NR 449 EVIDENCE BASED PRACTICE Questions and answers

NR 449 EVIDENCE BASED PRACTICE Questions and answers 1. A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care? 1. Fold the top of the stocking over neatly 2. Apply the stockings after the client is in a chair 3. Massage the client's legs once every 8 hr while the stockings are in place 4. Determine if the stockings are binding -This ensures that antiembolic stockings are serving its purpose. It checks whether the stockings are of the right fit. First 3 choices are not necessary. 2. A nurse on a medical surgical is performing medication reconciliation for a newly admitted client. Which of the following should the nurse take? 1. Compare the prescription to the allergy history of the client 2. Compare the medication label to the provider's prescription on three occasions before administration 3. Compare a list of common medications to treat a condition to the actual prescriptions 4. Compare for client's list of home medications to the admission prescriptions written for the client allergies. 2nd-This ensures that prescribed drugs do not cause harm to the patient due to drug choice is wrong because you need to check for name of patient, drug, dosage and do not necessarily have to do it 3x. 3rd and 4th choices are not necessary. 3. A community health nurse is receiving laboratory reports for a group of clients. The nurse should identity that which of the following disorders is on the CDCs Nationally Notifiable Conditions list? 1. Pediculosis capitis 2. bacterial vaginosis 3. respiratory syncytial virus 4. Lyme disease -Lyme disease is only disease found on list. 4. A nurse is caring a client following application of a cast. Which of the following actions should the nurse take first? 1. Place an ice pack over the cast 2. Position the casted extremity on a pillow 3. Palpate the pulse distal to the cast 4. Teach the client to keep the cast clean and dry This check whether there is adequate blood flow to that extremity or not. Distal pulses signify adequate blood flow. If cast is impeding blood flow, it could compromise the extremity. So this must be the priority nursing action before anything else. 5. A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licenses nurse requires interventions by the staff nurse? 1. Applies suction for 15 seconds 2. Encourages the client to cough during suctioning 3. Wait for 2 min between suctions 4. Inserts the catheter without applying suction 1st 2nd is correct because you must suction for 10-15 seconds (so it isn't the answer) is correct because encouraging patient to cough displaces secretions towards upper airway, allowing it to be suctioned and removed, promoting clearance of airway (so it isn't the answer) 3rd is incorrect because you must allow patient to rest for 20-30 seconds but waiting 2 mins between suctions is too long. You however must always allow patient to rest between suctioning to allow them to oxygenate and rest. (the answer) 4th is correct because you must not suction while inserting catheter. This ensures proper placement and insertion of the catheter. You must insert and suction while slowly pulling it out (so it isn't the answer) 6. A nurse is working with a client who has an anxiety disorder and is in in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? 1. Let's talk about how you can change your response to stress 2. Let me show you simple relation exercise to manage stress 3. We should establish our roles in the initial session 4. We should discuss resource to implement in your daily life 3rd is the answer because since nurse-client relationship is in orientation phase, it is important to establish and orient the patient on their roles and goals. Other choices are incorrect because they are more focused on the interventional aspect and not on the orientation phase. 7. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunization should the nurse recommend? a. influenza b. human Papillomavirus C. Measles, mumps, and rubella d. varicella A is the answer as it is the recommended vaccine for the patient's age. B is wrong because it is usually administered/initiated at age 9-14. While C and D are also wrong because they are usually given at 12-18 months. 8. A home health nurse is preparing to make a initial visit to a family following a referral from a local provider. Identify the sequence of step the nurse should take when conducting a home visit. Placing them in the order of performance. Use all steps 1. Discus plans for future visits with the family 2. Clarify the reason for the referral with the provider's office 3. Record information about the home visit according to agency policy 4. Identify family needs and interventions using the nursing process 5. Contact the family to determine availability and readness to make an appointment