NR304 Week 7 Complete Health
Assessment
Failure to rescue is the (capability/inability) to save a client's life with timely
(diagnosis/planning) and (treatment/evaluation) when complications develop. Failure to
rescue is (never/usually) preventable. - answer- inability
- diagnosis
- treatment
- usually
Which nursing actions demonstrate a potential cause of failure to rescue? (SATA)
- Review the client's current laboratory results before administering medication.
- Failure to record the percentage of food intake at dinner time.
- Return to assess the client 1 hour after administering a high dose of narcotic pain
medication via intramuscular (IM) injection.
- Ask a colleague to check on a critically ill client during a meal break.
- Administer STAT medication 2 hours after it was ordered.
- Delay notifying a healthcare provider (HCP) that a post-operative client's pain
medication is no longer working. - answer- Return to assess the client 1 hour after
administering a high dose of narcotic pain medication via intramuscular (IM) injection.
- Administer STAT medication 2 hours after it was ordered.
- Delay notifying a healthcare provider (HCP) that a post-operative client's pain
medication is no longer working.
What is the most common cue to indicate a client is at risk for clinical deterioration? -
answerChange in one or more vital signs
Detecting (late manifestations/early signs) of clinical (deterioration/improvement) and
taking appropriate action, including (communicating/documenting) assessment findings
with the (healthcare provider/nursing supervisor) immediately, are critical steps the
nurse should take to avoid failure to rescue. - answer- early signs
- deterioration
- communicating
- Healthcare Provider
Changes in which assessment data may indicate failure to rescue? (SATA)
- Gait
- Handwriting
- Heart rate
- Oxygen saturation
, - Level of consciousness - answer- Heart rate
- Oxygen saturation
- Level of consciousness
Nurses must be __________, rather than reactive, during each __________ by
___________ seeking information that indicates their current health status.
WORD BANK:
reactive
actively
advocating
passively
proactive
shift
client interaction - answer- proactive
- client interaction
- actively
Which benefits does structured-debriefing training provide for staff and clients? (SATA)
- Increased positive perceptions regarding the culture of safety
- Decisions about care are more accurate
- Colleagues demonstrate improved teamwork skills
- Increased length of stay
- Decreased rates of healthcare-acquired infections (HAI) - answer- Increased positive
perceptions regarding the culture of safety
- Decisions about care are more accurate
- Colleagues demonstrate improved teamwork skills
- Decreased rates of healthcare-acquired infections (HAI)
Which nursing action is an example of anchoring bias after a BP of 88/42 is obtained on
a client admitted with chest pain? - answerLeaving the room to get a blood pressure cuff
that works
The nurse is caring for Charley (pronouns: she/her/hers), an older adult on the medical
floor for an exacerbation of chronic obstructive lung disease (COPD). Her past medical
history includes primary hypertension, a 52-pack-year smoking history, and an
appendectomy as a child. During the handoff report, the off-going nurse shared that the
client was resting comfortably with normal vital signs.
Indicate if the finding is a cue to the potential clinical decline or an expected clinical
finding for the client.
- Circumoral pallor
- Decreased breath sounds
- Rapid, labored breathing with use of accessory muscles
Assessment
Failure to rescue is the (capability/inability) to save a client's life with timely
(diagnosis/planning) and (treatment/evaluation) when complications develop. Failure to
rescue is (never/usually) preventable. - answer- inability
- diagnosis
- treatment
- usually
Which nursing actions demonstrate a potential cause of failure to rescue? (SATA)
- Review the client's current laboratory results before administering medication.
- Failure to record the percentage of food intake at dinner time.
- Return to assess the client 1 hour after administering a high dose of narcotic pain
medication via intramuscular (IM) injection.
- Ask a colleague to check on a critically ill client during a meal break.
- Administer STAT medication 2 hours after it was ordered.
- Delay notifying a healthcare provider (HCP) that a post-operative client's pain
medication is no longer working. - answer- Return to assess the client 1 hour after
administering a high dose of narcotic pain medication via intramuscular (IM) injection.
- Administer STAT medication 2 hours after it was ordered.
- Delay notifying a healthcare provider (HCP) that a post-operative client's pain
medication is no longer working.
What is the most common cue to indicate a client is at risk for clinical deterioration? -
answerChange in one or more vital signs
Detecting (late manifestations/early signs) of clinical (deterioration/improvement) and
taking appropriate action, including (communicating/documenting) assessment findings
with the (healthcare provider/nursing supervisor) immediately, are critical steps the
nurse should take to avoid failure to rescue. - answer- early signs
- deterioration
- communicating
- Healthcare Provider
Changes in which assessment data may indicate failure to rescue? (SATA)
- Gait
- Handwriting
- Heart rate
- Oxygen saturation
, - Level of consciousness - answer- Heart rate
- Oxygen saturation
- Level of consciousness
Nurses must be __________, rather than reactive, during each __________ by
___________ seeking information that indicates their current health status.
WORD BANK:
reactive
actively
advocating
passively
proactive
shift
client interaction - answer- proactive
- client interaction
- actively
Which benefits does structured-debriefing training provide for staff and clients? (SATA)
- Increased positive perceptions regarding the culture of safety
- Decisions about care are more accurate
- Colleagues demonstrate improved teamwork skills
- Increased length of stay
- Decreased rates of healthcare-acquired infections (HAI) - answer- Increased positive
perceptions regarding the culture of safety
- Decisions about care are more accurate
- Colleagues demonstrate improved teamwork skills
- Decreased rates of healthcare-acquired infections (HAI)
Which nursing action is an example of anchoring bias after a BP of 88/42 is obtained on
a client admitted with chest pain? - answerLeaving the room to get a blood pressure cuff
that works
The nurse is caring for Charley (pronouns: she/her/hers), an older adult on the medical
floor for an exacerbation of chronic obstructive lung disease (COPD). Her past medical
history includes primary hypertension, a 52-pack-year smoking history, and an
appendectomy as a child. During the handoff report, the off-going nurse shared that the
client was resting comfortably with normal vital signs.
Indicate if the finding is a cue to the potential clinical decline or an expected clinical
finding for the client.
- Circumoral pallor
- Decreased breath sounds
- Rapid, labored breathing with use of accessory muscles
