EDAPT: Nursing Care: Complex
Health Situations
A purchaser arrives thru ambulance to the emergency branch (ED) in complete
cardiopulmonary arrest receiving cardiopulmonary resuscitation (CPR). After receiving the
record from the emergency scientific technicians (EMTs), the nurse assists the healthcare
issuer (HCP) with intubation and other life-saving interventions.
After inserting a 2d peripheral venous get right of entry to tool (VAD), the nurse reviews the
client's digital health document (EHR) and discovers an advance directive indicating that this
patron did not wish to be intubated have to they prevent respiration. Which three priority
moves have to the nurse take?- ANS-Contact the client's emergency contact.
Verify the improvement directive is legitimate.
Notify the ED HCP of the customer's documented needs.
A consumer has been admitted to the extensive care unit (ICU) with a diagnosis of acute
respiratory misery syndrome (ARDS) and COVID-19 contamination. Which health disparities
inside the nurse's note suggest an accelerated risk of a terrible outcome all through the
purchaser's hospitalization? Highlight all that follow.- ANS-Completed tenth grade
Unemployed
Receiving unemployment
Lives in a small, rural city
Trouble getting delivery
A consumer has been inside the demise procedure for 10 days. His spouse appears light
and exhausted, handiest leaving his facet for brief moments. The nurse suggests that the
wife take a damage to consume and relaxation. The woman declines, saying, "I do not want
to leave him. I might not have him a lot longer, and I do not want him to head after I'm long
past." What ought to the nurse do?- ANS-Arrange a cot for the wife on the bedside and
arrange to have food introduced to her.
A purchaser on a medical-surgical unit is coming near the cease of life. The customer has
had numerous episodes of dyspnea and a prescribed order for morphine sulfate elixir. The
patron's accomplice states, "I do not recognize why they want morphine. They inform me
they're no longer in ache." How must the nurse explain the motive of using the morphine?-
ANS-Helps to reduce tension and oxygen consumption.
A distraught customer informs the nurse that they want a new healthcare issuer (HCP)
because their current HCP refuses to write a do-now not-resuscitate (DNR) order because
the patron has asked. What is the nice movement for the nurse to take at this time?-
ANS-Gather all relevant records regarding the medical, social, and spiritual aspects of the
modern situation.
, A younger adult patron isn't always anticipated to recover from the blunt-force accidents
sustained in a car crash. The family has informed the healthcare crew that the customer
would like to be an organ donor. For which evaluation findings have to the nurse monitor,
informing that the death has befell and the focal point of care can shift to organ renovation?
Select all that follow. - ANS-Respiratory efforts end.
Brainstem reflexes are absent.
The electrocardiogram (ECG) indicates no cardiac pastime.
After activating the rapid reaction crew (RRT), which three priority moves must the nurse
take before the RRT arrives? Drag the three priority movements to the "Three Top Priorities"
column.- ANS-Clear the room of extra human beings and furnishings.
Return the customer to mattress, if wanted.
Review the client's strengthen directive.
After hearing the alarms for the infusion pump, telemetry display, and ventilator sound, the
nurse enters the room of a client with a complicated fitness alteration. In which order must
the nurse complete the indexed moves? Place the movements so as from first to remaining.
- ANS-1. Assess the client's stage of consciousness and hobby.
2. Check the endotracheal tube.
Three. Observe the rise and fall of the chest for the duration of ventilation.
4. Feel for a carotid pulse.
Five. Check the ventilator alarm and deal with any problems as wished.
6. Check the telemetry alarm and deal with any troubles as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and cope with any troubles as wanted.
Although the consumer refused the system, the nurse insisted and inserted a nasogastric
tube in the proper nose. The administrator of the health facility makes a decision to settle a
lawsuit because the nurse committed __________ that is __________ __________.-
ANS-Battery
An intentional
Tort
Based on the customer's reaction to the extended supplemental oxygen, the nurse
determines their status is __________ due to the __________ and should __________. -
ANS-Declining
Pneumonia
Activate the rapid reaction group (RRT)
Health Situations
A purchaser arrives thru ambulance to the emergency branch (ED) in complete
cardiopulmonary arrest receiving cardiopulmonary resuscitation (CPR). After receiving the
record from the emergency scientific technicians (EMTs), the nurse assists the healthcare
issuer (HCP) with intubation and other life-saving interventions.
After inserting a 2d peripheral venous get right of entry to tool (VAD), the nurse reviews the
client's digital health document (EHR) and discovers an advance directive indicating that this
patron did not wish to be intubated have to they prevent respiration. Which three priority
moves have to the nurse take?- ANS-Contact the client's emergency contact.
Verify the improvement directive is legitimate.
Notify the ED HCP of the customer's documented needs.
A consumer has been admitted to the extensive care unit (ICU) with a diagnosis of acute
respiratory misery syndrome (ARDS) and COVID-19 contamination. Which health disparities
inside the nurse's note suggest an accelerated risk of a terrible outcome all through the
purchaser's hospitalization? Highlight all that follow.- ANS-Completed tenth grade
Unemployed
Receiving unemployment
Lives in a small, rural city
Trouble getting delivery
A consumer has been inside the demise procedure for 10 days. His spouse appears light
and exhausted, handiest leaving his facet for brief moments. The nurse suggests that the
wife take a damage to consume and relaxation. The woman declines, saying, "I do not want
to leave him. I might not have him a lot longer, and I do not want him to head after I'm long
past." What ought to the nurse do?- ANS-Arrange a cot for the wife on the bedside and
arrange to have food introduced to her.
A purchaser on a medical-surgical unit is coming near the cease of life. The customer has
had numerous episodes of dyspnea and a prescribed order for morphine sulfate elixir. The
patron's accomplice states, "I do not recognize why they want morphine. They inform me
they're no longer in ache." How must the nurse explain the motive of using the morphine?-
ANS-Helps to reduce tension and oxygen consumption.
A distraught customer informs the nurse that they want a new healthcare issuer (HCP)
because their current HCP refuses to write a do-now not-resuscitate (DNR) order because
the patron has asked. What is the nice movement for the nurse to take at this time?-
ANS-Gather all relevant records regarding the medical, social, and spiritual aspects of the
modern situation.
, A younger adult patron isn't always anticipated to recover from the blunt-force accidents
sustained in a car crash. The family has informed the healthcare crew that the customer
would like to be an organ donor. For which evaluation findings have to the nurse monitor,
informing that the death has befell and the focal point of care can shift to organ renovation?
Select all that follow. - ANS-Respiratory efforts end.
Brainstem reflexes are absent.
The electrocardiogram (ECG) indicates no cardiac pastime.
After activating the rapid reaction crew (RRT), which three priority moves must the nurse
take before the RRT arrives? Drag the three priority movements to the "Three Top Priorities"
column.- ANS-Clear the room of extra human beings and furnishings.
Return the customer to mattress, if wanted.
Review the client's strengthen directive.
After hearing the alarms for the infusion pump, telemetry display, and ventilator sound, the
nurse enters the room of a client with a complicated fitness alteration. In which order must
the nurse complete the indexed moves? Place the movements so as from first to remaining.
- ANS-1. Assess the client's stage of consciousness and hobby.
2. Check the endotracheal tube.
Three. Observe the rise and fall of the chest for the duration of ventilation.
4. Feel for a carotid pulse.
Five. Check the ventilator alarm and deal with any problems as wished.
6. Check the telemetry alarm and deal with any troubles as needed.
7. Assess the intravenous (IV) site.
8. Check the infusion pump alarm and cope with any troubles as wanted.
Although the consumer refused the system, the nurse insisted and inserted a nasogastric
tube in the proper nose. The administrator of the health facility makes a decision to settle a
lawsuit because the nurse committed __________ that is __________ __________.-
ANS-Battery
An intentional
Tort
Based on the customer's reaction to the extended supplemental oxygen, the nurse
determines their status is __________ due to the __________ and should __________. -
ANS-Declining
Pneumonia
Activate the rapid reaction group (RRT)
