EDAPT: Nursing Care: Complex Health
Situations
Based on the reason for admission to an inpatient facility, which inpatient care area should the
nurse anticipate caring for each of these clients? Drag and drop a unit in the left column to
match the corresponding client.- ANS *Trauma unit* - Young adult with a broken femur and
closed head injury sustained in a motorcycle crash.
*Intensive care unit (ICU)* - Middle-aged adult with recent onset of left-sided weakness and
slurred speech.
*Orthopedic unit* - Older adult requiring traction while awaiting surgical repair of a hip fracture.
*Medical-surgical unit* - Middle-aged adult after an uncomplicated colon resection surgery.
In which situations should the nurse use the identify, situation, background, assessment, and
recommendation (ISBAR) tool to ensure clear and complete communication? Drag the
situations in which ISBAR should be used from the left column to the right column.- ANS
Calling the healthcare provider regarding a change in the client's status.
Explaining the client's status to their family.
Giving report to the oncoming nurse.
Transferring a client to a long-term care facility.
Which technique can be used to decrease the noise created by the alarms on the technology
used while delivering client care?- ANS Change the default alarm settings to specific settings
based on each client's condition.
For each nursing action in the left column, specify if it addresses the concerns in the other
columns that are experienced by clients in a critical care environment.- ANS *Physical
Environment:*
Keep the window coverings open.
Close the door to the room.
Encourage the family to bring objects from home.
Keep tubing, wires, and cords free of tangles.
*Excess Noise:*
, Adjust device alarms to accommodate the client's condition.
Close the door to the room.
Turn off the ringer on the phone in the room.
*Sensory Deprivation:*
Keep the window coverings open.
Encourage the family to bring objects from home.
Allow visitors per the facility policy.
The nurse is caring for a client who is sedated and using a ventilator to support breathing.
Which ideas should the nurse offer to increase the family's involvement with the client? Select
all that apply.- ANS Show the family how to touch the client without harming them.
Ask the family to bring small objects from home, which the client will recognize.
Ask the family how they would like to be more involved.
Encourage the family to ask questions related to the client's condition.
Encourage the family to speak to the client.
After hearing the alarms for the infusion pump, telemetry monitor, and ventilator sound, the
nurse enters the room of a client with a complex health alteration. In which order should the
nurse complete the listed actions? Place the actions in order from first to last. - ANS 1. Assess
the client's level of consciousness and activity.
2. Check the endotracheal tube.
3. Observe the rise and fall of the chest during ventilation.
4. Feel for a carotid pulse.
5. Check the ventilator alarm and address any issues as needed.
6. Check the telemetry alarm and address any issues as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and address any issues as needed.
Review the recorded communication. Which TeamSTEPPS tool is used in the conversation?-
ANS Call-out
Situations
Based on the reason for admission to an inpatient facility, which inpatient care area should the
nurse anticipate caring for each of these clients? Drag and drop a unit in the left column to
match the corresponding client.- ANS *Trauma unit* - Young adult with a broken femur and
closed head injury sustained in a motorcycle crash.
*Intensive care unit (ICU)* - Middle-aged adult with recent onset of left-sided weakness and
slurred speech.
*Orthopedic unit* - Older adult requiring traction while awaiting surgical repair of a hip fracture.
*Medical-surgical unit* - Middle-aged adult after an uncomplicated colon resection surgery.
In which situations should the nurse use the identify, situation, background, assessment, and
recommendation (ISBAR) tool to ensure clear and complete communication? Drag the
situations in which ISBAR should be used from the left column to the right column.- ANS
Calling the healthcare provider regarding a change in the client's status.
Explaining the client's status to their family.
Giving report to the oncoming nurse.
Transferring a client to a long-term care facility.
Which technique can be used to decrease the noise created by the alarms on the technology
used while delivering client care?- ANS Change the default alarm settings to specific settings
based on each client's condition.
For each nursing action in the left column, specify if it addresses the concerns in the other
columns that are experienced by clients in a critical care environment.- ANS *Physical
Environment:*
Keep the window coverings open.
Close the door to the room.
Encourage the family to bring objects from home.
Keep tubing, wires, and cords free of tangles.
*Excess Noise:*
, Adjust device alarms to accommodate the client's condition.
Close the door to the room.
Turn off the ringer on the phone in the room.
*Sensory Deprivation:*
Keep the window coverings open.
Encourage the family to bring objects from home.
Allow visitors per the facility policy.
The nurse is caring for a client who is sedated and using a ventilator to support breathing.
Which ideas should the nurse offer to increase the family's involvement with the client? Select
all that apply.- ANS Show the family how to touch the client without harming them.
Ask the family to bring small objects from home, which the client will recognize.
Ask the family how they would like to be more involved.
Encourage the family to ask questions related to the client's condition.
Encourage the family to speak to the client.
After hearing the alarms for the infusion pump, telemetry monitor, and ventilator sound, the
nurse enters the room of a client with a complex health alteration. In which order should the
nurse complete the listed actions? Place the actions in order from first to last. - ANS 1. Assess
the client's level of consciousness and activity.
2. Check the endotracheal tube.
3. Observe the rise and fall of the chest during ventilation.
4. Feel for a carotid pulse.
5. Check the ventilator alarm and address any issues as needed.
6. Check the telemetry alarm and address any issues as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and address any issues as needed.
Review the recorded communication. Which TeamSTEPPS tool is used in the conversation?-
ANS Call-out
