B. Storming

C. Norming

D. Performing

E. Adjourning

Answer: C. Rationale: In norming the group is able to effectively cooperate and
collaborate when it comes to a specific goal.

31

Samantha is a nurse on the telemetry floor. She is having an argument with anotherstaff member and states, “I have patients to attend to and do not have time to talk aboutthis. I will talk to you later,” as she walks away. What type of response was displayed bynurse?
A. Compromising

B. Accommodation

C. Competition

D. Avoidance

Answer: D. Avoiding conflict is generally not advised. However, in some cases if used
strategically, it can allow time for people to cool down and collect their composure. Inthis case, the nurse used avoidance because she knew that her patient’s care was toppriority.

32

The patient complains of mouth pain when eating. Which member of thehealth care team should the nurse consult?
a.) Charge nurse

b.) Dietician

c.) Physical therapist

d.) Spouse/family member

Answer: b. Rationale: A dietician often has special knowledge about the diets required
to maintain health and to treat disease. In hospitals, they are generally concerned withtherapeutic diets, and may design special diets to meet the nutritional needs ofindividuals. (Pearson: 2015 p.23770)

33

A patients’ case has been determined to be one that is commonly of high
cost, represents a high volume for the diagnosis, and has a high risk for complications.Which health care team member is best suited to plan an appropriate continuum ofcare?
a.) Physician

b.) Chief Financial Officer (CFO)

c.) Nursing case manager

d.) Charge nurse

Answer: c. Rationale: To initiate case management, specific client diagnoses thatrepresent high-volume, high-cost, and high-risk cases are selected. (Pearson: 2015, p.2383)

34

An older client is admitted to the cardiac floor after suffering a myocardial
infarction. As the nurse is gathering admission history on the client, the client states, “Ihope I don’t end up on a machine that keeps me breathing if I’m already brain dead.”
Which of the following questions should the nurse ask next?a) “Do you have an advance directive?”

b) “I’ll be sure to write that down.”

c) “You should talk to your physician about this.”

d) “Is your family aware of how you feel?”

Rationale: Answer is A. An advance directive is a legal document that will ensure the
patient’s wishes are carried out, independent of what his family would like to do.

35

A fellow nurse on your unit was injured four months ago in a car accident. Her left leg
was badly fractured. She has just been cleared for work by a rehabilitation facility, butshe walks with a limp and an unsteady gait unsuited for a fast-paced workingenvironment. The nurse wants to return to work on her unit, which was an emergencydepartment. To assist the nurse, you should take which of the following actions?
a) Look into other units for positions more suitable for the nurse’s abilities

b) Recommend the nurse take sick leave until her rehab is more complete.

c) Transfer the nurse to a surgical unit.

d) Discuss options with the charge nurse.

Rationale: Answer A. Reasonable accommodations should be made for the nurse, but
he/she should also be able to perform the job. The surgical unit will be just as physicallydemanding as the ED. The nurse does not have the authority to make a transfer. Thenurse should not suggest a plan of action concerning a fellow nurse’s future with the
charge nurse. The nurse needs a position more appropriate, so other units should beinvestigated.

36

65 year old patient suffering from COPD is admitted to the hospital for anexacerbation. The nurse needs to create a nursing care plan with an inter-professionalcollaboration interventions. Who is the priority professional to contact?
A. The Charge Nurse

B. Respiratory Therapist

C. Dietitian

D. Certified Nursing Assistant

Answer: B. Rationale: An inter-personal collaboration would include anyone other than
a nurse who provides health care. The respiratory therapist would be the priority contactbecause COPD is a respiratory illness and they would have specialized detail on how toapproach the patient’s care.

37

The nurse is assessing a 4 year old patent with petechiae to his neck and multiplecircular first degree burns to the right upper and lower arm. She suspects possibly childabuse. Who is the nurses’ priority point of contact?
A. Charge Nurse

B. Family member

C. Physician

D. Social Worker

Answer: D. Rationale: When child abuse is suspected by the nurse, they should never
approach a family member in it. The priority action would be to contact the social workerfirst. The social worker would first come in and evaluate the child before further action istaken.

38

A nurse witnesses a mental health worker kissing a patient in the patient’s room.The patient tells the nurse, “Please don’t tell anyone about this. It just happened. I careso much about him, but we have agreed not to date until I’m discharged.” Which of the
following is an appropriate response?
A. I can’t tell you what is appropriate outside the hospital, but while you are here youcannot engage in any physical contact with each other.
B. I have to report this situation to the authorities.
C. I will have to make a note about this and reassign him to work on another unit whileyou are here.
D. You should know better than to get involved with each other. It’s inappropriate.

Answer: B. Rationale: Even if a patient consents or initiates the sexual conduct, it isstill sexual misconduct. Due to the power dynamic between a patient and a nurse, andespecially with patients with mental illness, there cannot be true consent because the
patient is in a vulnerable position. It is always the responsibility of a health careprofessional to maintain appropriate boundaries with current and former patients.

39

A nurse is providing discharge instructions to a Chinese patient. The patient isturned away from the nurse and does not make eye contact. Which of the following ismost appropriate? Select all that apply.
A. Ask the patient to pay attention

B. Come back at a later time when the patient is more interested

C. Continue with the discharge instructions

D. Position yourself to be in front of the patient at all times

E. Take the cue from the patient and do not continue to try to make eye contact

Answers: C, E. Rationale: Many Chinese, due to a difference in culture, show respect
by not making eye contact or avoid direct, face-to-face communication. The nurse
should not force eye contact but should view this patient’s actions as normal and
continue with discharge instructions.

40

A charge nurse observes that a staff nurse is not able to meet client needs in areasonable time frame, does not problem-solve situations, and does not prioritizenursing care. The charge nurse has the responsibility to:
a) Supervise the staff nurse more closely so that tasks are completed

b) Ask other staff members to help the staff nurse get the work done

c) Provide support and identify the underlying cause of the staff nurse's problem

d) Report the staff nurse to the supervisor so that something is done to resolve the
problem

Answer C. Option C empowers the charge nurse to assist the staff nurse while trying toidentify and reduce the behaviors that make it difficult for the staff nurse to function.Options A, B, and D are punitive actions, shift the burden to other workers, and do notsolve the problem.

41

The nurse manager is planning to implement a change in the nursing unit from teamnursing to primary nursing. The nurse anticipates that there will be resistance to thechange during the change process. The primary technique that the nurse would use inimplementing this change is which of the following?
a) Introduce the change gradually
b) Confront the individuals involved in the change process

c) Use coercion to implement the change

d) Manipulate the participants in the change process

Answer A. The primary technique that can used to handle resistance to change during
the change process is to introduce the change gradually. Confrontation is an importantstrategy used to meet resistance when it occurs. Coercion is another strategy that canbe used to decrease resistance to change but is not always a successful technique formanaging resistance. Manipulation usually involves a covert action, such as leaving outpieces of vital information that the participants might receive negatively. It is not the bestmethod of implementing a change.

42

Nurse Ariel has just come onto shift and is greeted by an angry patient, whocomplains of pain that has not been tended to. Nurse Aurora, who she is relieving,
comes in to do handoff and Ariel ignores Aurora’s apology for not administering the
meds on time. This is an example of:

A. Interpersonal conflict

B. Covert conflict

C. Intrapersonal conflict

D. Overt conflict

Answer: B, Covert conflict. Rationale: Covert conflict is not discussed openly and may
be exhibited through intentional ignoring, avoidant, and passive-aggressive behavior (pg2387).

43

A 79-year old female presents to the ER in myocardial infarction. The nurse case
manager is assisting in her care. The medical team is aware that the case manager’s
goals include which of the following? Select all that apply.

A. Improving the coordination of patient care

B. Discharging the client quickly

C. Increasing referrals to local organizations

D. Evaluate outcomes of patient care

Answers: A, D Rationale: One of the primary goals of case management is to improve
coordination of care in order to ensure that nothing is missed. By evaluating patientoutcomes, the case manager can collaborate with the healthcare team to gaugeeffectiveness of care and goals (pg 2382).

44

a client has just undergone hip surgery and needs to start post operation
exercises, which occupation would be able to collaborate with the nurse to make surethese exercises are done?
- A. Respiratory therapist-

B. Physical therapist-

C. Occupational therapist-

D. Surgeon

Rationale: B. The physical therapist works with patients on gross motor movement aftersurgery

45

which of the following is the best example of a covert conflict?

A. A patient refuses to take blood pressure medication in front of the nurse.

B. Nurse refuses to provide care to a patient that was reacting to care with sexual
advances.

C. Physician yells at nurse for calling them in the middle of the night.

D. Day shift nurses commenting to the patients about the lack of quality care provided
by the night shift nurses.

Rationale: D. Covert behavior is lack of open feedback; the nurses in option D are notopenly communicating their issues with the night shift nurses.

46

A 52 year-old male patient becomes verbally abusive when denied another dose of painmedication because it was too soon. How should the nurse handle this situation?
1. Give him an unscheduled dose of the pain medication

2. Take away his call bell

3. Explain to the patient why he cannot receive medication at this time and then
leave the room

4. Call the healthcare provider

Answer 3. Rationale: By calmly explaining to the patient why they cannot have more
medication you are still doing your job in a professional manner. After you have
explained to them why they cannot have medication and they are still verbally abusiveyou have the right to walk away.

47

A 4 year-old patient has multiple wounds at different stages of healing and all ofunknown origin. As the nurse you suspect your patient is being abused, how do youproceed?
1. Confront the parents about your suspicions

2. Deny the parents access to the child

3. Report your findings to child protective services and to the hospital social worker

4. Dismiss the findings as just accidents

Answer 3. Rationale: Any suspicion of abuse should be reported. It is not the nurse’s job
to confront the parents and it is also not appropriate to ignore obvious signs of abuse.

48

Reducing your stress, allocating resources fairly, defining and reminding roles for allteam members are all ways to provide:
a. Professional Identity

b. Conflict Resolution

c. Implementing the nursing process

d.Assessment, diagnosis, provide, implement, and evaluate.

*B. these are all ways to provide conflict resolution. By addressing stresses, fairly
assigning workloads, and ensuring all staff is clear with other team members’ assignedduties and what falls under those duties can prevent members from feelingoverwhelmed or abused. These are all key in providing conflict resolution.

49

A charge nurse observes that a staff nurse is not able to meet client's needs in areasonable time frame, does not problem solve the situation, and does not prioritizenursing care. The charge nurse has a responsibility to:
a. Supervise the staff more closely so tasks are completed.

b. Asks other staff members to complete tasks.

c. Provide support and identify the underlying cause of the staff nurses problem

d. Report staff nurse to supervisor so that action is taking to resolve the issue.

*C is the answer. This allows the charge nurse to assist and help the staff nurse whiletrying to identify and resolve the behaviors that make it difficult for the staff nurse tocomplete her assignments.

50

What would be important environmental assessments for the home care nurse toexplore with a client who is being discharged home?
a) Checking the cleanliness of the home, ensuring removal of clutter, and organizing allessentials on one level of the house.
b) Ordering a wheelchair, special utensils, and a raised toilet seat and rearranging thefurniture in the home.
c) Checking access to the home with a walker, access and safety measures in thebathroom, and access to food preparation in the kitchen, and ensuring safety in thesleeping environment.
d) Reinforcing the importance of having renovations done before discharge to enablewheelchair access and accessibility to all needs for daily living.

C is Correct. Explanation: Safety and access in the client’s home are important to
assess before discharge to ensure that the client can manage at home.

51

An adolescent admitted to the adolescent unit with pain caused by sickle cell crisis.
Who should be consulted first about this adolescent's care?
A. pediatric pain specialist

B. nutritionist

C. case worker

A is Correct. Explanation: Children and adolescents hospitalized with sickle cell crisisare commonly in excruciating pain. Therefore, the pediatric pain specialist should beconsulted first to help relieve the adolescent's pain. The adolescent also requireshydration with I.V. fluids, but consulting a nutritionist isn't important at this time. Bed restis commonly ordered to minimize energy expenditure and oxygen demand; therefore,consulting a physical therapist isn't necessary at this time. It isn't necessary to consultthe case manager first; pain relief is most important at this time.