HESI Case Study- Management of a Medical Unit

A newly licensed RN is assigned the care of a client with an intravenous heparin infusion. The client has prescribed heparin protocol, and based on the lab results, the client's heparin dosage should be increased by 200 units/ hr It is best for the newly licensed RN to collaborate with which team member to ensure that the dosage is adjusted correctly?

The RN who is precepting the newly licensed nurse. (the staff preceptor has the time and expertise and responsibility to assist newly licensed RN through their orientation as they adjust to their new role, responsible to help the newly licensed RN resolve problems, for guiding decision making, and supervising care)

While Mr. Young is assessing the client with ECG changes, the client reports that he just experienced an episode of chest pain and took a dose of nitroglycerine that he brought from home. The UAP enters the room and informs Mr. Young that the confused client with hyponatremia is attempting to climb over the bedrails. How should the charge nurse respond to this situation?

Remain with he client who has angina and assign a PN to monitor the confused client while the UAP obtains a bed alarm. (PT w/ angina and ECG changes remains unstable and requires the expertise of the charge nurse to assess and manage his care. The PN, assisted by the UAP, can safely monitor a confused client to prevent injury.

The UAP is assisting the RN in the care of the client with low back pain who is receiving morphine via PCA pump. Which instruction should the nurse convey to the UAP?

Report any changes in mental status, such as disorientation. (this instruction is specific and provides clear direction as to what to report. The UAP is not asked to discriminate between varying levels of confusion or disorientation, but to report any changes observed)

As he enters the client's room, Mr. Young hears his name paged over the intercom. He learns that the emergency department needs to give report on a client to be admitted to the medical unit as soon as possible. What action should Mr. Young take?

Request that another staff RN obtain the report.

Mr. Young and several staff nurses attend a mandatory in-service program on the use of insulin pens. The nursing staff will begin using the insulin pens immediately, and they will be responsible for teaching clients how to use them. To ensure that all the staff are competent in the use of the new equipment, which action is most important for Mr. Young to implement?

Schedule time for each nurse on the unit to practice using the insulin pens. (practice is the best method to ensure the successful learning of this skill, and it will help develop the nurses' competence in using the insulin pens)

The telemetry-monitored beds on the units are full. The nursing who handles admissions and room assignments requests that Mr. Young arrange the transfer of a client from telemetry-monitored bed to a general medical unit bed so that a new client can be admitted for monitoring. The client with which telemetry pattern is best to consider for transfer?

Sinus arrhythmia with rate fluctuation during respiration. (This is a normal ECG pattern and does not require telemetry monitoring)

THe charge nurse and the preceptor meet to discuss the progress made by the newly licensed RN orientating to the medical unit. In planning a client care assignment independent of the preceptor for the next day, which client is best to assign to the new RN?

-Experiencing dysphagia following a CVA, which necessitates the use of total parenteral nutrition via a central line. (This client requires a level of skill that the newly licensed RN should be able to provide) -Recovering second day postoperatively from total hip replacement surgery

As part of the client's preparation for hemodialysis, the nurse prepares to administer minocyline 75 mg intravenously in 500 ml D5W. The medication comes in the following dilution: 100 mg minocycline/10 ml How many mL should be added to the 500 mL bag?

7.5 mL 75 mg x 10 ml --------------- = 100mg 750/100 = 7.5 mg

In order to do this, one of the clients will be reassigned to a PN who discharged one of her clients an hour earlier. Which one of the RN's cients can best be assigned to the PN?

A 56-year-old female client with anemia due to long-term chronic renal failure who is scheduled for a hemodialysis treatment that afternoon.

The RN then enters the room of the client who underwent cardiac catheterization 1 hr ago and observes that the UAP is assisting the client to sit on the side of the bed. THe UAP states that the client wanted to sit up for a few minutes. Which action should the nurse implement?

Assist the client in returning to a supine position in the bed. (By assisting the client to a sitting position too soon after the procedure, the UAP has placed the client at risk for post-procedure complications. The RN should assist the client back to a supine position and complete an assessment of the catheter site and distal circulation.)

Mr. Young discovers that drawing up inaccurate insulin doses is occuring when pens are used. After having the pens checked by the pharmacy for accuracy, Mr. Young requests a further study to be initiated. The next day, the quality improvement team, comprised of the unit manager, charge nurse and two other nurses, meets to develop a plan to further evaluate the problems clients are having with the insulin pens. In preparing a study of this problem, which goal statement is best for the team to identify?

All clients using insulin pens will measure an accurate dose 100% of the time. (This is the best goal for this study because it reflects the desired outcome for use of the insulin pens. If the study indicates that this goal cannot be achieved, the quality improvement team may choose to recommend a change in the protocol.)

Late in the afternoon, one of the staff RNs notifies Mr. Young that she is ill and needs to go home. Mr. Young determines that the RN's client load can be safely be reassigned to the present staff, and he chooses not to call in a replacement nurse for the rest of the shift. When changing client care assignments, Mr. Young knows that it is important to assign the client on which medication/solution to the care and expertise of another RN rather than a PN?

An insulin/potassium infusion to treat diabetic ketoacidosis (DKA)

The PN continues to express fear that this client care situation will place her pregnancy at risk. The PN states, I know that my fear is ungrounded if I follow isolation precautions but this situation makes me really uncomfortable. When adhering to the ethic of caring in a leadership role while still maintaining client safety, what is the best action for the charge nurse to implement?

Assign another PN to care for the client and reassign the pregnant PN to other clients. (Since the PN is not refusing the assignment and because her request is not based on discrimination or lack of knowledge, the charge nurse may choose to respond to the PNs concern in a caring manner by changing the assignment. )\ Another PN agrees to assume the care of the client in isolation and will be assigned the care of a second client)

The newly admitted client has uncontrolled atrial fibrillation and is scheduled for elective cardioversion later in the day. The new RN tells the preceptor that he has never observed this procedure and would like to go with the client. What is the best response by the preceptor?

Because observation of the procedure will help you provide better care, I will manage our assigned clients while you go. (Role of the preceptor is to ensure that the newly licensed RN gains the necessary knowledge and skills to practice safely. Since the preceptor can assume the responsibilities of the new RN, this allows the new RN an excellent opportunity to learn about the procedure. It should be encouraged by the preceptor if at all possible.)

After identifying the client that is the safest to transfer from the telemetry area, what action should Mr. Young take next?

Contact the healthcare provider for a prescription to remove the telemetry and transfer the client. (The charge nurse must obtain the consent of the HCP before discontinuing a prescribed treatment such as telemetry monitoring)

The UAP is assigned to assist the PN who is caring for the client with MRSA and the client osteoporosis. The UAP us also assigned to assist an RN who is caring for a client with cirrhosis, esophageal varices, and delirium tremens, as well as a client with chronic obstructive pulmonary disease (COPD) Which task can be delegated to the UAP who is assisting the PN and RN in the care of these 4 clients?

Deliver and prepare the meal tray of the client who is in isolation with MRSA-induced pneumonia. (The UAP is trained in precautions needed to provide basic care to clients in isolation) -Assist an elderly client who is 3 days postoperative with a bath and change of a gown (The UAP is trained in assisting stable patients with personal hygiene)

After the insulin pends have been used on the unit for 2 weeks, a staff nurse reports to Mr. Young that several clients have experienced difficulty using them and requests that insulin syringes be made available for client teaching instead of the pens. Which action should MR. Young implement first?

Go with the nurse to observe the difficulty the clients are experiencing with the pens. (To evaluate the need for change in the protocol, the charge nurse should first gather as much data as possible about the problems encountered by those clients using the pens.)

The PN notifies the charge nurse that the oxygen saturation level of the client in the isolation room has decreased to 88%. Mr. Young contacts the unit respiratory therapist immediately about this change. Which action should the respiratory therapist take?

Increase the rate of oxygen being administered. The respiratory therapist can evaluate the oxygenation with defined parameters

The client with cirrhosis is preparing for discharge the following day. The RN caring for this client seeks Mr. Young's assistance in coordinating discharge plans. Mr. Young consults with the case manager about which aspect of the client's care?

Initiating a referral for durable medical equipment and home health care. (case managers initiate referrals and help clients to manage resources effectively.)

In reviewing the situation with the UAP and RN assigned to the client, Mr. Young needs to emphasize which problem?

Insufficient instruction and supervision by the RN.

After the client is transferred to a general unit bed, the new client is admitted and given the telemetry-monitored bed. The newly admitted client is assigned to the newly licensed RN and staff nurse preceptor who are working together, It is most important for the preceptor to supervise which nursing intervention performed by the newly licensed RN?

Interpretation of the cardiac rhythm. (this action required expert knowledge and judgment generally beyond the scope of the new RN. by interpreting the cardiac rhythm within the newly licensed RN, the preceptor provides the supervision and mentoring)

Which client situation requires the most immediate intervention by the charge nurse?

New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. (ECG finding indicates ischemic changes that require immediate client assessment and management to prevent myocardial damage

One of the PNs is having difficulty manipulating the insulin pen. How should Mr. Young respond?

Offer to repeat a demonstration and allow the PN additional practice time. (repeating the demonstration and practicing the procedure is often an effective teaching strategy.)

Which diagnosis and upcoming procedure can best be assigned to this PN, rather than an RN? A client with:

Osteoporosis scheduled for a bone mineral density test that day. (The client is the most stable of the clients and is scheduled for a test requiring minimal client teaching and preparation. The PN will not require a high level of expertise to monitor the post-procedure condition)

As part of the study, clients are reinstructed on the use of the insulin pen and asked to demonstrate the pen's use. Review of this data indicates that one-half of clients were unsuccessful in obtaining the correct dose of insulin. What additional information is most important for the quality improvement team presenting a recommendation to the administration about teaching clients how to use insulin pens?

The inability of these clients to measure an accurate dose with a syringe. (Clients who are unable to obtain an accurate dose with an insulin pen may also be unable to obtain an accurate dose with a syringe. This data is important in determining the best strategy for client teaching.)

A newly licensed RN who is assigned to the unit obtains the vital signs of the client with cellulitis whose WBC count has increased from 8,000 to 15,000 mm3. The RN reports the vital signs to Mr. Young as T 102 F (38.9 C), P 112, R 28 and BP 84/42 Who should the charge nurse assign to care for this client?

The newly licensed nurse and staff nurse preceptor. (The client is exhibiting manifestations of septic shock, a potentially fatal problem. The newly licensed RN does not yet have the expertise to respond to this situation independently and will best obtain the needed experience by working closely with the staff nurse preceptor)

Based on the data obtained by the quality improvement team, a recommendation is made that both insulin pens and syringes remain available for client teaching on the unit. After obtaining further data, the quality improvement team plans to make a recommendation regarding the use of the insulin pens. In preparing the recommendation, it is most valuable to obtain input from which member of the healthcare team?

Unit pharmacist. (The pharmacist is responsible for dispensing medications and can provide valuable information related to policies and procedures involving medications)

After the immediate problems are resolved, Mr. Young completes client care assignments for the staff. He assigns a PN to provide care to a client with pneumonia caused by methicillin-resistant staphylococcus aureus (MRSA). Airborne precautions are required to prevent transmission to healthcare providers and other clients. The PN requests a change in assignment, stating that due to her pregnancy, she is concerned about entering isolation rooms. How should the charge nurse respond?

What concerns do you have about your pregnancy and this client care situation? (The charge nurse should first determine what concerns the PN has related to the situation before making a decision about changing the assignment)