Leadership and Management

(Prior) Acute Transfusion Reactions

Acute transfusion reaction is a priority as it can be life-threatening if not immediately stopped and supportive care initiated. If untreated, hypotension, vascular collapse, respiratory distress, and disseminated intravascular coagulation ensue quickly. (Option 1) Opioid withdrawal can be quite painful but usually is not life-threatening. (Option 3) Pyelonephritis (kidney infection) is also serious and requires an IV antibiotic as soon as possible. However, it is not immediately life-threatening as complications do not usually occur within minutes to hours. (Option 4) Clients with hepatic encephalopathy need lactulose (takes hours to days to take effect). However, this condition is not immediately life-threatening.

(Manag Conc.) Adverse Event

Adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable.

(Prior) Medications Priority

Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. (Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately. (Option 3) This client has intestinal obstruction and needs nasogastric tube placement. However, this is not a priority over a client with heart failure. (Option 4) This client with a sternal wound infection needs a dressing change and an antibiotic. Although this localized infection is important, it is not the priority.

(Prior) Heart Sounds

An S3 sound is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It may present as a normal finding in young adults. However, a new S3 in older adults is a significant finding as it may indicate development of volume overload or heart failure. These conditions require prompt intervention as they may rapidly progress to life-threatening events (eg, respiratory compromise, cardiogenic shock). This client may be receiving excessive IV fluids that are causing volume overload. Repeated high gastric residual volumes (>250 mL) in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent nausea, vomiting, or abdominal distension. Metoprolol is a beta adrenergic blocker often used to treat heart failure and hypertension. Common side effects of beta blockers are bradycardia and hypotension.

(Prior) Carbon Monoxide (CO)

Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen. The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia.

(Prior) PRIORITY CARE II

Change in level of consciousness is a high priority problem as it can indicate a neurologic deficit that can be associated with a closed head injury. At the beginning of the shift, the nurse must perform a basic neurologic assessment (eg, pupil size and response, level of consciousness (LOC), mentation, speech, hand grasps). This is done to obtain the baseline data against which subsequent assessments can be compared and to assess for indicators of increased intracranial pressure (eg, change in LOC, Cushing's triad, pupillary changes). A pulse oximeter reading of 89%-92% is adequate and is an expected finding in a client with COPD who often relies on the hypoxemic drive to breathe. This finding is nonurgent and this client's assessment does not take priority.

(Manag Conc.) Client Care II

Clients receiving IV heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg, petechiae, purpura) Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status). Clients receiving IV furosemide should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac arrhythmia). A femoral-popliteal angioplasty is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease. After the procedure, the client should be able to ambulate without evidence of extremity ischemia (eg, leg pain). A PCI prevents/treats ischemia or infarction. expected to not have pain at rest.

(Prior) Priority Care

Clients who are bedridden, have undergone major surgery (eg, hip or knee replacement), or are taking estrogen-containing contraceptive pills are at high risk of developing deep venous thrombosis. This condition can result in subsequent embolus and life-threatening pulmonary embolism. When blood flow is blocked to certain parts of the lung, the area can become infarcted, resulting in chest pain, shortness of breath, and cough. These clients require immediate anticoagulation to prevent extension of the blood clot. Clients with acute pericarditis have chest pain that is worse with inspiration/coughing and improves with leaning forward. This is an expected finding. Large pericardial effusion with resultant cardiac tamponade is more serious and is evidenced by jugular venous distension, hypotension, and muffled heart sounds. This client who underwent femoropopliteal surgery likely has acute occlusion of the graft and is at risk of limb loss if flow is not restored. life > limb

(Prior) Dementia

Clients with dementia are expected to be in an alert but disoriented state with gradual development of symptoms. The sudden onset of a new behavior (eg, restlessness, confusion) may indicate delirium caused by an infection or another serious etiology (eg, hypoglycemia, stroke, hypoxemia) and is considered a priority.

(Prior) Large Body Cast

Clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome (ie, superior mesenteric artery [SMA] syndrome). Cast syndrome is a rare complication of an overly tight cast that involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus (ie, bowel obstruction). If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of a bowel obstruction (eg, abdominal pain, distension, nausea, vomiting) (Option 1). If cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure.

(Prior) Sepsis

Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs.

(Assign/Deleg) continuous IV infusion

Continuous IV drug infusions are managed by the RN. This is especially true with drug categories such as anticoagulants, which will require titration depending on client response.

(Eth/Leg) Client's Privacy

The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their medical information. If another staff member asks a question about a client's medical information in an open area with visitors, the nurse should first move the conversation to a secure area. Answering the question will promote further conversation, making it likely that the client's privileged health care information will be discussed and overheard by others. The best response is to suggest changing the location of the conversation so that the information can be discussed privately

(Prior) Seizure

The nurse should assess the client with seizure activity first. This client is at increased risk for injury, aspiration, and airway obstruction. The nurse should obtain baseline neurological vital signs (eg, level of consciousness, pupillary reaction, speech, hand grasps) against which to compare subsequent findings and to evaluate the client's response to lorazepam. The client requires a safe environment, so the nurse should also ensure that fall and seizure precautions (eg, full side rail pads, low bed, floor mats, suction equipment, oxygen at bedside) have been initiated.

(Manag Conc.) Dealing with Staff issues

The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action.

(Prior) Priority Assessments

The nurse should first assess the client with alcoholic cirrhosis, as this condition is associated with gastritis, clotting abnormalities (eg, thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (eg, hypotension, decreased urine output, peripheral vasoconstriction, pallor) and notify the health care provider of any significant changes from baseline as immediate esophagogastroduodenoscopy is necessary to determine the bleeding site. Treatment to stop the bleeding (eg, heat probe, sclerotherapy) may be indicated.

(Prior) Client Calls

The nurse should first call the client with tingling in the right foot. Musculoskeletal injuries and immobilization devices (cast) can cause neurologic or vascular damage to the extremity distal to the injury. Paresthesia (eg, numbness, tingling) is an early sign of neurovascular impairment (nerve ischemia). It would be important for the client to report to the HCP for immediate evaluation. This is the most urgent call to return. Nausea is an expected side effect of the synthetic opioid pain reliever, oxycodone. The nurse can instruct this client to take this medication with food, which may help alleviate the nausea. This is not the most urgent call. Clients with diabetes are usually able to take the prescribed insulin dose when ill, and some clients may need a higher dose. Illness is a physiologic stressor and can increase blood glucose level. The best step is to check glucose level Q4H. not most urgent call.

(Eth/Leg) Patient Family Calls

The nurse should further assess the situation and gather more information when a spouse calls reporting troublesome symptoms in a client. It is not a violation to obtain information about a client from a knowledgeable source.

(Manag Conc.) Advocate

The nursing role in advocating for the client includes ensuring the use of interpreters for clients who speak a different language, particularly during the informed consent process. The person interpreting for the client should ideally possess the following: Training in medical terminology and procedures Ability to protect the client's rights in a medical setting Fluency in the language Understanding of cultural beliefs and nuances For these reasons, and to protect client confidentiality, family members should not be used as medical interpreters unless the situation is urgent and a family member is the only one available to fill this role. The use of family members as translators of medical information is not ideal but may be used when necessary, particularly when a situation is urgent and an interpreter is not available.

(Manag Conc.) Disaster Events

Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies clients who are safe to recommend for discharge to make room for newly admitted clients. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (Option 2). Clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy are required.

(Assign/Deleg) Neonate issues

Green amniotic fluid indicates that the fetus has passed its first stool (meconium) in utero. Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome, a type of aspiration pneumonia. A skilled neonatal resuscitation team should be present at the birth of any newborn with meconium-stained fluid for immediate evaluation and stabilization (Option 4). Previously, endotracheal (ET) suctioning was recommended for nonvigorous newborns (eg, depressed respirations, decreased muscle tone, heart rate <100/min) born with meconium-stained fluid; however, recent guidelines indicate that routine ET suctioning is no longer necessary.

(Prior) OSHA

Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce workrelated injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required. The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard.

(Prior) hypertensive encephalopathy

Hypertensive encephalopathy (HE) is a medical emergency caused by a sudden elevation in blood pressure (eg, hypertensive crisis) creating cerebral edema and increased intracranial pressure (ICP). Triggers of HE include an acute exacerbation of pre-existing hypertension, drug use, MAOI-tyramine interaction, head injury, and pheochromocytoma. The client may report severe headache, visual impairment, anxiety, confusion, and observed epistaxis, seizures, or coma. HE may precipitate life-threatening complications such as myocardial infarction, hemorrhagic stroke, and acute kidney injury. The client with a history of chronic hypertension and active signs of increased ICP (eg, anxiety, epistaxis) requires immediate assessment and treatment (Option 1).

(Prior) Immature Immune Systems

Infants <30 days old have immature immune systems and a blunted response to infection. The 7-day-old infant is at high risk for bacteremia. Infectious manifestations are often subtle at this age (eg, fever can be the only symptom), although some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Rectal temperature >100.4 F (38.0 C) or <96.8 F (36.0 C) is a "red flag" in a neonate.

(Assign/Deleg) UAP III

Just as in clinical situations, the nurse should first assess in management situations. The UAP may not have the skills or abilities to do the task or the availability if doing something else. The nurse may need to reprioritize the tasks that the UAP has been delegated or provide additional instructions/education. However, finding out the reason for the response is the first step.

(Ethical) Ethics

Justice is treating every client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing. Accountability refers to accepting responsibility for one's actions and admitting errors. Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Autonomy is freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). Confidentiality means that information shared with the nurse is kept in confidence unless permission is given to share or it is required by law to be shared to protect the client and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with the nurse, it must be appropriately reported to protect the client from selfharm.

(Prior) Phlebitis

Manifestations of phlebitis associated with a peripheral IV catheter include pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis. Itching (pruritus) and nausea are common and expected adverse effects associated with the administration of opioids. Histamine blockers, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), and an antiemetic, such as ondansetron (Zofran), can provide relief. Parenteral and oral anticoagulant medications are administered concurrently until the International Normalized Ratio reaches a therapeutic range of 2-3, at which time the heparin infusion can be discontinued and the warfarin continued. This therapy is expected.

(Manag Conc.) Miscommunication

Miscommunication between health care providers may cause serious medical errors when clients are handed off or transferred. Medical errors can be effectively reduced by employing strategies (eg, Situation, Background, Assessment, and Recommendation [SBAR] reporting technique, nurse-to-nurse change of shift reports, multiprofessional bedside rounds) to improve communication and collaboration. Nurses should be as proficient in their communication skills as they are in their clinical skills.

(Prior) MAOIs

Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs.

(Prior) Bowel Obstruction

Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner. Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel manipulation. Increasing food or fluids might help the client have a bowel movement. (Option 3) Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity or applying ice or heat might help until the client can be evaluated by the health care provider. (Option 4) Active infection is a relative contraindication for elective surgical procedures. The client should be called back for assessment and likely rescheduling of surgery, not priority..

(Prior) New-onset Agitation

New-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. (Option 1) Bowel and/or bladder incontinence or retention is an expected sign/symptom in clients with multiple sclerosis. (Option 2) Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the diaphragm. (Option 3) Drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings of Parkinson disease.

(Assign/Deleg) Floating

Nurses must sometimes "float" to a nursing unit outside of their normal area of practice based on staffing needs. A nurse who floats to an unfamiliar practice area should be assigned clients who do not require specialized knowledge and can be safely managed with similar skills as with their usual client population. It is the responsibility of the floated nurse to inform the supervisor of any lack of experience with the client population and to request orientation to the unit. Labor and delivery (L&D) nurses possess focused knowledge and training to care for the obstetric population but are able to generalize many skills to other client populations. L&D nurses frequently care for pregnant women with urinary tract infections and would be familiar with the management of a client with pyelonephritis. The administration of IV antibiotics is a general nursing skill with which all nurses should be familiar.

(Prior) obstructive sleep apnea (OSA)

Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction that occurs from relaxation of the pharyngeal muscles, airway closure, and lack of airflow. This leads to repeated episodes of apnea (=10 seconds) and hypopnea (=50% of normal ventilation), resulting in hypoxemia and hypercapnia. Administration of general anesthesia or sedating medications (eg, opioids and benzodiazepines) can exacerbate OSA by decreasing pharyngeal muscle tone and increasing airway closure even further. Therefore, being on continuous positive airway pressure (CPAP) is very important in these clients, especially during sleep. The nurse should assess level of consciousness, lung sounds, vital signs, and pulse oximeter readings, and then compare these with the client's baseline measurements. The nurse should also continue to monitor respiratory status as IV morphine peaks in 20 minutes and has a duration of 3-4 hours

(Prior) Overdose

Overdoses are generally a priority due to the unpredictability of dosing and client response. Specifically, the tricyclic antidepressant amitriptyline (Elavil) is lethal if taken in overdose, especially if consumed with alcohol. It is estimated that 70%-80% of clients with tricyclic antidepressant overdose die before reaching the hospital. Amitriptyline was historically used for depression; it is now used for insomnia and neuropathic pain. Death results from serious cardiac arrhythmias. A knee pop can also be heard in fractures. Regardless of the specific diagnosis, this is an isolated orthopedic injury. As a rule, a systemic problem (eg, overdose) takes priority over a localized one. Glomerulonephritis is inflammation (acute or chronic) of the kidney; manifestations include hematuria that results in urine with a rusty 'iced tea' color (presence of blood).

(Manag Conc.) PID

PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding. Varicella (chicken pox, herpes zoster) requires airborne precautions (and contact precautions also if open lesions are present). Pertussis requires droplet precautions. Both the precautions and the organisms are different, and the clients could cross-infect each other. An AIIR (formerly negative-airflow room) is indicated when the client has an organism transmitted by the airborne route (eg, tuberculosis). No other client should be in the room with a client with this type of infection, especially one with a significant co-morbidity. Chemotherapy causes bone marrow suppression with immunosuppression. Although the client may not need reverse or protective isolation an infectious client should not be with them.

(Assign/Deleg) Parvovirus B19

Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions.

(Prior) Petechiae

Petechiae (small pinpoint red/purple spots on mucus membrane or skin) and purpura (irregular purplish blotches) can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response. This systemic symptom takes priority over a more localized dermatological presentation.

(Prior) PP Psychosis

Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of moodstabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.

(Eth/Leg) Professional Boundaries

Professional boundaries set limits to maintain a therapeutic professional relationship between the nurse and client. However, the line between professional and personal interactions is sometimes blurred in extended relationships or when care is given in the client's home. The nurse should always put the client's needs first and never seek personal gain (eg, accepting gift worth >$20, asking for financial investment/loan). The nurse should follow a facility's policy on professional standards of behavior. In the absence of a formal policy, the nurse should consider if the action would be appropriate to include in the medical record. If the nurse is unsure, it may be indicative of a violation of professional boundaries (eg, flirting with client, consuming alcoholic beverages with client). An occasional visit to a previous client in a different circumstance (hospital, nursing home) is considered appropriate and caring.

(Assign/Deleg) Tasks for each staff

RN: Clinical asessment Initial/Discharge client education Clinical judgment Initiating blood transfusion LPN/LVN: Monitoring RN findings Reinforcing education Routine procedures, ostomy care, limited assessments Med. administrations Tube patency and enteral feeding UAP: ADLs Hygiene, linens, stable VS, I&O, positioning

(Manag Conc.) Foley Bag

The Foley bag is too high and needs to be lowered. When observing a provider making an error, the RN should immediately intervene to stop any potential harm to the client. It is important to timely correct a staff member who is making a mistake to help ensure that the error is not repeated. Correction of staff should always be done privately, not in front of the client

(Assign/Deleg) LPN

The LPN should be assigned stable clients with expected outcomes. A 5-day post-diaphragmatic hernia client is stable at this time. The LPN cannot perform initial teaching, assessments, or evaluate a client condition (Option 2). Scheduled surgery (Option 1) This client is scheduled for surgery today and will require education and evaluation. New (Option 3) This client is newly admitted to the unit and will need to be assessed by an RN. Unstable (Option 4) This client is not stable. The client is exhibiting signs of diabetic ketoacidosis and will require care provided by an RN.

(Assign/Deleg) Nurse Delegates

The RN can safely delegate the following tasks to the UAP to promote client safety during toileting and ambulating: Place the bedside commode, assistive devices (eg, canes, walkers), and personal belongings (eg, eyeglasses, hearing aids, cell phones) as close to the client as possible Remind the client of the importance of changing position slowly to minimize orthostatic hypotension Report observations of changes in the client's condition (eg, level of consciousness, vital signs, pain level) immediately Keep the bed in the lowest position (locked) as it reduces the distance to the floor in the event of a fall Provide nonskid footwear for the client before ambulating Keep the environment dry and free of clutter and obstacles (eg, intravenous infusion device tubing and poles, electronic device wires and cords)

(Assign/Deleg) UAP II

The RN can safely delegate these tasks to UAP: Ambulate and promote mobility of stable clients (Option 1) Assist with activities of daily living (eg, feeding, bathing, dressing, hygiene) Perform oral (nonsterile) suctioning for clients during oral care (Option 2) Collect and document vital signs (Option 3) Turn and reposition stable clients (Option 5)

(Manag Conc.) Successful Intervention

The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. (Option 2) Attending an inservice seminar for staff education is an important and necessary step for intervention implementation. However, the intervention will be successful only if the information is applied and the desired outcome achieved. (Option 3) Reporting the number of written reminders given to respective clients is necessary. However, this reporting of intervention achievement is subjective as recall can be inaccurate. Even if it were an accurate recounting, it does not prove that the intervention succeeded. The appropriate focus should be on client outcomes, not nursing staff behaviors. (Option 4) Although approval from surgeons provides helpful support for the intervention, an objective evaluation beyond personal opinions is required.

(Manag Conc.) Patient placement

The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3) as this does not place the immediate post-operative client at increased risk for infection. The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3, normal is 5001,200/mm3) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased WBC count (>11,000) has an infection.

(Prior) BKA (below knee amputation)

The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics.

(Assign/Deleg) Client Assignment

The client with a complex illness or one who is unstable (uncontrolled diabetes with hyperglycemia) should be assigned to a more experienced nurse. In addition, tasks requiring advanced skills (ultrafiltration, IV administration of high-risk medications) should be assigned to nurses who have had time to refine their basic skills and have acquired more advanced assessment expertise. The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable.

(Assign/Deleg) Floating II

The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues.

(Manag Conc.) Health Care Provider

The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information.

(Eth/Leg) Emergency Calls

The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client: Falls Deteriorates significantly or dies Has critical laboratory results Needs a prescription that requires clarification Leaves against medical advice or runs away Refuses key treatments in a relevant period The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall ) (Options 1 and 2). Administration of heparin is normally discontinued prior to surgery due to the increased risk of bleeding and should be clarified with the HCP (Option 3). A serum sodium of 124 mEq/L (124 mmol/L) (normal: 135-145 [135145]) represents a critical value that can lead to altered mental status and seizures (Option 4).

(Manag Conc.) Immunocompromised

An immunocompromised client should not be assigned to a room with a client who is contagious or potentially infected as there is an increased risk for infection.

(Manag Conc.) Interpreter

An interpreter's job is to literally translate the words/concepts spoken (as much as possible). The role does not include personally editorializing or embellishing with advice beyond what the health care provider (HCP) said. It is important to find out if there was any discussion related to the procedure or if the follow-up conversation was about other topics (eg, social). The nurse needs to obtain feedback to be certain that the client understands about the procedure and had no additional questions that the interpreter personally answered. The nurse can ask the client additional questions using this interpreter or use a different interpreter/a language line. After the nurse is satisfied that no additional information was provided and the client understands what the client is signing, the nurse (as the hospital employee) should then witness the signature. The nurse should indicate that an interpreter was used in the process.

(Manag Conc.) Anticipatory Guidance

Anticipatory guidance prepares clients and caregivers for future health needs and is useful throughout life, from pediatric growth and development to anticipated changes related to disease processes. This type of education promotes health and helps to reduce client/caregiver stress and anxiety, which heighten with unexpected cognitive, physical, and emotional changes. Anticipatory guidance educational goals should be client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client. The client with Alzheimer disease and osteoarthritis is at high risk for falls with disease progression. In the early stage, the client can make changes in the home to promote safety in the future.

(Manag Conc.) Assertive Community Treatment (ACT)

Assertive communication should be encouraged initially when there is interpersonal conflict. The involved parties should speak directly with each other, using "I" statements. Assertive communication involves speaking directly to the person with whom there is a conflict. People should use "I" statements, indicate how they felt when the incident occurred, and communicate how they would like to be spoken to in the future.

(Prior) Bronchilitis

Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first.

(Manag Conc.) Sharing Rooms

(Option 2) Children with infections requiring airborne precautions (eg, varicella, tuberculosis, measles) should be placed in a private, airborne infection isolation room (eg, negative airflow room). If required, clients infected with the same organism can be roomed together, but a private room is preferred. (Option 3) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The risk for cross contamination is high, especially with caregivers sharing the facilities. (Option 4) A client with sickle cell anemia is at risk for infection due to spleen dysfunction (repeated infarctions), and a client with periorbital cellulitis has an infection. Although compatible in age and sex, these clients should not share a room.

(Manag Conc.) Patient placement II

(Option 3) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzae type B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option 4) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4.

(Assign/Deleg) Altered Mental Status (AMS)

A client experiencing changes in mental status severe enough to require transfer to the intensive care unit (ICU) is considered critically ill and is the most appropriate assignment for the RN. This client is unstable and requires the RN's advanced skills to perform ongoing neurological assessments (eg, respiratory pattern, level of consciousness, mental status, motor and sensory activity) and vital sign checks, to document findings, and to report the client's condition to the ICU nurse until the transfer can be completed.

(Manag Conc.)

A client who is postoperative total knee replacement is at increased risk for infection. This client should not be assigned to a room with a client who has an actual (eg, cellulitis, osteomyelitis) or potential (eg, skeletal traction, fasciotomy) infection.

(Prior) Traumatic Head Injury

A client with a traumatic head injury from blunt force can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated.

(Manag Conc.) Handoff Report

A handoff of care report is the critical communication that occurs when transferring client care to another nurse (eg, shift change, department transfer). Transitions of care require thorough, precise communication to ensure client wellness and safety. Appropriate handoff communication allows for continuity of care and provides a synopsis of client needs and details of the client's care. To ensure appropriate and effective handoff communication, the nurse should: Provide identifying information (eg, client's name and room number). Note care priorities and upcoming or outstanding tasks (eg, time to replace a medication infusion bag, need to perform delayed wound care and cause of delay) (Option 1). Provide exact, pertinent information (eg, medication dose, time, measurable outcomes) (Option 3). Include multidisciplinary plans (eg, radiology examinations, family meetings, physical therapy) (Option 5). Relay significant client changes in a clear manner (ie, assessment, interventions,

(Prior) A lung contusion (bruised lung)

A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary

(Manag Conc.) Glucose

A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first.

(Eth/Leg) Nurse impaired by alcohol

A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse should notify the supervisor, document the incident, and not give client responsibility to the impaired nurse.

(Assign/Deleg) panic/critical value

A panic/critical value is a result that is significantly abnormal and requires the nurse to contact a provider immediately to initiate appropriate interventions. An example is a potassium level of 7 mEq/dL. The nurse must have a charge nurse take the results and initiate appropriate response until the nurse is done with the sterile procedure. This is the option with the least risk. Timely reporting of critical results is part of the Joint Commission Hospital National Patient Safety Goals.

(Prior) subarachnoid and intracerebral bleed

A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent bleeding and is the highest priority presentation.

(Manag Conc.) Unit Quality Improvement Committee

A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met.

(Assign/Deleg) Delegating tasks

The registered nurse (RN) should consider the 5 rights of delegation prior to delegating a task. Tasks such as monitoring pain, administering medications, and titrating oxygen may be delegated by the RN to the licensed practical nurse (LPN) (Options 3 and 6). Client positioning and measurement of vital signs and pulse oximetry may be delegated to unlicensed assistive personnel (UAP). Although LPNs can carry out these tasks, their time is better spent performing more complex client care (eg, medication administration) if UAP is available. The registered nurse (RN) is responsible for the client's initial assessment, plan of care development, evaluation, and initial teaching. The RN can delegate most medication administration, client monitoring, education reinforcement, and routine procedures to the licensed practical nurse.

(Eth/Leg) Spouse Authority

The spouse does not have the authority to refuse the required medication for the client as the client is competent and has decisionmaking capacity. An informed refusal includes knowing the risks and benefits of the decision, including the potential of latent infection/damage in this case. If the client does not call back, the typical facility policy is to try to reach the client by phone 3 times, then by certified letter, and (depending on the seriousness of the result) then sending the police to contact the client.

(Prior) 3rd Degree AV Block

Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, as the client may decompensate to cardiogenic shock and even periods of asystole. Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed. Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation >90%.

(Assign/Deleg) Bronchoscopy

To prepare a client for a bronchoscopy, the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain nothing-by-mouth status; prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure. Because these are skills a graduate nurse possesses, this is an appropriate assignment. When assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member. The more experienced RN is assigned to the client with the more complex physiologic and psychologic needs, who requires a more advanced level of nursing skill. The new graduate nurse is assigned to the client with less complex needs, who requires basic nursing skills, such as measurement of vital signs and basic physical assessment.

(Prior) Triage

Triaging clients involves decision-making about whose needs/problems are most urgent and create the greatest risk to survival. Two popular frameworks can assist the nurse in making these decisions and setting priorities. In the "First, Second, and Third" priority level framework, the priority needs progress from the first (most immediate) to the third (least) level of risk. They include: ABCs plus V - airway, breathing, circulation, and vital signs Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risk Longer-term issues such as health education, rest, and coping Maslow's Hierarchy of Needs is a 5-level framework in which the priority needs progress from the bottom to the top level of the pyramid. Infants have a high percentage of body water (70%-80% of body weight) and become dehydrated rapidly. This client is at increased risk for fluid and electrolyte disturbances.

(Assign/Deleg) UAP

Unlicensed assistive personnel (UAP) may perform routine tasks for stable clients under the direction of the registered nurse (RN). Tasks related to the nursing process (eg, assessment, planning, evaluation) require trained knowledge, critical thinking, and individualized application by the RN and cannot be delegated. A client 1-day post chest tube placement must be assessed by the RN to establish safety and readiness for ambulation. However, the UAP can assist the RN in ambulating if appropriate (Option 1). UAP can empty, measure, and record output from a surgical drain. However, the RN is responsible for assessing the drainage (eg, type, amount, odor, color) and maintaining the wound drainage device (Option 2). As directed by the RN, UAP can courier blood products to and from the blood bank (Option 4). However, verification of any blood products must be performed by 2 RNs prior to transfusion. UAP can carry out comfort measures such as escorting family members to waiting area

(Prior) Client Priority

When deciding which client to see first, the nurse should apply the "ABC" (airway, breathing, circulation) guideline to problems that clients may have or could develop.

(Assign/Deleg) Delegating Tasks II

When delegating tasks, the registered nurse (RN) should consider the 5 rights of delegation along with the scope of practice. The scope of practice for a practical nurse (PN) includes administering medications, although regulations related to narcotics and IV medications vary by state (Option 1). Based on staff member availability, it can also be appropriate to perform or delegate tasks below the scope of a given staff member (eg, delegating vital signs to a PN, an RN performing ostomy care) (Option 3). Measuring peak expiratory flow with a peak flow meter is also within the scope of practice for a PN (Option 4). The PN can collect data (eg, auscultating breath sounds, observing for accessory muscle use). However, evaluation of the collected data (ie, determining the client's response to a bronchodilator medication) is the responsibility of the RN. PNs are able to reinforce education initiated by the RN. However, providing teaching on new topics may not be delegated to the PN.

(Manag Conc.) Deliberate inaccurate documentation

When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.