Management and Safety # 1

The nurse learns that an adolescent client 's best friend has a driver 's license and a new car. Which comment is the most appropriate for the nurse to make?

- "How often do you ride in the car with your friend? " The nurse should assess, before counseling the adolescent about the importance of wearing seat belts and acting appropriately when riding with another adolescent. Not --> What kind of driver is your friend? " The nurse needs to first determine if the adolescent is riding with the friend and then concentrate on appropriate behavior when being a passenger.

The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.)

- "Sometimes I don 't get to the bathroom in time. " - "My hands always shake when I try to pick things up. " - "My dentures don 't fit so I don 't wear them, but I eat just fine. " - "I can 't feel a thing in my feet. It 's been that way for a while. " CORRECT— A home health referral could benefit this client by assessing for durable medical equipment that might assist the client in using the bathroom. If incontinence is a problem, the client may need assistance with personal care. CORRECT— This client may need assistance preparing meals, and managing medication administration. Home health care can provide accurately assess and provide appropriate referrals. CORRECT— Although the client says, "I eat just fine, " a dietary referral will ensure the client has the home resources and ability to eat a balanced diet. The fact that the dentures don 't fit may indicate the client has lost significant weight. CORRECT— A home health referral will determine if this client has safety needs in the home because of numbness in the feet. Slippery or uneven surfaces could be dangerous for this client.

The emergency department triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed?

- 17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival. - 63-year-old client who reports a severe, localized headache with no history of headaches. - 77-year-old client who has had generalized weakness for the past day (this is a bullshit selection). Generalized weakness could indicate a cardiac, neurologic, or electrolyte imbalance problem and requires immediate assessment.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first?

- A 40-year old who reports nausea, general anxiety, and is diaphoretic. Even though not complaining of chest pain, these symptoms should be treated as a potential MI. A cardiac workup should be performed immediately. Not --> A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain. Ask the client to rest and offer reassurance until evaluated by HCP. This may be an ectopic pregnancy. This client needs continuous monitoring, frequent comforting, and to be evaluated as quickly as possible. The loss of a pregnancy in this manner cannot be stopped. The goal is to prevent rupture and internal hemorrhage.

The nurse in the long-term care facility provides care for clients during an outbreak of Legionnaire disease. The nurse recognizes that which client is most at risk to develop the disease?

- A 65-year-old client diagnosed with end-stage kidney disease. Clients diagnosed with Legionnaire disease develop pneumonia caused by Legionella pneumophila. Risk factors include advanced age (50 years or greater), end-stage kidney disease, immunosuppression, diabetes, smoking, and pulmonary disease.

The unlicensed assistive personnel (UAP) reports to the nurse that four clients are vomiting. Which client does the nurse see first?

- A client with a nasogastric (NG) tube attached to low suction. Assess for patency of the NG tube first. Clients should not vomit around an NG tube. The tube is there to maintain decompression of gastrointestinal pressure and continuous removal of contents. The nurse must assess the client and the NG system and suction to ensure patency and rule out emergent needs.

The nurse provides care for clients on a cruise ship. The nurse interviews several clients who are experiencing severe vertigo unrelieved by dimenhydrinate. Which client does the nurse assign to see the health care provider first?

- A client with a temperature of 100°F (38°C) who complains of hearing loss in the right ear. This client has symptoms that indicate infection. This is the priority client. Not --> A client who reports ringing in the ears and occasional vertigo. This client is experiencing tinnitus, which is uncomfortable for the client but is not life-threatening. The client with an infection takes priority.

The nurse provides care to clients on the inpatient psychiatric unit. The nurse intervenes immediately with which client?

- A client with paranoid schizophrenia is pacing the hall at an increasingly rapid rate. Immediate intervention is required for the agitated client, which is considered an acute behavioral emergency. The use of physical and chemical (medication-based) restraints have been replaced with the use of non-coercive approaches. The nurse should de-escalate the situation by verbally engaging the client and establishing a collaborative relationship. While de-escalating the situation, the nurse should avoid coercive interventions that escalate the client's agitation; avoid the use of physical or chemical restraints, if possible; ensure safety for all (client, staff, and others in the care area); and help the client manage emotions and distress and maintain or regain control of behavior.

Four clients arrive in the emergency department within a 5-minute period. Which client does the nurse see first?

- A client with sudden epigastric pain and nausea who is vomiting blood and has an odor of alcohol on the breath. The client is experiencing symptoms of acute gastritis or ruptured esophageal varices related to excessive alcohol intake. This client is vomiting blood and is at risk for hypovolemic shock and aspiration of blood. This client should be seen and stabilized first. Not --> A client, pale and diaphoretic, who reports sudden and severe pain radiating from the flank to the scrotum. The client is experiencing symptoms of kidney pain, which may be due to pyelonephritis or renal calculi (kidney stones). The client requires quick attention to diagnose and manage the pain, but there is another client who requires priority attention.

The nurse provides care for clients in the emergency department. Which client does the nurse see first?

- An older adult client with one episode of fainting. The fainting episode may be the result of an irregular cardiac rhythm or rate change, and this requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest. Older adults have lower cardiac reserve and have an increased risk for fainting, or syncope. Serious heart conditions, such as bradycardia, tachycardia, or blood flow obstruction, may lead to syncope. The nurse should examine this client first. Not --> A young adult client with asthma and a productive cough. There is an increased risk of respiratory compromise due to the client's history of asthma, and a productive cough is indicative of a probable upper respiratory infection. Even though this is a breathing issue with potential to become an airway issue, this is not the highest priority.

A client diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection has a chest x-ray prescribed. Which arrangement does the nurse make for this client?

- Arrange for a portable bedside x-ray. The client on transmission-based precautions is certainly able to be transported to the radiology department. For any imaging study more complex than a simple chest x-ray, the client will be transported. However, a chest x-ray is easy to do at the bedside, limits potential contamination, and reduces the cleaning required from the radiology team. By requesting the study be done at bedside, the nurse advocates for other clients, visitors, and staff.

The public health nurse assesses a client reporting a persistent cough with blood-tinged sputum and night sweats. Which action does the nurse take first?

- Assist the client in putting on a mask. A cough with bloody sputum and night sweats are classic symptoms of tuberculosis. The nurse's priority is preventing the potential spread of disease. Not --> Assess the client's lung sounds. Assessing the client is an appropriate action. However, prevention of potential spread of disease takes precedence. The nurse has enough subjective and objective data to assume the client has tuberculosis until proven otherwise.

The nurse assesses the pain level of clients recovering from surgery. Which clients' pain relief are appropriate for the nurse to delegate to the LPN/LVN? This questions is asking which of these are stable such that the LPN can take care of them (remember that LPNs take care of only stable patients)

- Client who had knee arthroplasty yesterday and is scheduled for physical therapy and reports pain as 3 out of 10. - Client ambulating on the unit who is recovering from a hernia repair 2 days ago and reports pain as 4 out of 10. - Client who had carpal tunnel release yesterday and reports pain as 6 out of 10. Not --> - Client who arrived from the post-anesthesia care unit a short while ago after an appendectomy, is dozing intermittently, and reports pain as 8 out of 10. - Client who had surgery to repair a hip fracture yesterday evening and is difficult to arouse, yet moans when moved. - Client on NPO status after a colon resection 4 days ago who reports pain as 7 out of 10 (possible rupture and infection).

The oncology nurse is reassigned to the medical-surgical unit. The charge nurse for the medical-surgical unit assigns which clients to the oncology nurse?

- Client who is receiving total parenteral nutrition (TPN) following gastrectomy 48 hours ago. - Client who requires QID dressing changes for treatment of a MRSA-positive stage 4 pressure injury. - Client admitted 3 days ago who is prescribed IV antibiotics for treatment of pneumonia. CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. The TPN administration requires application of the nurse's fundamental knowledge and skills. CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Dressing changes and implementation of MRSA precautions require application of the nurse's fundamental knowledge and skills. CORRECT - Based on the available client data, no unexpected assessment findings are present and there is no apparent deterioration of the client's condition. Administration of IV antibiotics requires application of the nurses's fundamental knowledge and skills. Not --> - Client who will be discharged to home today following total hip replacement 72 hours ago. - Client who requires administration of pain medication after undergoing bariatric surgery 6 hours ago. - Client admitted yesterday who is newly diagnosed with atrial fibrillation. INCORRECT - The client being discharged will require specialized teaching related to postoperative care, hip precautions, equipment, and referrals. The client's care is best assigned to a nurse who is familiar with the specialized plan of care. INCORRECT - The client underwent a surgical procedure within the past 24 hours and, as such, is at high risk for complications. The client's care is best assigned to a nurse who is familiar with postoperative complications relevant to the procedure. INCORRECT - The client with a newly-diagnosed cardiac abnormality is at high risk for instability and will require close monitoring for complications. The client's care is best assigned to a nurse who is familiar with the specialized plan of care.

The nurse receives hand-off communication from the previous shift about assigned clients with mental health disorders. Which client will the nurse see first?

- Client with depression stating that things are better and that he will be leaving soon. The client with depression who states that things are better and will be leaving soon may be an indirect suicide threat with a plan. The nurse must clarify the client's statement, as this client can be in immediate danger. Not --> Client with delusions stating a plan to kill the spouse after being discharged. The client threatening to kill the spouse should be seen second. The nurse has the "duty to warn," even though the client is unable to carry out the threat immediately due to being hospitalized.

The nurse in the outpatient clinic receives a phone call from a young adult client who says a friend has overdosed. In caring for the overdosed client, which action does the nurse take first?

- Determine if the client is responsive and alert. Ask the friend if the overdosed client is conscious, if there are breathing difficulties, and what the respiratory rate is. Guide the friend through this assessment. A drug overdose incident is an emergency. The nurse can first instruct the caller to verify if the client is responsive, and then to tell the caller to call 911 immediately. As a general guide in handling drug overdose, the nurse should assess and activate; check for unresponsiveness and call for nearby help; have someone to call 911 and get automated external defibrillator (AED) and naloxone. Observe client for breathing, versus not breathing or only gasping. If client is unresponsive with no breathing or only gasping, begin cardiopulmonary resuscitation (CPR). Not --> Find out what the client ingested and in what amount. Determining what the client overdosed on is important information, but the priority is determining the client's current condition.

Due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action does the nurse take next?

- Place an identification bracelet on each child. Children need constant supervision to assess their behaviors and the environment for potential dangers. Ensuring a safe environment and identifying all children to reduce injury are the priority nursing actions. Once the children's physical needs for safety have been met, the nurse can encourage questions and address the fear and anxiety that the children may be experiencing. The nurse should answer individual questions with a simple, honest, and genuine response while assessing the child's understanding.

The nurse administers an incorrect dose of medication to the client. Which actions are appropriate for the nurse take in this situation? (Select all that apply.)

- Record the dose of medication administered. - Perform an assessment of the client. - Contact the health care provider. - Document any adverse reaction the client experienced Not --> Document in the health record that an incident report was completed. The nurse must document the event in the client's medical record, but should not document that an incident report was completed.

As the nurse assists an older adult client with personal care, the client states, "My son is sometimes violent." Which action by the nurse is best?

- Report the information to the nurse manager. The nurse provides for the client's safety by meeting physical needs. This means reporting the information to the nurse manager, who will notify the health care provider and the appropriate authorities. Not --> Share the information with the care team. his response does not address the chain of command the nurse follows when reporting suspected abuse.

The nurse supervises care of clients on the orthopedic unit. Which action by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

- The UAP raises the leg rests of the wheelchair for a client wearing halo vest traction. The leg rests should be lowered. The weight of the halo vest is likely to cause a wheelchair to tip backward. This is a safety issue and requires that the nurse intervene.

The nurse observes the unlicensed assistive personnel (UAP) providing care on the medical-surgical unit. Which observation causes the nurse to intervene?

- The UAP removes dead leaves from a plant in the client's room. Caregivers should not be caring for plants and clients, as they may transmit bacteria, pesticides, or plant residue from the plant to the client. Plants should be cared for by a different person than the caregiver. Health care providers responsible for direct client contact and care should not be touching plants since microorganisms from the plant can be easily transferred to the client. The nurse should intervene when this action is observed. Not --> The UAP removes the contact lenses from a client with right-sided weakness. This is an appropriate action for the UAP.

The nurse supervises the care provided by an unlicensed assistive personnel (UAP) to a client being treated with a radioactive implant for vaginal cancer. Which situation requires the nurse to intervene?

- The UAP stands behind the portable bedside shield placed at the foot of the client's bed. The shield should be placed on the hallway side of the client's bed to protect caregivers and visitors who enter the client's room. They should not stand at the foot of bed.

Which information is essential to report when communicating client information at the change of shift?

- The client is newly diagnosed with type 1 diabetes and needs follow-up teaching about insulin administration. - The client is seemingly more confused and has been attempting to get out of bed without assistance. - The attending health care provider prescribed lorazepam PRN for restlessness. Not --> - The client has a 20-year history of smoking. - The client receives carvedilol, benztropine mesylate, and losartan on a daily basis. Information to include during change of shift report includes any teaching needs, changes in client condition, and new prescriptions. Routine information can be obtained by reviewing the medical record. Medications previously prescribed or are routine do not need to be included in change of shift report, unless a medication adverse/side effect is being considered as a reason for the client's change in condition.

The nurse in the emergency department assists forensic investigators with evidence preservation and collection after a client's sudden death. Which actions by the nurse are considered professionally negligent? (Select all that apply.)

- The nurse cuts holes through fabric to remove client's shirt. - The nurse gives the client's clothing to the family. - The nurse places any evidence in a plastic bag. - The nurse removes intravenous lines before the medical examiner arrives. CORRECT— This is a negligent action. The nurse should not cut through or disrupt any tears, holes, blood stains, or dirt present on clothing. CORRECT— This is a negligent action. Clothing should not be given to families because clothing may contain evidence. CORRECT— This is a negligent action. Plastic bags are not used because they retain moisture. Moisture may promote mold and mildew formation, which can destroy evidence. CORRECT— This is a negligent action. All tubes and lines must remain in place for the medical examiner. Not --> - The nurse documents the time events occurred. - The nurse places paper bags over the client's hands. INCORRECT— Covering the client's hands is appropriate and necessary. Only paper bags should be used because they preserve evidence on the hands and under fingernails.

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a toddler near-drowning victim on a ventilator. The other contains an older adult client with a left-sided cerebrovascular accident (CVA) who is conscious and has a blood pressure of 220/130 mm Hg. Which client does the nurse see first?

- The older adult client because the client is hypertensive. The toddler receives mechanical ventilation. The older adult has severe hypertension and left-sided weakness. The nurse should think, "Which client's condition is life-threatening, but survivable with rapid intervention?" The toddler's airway and breathing are currently supported by mechanical ventilation. The older adult has severe hypertension and left-sided weakness. If left untreated, the older adult client could suffer life-threatening consequences.

The home health nurse visits the home of a client diagnosed with Alzheimer disease. The client lives with an adult child and that adult child's spouse, who both insist the client stay with them for as long as possible. Which observation concerns the nurse?

- There is a blow-dryer on a hook on the bathroom wall. Not --> There are door locks at the top of the doors. This does not require intervention by the nurse. Wandering is a frequent behavior of clients with Alzheimer disease. By the time clients are in the middle to late stages of the disorder, they are unable to look up and reach upward. Door locks that are complex or located at the top of the door are best for these clients.

The nurse plans care for assigned clients. In which order will the nurse prioritize the care for these clients?

1. First, the nurse will care for the client with vomiting and frothy oral secretions, since this could indicate a tracheoesophageal fistula and potentially cause aspiration. The client's airway must be maintained as a priority. 2. Second, the nurse will care for the client requiring observation after an acute asthma attack. The airway may still be compromised. 3. Third, the nurse will care for the client with a temperature increase. 4. And last, the nurse will care for the client diagnosed with priapism and a sickle cell crisis. This client may need intervention if the symptoms persist. However, this client's problems are not as acute as the other clients' health problems.