Test Bank For Nursing Interventions & Clinical Skills, 6th Edition- by Anne Griffin Perry – Potter – Ostendorf

Description

Test Bank For Nursing Interventions & Clinical Skills, 6th Edition- by Anne Griffin Perry – Potter – Ostendorf

Chapter 04: Patient Safety and Quality Improvement

Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition

MULTIPLE CHOICE

1. The nurse is caring for a 79-year-old male who has a non–weight-bearing cast on the left lower extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance. Which response by the nurse is most likely to keep the patient from falling?

a.

Apply a vest restraint and offer frequent toileting.

b.

Plan fall prevention with patient, family, and healthcare provider.

c.

Inform family that the patient needs physical restraints.

d.

Document that the patient has a high potential for falling.

ANS: B

Planning an individualized fall prevention program with the help of the patient, family, and healthcare provider is more likely to reduce the patient’s risk of falls because he gains some control over the plan of care and still benefits from the input of the provider, family, and nurse and the fall prevention program. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him ownership of the plan, making it less likely that he will disregard a plan he helped to design. Vest restraints are associated with serious injuries and are not recommended for use. Documenting the patient’s risk is important because it communicates the information and records the nurse’s acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because it is indirect. Alternative methods of engaging the patient in a care plan that minimizes risks should be exhausted before resorting to restraints.

DIF:Cognitive Level: AnalyzeREF:Page 48-49

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

2. The nurse plans a fall prevention program for a confused patient. Which task from the program is suitable for the nurse to delegate to nursing assistive personnel (NAP)?

a.

Evaluating patient understanding of fall prevention plan

b.

Keeping the patient’s bed in the low position at all times

c.

Assessing the patient’s circulatory and respiratory status

d.

Instructing the patient’s family about alternatives to restraints

ANS: B

The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision. Skills used to prevent falls can often be delegated. The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform.

DIF:Cognitive Level: ApplyREF:Page 49

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

3. The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for this patient?

a.

The patient remains free of any injury.

b.

The nurse checks the restraint every hour.

c.

The nurse uses the least restrictive restraint.

d.

The patient allows the nurse to apply restraints.

ANS: A

When restraints become necessary, the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibility. Checking the restraint is a nursing intervention; it is not a goal because it is not patient centered. Using the least restrictive restraint can defeat the purpose of a restraint. When a restraint is required, the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse. If the patient or staff members’ safety is at risk, the nurse applies restraints without the patient’s permission.

DIF:Cognitive Level: UnderstandREF:Page 58-60

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

4. The nurse applies a physical restraint to the patient. Which entry should the nurse make after applying physical restraints?

a.

Performed restraint application reluctantly

b.

Applied bilateral soft lamb’s wool wrist restraints; skin pink, moist, and intact

c.

Will perform a neurovascular assessment every 4 hours

d.

Checked provider’s prescription for prn restraints

ANS: B

The nurse documents the type of restraint applied and the condition of the skin where the restraint was placed in the progress notes to communicate the information to the healthcare team. The nurse does not document subjective statements about the nurse. Neurovascular assessments of a patient’s extremity must take place at least every 2 hours because skin breakdown can occur very quickly. The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.

DIF:Cognitive Level: ApplyREF:Page 63

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Apply

5. The patient sustains a minor leg abrasion and stops breathing for a few seconds during a grand mal seizure. Which is the best nursing documentation after the patient’s seizure?

a.

Type of muscle contractions

b.

Size and description of the abrasion

c.

Length of the patient’s apneic episode

d.

Description of the seizure in detail

ANS: D

Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure, the description of injuries, how the injuries occurred, and the description of any breathing abnormalities.

DIF:Cognitive Level: AnalyzeREF:Page 67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

6. A patient at risk for falling is being ambulated. Which action by the nurse is most important to prevent the patient from falling?

a.

Raising the bed to an appropriate working height

b.

Placing nonskid shoes on the patient

c.

Dangling the patient on the side of the bed for 10 minutes

d.

Turning on the brightest lights in the room

ANS: B

Placing nonskid surfaces on the patient’s feet helps to prevent falls. The height of the bed should be as low as possible before attempting to have the patient stand. Dangling prevents dizziness, but the length of time differs, and it is not required for all patients. Adequate light is important, but the brightest lights are not needed.

DIF:Cognitive Level: ApplyREF:Page 50

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

7. The nurse is orienting a group of new nurses and explaining the concept of sentinel events and their causes. What should the nurse explain as the number one root cause of all sentinel event reports to The Joint Commission?

a.

Medication errors

b.

Falls

c.

Communication failures

d.

High patient-to-nurse ratios

ANS: C

Communication failures are the number one root cause of all sentinel events reported to The Joint Commission. A sentinel event is an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof. Although the other elements may cause sentinel events, they are not the number one root cause.

DIF:Cognitive Level: RememberREF:Page 46

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

8. The nurse discovers smoke in the second floor utility room. What intervention should he or she implement first?

a.

Find the fire extinguisher and try to extinguish the fire.

b.

Evacuate the entire second floor to the first floor lobby.

c.

Rescue any patients, visitors, or staff in immediate danger.

d.

Pull the nearest alarm box and call the telephone operator.

ANS: C

The first step after identifying an actual or potential fire is to rescue victims at risk for injury from the fire, including patients, visitors, or staff, to reduce injuries from the fire. The second step is to activate the alarm. The third step is to contain the fire: find the extinguisher and empty the container onto the fire or source of the smoke. Finally the evacuation begins if the fire is uncontrolled or the smoke is excessive. This follows the acronym RACE.

DIF:Cognitive Level: ApplyREF:Page 68

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

9. The daughter of a female patient tells the home health nurse that using the bathroom is embarrassing for the patient and she refuses to use a call light when she needs to get up. Which is the best response by the nurse?

a.

Ask the patient why she does not use the call light.

b.

Instruct the daughter to remain at the patient’s side.

c.

Tell the patient that home visits require patient cooperation.

d.

Discuss call light alternatives with patient and daughter.

ANS: D

Discussing call light alternatives with the patient and daughter is the best method of engaging the patient in planning nursing care. This recognizes the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. Including the patient in planning alternatives also gives her ownership of the plan and increases the likelihood of cooperation. Asking a “why” question is not an ideal response because it is confrontational and requires the patient to justify feelings. Remaining with the patient is an impractical solution for home care.

DIF:Cognitive Level: AnalyzeREF:Page 47

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

10. Although the interdisciplinary team is responsible for the safety of the patient, who has the ultimate responsibility for making the patient’s bedside area safe?

a.

The nurse

b.

Housekeeping

c.

Nursing assistive personnel (NAP)

d.

The maintenance department

ANS: A

The nurse has the ultimate responsibility for making the patient’s bedside area safe. Other personnel assist with their specific roles, but the nurse oversees the safety.

DIF:Cognitive Level: AnalyzeREF:Page 47

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

11. The nurse listens to a family’s request to bring a few familiar items into the room of a patient who is confused. How does the nurse justify the decision to allow personal items?

a.

Personal items can increase patient agitation.

b.

Personal items can restore cognitive function.

c.

Personal items are likely to alienate the patient.

d.

Personal items can comfort a confused person.

ANS: D

Personal items can comfort and calm a confused person because familiar items are part of the patient’s customary environment, patterns, and habits; in addition, these items personalize an otherwise strange environment and surround the patient with recognizable things. The personal items are likely to engage the patient but on their own do nothing to restore cognitive function.

DIF:Cognitive Level: AnalyzeREF:Page 54-55

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

12. The nurse plans a restraint-free environment but cannot find activities to engage an agitated middle-aged patient. Which should the nurse implement to maintain the patient’s safety?

a.

Request help from interdisciplinary team members.

b.

Transfer the patient to a private room to protect others.

c.

Document that the patient is uncooperative and hostile.

d.

Ask the healthcare provider for a sedation prescription.

ANS: A

A nurse’s expertise does not include occupational therapy, so the nurse collaborates with other experts to meet the patient’s safety and psychosocial needs. After assessing the patient, the experts make recommendations, and the nurse incorporates the activities into the patient’s plan of care. Putting the patient in a private room decreases the risk of injury to other patients; but it isolates the patient, increases the need for distraction, and increases the risks to the staff and patient. Documentation should always be descriptive and never judgmental. In this case the nurse would document: “The patient stated, ‘Stay away.’” Sedation increases the risk of falls from potential adverse effects, including hypotension, dizziness, and confusion.

DIF:Cognitive Level: ApplyREF:Page 57

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

13. A patient has been wandering and is at risk for falling. Which approach by the nurse regarding the use of chemical and physical restraints in the long-term care setting should be considered initially?

a.

Use nonprescription restraints first.

b.

Obtain with a telephone prescription.

c.

Implement alternative measures first.

d.

Notify patient’s family within 24 hours.

ANS: C

According to the standards governing the use of restraints, the nurse must implement several alternative measures in a serious attempt to avoid applying restraints. The patient must be assessed by the healthcare provider before restraints are implemented unless the patient is a serious and imminent risk to self and others. The patient’s family is notified in a timely manner but is not an initial consideration.

DIF:Cognitive Level: RememberREF:Page 54

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

14. The nurse plans a safety program for the patients on a medical-surgical unit. Which patient has the greatest likelihood of falling?

a.

A 79-year-old after a pacemaker battery replacement

b.

A 68-year-old anemic who is dehydrated and has heart failure

c.

A 21-year-old fresh postarthroscopy after a college football injury

d.

A 33-year-old post–right salpingectomy for ectopic pregnancy

ANS: B

The patient with anemia and dehydration with heart failure has the highest risk of falling. The patient will be taking other medications, including antihypertensive agents that increase the risk of falls caused by confusion, dizziness, or orthostatic hypotension. The replacement of a pacemaker battery in a stable patient is a low-risk, routine procedure. The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating. The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery.

DIF:Cognitive Level: AnalyzeREF:Page 48

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment

15. The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears that the patient will pull them out. Which nursing intervention should the nurse implement to maintain the patient’s self-esteem and avoid applying restraints?

a.

Cover or camouflage tubes and drains.

b.

Provide constant activity for the patient.

c.

Instruct family members to watch the patient.

d.

Keep the patient close to the nurses’ station.

ANS: B

The nurse keeps the patient busy with nursing care and activities that provide an effective distraction to limit awareness of the NGT and surgical drain; in this manner the nurse avoids the need for restraints and maintains the patient’s self-esteem. Covering or camouflaging the tubes is unlikely to be an effective method of avoiding restraints because the patient is likely to find the tubes despite the disguise. Engaging the family in the care of the patient is reasonable; however, the nurse does not rely on the family to provide nursing care. Keeping the patient out by the nurses’ station allows the nurse to observe the patient closely; however, this is likely to lower the patient’s self-esteem because his or her problem is on public display.

DIF:Cognitive Level: ApplyREF:Page 56

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

16. The female patient wearing bilateral wrist restraints complains that her hands are numb; and the nurse assesses pale, cool fingers. Which is the nurse’s priority intervention?

a.

Notify the provider quickly.

b.

Remove the wrist restraints.

c.

Try another type of restraint.

d.

Increase the restraint padding.

ANS: B

The patient displays clinical indicators of neurovascular impairment, and a delay in resolving the problem can result in tissue damage, so the nurse removes the restraint, thoroughly assesses the extremities, and plans nursing care. Before another type of restraint is applied, the nurse completes the assessment and notifies the provider as necessary. Increasing the padding is a reasonable intervention after the nurse’s assessment and provider notification.

DIF:Cognitive Level: AnalyzeREF:Page 63

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

17. The patient is having a generalized tonic-clonic seizure. To maintain the airway, which intervention should the nurse implement after the patient’s motor activity ceases?

a.

Apply chin-lift position.

b.

Insert a curved oral airway.

c.

Sit the patient in upright position.

d.

Turn the patient on his side.

ANS: D

Patients who have been rolled onto their side during a major motor seizure are at greater risk for self-injury, such as a dislocated shoulder. Since patients are not breathing during a generalized tonic-clonic seizure, they are not at high risk for aspiration until the event ends. Immediately following such a seizure, patients usually take a deep breath. Therefore, a patient should be rolled over onto his or her side immediately after the motor activity ceases. Chin-lift is an effective method of maintaining a patient’s airway; however, it does not protect the patient against aspiration. Oral airways are not inserted during a seizure unless the patient’s jaw relaxes enough to properly insert the airway without causing tissue damage. The upright position is contraindicated for airway maintenance.

DIF:Cognitive Level: ApplyREF:Page 65

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

18. The nurse is instructing a male patient who has a difficult-to-control seizure disorder on home care issues. Which issue affecting safety is most important for the nurse to address with patient teaching before discharge?

a.

Avoiding substances containing alcohol

b.

Maintaining a current list of medications

c.

Keeping a supply of medications at work

d.

Purchasing lawn equipment with a safety switch

ANS: D

The most important issue to address is to have him purchase any motorized lawn equipment with a safety switch that will stop the machine when the handle is released. Thus the patient avoids injury if he has a seizure while operating the equipment. Although the patient should avoid alcohol to decrease the risk of possible alcohol-drug interactions, and he should keep a list of current medications to avoid confusion over his therapeutic regimen, failure to do so poses a risk only to himself. Likewise, although keeping a supply of medication at work is a good idea, it is not a safety risk not to do so.

DIF:Cognitive Level: AnalysisREF:Page 70

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

19. A child had surgery on his face and needs to keep his hands away from it. Which restraint should the nurse use to accomplish this outcome?

a.

A jacket restraint

b.

Mitten restraints

c.

A mummy restraint

d.

Elbow restraints

ANS: D

The nurse applies bilateral elbow restraints so the child cannot touch the operative area. They prevent elbow flexion. The child will still be able to hug the parent or hold onto objects. Mitten restraints are inadequate because the hands could still access the face. A mummy restraint is used for short-term examination of a child. Although it does confine, the mummy restraint is more like swaddling. The use of jacket restraints has been discouraged because of safety risks associated with their use.

DIF:Cognitive Level: RememberREF:Page 62

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

20. The nurse participates in the investigation of an incident in the facility. As a result of the root cause analysis, what would the nurse expect as the ultimate outcome?

a.

Identification of the person at fault

b.

An appropriate punishment for the individual who caused the event

c.

Reason the event occurred

d.

A plan for the prevention of this event

ANS: D

A plan for prevention of a similar event happening again is the ultimate outcome of this investigation. The investigation will determine all contributing factors in the occurrence of the event, with the goal of identifying methods to prevent those failures from recurring.

DIF:Cognitive Level: ApplyREF:Page 46

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

21. The nurse is giving report to the next shift and describes how it is important to maintain a regular schedule for Mr. Jones, a confused elderly man who wanders. Why is it important for this intervention to be maintained?

a.

Regular routine helps nurses find the patient early if he wanders.

b.

Regular routine decreases his confusion.

c.

Regular routine decreases wandering.

d.

Regular routine decreases stress.

ANS: C

The Department of Veterans Affairs has many suggestions for managing the wandering patient, most of which are environmental adaptations. Some of these include hobbies, social interaction, and regular routines (Veterans Administration, 2010). Modifications of the environment are effective alternatives to restraints. Regular routines may reduce stress and confusion, but this patient’s main problem is wandering.

DIF:Cognitive Level: ApplyREF:Page 54

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

22. The nurse is caring for a patient who has brought in his own CPAP device to use at night. What does the nurse need to do in addition to contacting Respiratory Therapy?

a.

Have the device inspected by the appropriate hospital department for safety.

b.

Have the patient take it home and get one from patient equipment.

c.

Tell the patient he cannot use it.

d.

Notify the physician.

ANS: A

If a patient brings a device, it must be inspected for safe wiring and function before use through the process established by the agency. A patient should be able to use his own equipment such as CPAP since it is fitted for his own use. Although you can notify the physician, the device still must be safety inspected.

DIF:Cognitive Level: ApplyREF:Page 68

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

23. The nurse is caring for a patient and is exposed to a chemotherapy drug during IV administration. Where can she obtain information about the drug that is necessary for an exposure-related incident?

a.

The nurse’s supervisor

b.

Poison control center

c.

MSDS sheets

d.

Employee health services

ANS: C

Chemicals in medications (e.g., chemotherapy drugs), anesthetic gases, disinfectants, and cleaning solutions are potentially toxic. They injure the body after skin or mucous membrane contact, after ingestion, or when vapors are inhaled. Healthcare agencies provide employees access to material safety data sheets (MSDSs) for each hazardous chemical in the workplace. An MSDS contains information about properties of the chemical (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, safe handling, storage, disposal, protective equipment to use, and spill-handling procedure. The nurse’s supervisor, employee health services, or poison control center may also have the information, but they will go to the same place (the MSDS sheets) to obtain that information.

DIF:Cognitive Level: ApplyREF:Page 68

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MULTIPLE RESPONSE

1. The nurse is caring for a patient who just received a diagnosis of a seizure disorder. What supplies should the nurse gather to have at the bedside? (Select all that apply.)

a.

A suction device with catheters

b.

Extra pillows to pad the bed

c.

A padded tongue blade

d.

Oxygen source and nasal cannula

ANS: A, D

A suction device with catheters and an oxygen source with nasal cannula will help maintain the airway should it become a problem. Extra pillows on the bed could cause suffocation during a seizure; firm padding on the sides of the bed are recommended instead. Padded tongue blades are no longer used in the care of patients with seizures.

DIF:Cognitive Level: UnderstandREF:Page 65

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning

2. A nurse notes smoke coming from a garbage can in an otherwise empty nursing station. Which actions should the nurse take? (Select all that apply.)

a.

Activate the fire alarm.

b.

Use a type A fire extinguisher.

c.

Rescue the patients from the unit.

d.

Put wet towels along the base of the doors.

e.

Use a type B fire extinguisher.

f.

Aim the nozzle at the top of the fire.

ANS: A, B

Activate the fire alarm first; then use a type A fire extinguisher to put out the fire. Aim the nozzle of the extinguisher at the base of the fire, not the top. The fire is just smoking; so there is no need to evacuate at this time. The patients are safer where they are since they are not in the area where the fire is smoldering. This small fire could be extinguished easily by the time wet towels are placed along the base of the doors.

DIF:Cognitive Level: ApplyREF:Page 68

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

3. Which of the following statements are examples of features that support a culture of safety? (Select all that apply.)

a.

Acknowledging that hospitals are risk-free environments

b.

Encouraging a high degree of teamwork and collaboration

c.

Commitment of resources by the organization to address safety concerns

d.

An environment where employees can report errors without punishment

e.

A system that does not use incident reports

ANS: B, C, D

The Agency for Healthcare Research and Quality (2012) has outlined key features for a culture of safety. These features are (1) acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations, (2) a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment, (3) encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems, and (4) organizational commitment of resources to address safety concerns. Incident reports are necessary to help identify errors and near misses to make corrections and improve safety.

DIF:Cognitive Level: ApplyREF:Page 47

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

4. The following is an example of an alternative to restraint use in patient care. (Select all that apply.)

a.

Frequent observation of patients

b.

Involving patients and families

c.

Frequent reorientation

d.

Four side rails

e.

Lap belt with quick release

ANS: A, B, C, E

Modifications of the environment are effective alternatives to restraints. More frequent observation of patients, involvement of family caregivers during visitation, and frequent reorientation are also helpful measures. Having all four side rails up is considered a restraint. A lap belt that the patient can release is not a restraint.

DIF:Cognitive Level: ApplyREF:Page 55-57

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

5. The Joint Commission restricts the use of restraints to the least restrictive device necessary to prevent disruption of needed care. The order for restraints must include which of the following? (Select all that apply.)

a.

Type

b.

Duration

c.

Purpose

d.

Location

e.

Size

ANS: A, B, C, D

Order must include purpose, type, location, and time or duration of restraint. Long-term care settings require informed consent from a family member prior to use. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours. Size is determined by the nurse’s judgment.

DIF:Cognitive Level: ApplyREF:Page 59

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MATCHING

While walking in the hallway with the nurse, the patient has a seizure. Match the nursing interventions with the step.

a.

Remove nearby furniture.

b.

Loosen restrictive clothing.

c.

Maintain the patient’s airway.

d.

Ease the patient to a safe location.

1. Step 1

2. Step 2

3. Step 3

4. Step 4

1.ANS:DDIF:Cognitive Level: AnalyzeREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC:Because the patient is unsupported in the hallway, the nurse should first gently lower him or her to the floor to prevent injury from a fall.

2.ANS:CDIF:Cognitive Level: AnalyzeREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC: Once the patient is on a stable surface, the nurse should take required steps to maintain his or her airway.

3.ANS:ADIF:Cognitive Level: AnalyzeREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC: Next the nurse should remove nearby furnishings so the patient does not flail into them.

4.ANS:BDIF:Cognitive Level: AnalyzeREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC:Finally the nurse should loosen restrictive clothing to prevent skin abrasions during the seizure muscle contractions.

The nurse enters the room and finds the patient sitting in a chair and just beginning to have a seizure. Match the nursing interventions with the step, beginning with the nurse’s first action.

a.

Call for additional help at the patient’s side.

b.

Maintain the patient’s airway.

c.

Clear away hazardous objects.

d.

Guide the patient to the floor.

5. Step 1

6. Step 2

7. Step 3

8. Step 4

5.ANS:ADIF:Cognitive Level: UnderstandREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC:The nurse begins by calling for help while remaining with the patient to observe the seizure, maintain the airway, and prevent injury. The patient needs to be guided to the floor to prevent injury from falling off the chair.

6.ANS:DDIF:Cognitive Level: UnderstandREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC: Once he or she is in a safe location, the nurse observes him or her for impaired airway or breathing.

7.ANS:BDIF:Cognitive Level: UnderstandREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC: The nurse implements nursing care to maintain the airway such as positioning the head or jaw.

8.ANS:CDIF:Cognitive Level: UnderstandREF:Page 65-67

OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation

MSC: Finally the nurse clears away objects that might lead to patient injury during the seizure, including furniture and equipment.