The Nursing Process
The nurse manager is developing a "read-back" procedure to reduce medication administration errors. Which of the following are purposes of the "read-back" requirement? Select all that apply. a) To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone. b) To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information. c) To encourage the use of electronic medical records. d) To prohibit orders and test results from being communicated verbally or by telephone. e) To make sure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
B. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information. E. To make sure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information. The requirement for verbal or telephone orders, or for telephonic reporting of critical test results, is to verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. Effective communication which is timely, accurate, complete, unambiguous, and understood by the recipient reduces error and results in improved client safety. "Read-back" procedures are not intended to discourage or prohibit telephone communications among health care providers or to promote use of electronic medical records. Safety procedures, such as provider identification codes, are in place for health care providers to give verbal or telephone orders.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. a) Medications and treatments administered. b) Identifying information when possible (such as name, age, and address). c) Next of kin. d) Triage priority. e) Presence of jewelry.
A. Medications and treatments administered. B. Identifying information when possible (such as name, age, and address). D. Triage priority. Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.
A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take? a) Strike through the entry ensuring the original entry is still visible b) Contact the previous nurse requesting that the nurse correct the error c) Report to the nurse manager that the nurse needs guidance on documentation d) Rewrite the entry on the correct health record indicating who made the error
B. Contact the previous nurse requesting that the nurse correct the error The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.
A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? a) The entry should list the specific reasons that the client was upset. b) The entry should include clearer descriptions of the client's mood and behavior. c) The entry should avoid mentioning cognitive or psychosocial issues. d) The entry should specify the subsequent interventions that were performed.
B. The entry should include clearer descriptions of the client's mood and behavior. Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.
The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique? a) I.V. insertion b) Urinary catheterization c) Nasogastric (NG) tube placement d) Wound care involving burns
C. Nasogastric (NG) tube placement The GI system isn't a sterile system; therefore, NG tube placement doesn't require sterile technique. I.V. insertion requires sterile technique because intentional penetration of the skin occurs. The urinary system is sterile, so the nurse must maintain sterility during catheter placement. Burns have a high risk for infection; the nurse must maintain sterile technique to decrease this risk.
The nurse should instruct the client with a platelet count of less than 150,000/µl (150 X 109/L) to avoid which of the following activities? a) Visiting with children. b) Ambulation. c) Valsalva's maneuver. d) Semi-Fowler's position.
C. Valsalva's maneuver. When the platelet count is less than 150,000/µl (150 X 109/L), prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae.
A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? a) Discuss the breach of practice with the physician. b) Complete an incident report. c) Notify the unit manager. d) Ask the nurse educator to in-service the physician.
A. Discuss the breach of practice with the physician. The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step.
When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method? a) Pulling the ear pinna back, down, and out b) Pulling the ear pinna back, up, and out c) Pulling the ear pinna down d) Pulling the ear pinna out
B. Pulling the ear pinna back, up, and out Pulling the pinna back, up, and out helps straighten an adult's ear canal so the nurse can properly place a tympanic thermometer probe. Pulling the ear pinna back, down, and out straightens a child's ear canal. Pulling the ear pinna only out or back does not straighten the ear canal for probe placement.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: a) Ask the nurse if she has been drinking. b) Assess the nurse's behavior for signs of intoxication. c) Report this to the nursing supervisor immediately. d) Report this to the head nurse when she arrives in the morning.
C. Report this to the nursing supervisor immediately. This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed a shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.
A client reports of a headache to an unregulated care provider (UCP). The UCP reports the client's concerns to the nurse, who is busy with other clients. What is the best action by the nurse to address the client's headache? a) Have the UCP inform another nurse that the client needs assistance. b) Have the UCP perform a thorough assessment of the client. c) Ask another nurse to observe the UCP administering the acetaminophen. d) Have the UCP perform a thorough assessment of the client.
A. Have the UCP inform another nurse that the client needs assistance. UCPs are not authorized to administer medication or perform assessments. However, they can enlist the help of another member of the team who is qualified to assist the client.
A car accident involves four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter to the nearest hospital? a) Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. b) 10-year-old with a simple fracture of the femur who is crying and cannot find his parents. c) 70-year-old man with a severe headache who is conscious. d) Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing.
A. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. The middle-aged woman is likely in shock. She is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III (urgent and should be treated within 30 minutes). The man with asthma and the man with the severe headache are classified as triage level II (emergent), and can be transported by ambulance and reach the hospital within 15 minutes.
