HESI: The Emergent Care Clinic and Rationale

24. Nurse managers have many responsibilities. One of those responsibilities is ensuring the Emergent Care Clinic's performance improvement (PI) plan is implemented. The nurse manager is putting together some performance improvement initiatives. Select items that should be included in the performance improvement plan. (Select all that apply. One, some, or all options may be correct.)

-Determine root cause of medication errors in practice. (The goal of performance improvement plans is to improve systems and processes, not to assign blame.) -Reduction of infection rates in the clinic. (High risk patient safety issues should be considered when developing performance improvement plans.) -Conduct chart reviews to determine compliance with nursing care on patient safety and healthcare outcomes. (Client records are confidentially reviewed by nurses for trends and statistics and compared with benchmark standards.)

11. The primary healthcare provider (HCP) prescribes a potassium supplement, potassium chloride 40 mEq PO stat. The supply is potassium chloride 20 mEq/tablet. The charge nurse notes that client's primary nurse has pulled four tablets from the automated medication delivery system. How many tablet(s) should the RN give? (Enter numerical value only. If rounding is necessary, round to the whole number.)

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1. The Emergent Care interdisciplinary team includes registered nurses (RN), licensed practical nurses (LPN), unlicensed assistive personnel (UAP), physicians, advanced practice registered nurses (APRN), and other collaborative care team members. The first action of the charge nurse for the day shift in the Emergent Care Clinic is to prepare the assignments for the day shift. In addition to the charge nurse, three registered nurses (RN), one licensed practical nurse (LPN), and two unlicenced assistive personnel (UAP) are scheduled from 7:00 a.m. to 7:00 p.m. Which client should the charge nurse assign to the LPN?

A client with pain to the right lower leg with swelling after tripping on the sidewalk. (Because this client is the least acute, this is the appropriate assignment for the LPN.)

2. The client reporting left arm pain and gastrointestinal upset, is assigned to an RN. It is most important for the RN to admit this client to which room in the Emergent Care Clinic?

A room with a continuous cardiac telemetry monitor. (Reports of left arm pain may indicate myocardial ischemia, and monitoring the ECG is critical.)

8. The client denies taking any prescription medications and is not on any over-the-counter medications or vitamin supplements. The client has recently returned from a long business trip overseas. The client denies previous health problems. Based on this information, the healthcare provider (HCP) prescribes: Nitroglycerin 0.4mg (1/150 grain) sublingual now and every 5 minutes until pain free. Maximum amount to be given is 3 doses. Blood draw for cardiac enzymes, complete blood count (CBC), electrolytes, capillary glucose Oxygen to maintain saturations above 95% Obtain IV access, saline lock Repeat ECG Which intervention should the RN implement first for the client?

Administer oxygen. (The client has increased respirations and low oxygen saturation (90%). Increasing the client's oxygen should be addressed first in this case (ABC's).)

4. The UAP obtains the client's vital signs and reports the results to the RN. Reported vital signs for client with left arm pain and GI upset are as follows: Temperature 98.8° F (37.1° C) Heart Rate 94 beats/min Respirations 30 breaths/min Blood Pressure 158/88 mmHg Which action should the RN assign to the UAP next?

Apply a continuous pulse oximeter monitor to the client. (The increased respiratory rate indicates that continuous monitoring is the primary concern for this client. The oxygen saturation level also needs to be monitored continuously. The pulse oximeter may be applied by the UAP, but the monitoring and assessment is done by the RN.)

19. Just before the change of shift, a 6-year-old client, is brought to the clinic by the grandmother. The charge nurse asks the grandmother what happened to the client. The grandmother states the client fell off a swing and broke an arm. The charge nurse observes the client holding the right arm. The client is not crying and is currently playing with a toy car. Which action should the charge nurse take first?

Ask the grandmother if she is the client's legal guardian. (The priority action for the charge nurse is to determine if the grandmother can legally give consent for the staff at the Emergent Care Clinic to treat the client. In non-emergent cases, care cannot be rendered to a minor unless legal guardian gives consent.)

26. The nurse manager conducts a time study and determines that the average wait time for clients is 55 minutes before being admitted to a room in the Emergent Care Clinic. The nurse manager decides to conduct a root cause analysis on lengthy wait times. Which action should be implemented?

Retrospective review of data to determine the cause of the problem. (This describes root cause analysis, which is used to investigate the reason for the problem instead of just the effect.)

28. Majority of the staff agrees that an electronic data system will allow them to make more efficient use of their time and improve client satisfaction. The system is purchased for all departments in the Emergent Care Clinic. After the education and training on the use of the electronic data system has been completed with the staff, which implementation strategy provides the best continuity of care to the clients?

Schedule implementation for each department on different dates. (Implementing one department at a time will allow for problems to be worked out prior to implementing it in another department and will be less stressful for the staff.)

20. The grandmother states that she is the child's legal guardian, and she gives her consent for treatment. The nurse asks the grandmother if she has any proof of legal guardianship for the client. The grandmother shows the charge nurse her custody papers for the client. The charge nurse assigns a nurse with 5 years pediatric experience to care for the client. Under which circumstance can healthcare personnel treat a child even when the legal guardian cannot be contacted?

When the child is experiencing a life-threatening condition. (If the child's life is in danger, the child can be legally treated even when consent cannot be obtained.)

12. The charge nurse questions the primary nurse taking care of the client about how much potassium was given. The nurse realizes there was an error in administration of the potassium chloride. The primary nurse has administered an incorrect amount of potassium chloride. What are the priority nursing actions following the medication error?

-Notify the primary healthcare provider (HCP) (The healthcare provider (HCP) must be informed of the error. The HCP may want to give orders for follow up potassium level.) -Assess client to determine the effects of the medication. (The nurse must determine the potential side effects of taking too much of the medication and monitor the client for adverse effects of the medication.) -Notify the client of the medication error. (The client should be notified and instructed to report any adverse effects.)

15. The participative style of leadership is usually the most effective, but there may be times when other styles are more appropriate. In which situations should a directive leadership style be used by the charge nurse? (Select all that apply. One, some, or all options may be correct.)

-When dealing with a mass casualty situation. (When decisions must be made quickly and there is no time for participants to provide input, the directive leadership style is effective. Example: Code team leader.) -When implementing policy changes at an organizational level. (When changes are made at the highest level of administration, middle level managers are obligated to implement the changes.)

25. As part of the PI plan, the nurse manager reviews trends in client satisfaction surveys. It is noted that 76% of clients are dissatisfied with the amount of time they had to wait in the waiting room. Which action should the nurse manager take first?

Conduct a study to determine the current average wait time. (Establishing the current wait time will give the nurse manager a frame of reference from which to work.-baseline)

22. The healthcare provider (HCP) calls the grandmother out of the room to ask her a few questions while the nurse interviews the client alone. When asked again about the injuries, the client states "Mom gets mad sometimes when I'm not good." The client says that the grandmother knows, but she doesn't do anything. The grandmother tells the HCP that the client is just accident-prone and likes to make up stories. The HCP believes the grandmother is being truthful. Which action should the nurse take?

Contact Child Protective Services to report a potential abuse situation. (The nurse has a duty to report suspected or confirmed abuse. If the interdisciplinary team includes a social worker, this would be an appropriate consult. In absence of a social worker, child protective services should be contacted.)

27. Upon completion of the root cause analysis, the nurse manager determines that the lengthy wait time is due to the manual processing and duplication of paperwork. After the nurse manager reviews different computerized data systems to help solve this problem, a recommendation is made that a system be purchased as soon as possible. The nurse manager plans to ensure a smooth transition and continuity of care for all clients when the clinic purchases a computerized data system for billing, charting, and medication administration. Which strategy should the nurse manager use with the staff to provide a smooth transition when implementing a computerized data system?

Explain that the new system will drastically decrease duplication of paperwork and streamline processes and include potential disadvantages. (Explaining how the system will benefit those using it and being honest about any flaws will let the staff know what to expect, which should help ensure a smoother transition.)

6. The nurse notices interference on the ECG monitor that looks like a wandering or fuzzy baseline. When encountering a strange reading from an ECG, which action should the nurse take first?

Remind the client to be as still as possible. (Artifact is interference seen on the monitor and can be caused by client's movement so it is important to assess the client's movement first.)

13. Several months ago, the nurse manager asked for volunteers to serve on a scheduling committee. The goal of the committee was to gather feedback from the staff regarding scheduling concerns. The committee was asked to devise two scheduling protocols to take back to the clinic staff. The nurse manager of the clinic is planning a staff meeting with the nurses and UAPs to communicate the proposed scheduling protocols for the clinic. Which method for scheduling the staff meeting allows for the best continuity of care for the clients and the best communication between management and employees?

Schedule two meeting times during the day to allow the nurses and UAPs to attend one of the sessions and maintain continuity of care in the clinic. (Because this method ensures that there are nurses and UAPs monitoring the clients during the meeting, it does not break continuity of care. Unlike a sign in the nurses' lounge, the face-to-face meeting allows for the exchange of ideas and questions and answers.)

23. The healthcare provider (HCP) approaches the nurse at the nurses' station. The HCP begins yelling at the nurse stating, "I told you this case was not a child abuse case. I am the HCP and I am the one who determines if a case is reported to child protective services!" What is the nurse's best response?

"I don't appreciate you yelling at me. I will be happy to explain my actions in a private area." (Confronting the HCP about the disruptive behavior using "I" statements is the best way to resolve the conflict. The nurse is correct to move the conversation away from the desk. The physician is trying to exert his power over the nurse and the nurse must be assertive in communicating why she did what she did.)

16. During the staff meeting, the nurse manager asks the nurses and UAPs to provide feedback about the daily operations of the clinic. One of the full-time nurses states, "I am always assigned the most challenging clients in the clinic, and it isn't fair." How should the nurse manager respond?

"I hear your concern. Please elaborate on that." (This is an open-ended statement. It does not sound judgmental, and it gives the nurse the chance to voice the concern.)

3. The RN admits the client with left arm pain and GI upset to a clinic room. The client is connected to a continuous cardiac telemetry monitor so that the heart rhythm can be monitored in the room and at the nurses' station. Which tasks should the RN assign to the UAP?

-Enter the obtained vital signs in the medical record. -Place a bedside commode in the room.

10. Telemetry Changes: The RN notes that the client is now having occasional premature ventricular contractions (PVCs) on the telemetry monitor. Based on the cardiac rhythm changes, select the priority nursing actions. Select all that apply

-Notify the healthcare provider of the changes in the cardiac rhythm. (The healthcare provider should be notified of all rhythm changes.) -Request order oral potassium supplement. (Potassium is low and needs supplementation. Hypokalemia is the most likely cause of the patient developing PVC's.)

14. The nurse manager conducts the meetings and presents two different protocols for scheduling. The staff nurses and UAPs vote on the two different options. The nurse manager demonstrates a participative leadership style by the use of which communication method?

Asking the clinic staff to vote on a staffing plan. (Voting is an example of participative (democratic leadership), which promotes and supports participant involvement.)

21. The client's grandmother states that she has had custody of the client since birth. The client's biological mother visits the client about once a month. In the examining room, the nurse helps the client get undressed and notices bruises in multiple stages of healing on the torso. The nurse asks the client about the bruises. The client says, "I don't know." The grandmother states the client "falls a lot." Which action should the nurse take first?

Continue with the nursing assessment. (The nurse should complete the assessment, paying close attention to any other signs of injury or abuse.)

17. Later that day, one of the licensed practical nurses (LPN) tells the nurse manager that there is reason to believe one of the nurse practitioners is stealing narcotics. What action should the nurse manager take first?

Have the LPN describe the situation to include specific observations of the nurse practitioner's behavior. (The nurse manager needs to gather more information prior to confronting the nurse practitioner, asking for a urine or blood sample, or reporting the nurse practitioner to the State Board of Nursing. Specific details will be needed to determine if the report is credible. The board or other authority may be contacted after the report is substantiated.)

7. When taking this client's history which information is most significant for the nurse to obtain first?

List of current prescription and over-the-counter medications. (It is essential to obtain information on current medications when the client arrives. Many health problems are caused from side effects or missed doses.)

18. When asked about the specifics of the accusation, the PN states that the nurse practitioner was observed taking out five pre-filled vials of morphine from the automatic drug dispenser and placing them in a pocket. The nurse manager investigates and determines that five vials of morphine sulfate were removed from the automatic drug dispenser using the nurse practitioner's login identification (ID), but no clients had prescriptions for morphine on this shift. Which approach should the nurse manager use to confront the nurse practitioner?

Meet with the nurse practitioner privately. Discuss the observation of narcotics being placed in the pocket. (This is a matter-of-fact approach in which the evidence is presented. If the nurse practitioner is guilty and decides to admit the wrongdoing, it will eliminate the need for an ongoing investigation and will be more therapeutic for the recovery process.)

5. The UAP applies the continuous pulse oximeter to the client's finger. The client's oxygen saturation is 90%. The RN applies an automated blood pressure cuff to assess his BP every 15 minutes. The client reports dull, aching pain from the left shoulder radiating to the left arm. The client states the pain comes and goes, and the pain is rated as 5 on a pain scale of 0 to 10. The RN applies electrodes from the ECG machine to obtain a tracing of the client's heart function What cardiac rhythm does the ECG reading show for the client?

Normal sinus rhythm.

9. After oxygen is applied, the client's oxygen saturation improves to 96% with respirations of 22 breaths/minute. The RN draws blood for laboratory analysis, starts an IV saline lock, and calls the UAP to prepare the client for a 12 lead ECG. After the RN receives the client's laboratory results, which data is most important to report to the primary healthcare provider (HCP)? (Select all that apply. One, some, or all options may be correct.)

-Serum potassium 3.0 mEq/L (3.0 mmol/L). (Because this is a critically low result that could contribute to cardiac complications, it should be reported immediately.) -Capillary blood glucose 180 mg/dL (9.99 mmol/L). (A capillary glucose level of 180 mg/dL (9.99 mmol/L) is elevated and should be reported.)