Umbrella Option
Strategy - Umbrella Option
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit
a local residential area and that numerous casualties have occurred. The victims will be brought to the
ED. The nurse should take which initial action?
Activate the emergency response plan.
In an external disaster (a disaster that occurs outside of the institution or agency), many victims may
be brought to the ED for treatment. The initial nursing action must be to activate the emergency
response plan. Once the emergency response plan is activated, the actions in the other options will
occur.
The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid
overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if
needed?
Resuscitation equipment
The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment
readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include
oxygen, a mechanical ventilator, and vasopressors (a drug causing the constriction of blood vessels)
The nurse provides an educational session on client rights. Which statement by a member of the session
demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are
respected?
"Being respectful and concerned will ensure that I'm attentive to my clients' rights."
The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights.
While it is true that autonomy is a basic client right, there are other rights that must also be both
respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those
rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a
client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for
the concept.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's
speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's
immediate priority of care?
Provide safety for the client and other clients on the unit.
Safety of the client and other clients is the immediate priority. The correct option is the only one that
addresses the safety needs of the client as well as those of the other clients.
Umbrella Option
, Umbrella Option
The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding"
when he is exercising vigorously. The nurse provides education to the client about increased cardiac
response based on which physiological concept?
Cardiac output is the body's attempt to meet metabolic demands.
The client's symptoms are the direct result of the body's attempt to meet the metabolic demands
generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital
organs of the body. With exercise, these demands increase, and the heart must beat faster (increased
heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number
used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting
the cardiac output for body surface area.
The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted
to the hospital. The priority nursing intervention in the plan of care should focus on which item?
Measures that will ensure safety
Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan for the
hospitalized client with Ménière's disease should be safety issues to prevent falls or injury. Although
client knowledge and psychosocial needs may be components of the plan of care, safety is the priority
issue.
The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken
by the nurse before leaving the room?
Instituting safety measures
Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties.
The nurse should institute safety measures before leaving the client's room to prevent injury as a result
of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed
are useful but not essential to the client's safety in this situation.
Which intervention should the nurse include in a postoperative teaching plan for a client who
underwent a spinal fusion and will be wearing a brace?
Tell the client to inspect the environment for safety hazards.
The client must inspect the environment for safety hazards. The client is instructed in the importance of
avoiding prolonged sitting and standing. Powders and lotions should not be used because they may
irritate the skin. The client should be taught to loosen the brace during meals and for 30 minutes after
each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each
meal will allow adequate nutritional intake and promote comfort.
Umbrella Option
Strategy - Umbrella Option
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit
a local residential area and that numerous casualties have occurred. The victims will be brought to the
ED. The nurse should take which initial action?
Activate the emergency response plan.
In an external disaster (a disaster that occurs outside of the institution or agency), many victims may
be brought to the ED for treatment. The initial nursing action must be to activate the emergency
response plan. Once the emergency response plan is activated, the actions in the other options will
occur.
The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid
overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if
needed?
Resuscitation equipment
The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment
readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include
oxygen, a mechanical ventilator, and vasopressors (a drug causing the constriction of blood vessels)
The nurse provides an educational session on client rights. Which statement by a member of the session
demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are
respected?
"Being respectful and concerned will ensure that I'm attentive to my clients' rights."
The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights.
While it is true that autonomy is a basic client right, there are other rights that must also be both
respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those
rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a
client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for
the concept.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's
speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's
immediate priority of care?
Provide safety for the client and other clients on the unit.
Safety of the client and other clients is the immediate priority. The correct option is the only one that
addresses the safety needs of the client as well as those of the other clients.
Umbrella Option
, Umbrella Option
The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding"
when he is exercising vigorously. The nurse provides education to the client about increased cardiac
response based on which physiological concept?
Cardiac output is the body's attempt to meet metabolic demands.
The client's symptoms are the direct result of the body's attempt to meet the metabolic demands
generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital
organs of the body. With exercise, these demands increase, and the heart must beat faster (increased
heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number
used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting
the cardiac output for body surface area.
The nurse creates a plan of care for a client with a diagnosis of Ménière's disease who is being admitted
to the hospital. The priority nursing intervention in the plan of care should focus on which item?
Measures that will ensure safety
Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan for the
hospitalized client with Ménière's disease should be safety issues to prevent falls or injury. Although
client knowledge and psychosocial needs may be components of the plan of care, safety is the priority
issue.
The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken
by the nurse before leaving the room?
Instituting safety measures
Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties.
The nurse should institute safety measures before leaving the client's room to prevent injury as a result
of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed
are useful but not essential to the client's safety in this situation.
Which intervention should the nurse include in a postoperative teaching plan for a client who
underwent a spinal fusion and will be wearing a brace?
Tell the client to inspect the environment for safety hazards.
The client must inspect the environment for safety hazards. The client is instructed in the importance of
avoiding prolonged sitting and standing. Powders and lotions should not be used because they may
irritate the skin. The client should be taught to loosen the brace during meals and for 30 minutes after
each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each
meal will allow adequate nutritional intake and promote comfort.
Umbrella Option
