NCLIN 301

Hemoglobin level

A high level (erythrocytosis) may indicate bone marrow disease, low blood oxygen levels (hypoxia), or dehydration; a low level may indicate anemia, bone marrow failure, cancer, or cancer treatments.

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

Consult with your health care provider about beginning an exercise program. Rationale: The nurse should advise the client to consult with the health care provider to create a plan for an exercise program. Regular exercise, including cardiovascular exercise, helps maintain strength and flexibility and can help slow bone loss, all of which aid in fall prevention. However, the type of exercise and equipment should be determined by the health care provider or another qualified health care professional, not by the nurse.

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing?

Using a rubbing, circular motion Rationale: Rationale: When washing the hands with soap and water, the nurse would use a rubbing circular motion to wash the palms and back of the hands, each finger, the areas between the fingers and knuckles, and the wrists and forearms. Throughout the process, the nurse would keep the hands lower than the elbows to allow water to flow toward the fingertips. The nurse would wash to at least 1 in (2.5 cm) above the level of contamination or to 1 in (2.5 cm) above the wrists. When drying the hands, the fingers are dried first and the nurse then moves upward toward the forearms.

White blood cell (WBC) count

A high count (leukocytosis) may indicate an infection. Leukocytosis may also occur in leukemia or myeloproliferative disorders, trauma or tissue injury, bronchogenic carcinoma, acute hemorrhage, polycythemia vera, or sickle cell disease, or after splenectomy; a low count (leukopenia) may indicate a problem with bone marrow production or it may be a result of some medications or chronic infection.

Platelet count

A high count (thrombocytosis) may indicate a bone marrow problem, kidney disease with increased erythropoietin production, smoking or severe inflammation, bleeding, or iron deficiency; a low count (thrombocytopenia) may indicate prolonged bleeding

The nurse is caring for a patient the day after invasive surgery. The nurse is aware that review of which of the following should be included when assessing for the presence of a systemic infection?

Body temp, WBC count Rationale: Nursing assessments include observing for signs and symptoms of a local or systemic infection. Manifestations of a systemic infection include fever and increased white blood cell count. Redness, swelling, and pain, or the presence of bacteria in a wound culture, indicate a local infection but do not confirm the presence of a systemic infection. Blood pressure is not a reliable indication of infection.

The nurse considers applying restraints to an agitated client. Which actions does the nurse take?

Dim the lights and speak softly about something the client enjoys. Rationale: The nurse attempts multiple techniques before restraining a person, even when the person is agitated. Among those techniques is providing a calming environment and distraction. The nurse can assess the client for injuries anytime he or she is agitated, but this is not immediately relevant. The client must at least be able to reach the call bell to request assistance and water, if allowed. Family members are not always helpful for someone with agitation, and a family member may find it difficult to accept that level of responsibility.

A nurse is preparing to perform hand hygiene using an alcohol-based handrub. When applying the product, the nurse would place the product at which location?

In the palm of one hand Rationale: The proper procedure for using an alcohol-based handrub is to apply the appropriate amount of product to the palm of one hand. This helps to ensure that the product will cover all the surfaces when the product is rubbed in. The nurse would rub the hands together, covering all surfaces of hands and fingers, between fingers as well as the fingertips and the area beneath the fingernails. It would be inappropriate to apply the product to each fingertip, on the back of the hand, or between each finger.

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors?

Increase joint flexibility, improve respiratory function, aid gastrointestinal motility Rationale: Ambulation helps the client increase joint flexibility, improve respiratory function and aid gastrointestinal motility. It does not necessarily help with pain control. In fact, clients may need pain medication prior to ambulation, especially if they are postsurgery. Ambulation is not related to wound infection risk.

The nurse is conducting a neurovascular assessment on a postoperative patient who experienced a total knee arthroplasty (TKA). What initial intervention(s) should be performed by the nurse when it appears that there is an absence of a pulse in the affected foot?

Elevate the affected extremity, assess the peripheral pulses in both lower extremities, assess for paresthesia in the affected extremity, assess the capillary refill and skin color in both lower extremities, notify the patient's health care provider of the assessment finding. Rationale: Assess capillary refill and skin color, comparing the findings of both extremities in order to evaluate arterial blood flow. Assess affected extremity for the presence of paresthesia, which may indicate reduced neurovascular competence. Evaluate comparative peripheral pulses in both extremities to determine venous blood flow in each. Elevation of the affected extremity is directed toward minimizing edema and encouraging venous return. The nurse should notify the health care provider when all relevant assessment data have been collected.

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency?

Every 1-2 hrs Rationale: The nurse would plan on increasing the frequency of client observation and surveillance, conducting client/nursing rounds every 1 to 2 hours. These rounds would include assessing for pain, assisting with toileting, providing client comfort, ensuring that personal items are within reach, and meeting client needs. Client care rounds/nursing rounds improve identification of unmet needs, which can decrease behaviors that increase risk for the use of restraints.

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

Every 60 mins Rationale: If a client who is at high risk for falls has no access to an activated bed or chair alarm, a nurse should observe the client every 60 minutes. Unless the client is on one-to-one observation, every 30 minutes is too frequent. Once a shift, or at 2- or 4-hour intervals, is too infrequent.

When bathing a patient who requires contact and droplet precautions, which personal protective equipment (PPE) will the nurse put on?

Gloves and mask Rationale: Droplet precautions are used for patients with an infection that is spread by large-particle droplets, such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Contact precautions are intended to prevent transmission of infectious agents that are spread by direct or indirect contact with the patient or the patient's environment. In many cases, such as with the novel coronavirus, the CDC will recommend both droplet and contact precautions be followed. Gloves, gown, and mask are the necessary PPE to wear when contact and droplet precautions have been ordered. HEPA respirators are required when airborne precautions are required. Goggles are needed when there is a risk of splatter of blood or body fluids into the eyes of the caregiver.

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse?

Increase the parent's social interaction, provide frequent reorientation, ensure the parent engages in regular exercise. Rationale: The nurse should instruct the adult child to provide frequent reminders of person, place, and time to help keep the client oriented in the environment and decreases the chance that the client will wander. The nurse should also instruct the adult child to ensure the parent engages in regular exercise and to work to increase the parent's social interaction, both of which help clients with dementia channel stress more appropriately. Taking naps frequently does not help to reorient the client with dementia or to channel energies. Changing the parent's routine frequently can disorient a client with dementia and increase the chance that the client will wander.

Neutrophils

Increased % may be due to acute infection or acute stress; decreased percentage may be due aplastic anemic, chemotherapy, influenza, viral infection, or widespread severe bacterial infection

Lymphocytes

Increased % may be due to chronic bacterial infection; decreased percentage may be due to sepsis or steroid use

Monocyte

Increased percentage may be due to chronic inflammatory disease or viral infection (mumps, measles, mono)

The nurse explains to another nurse the meaning of situational awareness. Which client exemplar does the nurse use to illustrate situational awareness?

If the call bell has been out of the client's reach, I ask if the client needs to void or defecate. Rationale: Awareness of the client's environment and of the client's situation is an integral part of nursing care. Situational awareness involves knowing and understanding what's happening around you. When the nurse notes the client has been unable to call for assistance because the bell was out of reach, the nurse asks the client about the need to use the commode based on the fact the client has been unable to ask for help. Body systems assessment is used to determine which body system is malfunctioning. Evaluating the assignments and delegation needs are not part of situational awareness. If the nurse notes that the unlicensed assistive personnel is frantically busy, however, this is situational awareness. Situational awareness does not allow nurses to anticipate using restraints because, nurses attempt to find solutions so that restraints do not need to be placed

The nurse caring for Mr. Griffin understands which of the following nursing interventions will have the greatest impact on minimizing the spread of methicillin-resistant Staphylococcus aureus (MRSA) to other clients on a surgical unit?

Instituting meticulous handwashing technique, implementing contact precautions, using appropriate personal protective equipment (PPE) Rationale: The nurse can minimize the spread of MRSA by implementing effective handwashing techniques and contact precautions, and by using appropriate PPE. Monitoring cultures and administering antibiotics are appropriate nursing interventions, but they are related to the treatment of existing MRSA, not to preventing the spread of MRSA. Family members should be permitted to visit, provided they follow precautions.

When considering a 40-year-old postoperative patient, which factor is likely to present the greatest risk for the development of an infection?

Invasive or indwelling medical procedures or devices Rationale: The use of invasive or indwelling medical devices provides exposure to and entry for potential sources of disease-producing organisms. This is particularly risky in immunosuppressed clients or those with weakened defenses due to disease or trauma, such as surgery. The pH levels of the gastrointestinal and genitourinary tracts help to ward off microbial invasion and are therefore important for infection prevention. The white blood cells provide resistance to certain pathogens. The patient's age, gender, race, and weight influence susceptibility to infection; however, they would not pose the greatest risk.

The nurse is completing a postarthroplasty focused assessment on Mr. Griffin to determine musculoskeletal and neurovascular status. Which of the following would be included in this assessment?

Skin color, skin temperature, capillary refill, pedal pulses, toe movement, range of motion, muscle strength Rationale: A focused musculoskeletal and neurovascular assessment for Mr. Griffin would include range of motion and muscle strength, as well as skin color, temperature, capillary refill, pedal pulses, and toe movement. These assessments would be performed bilaterally to determine differences between the affected and unaffected side.

The nurse is conducting a neurovascular assessment on a postoperative knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment?

Patient reports "pins and needles" sensation below the incision site. Rationale: Paresthesia, often described as a sensation of "pins and needles," may be the first symptom of changes in sensory nerves to appear. This finding requires further assessment both above and below the affected area. While the other options may indicate neurological impairment, they may be a result of other factors and are not usually the initial indicator of neurological impairment.

The nurse caring for Mr. Griffin identifies which of the following as priority nursing actions when caring for a client under contact precautions?

Performing hand hygiene, putting on gown, donning gloves, isolating client care equipment Rationale: Hand washing, gowning, and gloving are necessary for contact isolation protection. It is important to avoid sharing client care equipment. The mask is appropriate for airborne or droplet precautions. Eye protection is needed if splashing is a risk.

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home?

Polypharmacy, extension cords, clutter Rationale: In the home of an older adult, the use of extension cords and clutter in the walkways are environmental hazards that increase the risk of falls in the home. Polypharmacy is common risk in the home of an older adult client. Placing objects in familiar places helps to decrease the risk in the home of an older adult. Using ambulation devices helps to decrease the risk of falls in the home of the older adult.

The nurse performs hand hygiene using an alcohol-based hand rub after exiting a client's room. The nurse does not touch another surface or client until what has occurred?

The antiseptic has evaporated from the skin Rationale: Although products may vary, typically the nurse would apply the antiseptic to the palm of the hand, covering all surfaces of the hands and fingers. The nurse would continue to rub until the antiseptic until it evaporates from the hand. Hand hygiene is not documented. Thirty seconds may not be enough time for the solution to dry. Hands are not dried with a paper towel after using the alcohol-based hand rub.

Eosinophils and Basophils

Increased % may indicate allergic rxn

The nurse provides client education regarding range of motion exercises to Mr. Griffin in preparation for his pending discharge home. The nurse recognizes that Mr. Griffin understands the information provided when he states which of the following?

'Range of motion exercises should be performed slowly and gently.', 'I should perform range of motion exercises on both sides.', 'It may be necessary to continue physical therapy after going home.', 'I will need to use a walker or crutches after discharge.' Rationale: Postoperative range of motion exercises are an important part of client rehabilitation after total knee arthroplasty. These exercises should be performed slowly and gently to avoid injury and limit pain. They should be performed on both sides to increase range of motion and strength. Physical therapy is commonly required after discharge. Regular range of motion exercises and movement promote healing and increase long-term function. Clients should utilize an assistive device such as a walker, cane, or crutches to slowly increase weight bearing over time and avoid injury. Adequate pain control is essential to a successful exercise program

Basophils normal range

0-1%

Eosinophils normal range

0-3%

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

1) Turn on the faucet and adjust the force and temperature of the water 2) Wet the hands and wrists 3) Apply soap 4) Wash the palms and backs of the hands for at least 20 seconds 5) Pat the hands dry with a paper towel 6) Turn the faucet off with a paper towel Rationale: First, turn on the water and adjust force. Second, wet the hands and wrists. Third, use about 1 teaspoon of liquid soap from the dispenser or rinse a bar of soap and lather thoroughly. Fourth, with firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers, and the knuckles, wrists, and forearms. Continue this friction motion for at least 20 seconds. Fifth, pat the hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Sixth, use another clean towel to turn off the faucet.

A nurse is preparing to perform hand hygiene using an alcohol-based hand rub. Place the following steps in the correct order.

1. Remove jewelry 2. Check the product label for the correct amount to use 3. Apply the product 4.Rub the hands together, covering all surfaces of the hands and fingers 5. Ensure that the hands are dry Rationale: Remove any jewelry. Then the nurse would check the product label for the appropriate amount to use and then apply the product to the palm of one hand. Next, the nurse would rub the hands together covering all the surfaces of the hands and fingers, and between fingers as well as the fingertips and the area beneath the fingernails. Lastly, the nurse would rub the hands together until they are dry (at least 15 seconds).

Platelet count normal range

140,000 to 400,000 × 103/mm3

A nurse is preparing to use an alcohol-based hand rub for hand hygiene. After applying the appropriate amount of product, the nurse would rub the hands together for at least how long?

15 seconds Rationale: The nurse would rub the hands together until they are dry, for at least 15 seconds. Drying ensures the antiseptic effect.

Sample urine output doumentation

12/06/20 0730 Patient placed on fracture bedpan with a two-person assist. Voided 400-mL dark yellow urine; strong odor noted. Perineal skin intact, without redness or irritation. Specimen sent for urinalysis as ordered. 12/06/20 0730 Patient using urinal at bedside to void. Voided 600-mL yellow urine. Perineal skin intact, without redness or irritation. Reinforced need for continued use of urinal for recording accurate output. Patient verbalized an understanding of instructions.

Lymphocytes normal range

25-40%

Monocytes normal range

3-7%

Sample transferring from bed to chair documentation

5/13/20 1135 Patient dangled at side of bed for 5 minutes without complaints of dizziness or lightheadedness. Patient assisted out of bed to chair with minimal difficulty; gait belt in place. Tolerated sitting in chair for 30 minutes. Assisted back to bed. Resting in semi-Fowler's position. Both upper side rails up.

Sample ambulation documentation

5/14/20 1720 Patient ambulated with assistance in hallway for a distance of approximately 15 ft. Patient tolerated ambulation well; denied any complaints of dizziness, pain, or fatigue. Ambulated back to room and sitting in chair listening to music.

Neutrophils normal range

50% to 70%

Sample oral care documentation

7/10/20 0945 Oral care performed. Oral cavity mucosa pink and moist. Small amount of bleeding noted from gums after using soft-bristled toothbrush. Resolved spontaneously when brushing completed. No evidence of ulceration. Lips slightly dry; lip moisturizer applied.

AIDET Format

Acknowledge - going into a patient room and acknowledging Mrs. Jones Introduce -- "Hi, I'm Kelly. I am going to be your nurse today. How are you?" Duration - "Hey, Mrs. Jones. This procedure is going to take about 10 minutes. Explanation - Thoroughly explain procedure to treatment and make sure they are informed. Today we are going to insert a foley catheter because you've been having trouble urinating. The insertion may be uncomfortable, but once it's in the discomfort should go away. Do you have any questions before we get started? Thank - Thank you for your time, I appreciate you cooperating with me. I understand that was a difficult procedure, but I'm sure that this is going to help us take better care for you.

A nurse demonstrates the correct use of hand hygiene using an alcohol-based hand rub for which situation?

After applying a clean, dry dressing, after removing gloves, before entering a client's room Rationale: An alcohol-based hand rub can be used if hands are not visibly soiled or have not come in contact with blood or body fluids. Appropriate situations would include before entering a client's room, after removing gloves, and after applying a clean, dry dressing. Soap and water should be used before eating and after using the restroom.

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse?

Ambulation helps prevent thromboembolism Rationale: Regular ambulation can decrease the risk of thromboembolism in the postsurgical client. It does not affect risk of surgical wound infection or hypoglycemia. This client should no longer be experiencing any acute effects of anesthesia.

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate?

Assess for the need to urinate Rationale: Client needs should be assessed before considering physical or pharmacologic restraint.

The nurse is providing training to the staff in a hospital setting regarding the prevention of health care associated infections (HAIs). The nurse identifies which of the following categories as being responsible for the majority of HAIs in the acute care hospital setting?

Central line associated bloodstream infection, catheter associated urinary tract infection, ventilator associated pneumonia, surgical site infection Rationale: Based on the premise that most HAIs are preventable, the HAI action plan published by the Centers for Disease Control and Prevention (CDC) includes the following as being responsible for the majority of all infections acquired in the health care setting: catheter associated urinary tract infections, surgical site infections, central line-associated bloodstream infections, and ventilator associated pneumonia. Gastrointestinal infections are not considered to be responsible for a large number of HAIs

Which intervention(s) will the nurse implement when maintaining medical asepsis?

Clean the least soiled areas first, practice good hand hygiene., keep personal fingernails short, do not place soiled bed linen on the floor. Rationale: Medical asepsis techniques are used continuously both within and outside health facilities, based on the assumption that pathogens are likely to be present. Nearly every nursing activity includes practices of medical asepsis. Principles of medical asepsis include good hand hygiene; keeping nails short; cleaning from least soiled to most soiled; and never placing contaminated items on the floor (which would cause contamination to spread). Allowing only sterile items to be touched by sterile items is a principle of surgical asepsis

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

Clear clutter in the walkways of the new home Rationale: The nurse should recommend that the client's family ensure that walking paths and floors in the home are free of clutter, which is an environmental hazard that increases the risk of falls in the home. Changing routines, taking walks outside, and using the stairs will not reduce the risk of falling in the home.

The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next?

Dry hands with paper towel Rationale: After rinsing the hands, the nurse would dry the hands using paper towels, wiping from the fingertips toward the forearms. Once dry, the nurse would then use another clean paper towel to turn off the water at the faucet to prevent clean hands from coming in contact with the soiled surface. The fingernails are cleaned before the hands are rinsed. The hands are dried using clean paper towel. An alcohol-based sanitizer or hospital-provided lotion can be used after handwashing and drying, if desired.

WBC count normal range

For all adults, 5.0 to 10.0 × 103 cells/mm3 (SI 4.5 to 11.0 × 109/L)

Which recommendations should be included in a teaching plan for preventing falls in the home?

Keep electrical and telephone cords against the wall and out of walkways, avoid climbing on a chair or table to reach items that are too high to reach, use a night light, remove clutter from walkways. Rationale: A teaching plan for fall prevention in the home should include the recommendations: avoid climbing on a chair or table to reach items that are too high to reach; use a night light; remove clutter from walkways; and keep electrical and telephone cords against the wall and out of walkways. Considering the use of an electronic personal alarm would not help prevent a fall, but it may be used to help alert others to the fact that one has fallen.

When washing the hands with soap and water what is an appropriate action for the nurse to perform?

Keep hands below elbows Rationale: The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips. When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.

Which intervention(s) will help minimize the risk of infection postoperatively?

Maintaining hydration, following aseptic technique when changing incision dressings, implementing standard precautions, assessing temperature frequently Rationale: Nursing interventions to prevent postoperative infection include assessing vital signs for increase in temperature or changes in pulse or respiratory rate; maintaining hydration; maintaining nutritional status; encouraging a diet high in proteins, carbohydrates, calories, and vitamins; implementing standard precautions, including proper hand hygiene; and following aseptic technique when changing dressings at the surgical site and exit sites for tubes and drains. Although pain management is important, it does not influence infection prevention

Hemoglobin level normal range

Males: 14 to 17.4 g/dL (SI 140 to 174 g/L) Females: 12 to 16 g/dL (SI 120 to 160 g/L)

Red blood cell count normal range

Males: 4.5 to 5.5 × 106 cells/mm3 (SI 4.6 to 6.2 x 1012/L) Females: 4.0 to 5.0 x 106/mm3 (SI 4.2 to 5.4 x 1012/L)

Hematocrit level normal range

Males: 42% to 52% (SI 0.42 to 0.52) Females: 36% to 48% (SI 0.36 to 0.47)

CBC - Complete Blood Count w/ Differential

Measures the amount, size, and shape of white blood cells, red blood cells, and platelets in the blood. Also measures hemoglobin and hematocrit levels. Helps diagnose anemia, infections, different types of cancer, or allergic reactions. Important to establish baseline values during routine checkups. Helps monitor effects of txts or meds or chronic health problems.

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include?

Pressure injuries, Falls, Contractures, Delirium Rationale: Restraint-free care is the standard of practice and an indicator of quality care in all health care settings. Physical restraints do not prevent falls, and they increase the possibility of serious injury due to a fall. Restraint use in older adults is associated with falls and injurious falls, pressure injuries, and other adverse outcomes. Additional negative outcomes of restraint use include skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration and respiratory difficulties, and even death.

The nurse is caring for a patient who has been diagnosed with an infection. The nurse identifies which of the following stages of infection as posing the greatest risk to others?

Prodromal Rationale: A person is most infectious during the prodromal stage. During this stage, early signs and symptoms of the disease are present, but these are often vague and nonspecific. The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying, but they may not be readily apparent. The presence of infection-specific signs and symptoms indicates the full stage of illness. During this stage, patients are more fully aware of their infectious status and methods to use to prevent exposure to others. The convalescent period involves the recovery from the infection.

Jared Griffin Case Study

SBAR Situation: Jared Griffin is placed on standard precautions, he is a carrier of MRSA, and the patient underwent a R total knee arthroplasty Background: Jarred is allergic to codeine Assessment: HR is 80 and regular, he manages w/o supplementary oxygen, pain level is 2/10, dressing is clean, dry, and intact, and he is using incentive spirometer Recommendations: monitor vital signs every 4 hours, monitor for signs of infection Simulation feedback: -Review orders -Review pt information -Introduce myself -Identify pt -Ask about allergies -Wash hands -Ask if he is in pain/scale from 1-10 -Measure BP -Attach automatic (non-invasive BP cuff) -Pt used incentive spirometer -Attach pulse oximeter -Assess breathing and resp rate -Review orders again -Assess temp -Check blood analysis in EHR to monitor for infection -Assess pts dressing -Educate pt about wound care, incentive spirometer, and PPE -Assess IV -Examine legs for sensation, motion, strength, pulse, and color -Verified oxycodone dose and administered -Pt handoff was performed

When performing a situational assessment, which assessment would the nurse complete as the last step?

Safety survey Rationale: The ABC, respiratory, and tubes and lines should be performed as the first part of a situational assessment. After surveying the client (ABCs, respiratory, tubes and lines), the nurse should survey any client safety issues to make sure that the client remains safe. Also, the nurse must validate, analyze, document, communicate, and act on the findings, as appropriate.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate?

Support the client's body against the nurse and gently slide the client onto the floor, firmly grasp the client's gait belt. Rationale: Firmly grasping the client's gait belt ensures a safe hold on the client. Supporting the client's body against the nurse's and gently sliding the client onto the floor enables the nurse to support the client's weight with large muscle groups and protects the nurse from back strain. The client should not be left alone. The cause of the weakness in unknown and it may not pass. Oxygen is not indicated. Assessing for the potential causes of the weakness should occur after client safety is assured.

The nurse is completing a situational assessment. Which findings would cause the nurse concern?

The client is wearing the oxygen around the neck, the skin is a bluish-color, there is spilled water on the floor, the IV is not infusing at the correct rate. Rationale: The situational assessment includes: ABCs, IVs, tubes, oxygen, safety, and environmental safety, including the nurse's intuition, hearing, smelling, seeing, or feeling that something needs to be explored. The client wearing oxygen around the neck is a concern in a situational assessment, because the client's SpO2 may be decreased if the oxygen is not worn properly. Moreover, tubing around the neck presents a safety issue, as does spilled water on the floor. The client's television is of no importance to the situational assessment. The situational assessment should check whether the IV is infusing at a correct rate. The client's skin being a bluish color is also a concern during situational assessment; it could be related to not wearing the oxygen correctly or indicate coldness or lack of perfusion.

The nurse typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding causes the nurse to perform this assessment rather than delegate it?

The client went to the emergency department to be evaluated after a fall. Rationale: The nurse must validate, analyze, document, communicate, and act on the findings, as appropriate. The nurse performs the assessment because there has been a change in the client's condition. Any acute change warrants an assessment by the registered nurse. This change indicates that there may need to be additional changes to the client's environment to prevent injury, too. The decision to delegate must be based on careful analysis of the client's needs and circumstances, as well as the qualifications of the person to whom the task is being delegated. Depending on the state's Nurse Practice Act and the facilities' policies and procedures, the unlicensed assistive personnel (UAP) may perform some or all of the parts of a situational assessment. Workload or lack of experience will not be factors in the delegation decision, because this is part of the job requirements upon hire; parts of the assessment, such as whether the client is safe, or what the client may need can be assessed by the UAP.

The nurse performs a situational assessment for a client with a high risk of injury. Which findings during this assessment require the nurse to act?

The client's adult child places shoes and a cane next to the raised bed rail, the client needs the assistance of two staff when getting out of bed, the client is confused as to why the call bell won't call home. Rationale: Integration of situational awareness as part of routine nursing care allows nurses to anticipate clients' needs and promotes a safer client care environment. The nurse can determine what is likely to happen next based on findings. When the client tries to use the call bell as a phone, the nurse knows the client is too confused to follow instructions and, for example, ensures the bed alarm device is activated. When a cane and shoes is placed next to the raised bed rail, the nurse anticipates that the client might try to exit on this side of the bed, resulting in injury. When the client requires two staff members to get out of bed, the nurse knows the client is not safe to be out of bed alone, ensures necessary items are within reach, and takes other actions to deter falls. The client having a do not resuscitate order and having a dry cough are not situational assessments and do not require action

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching?

The students wash their hands for 15 seconds prior to drying them Rationale: Hand washing is done for about 20 seconds, followed by a focus on the fingernails prior to rinsing off the soap. When performing hand washing, the water temperature should be warm to the touch. The hands should be kept lower than the elbows at all times to allow water to flow to the fingertips. Firm rubbing and a circular motion promotes friction that helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of the knuckles, on the palms and backs of the hands, and on the wrists and forearms.

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned?

To either side and slightly behind the client with near hand on gait belt Rationale: When ambulating a client with a gait belt, the nurse should stand to either side and slightly behind the client with near hand on gait belt. The other positions do not allow the nurse to properly use the gait belt to help provide stability and balance.

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients?

To improve grasp and help provide more stability and balance. Rationale: A gait belt helps to improve the nurse's grasp and help provide stability and balance. It does not help with center of gravity. It is not used as a weight for added exercise. A gait belt alone does not increase the client's activity tolerance.

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

Use the call bell for any needs and wear nonslip footwear. Rationale: All of these teaching points are correct. However, the best action is for the nurse to teach the client how to be safe by using the call bell for assistance and wearing nonskid footwear. Telling the client that it is important for the nurse that the client remains free from injury is true, but this statement does not inform the client how to avoid becoming injured in this new environment. The client may remain in bed for a large portion of the stay, but the client will need to get up and should be taught how to safely do that. Instructing the client to not get out of bed for any reason is not healthy for the postoperative client, and it is not reasonable. Rather, the nurse teaches the client how to be safe when getting up.

The nurse is reviewing Mr. Griffin's diagnostic results and recognizes which findings should be reported to the health care provider immediately?

WBC 19,000/µL, Hb 8.5 g/dL

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?

Waiting outside of the closed bathroom door while the client uses the toilet Rationale: To prevent falls for a client who is at high risk for falls, the nurse should not wait outside the closed bathroom door but should remain with the client in the bathroom and assist the client in toileting. The other actions are appropriate measures for a client who is at high risk for falls and would not require the charge nurse to intervene.

The nurse caring for Mr. Griffin is assessing for signs and symptoms of infection and recognizes the importance of including which of the following as part of the assessment?

White blood cell count, Temperature, Pain level, Surgical site assessment Rationale: Common manifestations of infection include pain, redness, swelling at a surgical site, fever, and an increased white blood cell count. The red blood cell count or range of motion would not provide information helpful in determining the presence of infection.