NU372 HESI Case Study: Management of a Medical Unit
Management of Care: Mentoring a Newly Licensed Nurse
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 nurse and staff nurse preceptor, who are working together.
Management of Care: Staff Communication
After the immediate problems are resolved, the charge nurse is approached by the PN who was assigned to a client who tested positive for Methicillin-resistant Staphylococcus aureus (MRSA) . Contact precautions are required for this patient. The PN requests a change in assignment, stating that due to her pregnancy, she is concerned about entering isolation rooms.
Management of Care: Quality Improvement
After the insulin pens have been used on the unit for two weeks, a staff nurse reports to the charge nurse that several clients have experienced difficulty using them and requests that insulin syringes be made available for client teaching instead of the pens.
A UAP is assigned to assist the PN who is caring for the client with MRSA and the client with osteoporosis. The UAP is 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).
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A newly-licensed nurse admits a client with cellulitis whose WBC count has increased from 8,000 mm3 (8.5 109/L) to 15,000 mm3 (15.0 109/L). The nurse reports the vital signs to the charge nurse as Temperature 102° F (38.8° C) , Pulse 112 beats/minute, Respirations 28 breaths/minute, and Blood Pressure 84/42 mm/Hg.
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A newly-licensed nurse is assigned the care of a client with an intravenous heparin infusion. The client has a prescribed heparin protocol, and based on the lab results, the client's heparin dosage should be increased by 200 units/hour. According to hospital policy, heparin adjustment requires a second person to verify dosing changes because it is a high-risk medication.
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One of the PNs is having difficulty manipulating the insulin pen.
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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."
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The charge nurse assigns one of the clients to a PN who discharged one of her assigned clients an hour earlier.
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The client with cirrhosis is preparing for discharge the following day. The nurse caring for this client seeks the charge nurse's assistance in coordinating discharge plans.
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The nurse then enters the room of the client who underwent cardiac catheterization one hour 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.
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Upon entering the problematic client's room, the charge nurse is paged to take report on a client being admitted to the medical unit.
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Management of Care
A UAP is assisting the nurse in the care of the client with pancreatitis who is receiving fentanyl via PCA pump.
Management of Care: Client Care Assignments
Another PN agrees to assume care of the client in isolation and will also be assigned the care of a second client.
Management of Care: Quality Improvement Data Guides Clinical Practice
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 the clients were unsuccessful in obtaining the correct dose of insulin.
Management of Care: Prioritization
At the beginning of the shift, the charge nurse identifies several problems that need attention.
Management of Care: Change in Assignments
Late in the afternoon, a staff nurse notifies the charge nurse about feeling ill and needing to go home. The charge nurse determines that the nurse's client load can be safely reassigned to the present staff, and no replacement nurse is needed for the rest of the shift.
Management of Care: Team Collaboration
The PN notifies the charge nurse that the oxygen saturation level of the client in the isolation room has decreased to 88%. The charge nurse contacts the unit respiratory therapist immediately about this change.
Management of Care: Float RN
The charge nurse receives notification that a nurse on night shift has called in sick. The charge nurse reviews the unit census and staffing needs and determines that the night shift will require a float nurse. A nurse from the orthopedic floor is assigned to help cover the medical unit from 7:00 p.m. - 7:00 a.m.
The charge nurse discovers that drawing up inaccurate insulin doses is occurring when pens are used. After having the pens checked by the pharmacy for accuracy, the charge nurse requests a further study 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.
Pharmacological and Parenteral Therapies
The nurse is administering an antibiotic to the client with ESRD. The prescription is vancomycin 1gm in 250mL IV to be administered by IV pump over 2 hours.
Meet the Client
The nurse manager is the 7:00 a.m. to 7:00 p.m. charge nurse on a general medical unit that includes five telemetry-monitored rooms. The nursing staff includes experienced nurses, newly-licensed nurses, practical nurses (PNs), unlicensed assistive personnel (UAPs), and a unit secretary. Each newly-licensed nurse has an assigned staff nurse as a preceptor. In addition to the nursing staff, a respiratory therapist, case manager, and pharmacist are assigned to the unit.
Management of Care
The telemetry-monitored beds on the unit are full. The nursing supervisor who handles admissions and room assignments requests a telemetry bed for a new client admission. The charge nurse reviews the clients that are currently on telemetry to determine if any clients can have telemetry discontinued.
Management of Care:
While the charge nurse is assessing the client with ECG changes, the client admits to having chest pain. The client also reports taking a dose of nitroglycerin that was brought from home. The UAP enters the room and informs charge nurse that the confused client with hyponatremia is attempting to climb over the bedrails.
Which client can best be assigned to the PN? a) A 56-year-old female client with anemia due to end stage renal disease who is scheduled for a hemodialysis treatment that afternoon. b) A 47-year-old male client who is receiving fentanyl via patient-controlled analgesia (PCA) for acute pancreatitis. c) A 62-year-old female client newly diagnosed with emphysema who needs instruction on breathing techniques and inhaler use. d) A 42-year-old male client with coronary artery disease who returned to the unit one hour ago following cardiac catheterization and stent placement.
a) A 56-year-old female client with anemia due to end stage renal disease who is scheduled for a hemodialysis treatment that afternoon. - This client is stable. Of these four clients, this client is best to be assigned to the LPN.
When adhering to the ethics of caring in a leadership role while still maintaining client safety, what is the best action for the charge nurse to implement? a) Assign another PN to care for the client and reassign the pregnant PN to other clients. b) Advise the PN that the UAP can do the majority of the client care in the room. c) Continue to reassure the pregnant PN that it is safe for her to care for the client with shingles. d) Assume primary care of the client with shingles so the PN does not need to go in the room.
a) 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 PN's concern in a caring manner by changing the assignment.
Which action should the charge nurse implement first? a) Go with the nurse to observe the difficulty that clients are experiencing with the pens. b) Notify the unit pharmacist of the need for additional insulin syringes for client teaching. c) Advise the case manager that some clients will need referral to the diabetes educator. d) Request that the quality improvement team evaluate the usefulness of the insulin pens.
a) Go with the nurse to observe the difficulty that clients are experiencing with the pens. - To evaluate the need for a 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.
It is most important for the preceptor to supervise which nursing intervention performed by the newly-licensed nurse? a) Interpretation of the cardiac rhythm. b) Insertion of the intravenous catheter. c) Measurement of orthostatic vital signs. d) Instruction regarding fluid restrictions.
a) Interpretation of the cardiac rhythm. - This action requires expert knowledge and judgment generally beyond the scope of the new nurse. By interpreting the cardiac rhythm with the newly-licensed nurse, the preceptor provides the supervision and mentoring needed.
Which client situation requires the most immediate intervention by the charge nurse? a) New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. b) A client with hyponatremia is becoming increasingly confused, disoriented, and agitated. c) The white blood cell (WBC) count of a client with cellulitis increases from 8,000mm3 (8.5 109/L) to15,000 mm3 (15 109/L). d) A client starting treatment for tuberculosis develops a productive cough of mucopurulent sputum.
a) New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. - This electrocardiogram (ECG) finding indicates ischemic changes that require immediate client assessment and management to prevent myocardial damage. (Potentially life threatening change in condition.)
The client with which telemetry pattern is best to consider for removal of telemetry? a) Sinus arrhythmia with rate fluctuation during respiration. b) Sinus bradycardia caused by digoxin toxicity. c) Third degree heart block resulting from loss of pacemaker capture. d) Sinus tachycardia with multifocal PVCs being treated with amiodarone.
a) Sinus arrhythmia with rate fluctuation during respiration. - This is a normal ECG pattern and does not require telemetry monitoring.
In planning a client care assignment, which clients are best to assign to the float nurse from the orthopedic unit? (Select all that apply. One, some, or all options may be correct.) a) The client experiencing dysphagia following a cerebrovascular accident, which necessitates the use of total parenteral nutrition via a central line. b) The client that is post op cardiac catheterization on telemetry. c) The client that is recovering from a total hip replacement surgery. d) The client receiving an intravenous infusion of dopamine while awaiting transfer to a critical care unit. e) The client exhibiting visual and auditory hallucinations while experiencing alcoholic delirium tremens.
a) The client experiencing dysphagia following a cerebrovascular accident, which necessitates the use of total parenteral nutrition via a central line. c) The client that is recovering from a total hip replacement surgery.
What action should the charge nurse take? a) Return to the nursing unit desk to obtain the report. b) Take the report over the telephone from the client's room. c) Request that another staff RN obtain the report. d) Advise the unit secretary to write down the report.
c) Request that another staff RN obtain the report. - Another registered nurse (RN) can obtain the report, while the charge nurse gives his full attention to assessment of the unstable client. This is appropriate delegation.
In preparing a study of this problem, which goal statement is best for the team to identify? a) All diabetic clients will select insulin pens as their preferred method of insulin administration. b) All clients using insulin pens will measure an accurate dose 100% of the time. c) All clients will demonstrate the ability to use the insulin pens correctly. d) Insulin pens will be available to all diabetic clients who are able to draw up accurate doses.
b) 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.
Which tasks can be assigned to the UAP who is assisting the PN and RN in the care of these four clients? (Select all that apply. One, some, or all options may be correct.) a) Notify the respiratory therapist about the oxygen needs of the client with COPD. b) Deliver and prepare the meal tray of the client who is in isolation with MRSA. c) Measure and record the abdominal circumference of the client with cirrhosis. d) Review teaching materials about foods that are high in calcium. e) Assist the COPD client with a bath and change of gown.
b) Deliver and prepare the meal tray of the client who is in isolation with MRSA. e) Assist the COPD client with a bath and change of gown.
Which action can the PN assign to the respiratory therapist? a) Write a prescription for an inhaled bronchodilator. b) Increase the rate of oxygen being administered. c) Evaluate the sputum culture and sensitivity report. d) Turn and position the client every 2 hours.
b) Increase the rate of oxygen being administered. - The respiratory therapist can evaluate the oxygenation needs of the client, and, within defined parameters, adjust oxygen administration accordingly.
In reviewing the situation with the UAP and nurse assigned to the client, the charge nurse needs to emphasize which problem? a) Task assignment to an unqualified staff member. b) Insufficient instruction and supervision by the RN. c) Lack of caring and client advocacy by the UAP. d) Inadequate client education and preparation.
b) Insufficient instruction and supervision by the RN. - Supervision includes the provision of instruction as indicated. Since this client requires specific post-procedure care, the nurse should have provided pertinent instruction to the UAP.
How should the charge nurse respond? a) Ask the practical nurse (PN) if she attended the required in-service. b) Offer to repeat a demonstration and allow the PN additional practice time. c) Remind the PN that only RNs should administer insulin. d) Advise the PN to continue using only insulin syringes.
b) 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 client can best be assigned to this PN, rather than a RN? a) Unstable angina scheduled for a cardiac catheterization that day. b) Osteoporosis scheduled for a bone mineral density test that day. c) Hepatic encephalopathy scheduled for a liver biopsy that day. d) Deep vein thrombosis scheduled for a vena cava filter insertion that day.
b) Osteoporosis scheduled for a bone mineral density test that day. - This client is the most stable of the clients and is scheduled for a test requiring minimal client teaching and preparation. Additionally, the PN will not require a high level of expertise to monitor the post-procedure condition.
What is the priority for the charge nurse in this situation? a) Instruct the client with angina to call if further assistance is needed, and assist the UAP in caring for the confused client. b) Remain with the client who has angina and assign a practical nurse (PN) to monitor the confused client while the UAP obtains a bed alarm. c) Assess the confused client and assign the UAP to take the vital signs of the client with angina. d) Implement fall precautions for the confused client and assign the PN to assess the client with angina.
b) Remain with the client who has angina and assign a practical nurse (PN) to monitor the confused client while the UAP obtains a bed alarm. - The client with angina and ECG changes remains unstable and requires the expertise of the charge nurse to assess and manage his care. The practical nurse (PN), assisted by the unlicensed assistive personnel (UAP), can safely monitor a confused client to prevent injury.
What information is most important for the quality improvement team to present to administration about clients that are using insulin pens? a) The average number of medications taken by this group of clients. b) The inability of these clients to measure an accurate dose with a syringe. c) The highest level of education achieved by this group of clients. d) A comparison of the costs of insulin syringes versus insulin pens.
b) 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.
How should the charge nurse respond? a) "As a staff member, you have to care for your fair share of the clients just like everyone else." b) "No one likes to care for clients in isolation. How do you expect me to change assignments now?" c) "What concerns do you have about your pregnancy and this client care situation?" d) "I did not consider your pregnancy in making assignments. I will change your assignment."
c) "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.
The charge nurse consults with the case manager about which aspect of the client's care? a) Evaluating the client's risk of liver failure after discharge. b) Providing discharge teaching about the medications to be taken at home. c) Initiating a referral for durable medical equipment and home health care. d) Establishing the plan of care to be implemented by the home care nurses.
c) Initiating a referral for durable medical equipment and home health care. - The case manager initiates referrals and helps the client to manage resources effectively. This is the team member most qualified to initiate referrals for client discharge.
Who should the charge nurse assign to care for this client? a) An experienced practical nurse (PN). b) The newly-licensed nurse, assisted by an experienced UAP. c) The newly-licensed nurse and the staff nurse preceptor. d) The newly-licensed nurse alone.
c) The newly-licensed nurse and the staff nurse preceptor. - The client is exhibiting manifestations of septic shock, a potentially fatal problem. The newly-licensed nurse 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.
Which team member should the new RN collaborate with to ensure that the dosage is adjusted correctly? a) The PN assigned to the medical unit. b) The pharmacist assigned to the medical unit. c) The nurse who is precepting the new nurse. d) The UAP that is also assigned to care for this patient.
c) The nurse who is precepting the new nurse. - The staff nurse preceptor has the time, expertise, and responsibility to assist newly-licensed nurses through their orientation as they adjust to their new role and work environment. The staff nurse preceptor is also responsible for helping the newly-licensed nurse resolve problems, for guiding decision-making, and for supervising care.
Which instruction should the nurse convey to the UAP? a) "Notify me if the client's pain becomes excessive." b) "Let me know if the client does not use the PCA correctly." c) "Tell me if the PCA pump is providing adequate pain control." d) "Report any change in mental status, such as disorientation."
d) "Report any change 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 change observed, and is given an example.
At what rate would the nurse program the infusion pump? a) 250 mL/hr b) 100 mL/hr c) 500 mL/hr d) 125 mL/hr
d) 125 mL/hr - Correct. 250 mL divided by 2 equals 125 mL. Submit
When changing client care assignments, which client should be assigned to a nurse? a) The client on clopidogrel following a transient ischemic attack (TIA). b) The client with a lactated Ringer's infusion following a barium swallow procedure. c) The client on pantoprazole for newly-diagnosed peptic ulcer disease. d) A client on an insulin and potassium infusion to treat diabetic ketoacidosis.
d) A client on an insulin and potassium infusion to treat diabetic ketoacidosis. - This client is the most physiologically unstable and is most likely to experience complications from the treatment being provided. A nurse should be assigned to care for the client requiring the highest level of expertise and effective critical thinking to ensure safe client care.
What is the most important consideration for the nurse administering the vancomycin? a) Administer after hemodialysis treatment. b) Educate patient to notify nurse if bloody or diarrhea stools develop. c) Monitor BUN and creatinine levels. d) Assess for hypotension during administration.
d) Assess for hypotension during administration. - Hypotension is a side effect of too rapid administration of vancomycin. If the medication is infused by pump at a controlled rate, hypotension should not be a primary concern. Vancomycin can be safely administered in most patients at 500 mg over 1 hour.
Which action should the nurse implement? a) Advise the UAP to stay with the client until the client is ready to lie back down. b) Instruct the UAP to assist the client to a supine position in the bed. c) Stay with the client while the client sits on the side of the bed. d) Assist the client in returning to a supine position in the bed.
d) 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 nurse should assist the client back to a supine position and complete an assessment of the catheter site and distal circulation.
A client is identified for removal of telemetry and transfer to a general medical bed. What action should the charge nurse take next? a) Notify the technician monitoring the telemetry patterns that the client's telemetry is being removed. b) Assess the client's vital signs and apical heart rate before removing the telemetry leads and equipment. c) Call the charge nurse of the unit where the client is being transferred to give a report of the client's condition. d) Contact the healthcare provider (HCP) for an order to remove the telemetry and transfer the client.
d) Contact the healthcare provider (HCP) for an order to remove the telemetry and transfer the client. - The charge nurse must obtain the consent of the healthcare provider (HCP) before discontinuing a prescribed treatment such as telemetry monitoring.
To ensure that all the staff are competent in the use of the new equipment, which action is most important for the charge nurse to implement? a) Review the in-service attendance records to determine if all nurses attended the class. b) Bring the equipment to the medical unit to demonstrate its use to all of the nurses. c) Invite the unit pharmacist to make a presentation on the benefits of the insulin pens. d) Schedule time for each nurse on the unit to practice using the insulin pens.
d) 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.