Nursing Application for Managing Patient Care
After returning from lunch, the nurse is reviewing Johnny's electronic health record (EHR) and sees that another nurse has administered medications. Select the item below that needs immediate action.
12:40
While organizing the equipment and explaining what is being done, the nurse receives a request from another client to assist them with required ambulation. The client is stable and practicing walking with crutches prior to discharge in a few hours. Nursing colleagues available to assist the client include two registered nurses (RNs), one practical nurse (PN), and one unlicensed assistive personnel (UAP). What is the best action for the RN to take?
Delegate the task to the UAP.
Place the actions in the order in which the nurse will perform them, starting with the first and ending with the last.
First action -initiate droplet precautions Second action -obtain arterial blood gasses Third action -insert intravenous access Fourth action -obtain blood and sputum cultures Fifth action -start intravenous fluids Sixth action -administer azithromycin Seventh action -administer acetaminophen
For which order, or orders, will the nurse contact the health care provider prior to taking action? Select all that apply.
Cefotaxime 1 g IV q8h
The nurse is approached by Johnny's oldest daughter, Cecilia, who is concerned about her father's privacy after overhearing one of the other nurses from this unit talking with colleagues about her father having been admitted. What is the best response by the nurse?
"I apologize, that should not happen. Are you comfortable telling me who it was so I can talk with them?"
As Johnny's condition begins to improve, his daughter asks if the do not resuscitate (DNR) order can be canceled. What is the best response by the nurse.
"Yes, all that is needed is for the health care provider to cancel the prescription."
Which actions are appropriate to assign to a practical nurse (PN) working under the supervision of a registered nurse (RN)? Select all that apply.
*Demonstrate proper process used to gently cleanse eyelid margins. *Reinforcing hand-washing and hygiene practices with an older adult with an eye infection. *Administering ophthalmic drops to a child with conjunctivitis. *Performing a routine check of a client's visual acuity using the Snellen eye chart
Based on priority assessment cues, on which hypotheses will the nurse base follow-up questions?
*Neglect is suspected *Susan's dementia is progressing *Richard frustrated as caregiver
When documenting Susan's complete assessment, what information related to caregiver role strain will the nurse include in the electronic health record (EHR)? Select all that apply.
*Presence of advance directive for healthcare *Description of physical injuries, if present *Susan's ability to describe the care she receives from Richard *Height and weight *Lack of personal hygiene *Statements made by Richard
The nurse discontinued the ventilator and suctioned the endotracheal tube in anticipation of extubation but noticed a potential improvement in his condition. Which cues indicate that Johnny's condition is improving? Select all that apply.
1. Follows commands 2. T 98.5 3. RR 18, breathing spontaneously 4. Scant amount pale yellow secretions
Select the words or phrases in the son's reason for admission that alert the nurse to seek additional information related to the relationship between Richard and his mother.
1. I lock her in her room when I leave. 2. I just can't do this anymore! 3. disheveled appearance 4. foul odor 5. even when directed at her 6. she withdraws and cries
The nurse and their family are at the lake with friends. During lunch, the nurse's partner says, "Look to the left about 50 feet out, I think someone is drowning!" Place the following nursing actions in an order of priority:
1. Observe the individual and the surroundings. 2. Direct someone to locate a phone and call 911. 3. Determine who is the strongest swimmer in the group. 4. Find a boat, raft, or some type of flotation device.
Based on the priority cues discovered about Susan, use a nursing diagnosis text to select the highest priority hypothesis suggested by the current cues, the top 2 actions the nurse will take to gather more data related to that diagnosis, and the top 2 findings that support that diagnosis.
Actions to Confirm Hypotheses -Interview with Richard -Complete Physical Assessment Hypothesized Nursing Diagnoses -Caregiver role strain Cues that support Priority hypothesis -Richard's behavior during interview -Client Appearnance
What information does the nurse provide to inform the family of what will happen next?
Healthcare providers must confirm that Johnny is unable to make his own medical decisions and his illness is now terminal.
A client with an expected outcome of "Able to bathe and brush teeth independently" is looking forward to discharge in the near future. The nurse observes the unlicensed assistive personnel (UAP) performing these actions. For which action must the nurse intervene?
Performing the client's complete bath.
For each client care activity planned for Susan, indicate which nursing colleague, registered nurse (RN), practical nurse (PN), and/or unlicensed assistive personnel (UAP) can complete the action.
RN- Every box PN- Every box EXCEPT gait stability and collaborate with HCP UAP- Every box EXCEPT Gait stability, monitor response to new medications, and collaborate with HCP