Professional Development Nclex - Sem3

A pt in labor is experiencing dystocia. In delivering care to this pt , the nurse should place the highest priority on which ongoing NIs?

- Monitoring of the status of both mother & fetus * Rationale: All of the options represent correct nursing actions, but the highest priority is to monitor the status of the mother & fetus. This option is the 1 that exemplifies the most urgent physiological need &, as such, takes precedence over the other NIs

A pt with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the pt tells the nurse that a living will was prepared 2 years ago & asks the nurse if this document is still effective. The appropriate nursing response is which of the following?

- "A living will needs to be reviewed yearly with your health care provider." * Rationale: The pt should discuss the living will with the HCP, & it should be reviewed annually to ensure that it contains the pts present wishes & desires

A nurse is providing instructions to the NA who will be caring for a pt with security devices (hand restraints). The nurse instructs the NA to check the pts skin & circulation under the security devices:

- Q 30 min * Rationale: The nurse should instruct the NA to assess restraints, circulatory status, & skin integrity q 30 minutes. Additionally, restraints need to be released at least q2hrs to permit muscle exercise & promote circulation. Agency guidelines regarding the use of restraints always should be followed

A nurse observes that a pt received pain med 1 hour ago from another nurse but the pt still has severe pain. The nurse has previously observed this same occurrence. On the basis of the nurse practice act, the observing nurse plans to do which of the following?

- Report the info to a nursing supervisor * Rationale: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing & may develop plans for tx & supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing

A nurse is assisting in reviewing the critical paths of the pts on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action & analysis?

- A postop pt who develops a cough & a fever * Rationale: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, & can be caused by a variety of factors. Positive variance occurs when the pt achieves max benefit & is d/c earlier than anticipated. Negative variance occurs when untoward events prevent a timely d/c. Variance analysis occurs continually to anticipate & recognize negative variance early so that appropriate action can be taken. A postop pt who develops a cough & a fever identifies a negative outcome

A nurse is assigned to care for 4 clients. When planning pt rounds, which pt would the nurse check 1st?

- A pt on a ventilator

A LPN employed in a LTC facility is planning assignments for the pts on a nursing unit. The LPN must assign 4 clients & has another LPN & 3 NAs on a nursing team. To which of the following pts should the nurse assign the LPN?

- A pt with an abdominal wound requiring wound irrigations & dressing changes q3hrs * Rationale: When delegating nursing assignments, the nurse needs to consider the skills & educational level of the nursing staff. Collecting a 24-hour urine, assisting with frequent ambulation, & giving a bed bath can be done by a NA. The LPN is skilled in wound irrigations & dressing changes, & this pt should be assigned to this staff member

A nurse is assigned to care for a newly admitted pt & is reviewing the HCPs rx. The nurse notes that the HCP has rx a med dose that is twice the amount that the pt reports taking prior to admission. The appropriate nursing action is to:

- Consult with the RN

A nurse is preparing to admin meds to an assigned pt & notes that the rx for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the HCP to clarify the rx & asks to rx a dosage within the recommended range. The HCP refuses to change the rx & instructs the nurse to admin the dose as rx. Which of the following actions should the nurse take?

- Contact the nursing supervisor * Rationale: If the HCP writes a rx that requires clarification, the nurse's responsibility is to contact the HCP for clarification. If there is no resolution regarding the rx because the rx remains as it was written after talking with the HCP, or because the HCP cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the rx until clarification is obtained

A nurse admins meds to the wrong pt. During the investigation of the incident, it was determined that the nurse failed to check the pts ID bracelet before admin the meds. The nursing supervisor evaluates the situation & determines that the nurse can be guilty of negligence because negligence is:

- Defined as the failure to meet established standards of care

A pediatric nurse arrives at work & is told to report (float) to the ER for the day because the ER is expecting numerous victims to arrive following a train accident. The nurse has never worked in the ER & is anxious about floating to this area. Which is the appropriate nursing action?

- Discuss her anxieties & concerns with the nursing supervisor about floating

A male pt who has heart failure receives an additional dose of bumetanide as rx 4 hrs after the daily dose. The nurse assesses him 15 minutes after admin the med & reminds him to save all urine in the bathroom. 30 minutes later the nurse finds the pt on the floor, unresponsive, & bleeding from a laceration. Determine the issues that support the pts malpractice claim. Select all that apply.

- Increased risk of hypotension - Failure to teach the pt adequately - Increased need to protect the pt - Lack of follow-up nursing actions * Rationale: To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the pt, that the nurse breached the duty, & that as a result harm was caused to person or property. The pt has an increased r/o hypotension because hypotension is a common adverse effect of bumetanide, this is the 2nd dose within 4 hrs, & the pt has heart failure. The pt can prove that the nurse did not protect him by failing to provide adequate teaching & perform correct & timely NIs after admin the bumetanide. After the 1st 15-minute check, the nurse should continue increased pt monitoring to ensure pt compliance with safety measures. However, because this med can cause hypotension, especially after a repeat dose, the nurse should instruct the pt to remain in bed & provide him with a urinal

A pt reports having had 2 BMs this am & refuses a dose of docusate sodium (Colace). After appropriately charting in the med admin record, the nurse should:

- Make a notation regarding the pts refusal in the nurse's notes

A pt with a perforated gastric ulcer is scheduled for emergency surgery. The pt cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this pt?

- Obtain telephone consent from the family member witnessed by 2 persons * Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the pt is unable to sign the consent form. Telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a pt who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In emergencies, the pt may be unable to sign, & family members may not be available. In this type of situation, the HCP is permitted legally to perform surgery without consent

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after the delegation of the tasks is to:

- Perform follow up with each staff member regarding the performance of the task & the outcomes r/t the implementation of the task * Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow up with each staff member regarding the performance of the task & the outcomes r/t implementing the task. Not all staff members have the education, knowledge, & ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented & outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift