The nurse is performing a dressing change on a client with a stage 3 sacral wound. Once the old dressing is removed, the nurse would perform which step next?
Rationale:
Assess the wound.
After removing the old dressing, assessing the wound is crucial to determine its condition, identify any infection or complications, and decide the appropriate treatment for effective healing and care.
A: wash hands Proper handwashing should occur before and after the procedure, but it is not the immediate next step after removing the dressing in this context.
B: chart the findings Documenting observations is essential, yet it cannot precede the assessment of the wound, which provides vital information needed for accurate charting.
D: prepare the sterile field Creating a sterile field is important for dressing changes; however, assessing the wound takes precedence to ensure that the field is prepared appropriately based on the wound's condition.
The nurse is caring for a client with dyspnea. Which interventions can the nurse delegate to an unlicensed assistive personnel (UAP)? Select all that apply.
Rationale:
B: checking a pulse oximetry, D: encouraging the client to cough and deep breathe. These interventions are within the UAP's scope, allowing them to monitor oxygen levels and support the client's breathing techniques effectively.
A: assessing lung sounds. This task requires a registered nurse's expertise and clinical judgment, making it unsuitable for delegation to UAP.
C: administering oxygen via nasal cannula. This intervention necessitates specialized knowledge and assessment skills, which UAP do not possess, thus it cannot be delegated.
E: showing the client how to use an incentive spirometer. This task involves teaching and assessing the client’s understanding, which falls outside the UAP's responsibilities and requires a nurse’s intervention.
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Select all that apply.
Rationale:
A sterile object is held below the table surface and returned to the sterile field. This action compromises the integrity of the sterile field by introducing potential contaminants from below the table.
B: The outer inch of the sterile towel hangs over the side of the table. This area is considered unsterile, making any contact with it a breach of sterility.
C: A partially emptied container of sterile betadine is replaced within the sterile field. Introducing a non-sterile item into the sterile field creates a risk for contamination.
D: Sterile packages are opened with the first edge away from the technician. This action maintains sterility, as it prevents the technician from touching the sterile contents directly and does not indicate contamination.
The nurse is responsible for his own actions while on duty caring for clients. What is the name of this ethical principle? Fill in the blank.
Rationale:
Accountability
This ethical principle emphasizes that the nurse must own their decisions and actions while providing care, ensuring that they adhere to professional standards and the welfare of their clients. Accountability fosters trust and integrity in the healthcare environment.
B: Autonomy
This principle refers to a client's right to make informed decisions about their own care, rather than focusing on the nurse's responsibility for their actions.
C: Beneficence
Beneficence involves acting in the best interest of the patient, prioritizing their well-being, but it does not specifically address the nurse's ownership of their actions.
D: Justice
Justice pertains to fairness and equality in healthcare delivery, ensuring all clients receive equitable treatment, which does not relate to the nurse's individual accountability for their actions.
The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.
Rationale:
The nurse makes sure the client understands treatment options, including possible outcomes if the client refuses treatment, obtains an interpreter for the client if her native language is not English, and asks the client for a copy of advance directives or a living will.
Understanding options and outcomes empowers the client in decision-making, while obtaining an interpreter ensures effective communication. Asking for advance directives respects the client's wishes, demonstrating strong advocacy.
A: The nurse speaks to the daughters regarding caremaking decisions, since the client is elderly and may not understand. This action undermines the client’s autonomy, bypassing their right to be involved.
B: The nurse tells the family that they should really consider making the client an organ donor in case something happens. This approach imposes decisions on the family without respecting the client's individual values and preferences.
The nurse is caring for a middle-aged woman who walks 3 miles every morning. The nurse notes that during her morning walk, the client called her son and stated that she thought she was having a heart attack. Which symptom, identified by the client, is the most common and consistent with a myocardial infarction (MI)?
Rationale:
C: uncomfortable feeling of pressure in the chest. This symptom is frequently associated with myocardial infarction, as individuals often describe it as a heavy or squeezing sensation, indicating a potential heart issue.
A: palpitations. Although palpitations can occur during a heart attack, they are not as consistently reported as chest pressure, which is a hallmark symptom of myocardial infarction.
B: lower extremity edema. This symptom typically relates to circulatory issues rather than an immediate heart attack, thus lacking the direct association with the acute nature of myocardial infarction symptoms.
D: nausea. While nausea can accompany heart attacks, it is less specific and often seen in various conditions, making it a less reliable indicator of myocardial infarction compared to chest pressure.
Nurses are expected to understand the principles of triage when caring for multiple clients. The ICU charge nurse is reviewing assignments. Based on the principles of triage, to which client would the charge nurse give priority for treatment? Select all that apply.
Rationale:
A: A client on a ventilator who has an alarm sounding, a client who has been talking with family and is now unresponsive, and a client receiving a new antibiotic who complains of tingling in the mouth warrant priority due to immediate risks to their safety and vital functions, reflecting the urgent nature of triage principles.
B: A client who has just returned from an open appendectomy represents a stable situation. Post-operative patients typically require monitoring but do not present immediate life-threatening conditions needing urgent intervention.
C: A client ready to transfer to the floor after the nurse calls report indicates stability and a lower acuity level. This situation does not necessitate priority attention compared to more critical clients.
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?
Rationale:
D: Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager. Prioritizing client safety and addressing potential impairment is crucial in nursing practice. Immediate action ensures that the client receives proper care while addressing any risks posed by the UAP's possible intoxication, maintaining a safe environment for all.
A: Work closely with the UAP during the shift and observe for any signs of impairment. This approach delays necessary action; immediate reporting is essential to safeguard client welfare rather than waiting for observable signs.
B: Complete the bed bath without comment. The unit is already short one staff member. Ignoring the situation compromises client safety and goes against the responsibility to address potential hazards posed by staff impairment.
C: Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired. This trivializes a serious concern; even non-medication staff must be unimpaired to ensure safe, quality care for clients.
The ED nurse is attending orientation for nurses new to working in the ED. As part of the training, the ED nurse would expect to report which conditions to the proper authorities? Select all that apply.
Rationale:
The ED nurse would expect to report West Nile virus, gunshot wounds, elder abuse or neglect, and bites from an unknown dog to the proper authorities.
Reporting these conditions is essential as they pose public health risks, indicate potential criminal activities, highlight vulnerable populations, and require immediate intervention to prevent further harm, aligning with legal and ethical nursing responsibilities.
B: herpes simplex This condition typically does not require reporting as it’s common and usually managed within the healthcare setting without implicating broader public health concerns or legal obligations.
The nurse in the senior dementia unit noticed an increase in client falls over the last six months. She worked with other unit nurses and the nurse manager to develop a new fall risk assessment tool and updated the unit policies regarding falls. Which activity did the nurse engage in?
Rationale:
The nurse engaged in quality improvement.
This answer is accurate as the nurse identified a problem, collaborated with colleagues to create a fall risk assessment tool, and updated policies, demonstrating a systematic approach to enhance care quality and reduce falls.
A: delegation. This option does not apply since the nurse worked collaboratively rather than assigning tasks to others without participating in the development of solutions.
B: peer review. While collaboration occurred, this activity emphasizes evaluating others' work rather than directly addressing a specific issue through tool development and policy updates.
C: consultation. This choice implies seeking expert advice, which was not the primary focus; the nurse proactively took steps to improve the situation rather than relying solely on external input.
D: client referral. This option suggests directing clients to other services or professionals, which does not align with the nurse’s actions of creating tools and policies to enhance safety.
The nurse notices an increase in the prevalence of deep vein thrombosis among clients in a surgical unit. The nurse collects data, develops a preventative program with peers, and works with her manager to implement a new policy and procedure. Which of the following best describes the nurse's actions?
Rationale:
The nurse's actions exemplify performance improvement.
The nurse identified an issue, collected data, and collaborated with peers and management to develop and implement a preventative program, demonstrating a commitment to enhancing patient outcomes through systematic evaluation and intervention.
A: collaboration. While the nurse worked with peers, the primary focus was on improving processes rather than just teamwork, which is a broader concept than collaboration alone.
B: consultation. The nurse did not seek expert advice or guidance; instead, she took initiative to create and implement a solution, which is different from merely consulting.
C: informatics. The situation did not involve the use of technology or information systems for data management; rather, it centered around direct actions and policy changes to enhance care quality.
The nurse is caring for a client when the attending physician comes in to round on the client. At the nurses' station, the nurse smells alcohol on the physician's breath when he hands her the chart with new orders. Which action by the nurse is appropriate?
Rationale:
Notify the nurse manager and/or charge nurse.
Reporting the physician's suspected impairment is a critical step in ensuring patient safety and maintaining professional standards. This action allows for appropriate assessment and intervention while protecting client care from potential harm.
B: Confront the physician about the smell of alcohol. Addressing the physician directly could escalate the situation and jeopardize patient safety, making it an inappropriate course of action.
C: Tell the client and request a consult with another physician. Informing the client could cause unnecessary alarm and confusion, undermining their confidence in the care being provided.
D: Enter the new orders as written, since there was only a morning lab draw ordered. Complying with the orders without addressing the physician's potential impairment poses significant risks to patient safety and care quality.
A nurse assigned to a client with congestive heart failure (CHF) is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.
Rationale:
C: The nurse should encourage alternating activity with rest periods. This approach helps manage fatigue and promotes optimal cardiovascular function in clients with congestive heart failure, enhancing their overall well-being.
A: The nurse should reduce fluid intake to less than 1,000 ml per shift. While fluid management is vital, such a drastic limit may not be necessary for all CHF patients.
B: The nurse should keep the client in a supine position as much as possible. Maintaining a supine position can hinder lung expansion and worsen symptoms, contradicting the need for optimal respiratory function.
D: The nurse should assess the ankles, legs, and feet for pitting edema. Regular assessments are crucial, but this alone does not encompass the holistic management required for CHF care.
Which diagnostic tool is most commonly used to determine the location of the myocardial damage?
Rationale:
Electrocardiogram (ECG) is the diagnostic tool most commonly used to determine the location of myocardial damage.
The ECG provides real-time graphical representations of the heart's electrical activity, allowing clinicians to identify specific patterns that indicate damage to particular regions of the myocardium. Its widespread availability and ability to quickly reveal ischemic changes make it the primary choice for assessing myocardial injury.
B: Echocardiogram This imaging technique focuses on the heart's structure and function rather than identifying the precise location of myocardial damage, thus lacking the direct electrical insights provided by an ECG.
C: Cardiac enzymes These biochemical markers indicate myocardial injury but do not localize damage. They reflect overall heart health rather than pinpoint specific areas of damage within the myocardium.
D: Cardiac catheterization While valuable for visualizing coronary arteries and assessing blockages, it is invasive and not primarily used for determining the specific location of myocardial damage compared to the ECG.
A charge nurse is preparing client care assignments for the upcoming shift. A client who underwent a laminectomy is scheduled to return from the recovery care unit. Which staff member should receive this client?
Rationale:
An RN with 1 year of experience should receive the client. This option provides the necessary nursing skills and knowledge to manage post-operative care for someone recovering from a laminectomy.
A: graduate nurse with 3 months of experience lacks the requisite experience to handle potential complications and comprehensive care needs of a post-operative patient effectively.
C: certified nursing assistant with 5 years of experience does not possess the nursing assessments and critical thinking required for the complexities involved in post-operative recovery.
D: charge nurse with 2 years of experience, while experienced, may be too focused on supervisory duties rather than providing direct patient care, which is essential in this scenario.
A client is admitted with inflammatory bowel syndrome (Crohn's disease). Which nursing measures would be included in the client's care plan? Select all that apply.
Rationale:
C: daily weight
Monitoring daily weight is crucial for clients with Crohn's disease, as it helps assess nutritional status and fluid balance, indicating potential weight loss or malnutrition complications.
D: corticosteroids
Corticosteroids are often part of the treatment regimen for Crohn's disease, utilized to reduce inflammation and manage symptoms effectively, making them essential in the care plan.
A: high-fat diet
A high-fat diet may exacerbate symptoms in Crohn's disease patients, as it can lead to increased gastrointestinal distress and malabsorption issues contrary to dietary recommendations for managing the condition.
B: lactulose therapy
Lactulose therapy focuses on treating constipation and hepatic encephalopathy, not typically addressing the inflammatory nature of Crohn's disease, thus lacking relevance in the care plan for this condition.
The nurse is caring for a 7-year-old child who presents to the ED with multiple bruises, a fractured ankle, and cigarette burns on the arms. Which action by the nurse is most appropriate?
Rationale:
Notify the charge nurse immediately so that the suspected child abuse can be reported.
This action is crucial for ensuring the child's safety and initiating the appropriate protocols for suspected abuse. Reporting allows authorities to investigate the situation thoroughly, protecting the child from further harm and facilitating access to necessary support services, while also adhering to legal obligations for healthcare professionals.
A: ask the parents if they burned the child with cigarettes. This approach could jeopardize the child's safety and may alert the parents, potentially leading to further harm for the child.
B: ask the client to tell you what happened to cause the bruising and burns. While gathering information is important, this method may place undue pressure on the child, who might not feel safe disclosing the truth.
C: inform the parents that they cannot leave with the child until they talk to the police. This action could escalate tensions and potentially endanger the child, as it may provoke a hostile reaction from the parents.
The nurse is preparing to interpret an electrocardiogram rhythm strip. Identify the order for interpreting the strip. Use all the options.
Rationale:
B: Determine the heart rate and rhythm. This initial step provides essential information about the overall cardiac function, establishing a baseline before delving into specific characteristics of the electrocardiogram.
A: Measure the P-R interval. This step follows rhythm identification, focusing on the time between atrial and ventricular depolarization, which is less critical before establishing the heart rate.
C: Analyze the P waves. While important for assessing atrial activity, analyzing P waves should come after determining heart rate and rhythm to frame the overall cardiac context.
D: Measure the QRS duration. This is a subsequent analysis that focuses on ventricular depolarization, which is less meaningful without first understanding the rhythm and heart rate.
The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following? Select all that apply.
Rationale:
Using standardized handoff reports, performing a chart check, following up on outstanding lab reports, and knowing proper transfer procedures collectively ensure continuity of care for the post-op CABG client.
A: Using standardized handoff reports fosters clear communication among healthcare providers, ensuring critical information about the client’s condition and care plan is consistently shared, thereby enhancing patient safety and care continuity.
B: Knowing how to perform a chart check aids in verifying patient information, but it does not directly facilitate communication or care transitions between different healthcare team members, limiting its effectiveness for continuity.
C: Following up on outstanding lab reports and incomplete orders is important for patient management; however, it does not encompass the comprehensive communication strategies necessary to ensure continuity of care across the healthcare team.
D: Knowing the proper procedures to transfer clients to another floor is essential for logistical care, but it does not address the ongoing communication or information sharing required for continuity after a surgical procedure.
A nurse manager and a case manager are talking to a group of new nurses about the differences of case management and care coordination. The nurse manager understands which to be true regarding the differences?
Rationale:
Case management is based on a holistic approach and an understanding of client-family dynamics. This perspective allows case managers to effectively address the comprehensive needs of the client, ensuring that care plans are tailored to individual circumstances and family context, ultimately enhancing the overall effectiveness of care delivery.
A: With care coordination, the stakeholder can be an insurance company or a hospital. This statement oversimplifies care coordination by focusing solely on stakeholders, neglecting the collaborative nature of client-focused care strategies.
B: The main goal of case management is to promote a better quality of life for the client. While this is an important aspect, it does not encompass the holistic approach that defines case management's broader purpose.
D: In care coordination, the client defines the scope of work based on a plan that is created with input from the client. This statement inaccurately portrays care coordination, which often involves multiple professionals guiding the plan rather than solely relying on the client's input.
The nurse is admitting a new client complaining of severe abdominal pain. When asked about valuables, the client says he has $1,500 cash in his wallet. He is from out of state and does not have anyone who can take his wallet into safekeeping for him. Which statement by the nurse best addresses this situation?
Rationale:
C: I can call security to bring a form to fill out, and they will lock it up for you. This response ensures the client's valuables are securely stored, providing safety and peace of mind during their hospital stay, while following hospital policies regarding personal belongings.
A: I can keep it locked up in the charge nurse's office for you. This option does not adhere to hospital protocols, as valuables must be secured by authorized personnel, like security.
B: It should be fine. Just hide it in a drawer when you go down for a CT scan. This suggestion poses significant risks, as hiding valuables does not guarantee their safety in a hospital environment.
D: You will have to call someone to come get it. We can't let you keep it in your room. This option creates unnecessary stress for the client and fails to offer a secure alternative for protecting their belongings.
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP?
Rationale:
C: A client with mild dementia who needs assistance with her food tray. This task aligns with the UAP's role in providing basic care and support for daily living activities, which they are trained to perform.
A: A client whose IV infiltrated and needs replacing. This task requires clinical judgment and advanced skills beyond the scope of UAP responsibilities, necessitating a nurse's expertise.
B: A client on BiPAP who needs arterial blood gases (ABGs) drawn. Performing ABG draws involves specialized training and knowledge of respiratory care, which UAPs are not qualified to undertake.
D: A client who needs a wet-to-dry dressing change on an abdominal incision. This procedure requires an understanding of wound care principles and infection control measures, making it inappropriate for UAP delegation.
An 84-year-old adult male requires nonurgent surgery. The client is considered to have diminished decision-making capacity due to a diagnosis of Alzheimer's. The nurse questions his ability to provide informed consent for the procedure. The best action for the nurse to take in this situation is which of the following?
Rationale:
Contacting administrative personnel ensures that the situation is handled according to hospital policy regarding informed consent, especially considering the client's diminished decision-making capacity due to Alzheimer's disease. This action promotes patient safety and legal compliance.
A: as this is nonurgent surgery with few risks, allow the client to sign the consent form. Dismissing the client's diminished capacity overlooks the ethical and legal implications of informed consent.
C: have the client's 54-year-old second cousin sign the consent form. Relatives without legal authority cannot provide consent, and this option disregards the necessity for proper legal documentation in medical decisions.
D: request the physician sign the consent form. Physicians typically cannot substitute for the patient in signing consent unless legally designated, which fails to address the client's decision-making abilities.
A 4-month-old infant is admitted to the pediatric unit for a 10-day course of antibiotics. The parents are only able to visit on weekends. Which action indicates the nurse understands the emotional needs of the infant?
Rationale:
Soothing music can provide comfort and stimulate auditory development, addressing the infant's emotional needs during hospital stays, especially when parental presence is limited. This approach fosters a calming environment, promoting emotional well-being.
B: Self-assigning care may not address the infant's emotional needs effectively, as it lacks collaboration and support from the entire nursing team, potentially limiting varied caregiving experiences.
C: Assigning a male nurse consistently does not necessarily cater to the infant's emotional needs, as comfort and familiarity are more related to consistent caregivers rather than gender.
D: Placing the infant near the nursing station prioritizes safety and monitoring but does not directly fulfill emotional needs, which are better met through soothing interactions and environmental comfort.
A nurse is precepting a nursing student in the pediatrics unit. The student nurse is preparing to administer an injection to a 14-month-old infant. Which statement by the student nurse indicates a need for further teaching by the licensed nurse?
Rationale:
D: I can give this injection with a 25-gauge needle in the dorsogluteal area. This statement indicates a need for further teaching because the dorsogluteal area is not recommended for infants due to the risk of injury to the sciatic nerve and inadequate muscle development.
A: I will use a needle that is 7/8 inch to 1 inch long. This length is appropriate for intramuscular injections in infants, ensuring adequate penetration without risking injury.
B: I will give this injection at a 90-degree angle of insertion. A 90-degree angle is suitable for intramuscular injections, which allows for proper administration into the muscle tissue.
C: I will give this injection in the vastus lateralis with a 27 gauge needle. The vastus lateralis is a recommended site for infants, and a 27-gauge needle is appropriate for this age group.
Which assignment made by a charge nurse should be questioned?
Rationale:
A student nurse assigned to a newly admitted child with acute leukemia who is receiving a blood transfusion should be questioned. This scenario poses significant risks, as a student nurse may lack the necessary experience and training to manage potential complications associated with blood transfusions, particularly in vulnerable pediatric patients with complex medical conditions like acute leukemia.
B: an RN assigned to a teenaged child diagnosed recently with bacterial meningitis. An RN possesses the requisite skills and experience to provide safe and appropriate care for this critical condition.
C: a CNA assigned to a stable male client who is 3 days post-stroke. A stable post-stroke patient is suitable for a CNA's care, as their needs are typically basic and manageable within this scope.
D: an LPN assigned to a newly admitted child with acute leukemia who is receiving IV fluids. An LPN is qualified to administer IV fluids and monitor the patient, ensuring appropriate care for the child’s condition.
A newly graduated nurse is working in the pediatric unit. Which client assignment is most appropriate for this nurse?
Rationale:
D: A 12-year-old with newly diagnosed type 2 diabetes whose parents need teaching on insulin. This assignment is suitable for a newly graduated nurse, as it involves education and support, which are fundamental aspects of nursing care, allowing the nurse to utilize their foundational knowledge while developing clinical skills in a less acute environment.
A: a 2-year-old with hemophilia A who has suddenly become less responsive. This situation requires advanced assessment and immediate intervention, which may exceed the competency of a newly graduated nurse.
B: a 15-year-old with sickle cell disease complaining of lower right quadrant abdominal pain. This case likely indicates a potential crisis requiring skilled assessment and management, posing significant risks for a novice nurse.
C: a 6-year-old who just had a tonsillectomy 2 hours earlier and is frequently swallowing. Frequent swallowing could signal bleeding, necessitating immediate and expert intervention beyond the capabilities of a newly graduated nurse.
The nurse has received report on the assigned night-shift clients. Which client should the nurse see first?
Rationale:
D: A client complaining of sudden warmth and pain at an appendectomy incision site 48 hours after surgery indicates a potential complication, such as infection or hematoma, requiring immediate assessment and intervention to prevent further deterioration.
A: a mildly confused client due for a dressing change on a diabetic ulcer to the heel presents a manageable situation; the dressing change can wait without immediate risk to the patient.
B: an elderly, stable client who just returned from an MRI to rule out a kidney mass does not display any urgent symptoms, allowing the nurse to prioritize more critical cases.
C: a client whose IV pump has started beeping, indicating that the antibiotic has completed infusing, suggests that the medication is done, but does not imply an immediate threat to the patient's health.
The nurse manager has approval to add one LPN to the RNs in the medical-surgical unit. Which nursing actions does the nurse manager expect the LPN to be able to perform according to most state board of nursing practice acts? Select all that apply.
Rationale:
The LPN is expected to perform tasks such as transcribing written physician orders, drawing blood from a PICC line, and conducting finger-prick blood glucose testing as per state nursing regulations. These actions align with the scope of practice designated for LPNs, ensuring they operate within their competencies while supporting the nursing team.
B: Access a port with a Huber needle. This procedure typically requires advanced training and is often reserved for RNs, making it outside the standard scope for LPNs.
C: Perform hemodynamic monitoring. This complex task is generally designated for RNs due to the critical analysis and assessment skills required, which exceed the LPN's scope.
A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further intervention?
Rationale:
The client expresses doubt over her decision and asks the nurse to explain more about the procedure. This indicates a need for further intervention to address her concerns and ensure informed consent.
A: The client refuses to sign the blood consent since she is a Jehovah's Witness. This reflects her personal beliefs and indicates her autonomy regarding medical decisions, requiring no further intervention.
B: The client identifies the right breast as the surgical site for a right mastectomy. Correct identification of the surgical site demonstrates understanding and preparedness for the operation, indicating no need for intervention.
C: The client signs the consent form with an X, which is witnessed by two licensed personnel. This method of signing is valid and recognized legally, ensuring the consent process is appropriately followed without further intervention needed.
The nurse is charting on his client, who had an open appendectomy the previous day. Which are appropriate nursing documentation entries? Select all that apply.
Rationale:
The client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping and ambulated 200 feet in the hall with a cane. No dyspnea or syncope noticed. Tolerated well.
C provides vital information on the client's nutritional intake and absence of gastrointestinal distress, essential for assessing recovery post-surgery. D highlights mobility progress and stability, indicating effective rehabilitation and monitoring.
A: The client appeared anxious when several family members came to visit. Emotional responses are subjective and less critical than physiological observations post-surgery, which are more relevant for recovery documentation.
B: The client appeared angry when the health care provider changed her medications. While emotional reactions are notable, they do not directly impact the client's physical recovery or nursing care requirements.
The ED nurse has triaged a client who was in a severe motor vehicle accident. He is unconscious with fractures to the left femur and left humerus and ulna. CT also reveals a large amount of internal hemorrhaging. No identification was found on the client at the scene. What is the correct action by the nurse?
Rationale:
Prepare the client for emergency surgery.
Immediate surgical intervention is crucial due to the severe internal hemorrhaging and the client's unconscious state, which poses a life-threatening risk. Stabilizing the client’s condition through surgery is the priority, surpassing consent issues in emergencies where the patient cannot respond.
B: Try to obtain informed consent from a family member. Seeking consent from a family member is impractical given the urgency of the situation and the client’s critical condition requiring immediate action.
C: Wait until the client is conscious, and then obtain the consent. Delaying treatment until the client regains consciousness risks worsening their condition and potentially leads to preventable complications due to the internal hemorrhaging.
D: Ask police to run the tag number so the client can be identified. Identifying the client does not address the immediate medical needs; urgent treatment takes precedence over identification in life-threatening scenarios.
E: Inform the health care provider that consent cannot be obtained at this time. While notifying the provider is important, it should not delay the necessary emergency surgery needed to save the client’s life.
The nurse is preparing to transfer a client from the ICU to the floor. Which of the following ensures continuity of care for the client? Select all that apply.
Rationale:
Providing report on the client using standard hand-off reports, informing the receiving nurse of pending lab results and when they are expected, and informing the receiving nurse of any care that needs to be done ensure continuity of care for the client.
B: Providing report on the client using standard hand-off reports guarantees that the receiving nurse has essential information for ongoing care, facilitating a smooth transition and minimizing the risk of errors.
C: Informing the receiving nurse of pending lab results and when they are expected allows for timely interventions and decision-making, thus enhancing patient safety and ensuring appropriate follow-up on critical information.
D: Informing the receiving nurse of any care that needs to be done, such as bathing, equips the next caregiver with necessary tasks, ensuring that the client’s needs are met without interruption.
A: Using approved abbreviations in documenting care does not directly correlate with the transfer process, as it focuses more on documentation clarity rather than the communication of critical patient information.
E: Telling the receiving nurse that the family is demanding and asks too many questions offers no relevant clinical information, potentially detracting from essential patient-focused communication vital for continuity of care.