Nursing Care Scenarios and Best Practices - Prof. Tutor, Exams of Nursing

Download Nursing Care Scenarios and Best Practices - Prof. Tutor and more Exams Nursing in PDF only on Docsity! ati-leadership-proctored- exams-2023-version-1-2-3-a- graded ATI Leadership Proctored Exam 1. Interdisciplinary Care Conference Recommendation A nurse in a prenatal clinic is caring for a group of clients. The nurse should recommend an interdisciplinary care conference for a client who has a biophysical profile of 6, indicating potential complications or concerns that may require a multidisciplinary approach to address the client's needs. 2. Caring for a Client with End-Stage Heart Failure A nurse is preparing to discharge a client who has end-stage heart failure. When the client's partner tells the nurse that she can no longer handle caring for the client, the nurse should contact the case manager to discuss discharge options. This allows the nurse to explore alternative care arrangements, such as home health services or placement in a long-term care facility, to ensure the client's needs are met. 3. Referral for a Client Unable to Afford Prescribed Equipment A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. When the parent states she is unable to afford the prescribed nebulizer, the nurse should recommend contacting social services to discuss options for obtaining the necessary equipment. 4. Correct Feeding Technique for a Client with Dysphagia A nurse is supervising assistive personnel (AP) who are feeding a client with dysphagia. The correct technique the nurse should identify is instructing the AP to have the client place their chin to their chest while swallowing, as this helps to facilitate safe swallowing. 5. Client Rights In-Service A nurse is providing an in-service about client rights for a group of nurses. The nurse should include the statement that a nurse can disclose information to a family member with the client's permission, as this respects the client's right to privacy and autonomy. 6. Addressing Delayed Oxygen Equipment Delivery A nurse is preparing to discharge a client who requires home oxygen. When the equipment company has not yet delivered the oxygen tank, the nurse should contact the case manager to discuss the delay in the delivery of the oxygen equipment. 7. Responding to a Client's Reconsideration of Consent A nurse is preparing a client for surgery. When the client has signed the consent form but tells the nurse that she has reconsidered due to concerns about pain, the appropriate response by the nurse is to inform the client that it is not too late to change her mind, respecting the client's right to withdraw consent. 8. Addressing Inappropriate Handling of a Client A nurse in a long-term care facility is caring for a client and witnessed the assistive personnel (AP) position the client in bed with excessive force. The nurse should first help the AP transfer the client correctly, then report the incident to the nurse manager to address the inappropriate handling of the client. 9. Reporting Immediate Findings in a Client with Meningitis A nurse is assessing a client who has meningitis. The finding the nurse should report to the provider immediately is a decreased level of consciousness, as this can indicate a worsening of the client's condition. 10. Addressing a Wandering and Verbally Aggressive Client A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. The appropriate action the nurse should take is to keep the client in her room with the door closed, as this helps to maintain the client's safety and the safety of others. 11. Intervention for a Newly Licensed Nurse Struggling with Client Care A nurse is assisting with the orientation of a newly licensed nurse who is having trouble focusing and difficulty completing care for their assigned client. The appropriate intervention is to recommend that the newly licensed nurse take time to plan at the beginning of their shift, as this can help improve their organization and focus. 12. Nurse Assessment Before Delegating Care A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel 25. Assigning Tasks to an LPN A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. The task the nurse should assign to the LPN is reinforcing dietary teaching with a client who has heart disease, as this falls within the LPN's scope of practice. 26. Scheduling an Interdisciplinary Conference A nurse working on a medical-surgical unit is managing care of four clients. The client the nurse should schedule an interdisciplinary conference for is a client who reports shortness of breath and left neck and shoulder pain, as this indicates a potential complication or change in the client's condition that may require a multidisciplinary approach. 27. Addressing a Visitor Accessing Client Information A nurse enters the hallway and discovers a visitor looking at a client's medical information on the computer. The first action the nurse should take is to close the documentation program on the computer, as this immediately secures the client's confidential information. 28. Responding to Suspected Elder Abuse A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. The appropriate action the nurse should take is to identify the suspected abuse to social services, as they are responsible for investigating and addressing elder abuse concerns. 29. Responding to Conflicting Wishes Regarding End-of- Life Care A nurse is caring for a client who is unconscious, and the client's partner, who is the healthcare surrogate, wishes to discontinue the client's feeding tube. Another family member tells the nurse they want the client to continue receiving treatment. The nurse should respond that, as the healthcare surrogate, the client's partner can make the decision regarding the discontinuation of the feeding tube. 30. Administering Medication Without Consent A nurse is caring for a client who reports acute pain but refuses intramuscular medication. The nurse distracts the client and quickly administers the injection. This action illustrates the ethical principle of battery, as the nurse administered medication without the client's informed consent. 31. Interdisciplinary Team Members for a Client with Anorexia Nervosa A nurse is caring for a client who has anorexia nervosa. The interdisciplinary team members the nurse should consult regarding this client's care are a mental health professional and a nutritional therapist, as they have specialized expertise in addressing the psychological and nutritional needs of clients with eating disorders. 32. Demonstrating Understanding of Isolation Guidelines A nurse manager is reviewing isolation guidelines with a newly licensed nurse. A statement by the newly licensed nurse that indicates understanding of the guidelines is "I will wear a surgical mask within 3ft of the client," as this demonstrates knowledge of the appropriate use of personal protective equipment for droplet precautions. 33. Appropriate Cost-Containment Measures Nurses on an inpatient care unit are working to help reduce unit costs. An appropriate measure to include in the cost-containment plan is identifying clients who are at risk for falls, as this can help prevent costly adverse events. 34. Responding to a Request for Client Information A nurse is caring for a client who has cancer. When the client's adult child asks the nurse for information about the client's treatment plan, the appropriate response is "I cannot provide this information to you without your mother's consent," as this respects the client's right to privacy and autonomy. 35. Triage Prioritization in a Train Crash A nurse in the emergency department is performing triage for a group of clients who were in a train crash. The client the nurse should tag as emergent is a client who has an open fracture of the femur, as this is a life- threatening injury that requires immediate intervention. 36. Determining Consent for Surgery A nurse is caring for a client who has a tumor. The provider recommends surgery, but the client refuses, while the client's partner wants the surgery performed. The deciding factor in determining if the surgery will be done is whether the client understands the risks of refusing the procedure, as the client's autonomy and informed consent take precedence. 37. Reporting a Communicable Disease Diagnosis A nurse is caring for a client who has a new diagnosis of chlamydia. The appropriate action the nurse should take is to report the infection to the local health department, as chlamydia is a communicable disease that requires public health monitoring and intervention. 38. Prioritizing Nurse Manager Interventions A nurse manager is receiving report and is faced with the following situations that require intervention: a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailable to take a client to occupational therapy. The situation the nurse manager should address first is the medication error incident report, as it involves a potential client safety issue that requires immediate attention. 39. Addressing Missed Meal Breaks A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. The first action the nurse should take is to determine the reasons the nurses are not taking scheduled breaks, as this can help identify any underlying issues that need to be addressed. 40. Transcribing a Verbal Prescription A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The prescription the nurse should transcribe in the client's medical records is "Morphine sulfate 10 mg IV q 4 hr for pain," as this includes the necessary details of the medication, dose, and administration route. 41. Prioritizing Client Assessment in the Emergency Department A nurse working in the emergency department is assessing several clients. The client who is the highest priority is a client who has a peri fatal ecchymosis, as this indicates a life-threatening condition that requires immediate intervention. 42. Consulting the Interdisciplinary Team for TENS Use A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). The member of the interdisciplinary team the nurse should contact for assistance is a physical therapist, as they have specialized expertise in the use of TENS for pain management. A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin. The LPN can provide the initial diabetes education and teach the client how to self-administer insulin, as this is within the LPN's scope of practice. Responding to a Client Exposed to Cutaneous Anthrax When a client who has been exposed to cutaneous anthrax is admitted to the emergency department, the nurse should take the following action: Prepare to administer antibiotics to the client. Cutaneous anthrax requires prompt antibiotic treatment to prevent the progression of the disease. Inform the housekeeping staff that the client is in the isolation room to ensure proper cleaning and disinfection procedures are followed. Provide an interpreter when obtaining consent from the client, as clear communication is essential for informed decision-making. Information to Include in a Change of Shift Report When preparing to transfer a client from a surgical unit to a rehabilitation facility, the nurse should include the following information in the change of shift report: The client's current medical condition and any recent changes. The client's level of independence and any assistive devices needed. The client's pain management regimen and any recent pain assessments. The client's discharge plan and any pending arrangements for the rehabilitation facility. Correct Use of Infection Control Precautions When evaluating an assistive personnel's use of infection control precautions, the nurse should identify the following action as indicating correct use of precautions: Removing personal protective equipment (PPE) before leaving the client's room. Proper removal of PPE, such as gloves, helps prevent the spread of infectious agents from the client's environment to other areas of the healthcare facility. Responding to a Client's Request for a Health Care Proxy When a client on a medical-surgical unit asks about advance directives and states that they want to appoint a health care proxy, the nurse should 1. 2. 3. 1. 2. 3. 4. respond by explaining that a health care proxy can make decisions for the client when the client is unable to do so. This response acknowledges the client's request and provides information about the purpose and role of a health care proxy in the client's care. Violation of Client Confidentiality When teaching newly licensed nurses about client confidentiality, the nurse should include the following example as a violation of client confidentiality: Discussing a client's condition with a client's family member without the client's consent. Sharing a client's protected health information with individuals who are not directly involved in the client's care, without the client's permission, constitutes a breach of confidentiality. Information to Include in a Change of Shift Report When providing a change of shift report for an oncoming nurse, the nurse should include the following information: The client's current medical condition and any recent changes. The client's vital signs, including any abnormal findings. The client's pain level and any pain management interventions. The client's intake and output, including any concerns. Any pending tests, procedures, or treatments for the client. Interventions for a Client Who Speaks a Different Language When preparing a teaching session with a client who speaks a different language than the nurse, the nurse should plan to take the following intervention: Arrange for an interpreter to be present during the teaching session. Having an interpreter available ensures clear communication and understanding between the nurse and the client, which is essential for effective teaching and client education. Action to Take When Witnessing Improper Linen Disposal When a charge nurse witnesses an assistive personnel failing to follow facility protocol when discarding contaminated linens, the nurse should take the following action first: Discuss the issue with the assistive personnel and provide immediate feedback and education on the proper linen disposal protocol. 1. 2. 3. 4. 5. Addressing the issue directly with the assistive personnel and providing guidance on the correct procedure is the appropriate first step to ensure compliance with infection control practices. Prioritizing Care for Clients On a medical-surgical unit, the nurse should recognize that the following client is the highest priority: A client who had a cardiac catheterization and has a capillary refill in the great toe of 4 seconds. Impaired peripheral perfusion, as indicated by the prolonged capillary refill time, is a critical finding that requires immediate assessment and intervention to prevent further complications. Appropriate Action for a Client with a Cardiac Arrhythmia In the emergency department, when caring for a client who is disoriented and has a cardiac arrhythmia, the nurse should take the following action: Proceed with treatment without obtaining written consent (Implied Consent). In an emergency situation, where the client is unable to provide informed consent, the nurse can rely on the principle of implied consent to initiate necessary treatment to stabilize the client's condition. Medication for Hypersensitivity Reaction Treating Hypersensitivity Reaction The medication is used to treat the child's hypersensitivity reaction. The terminology and jargon used may be too advanced for a preschooler to fully understand. Child's Feelings about Medication Sometimes, when a child has to take medication, they may feel sad about it. The nurse should be aware of the child's emotional response to taking medication. Bicycle Safety Teaching Bicycle Riding Instructions The child's feet should be 3-6 inches off the ground when seated on the bicycle. • • • • • Post-Operative Findings for Adolescent Reportable Findings The nurse should report abdominal pain to the provider, as it may indicate a complication. Immunizations for 12-Year-Old Client Planned Immunization The nurse should plan to administer the diphtheria, tetanus, and pertussis (DTaP) vaccine. Care for Infant with Heart Failure Nursing Interventions The nurse should provide less frequent, higher volume feedings to the infant. Promoting Sleep for School-Age Child Nursing Interventions The nurse should follow the child's home sleep routine to reduce anxiety. The nurse should not provide video games prior to bedtime, as they can increase stress. The nurse should not leave the lights on in the child's room, as it can disrupt sleep. Initiating IV Antibiotic Therapy for Infant Nursing Actions The nurse should use a 24-gauge catheter to start the IV. The nurse should start the IV on the infant's foot. The nurse should change the IV site every 3 days. Teaching about Digoxin Toxicity Manifestations of Toxicity The nurse should include bradycardia as a manifestation of digoxin toxicity. • • • • • • • • • • Calculating Amoxicillin Dose Dose Calculation The nurse should administer 10 mL of amoxicillin suspension per dose. Laboratory Tests for Rheumatic Fever Relevant Tests The nurse should identify that the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can contribute to confirming the diagnosis of rheumatic fever. Healthy Eating Teaching for Adolescents Dietary Recommendations The nurse should instruct the adolescents to increase their dietary iron intake. The nurse should recommend limiting sodium intake to 3,000 mg per day. The nurse should advise consuming 1,500 to 1,700 calories per day. Administering Enteral Feeding for Infant Nursing Actions The nurse should warm the formula to 39°C (102°F) prior to administration. The nurse should instill the formula over a period of 30 to 45 minutes. Care for Child with Osteomyelitis Nursing Interventions The nurse should maintain a patent intravenous catheter. The nurse should provide a high-calorie, high-protein diet. Teaching for Child with Sickle Cell Disease Instructions The nurse should advise the guardian to apply cold compresses to painful areas. The nurse should instruct the guardian to offer fluids at bedtime. • • • • • • • • • • • Infant Assessment Findings Reportable Findings The nurse should report the infant's inability to hold a bottle to the provider. Findings Indicating Hemorrhage after Tonsillectomy Hemorrhage Indicator The nurse should identify increased blood-tinged expectoration as an indication of hemorrhage. Coping Mechanism Discussion with Parent Therapeutic Question The nurse should ask the parent, "What do you do when your infant is fussy?" Teaching about Sun Exposure for Toddler Parent Understanding Indicators The parent understands that the toddler should wear a wide-brimmed hat. The parent understands that the toddler should remain under a beach umbrella during morning hours. The parent understands that the toddler should be dressed in loose, lightweight clothing. Evaluating Chest Physiotherapy Effectiveness Indicator of Effective Therapy The nurse should identify reduced pain as an indication that the chest physiotherapy has been effective. Care for Infant with Bacterial Meningitis Nursing Interventions The nurse should place the infant in a semi-private room. • • • • • • • • Cranial Nerve Assessment Accessory Nerve When assessing the accessory (11th cranial) nerve, the nurse should ask the child to shrug their shoulders against resistance. This tests the function of the trapezius and sternocleidomastoid muscles innervated by the accessory nerve. Trigeminal Nerve Proper function of the trigeminal (5th cranial) nerve is indicated by the child exhibiting asymmetrical jaw strength when biting down. The trigeminal nerve controls the muscles of mastication. Sudden Infant Death Syndrome (SIDS) Support Encourage Viewing the Body The nurse should encourage the parents to allow siblings to view the infant's body, as this can help with the grieving process and provide closure. Discuss Resuscitation Attempts The nurse should not avoid discussing the details of the attempts to revive the infant, as this information can help the parents understand what occurred. Provide Follow-up Call The nurse should provide a follow-up phone call one week after the infant's death to continue supporting the family. Bacterial Meningitis Care Prepare for Lumbar Puncture The first action the nurse should take is to prepare the child for a lumbar puncture, as this is necessary to confirm the diagnosis of bacterial meningitis. Implement Droplet Precautions The nurse should implement droplet precautions for the child to prevent the spread of the infectious disease. Administer Antipyretic Administering an antipyretic medication to reduce the child's fever should not be the first priority, as the lumbar puncture and infection control measures are more urgent. Rotavirus Dehydration Assessment Capillary Refill Time A capillary refill time of greater than 2 seconds indicates moderate dehydration in an infant with rotavirus. Respiratory Rate A respiratory rate of 28 breaths per minute is not an indicator of moderate dehydration in this context. Bradycardia Bradycardia is not a typical finding associated with moderate dehydration from rotavirus. Seizure Disorder Education Lack of Sleep Lack of sleep is a common trigger that can increase the risk of seizures in a child with a seizure disorder. Decreased Temperature Decreases in body temperature are not typically considered a seizure trigger. Exposure to Secondhand Smoke Exposure to secondhand smoke can increase the risk of seizures in a child with a seizure disorder. Electrolyte Imbalance in Gastroenteritis Hyporeflexia Hyporeflexia, or decreased deep tendon reflexes, is a common finding associated with hypokalemia, which can occur with severe gastroenteritis. Hyperactive Bowel Sounds Hyperactive bowel sounds would not be an expected finding with a low potassium level. Oliguria Oliguria, or decreased urine output, can be seen with dehydration and electrolyte imbalances associated with gastroenteritis. Immunizations for Sickle Cell Anemia Pneumococcal Conjugate Vaccine (PCV13) The pneumococcal conjugate vaccine (PCV13) should be included in the plan of care for an adolescent with sickle cell anemia, as these patients are at increased risk for pneumococcal infections. Respiratory Syncytial Virus (RSV) Vaccine There is no RSV vaccine currently available, so this would not be an appropriate immunization to include. Rotavirus Vaccine The rotavirus vaccine is not specifically recommended for individuals with sickle cell anemia. Measles, Mumps, and Rubella (MMR) Vaccine The MMR vaccine should also be included in the plan of care, as individuals with sickle cell anemia are at increased risk for complications from these viral illnesses. Varicella (Chickenpox) Management Assess for Koplik Spots Assessing the oral cavity for Koplik spots is not relevant for a child with varicella, as these are more characteristic of measles. Administer Aspirin Aspirin should not be given to a child with varicella, as it has been associated with the development of Reye's syndrome. Medication Dosage Calculation The child weighs 55 lb, which is equivalent to 24.95 kg (1 lb = 0.454 kg). The dose of diphenhydramine is 1.25 mg/kg IV. The concentration of the diphenhydramine solution is 50 mg/mL. To calculate the volume to administer: * Dose = 1.25 mg/kg * Weight = 24.95 kg * Total dose = 1.25 mg/kg x 24.95 kg = 31.19 mg * Volume to administer = 31.19 mg / (50 mg/mL) = 0.6 mL Rounding to the nearest tenth, the nurse should administer 0.6 mL of the diphenhydramine solution. Interprofessional Team for Reducing MRSA Transmission Nurse Consultation When coordinating an interprofessional team to review proposed standards for reducing the transmission of methicillin-resistant Staphylococcus aureus (MRSA), the nurse should consult the following members of the team: Infection control nurse: The infection control nurse is responsible for developing and implementing policies and procedures to prevent and control the spread of infectious diseases, including MRSA. Nursing supervisor: The nursing supervisor oversees the nursing staff and can provide insights into the practical implementation of infection control measures on the unit. Risk management coordinator: The risk management coordinator is responsible for identifying and mitigating potential risks, including those related to MRSA transmission, and can provide valuable input on the proposed standards. Caring for a Client with Uterine Prolapse Client Concerns and Treatment Options When caring for a client who has uterine prolapse and the provider has recommended a total abdominal hysterectomy, but the client refuses the surgery, the nurse should take the following actions: Discuss the client's concerns regarding the procedure. Provide the client with information on alternative treatment options and their outcomes. Inform the client of the consequences of uterine prolapse and the need for intervention. 1. 2. 3. 1. 2. 3. The nurse should avoid initiating a mental health consult to determine the client's reasons for refusing the surgery, as this may be perceived as dismissive of the client's autonomy. Obtaining Informed Consent for Emergency Surgery Appropriate Actions in the Emergency Department When assessing a client who is unconscious following a motor vehicle crash and requires immediate surgery, the nurse should take the following actions: Transport the client to the operating room without verifying informed consent, as the client's condition requires immediate intervention. Obtain telephone consent from the facility administrator before the surgery, if possible. Avoid delaying the surgery to obtain informed consent, as the client's condition is critical. The nurse should not ask the anesthesiologist to sign the consent, as this would be an inappropriate delegation of the informed consent process. Delegating Client Care Assignments Appropriate Tasks for Assistive Personnel When planning to delegate client care assignments, the nurse should consider the following tasks as appropriate for an assistive personnel (AP): Performing postmortem care prior to transferring the client to the morgue. Advising a client on self-administration of acetaminophen. Teaching a client to perform a finger-stick for testing blood glucose levels. Informing a family of a client's progress in physical therapy. The nurse should avoid delegating tasks that require nursing judgment or assessment, such as informing a family of a client's progress in physical therapy. Quality Improvement Process for Client Falls Initial Actions in the Quality Improvement Process After identifying an increase in client falls at the facility, the nurse should take the following actions as part of the quality improvement process: Review current literature regarding client falls. Identify clients who are at risk of falls. 1. 2. 3. 1. 2. 3. 4. 1. 2. Notify staff of the increased fall rate. Implement a fall prevention plan. The nurse should avoid implementing a fall prevention plan before reviewing the current literature and identifying clients at risk, as this would not be an evidence-based approach. Monitoring Assistive Personnel Performance Appropriate Interventions by the Nurse When observing an assistive personnel (AP) in the clinical setting, the nurse should intervene in the following situations: The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile (the nurse should intervene, as hand washing with soap and water is required for clients with C. difficile). The AP closes the door of a client who is on airborne precautions (the nurse should intervene, as this is an appropriate infection control measure). The AP removes cut flowers from the room of a client who is in a protective environment (the nurse should intervene, as this is an appropriate infection control measure). The AP wears a mask when caring for a client who has varicella (the nurse should not intervene, as this is an appropriate infection control measure). Addressing Staff Challenges with New Equipment Priority Action by the Charge Nurse When the charge nurse notices that the staff nurses are having difficulty using new IV infusion pumps for medication administration, the priority action should be: Assess the staff nurses' knowledge deficit. Demonstrate the use of the pump during medication administration. Plan an in-service education program on the unit. Pair an inexperienced nurse with an experienced nurse. The charge nurse should prioritize assessing the staff nurses' knowledge deficit and providing hands-on training to address the issue, rather than immediately implementing a pairing or in-service program. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. The nurse should not consider an adult client with moderate Alzheimer's disease or an adult client with alcohol intoxication as able to provide informed consent. Safekeeping of Client Valuables Appropriate Client Statements When discussing the safekeeping of valuables with a client scheduled for surgery, the nurse should identify the following client statement as indicating the need for further teaching: "I can wear my ankle bracelet since I am just having a local anesthetic." The other client statements, such as removing dentures, leaving valuables with a family member, and taping a wedding ring in place, are appropriate actions for the client to take. Consulting a Wound Care Specialist Appropriate Actions when Working with a Consultant When requesting a consultation with a wound care specialist for an older adult client with a Stage III pressure ulcer, the nurse should take the following actions: Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation. Provide the consultant with objective data and observations about the client's wound care, rather than subjective opinions and beliefs. The nurse should not request the consultation after several wound care treatments have been tried or arrange for the wound care nurse specialist to see the client daily, as these actions may not be necessary or appropriate. Administering a Sodium Chloride Enema Appropriate Actions by the Assistive Personnel When observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client, the nurse should intervene if the AP: Points the tubing in the direction of the umbilicus during insertion. Inserts the tubing 8 cm (3.1 in) into the rectum. The nurse should not intervene if the AP positions the client on their left side with knees flexed or administers the solution at room temperature, as these are appropriate actions. 1. 1. 2. 1. 2. Reinforcing Ethical Principles with a Licensed Practical Nurse Appropriate Ethical Principle to Reinforce When a charge nurse observes a licensed practical nurse (LPN) tell a client that she will return with a medication to help relieve the client's nausea, but the LPN does not return with the medication, the charge nurse should reinforce the ethical principle of: Veracity (truthfulness) The charge nurse should address the LPN's failure to follow through on the promise to provide the medication, which is a breach of the ethical principle of veracity. Benchmarking and Policy Review Appropriate Actions for the Nurse Administrator When using benchmarking as a control criterion while reviewing current policies and procedures, the nurse administrator should take the following actions: Compare practices within the facility against other high-performing facilities. Determine how current practice will affect future performance within the facility. The nurse administrator should not use root cause analysis to identify gaps in meeting standards or establish work initiatives to promote a positive environment, as these actions are not directly related to the benchmarking process. Responding to a Malfunctioning IV Pump First Action by the Nurse When a nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly, the first action the nurse should take is: Place a faulty equipment tag on the pump. This ensures the pump is taken out of service and prevents further use, which is the immediate priority in this situation. 1. 1. 2. 1. Responding to a Client's Emotional Distress Before Surgery Appropriate Nursing Statement When a client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite, the appropriate nursing statement is: "It's not too late to cancel the surgery if you want to." This statement acknowledges the client's emotional distress and provides an opportunity for the client to reconsider the procedure if desired. Reporting Infections to the Public Health Department Infection that Requires Reporting The facility infection control nurse should report the following infection to the public health department: MRSA MRSA is a healthcare-associated infection that is typically reportable to public health authorities, unlike the other infections listed (Lyme disease, bacterial conjunctivitis, and healthcare-acquired pneumonia). Information to Include in a Change-of-Shift Report Appropriate Information to Include When preparing to transfer a client to a rehabilitation facility, the nurse on the surgical unit should include the following information in the change-of- shift report: The time the client received his last dose of pain medication. The nurse should not include information about the steps to follow when providing wound care, the client's preferred time for bathing, or the nurse's belief about the client's relationship with his son, as these details are not essential for the change-of-shift report. 1. 1. 1. Identifying Breach of Confidentiality Appropriate Tort Identified by the Nurse Manager When reviewing documentation and noting a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners, the nurse manager should identify that the tort of: Libel has occurred. Libel is the written form of defamation, which involves the false publication of information that damages a person's reputation. In this case, the false identification of the client's HIV status would constitute libel. Prioritizing Client Assessments Client to Assess First When preparing to complete morning assignments on several assigned clients, the nurse should plan to assess first the client who had a bladder scan that indicated 250 mL of urine in the bladder. This client should be assessed first, as the presence of a significant volume of urine in the bladder may indicate a potential urinary retention issue that requires immediate attention. Postoperative Client with Serosanguinous Drainage Scenario A client who is 3 days postoperative and whose dressing has serosanguinous drainage. Nursing Considerations Monitor the client's vital signs and wound site closely for signs of infection or complications. Assess the drainage for color, consistency, and amount to determine if it is within normal limits. Ensure the dressing is changed using sterile technique to prevent further contamination. Administer any prescribed medications, such as antibiotics, to prevent or treat infection. Educate the client on proper wound care and signs/symptoms of infection to monitor. Collaborate with the healthcare team to determine the cause of the drainage and develop an appropriate plan of care. 1. • • • • • • Client with Diabetes and Hyperglycemia Scenario A client who has diabetes and an early morning blood glucose of 220 mg/dL. Nursing Considerations Monitor the client's blood glucose levels closely and administer insulin as prescribed. Assess the client for signs and symptoms of hyperglycemia, such as increased thirst, frequent urination, and fatigue. Encourage the client to follow their diabetic diet and exercise regimen to help manage blood glucose levels. Educate the client on the importance of maintaining tight glycemic control to prevent long-term complications. Collaborate with the healthcare team to adjust the client's insulin regimen or medication as needed. Client with Nasogastric Tube and Nausea Scenario A client who has a nasogastric tube to intermittent suction and reports nausea. Nursing Considerations Assess the client's level of nausea and any contributing factors, such as medication side effects or underlying conditions. Ensure the nasogastric tube is functioning properly and not causing discomfort or irritation. Administer any prescribed anti-nausea medications or interventions, such as ginger or peppermint. Encourage the client to take small, frequent meals and avoid strong odors that may exacerbate nausea. Provide comfort measures, such as cool compresses or relaxation techniques, to help alleviate the client's nausea. Collaborate with the healthcare team to determine the underlying cause of the nausea and develop an appropriate plan of care. Breach of Client Confidentiality Scenario A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. • • • • • • • • • • • Nursing Considerations Politely intervene and remind the staff nurse that discussing client information in a public area is a breach of confidentiality. Educate the staff nurse on the importance of maintaining client privacy and the HIPAA regulations that govern the protection of health information. Suggest that the staff nurse and charge nurse discuss any concerns about the client's care with the appropriate members of the healthcare team. Document the incident and report it to the appropriate authorities or supervisors, as per facility policy, to ensure proper follow-up and prevent future breaches. Maintaining Sterile Technique Scenario A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Nursing Considerations The nurse preceptor should identify the following actions as maintaining sterile technique: - Placing sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape to maintain the sterile field. - Using sterile forceps to pack sterile gauze into the wound. - Setting up the sterile field 30 minutes prior to performing the dressing change to allow for proper drying and preparation. The nurse preceptor should identify the use of a sterile-gloved hand to adjust the back of the sterile gown as a breach of sterile technique. Client with Antibiotic-Associated Diarrhea Scenario A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Nursing Considerations The appropriate action for the nurse to take is to clean the equipment in the client's room with bleach. This helps to prevent the spread of Clostridioides difficile (C. diff), a common cause of antibiotic-associated diarrhea. The nurse should not: - Place the client in a negative-pressure airflow room, as this is not necessary for a client with antibiotic-associated diarrhea. - Perform hand hygiene with alcohol-based hand sanitizer, as this is not • • • • Prioritizing Client Assessments Scenario A nurse is prioritizing care after receiving a change-of-shift report on four clients. Nursing Considerations The client that the nurse should assess first is the client who reports a headache with sensitivity to light. This could be a sign of a more serious neurological condition, such as a migraine or increased intracranial pressure, and requires prompt assessment and intervention. The other clients' reported symptoms, while important, are not as immediately life-threatening as the client with the headache and light sensitivity: - The client who reports feeling lightheaded when standing up can be assessed after the client with the headache. - The client who reports indigestion and jaw pain may be experiencing a cardiac event and should be assessed, but not before the client with the neurological symptoms. - The client who reports an urge to void but has not urinated during the prior shift should be assessed, but is not the highest priority in this scenario. Prioritizing Client Assessments in an Acute Mental Health Unit Scenario A nurse on an acute mental health unit is assessing four clients. Nursing Considerations The client who is the highest priority for assessment is the client who has bipolar disorder and displays constant pacing. This behavior can lead to physical exhaustion and, in severe cases, death. Immediate intervention is necessary to ensure the client's safety and well-being. The other clients, while also requiring assessment and care, are not as immediately life-threatening as the client with the bipolar disorder and pacing behavior: - The client with depressive disorder and poor personal hygiene should be assessed, but is not the highest priority. - The client with dementia and aphasia should be assessed, but their condition is not as acutely unstable as the client with bipolar disorder. - The client with schizophrenia and use of neologisms should be assessed, but their condition is not as immediately life-threatening as the client with bipolar disorder. Prioritizing Nursing Actions Scenario A nurse is planning care for a group of clients. Nursing Considerations The action the nurse should take first is to obtain a breakfast tray for the client whose total parenteral nutrition was discontinued 4 hours ago. This client's nutritional needs should be addressed as a priority. The other actions, while important, are not as time-sensitive as the client who needs a breakfast tray: - Auscultating the bowel sounds of the client who has not had a bowel movement after taking a laxative 12 hours ago can be done after the client with the discontinued TPN receives their meal. - Providing instruction to the caregiver of the client with dementia and a new diagnosis of diabetes mellitus is important, but not as immediate as the client with the discontinued TPN. - Checking on the client with a leg cast and a new onset of pain should be done, but is not the highest priority in this scenario. Discussing Advance Directives and Health Care Proxies Scenario A nurse on a med-surg unit is caring for a client who asks about advance directives and states that they want to appoint a health care proxy. Nursing Considerations The appropriate response the nurse should make is: "A health care proxy can make decisions for you when you are unable to do so." The other responses are not appropriate: - "You must choose a member of your family to serve as your health care proxy" - the client can choose any competent adult, not just a family member. - "You should appoint a health care proxy before undergoing an invasive procedure" - this is not a requirement, and the client can appoint a proxy at any time. - "It is necessary for an attorney to approve your health care proxy" - this is not a legal requirement in most jurisdictions. Clarifying Medication Orders Scenario A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Nursing Considerations The appropriate action the nurse should take first is to review the intended purpose of the prescribed medication with the client. This allows the nurse to provide education and address the client's concerns about the unfamiliar medications. The other actions, while potentially helpful, are not the first step the nurse should take: - Consulting the pharmacist about the client's prescribed medications can be done, but after the nurse has reviewed the purpose of the medications with the client. - Comparing the client's medication administration record with the prescriptions on the transfer orders can be done, but is not the immediate priority. - Calling the provider to clarify the client's prescribed medications can be done, but should not be the first action taken. Prioritizing Client Care on a Med-Surg Unit Scenario A nurse on a med-surgical unit is caring for four clients. Nursing Considerations The client who is the highest priority for the nurse to assess is the client who is postoperative following laminectomy 12 hours ago and is unable to void. This client's inability to void could indicate a serious complication, such as urinary retention, and requires prompt assessment and intervention. The other clients, while also requiring assessment and care, are not as immediately life-threatening as the client with the postoperative urinary issue: - The client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy should be assessed, but is not the highest priority. - The client with peripheral vascular disease and an absent pedal pulse in the right foot should be assessed, but is not as urgent as the client with the postoperative urinary issue. - The client with MRSA and a fever should be assessed, but is not the highest priority in this scenario.