The nurse is caring for a client who is post-op day 1 for a...

The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following? Select all that apply.

A. using standardized handoff reports
B. knowing how to perform a chart check
C. following up on outstanding lab reports and incomplete orders
D. knowing the proper procedures to transfer clients to another floor

Correct Answer: A,B,C,D

Rationale: Standardized handoffs, chart checks, following up on labs/orders, and proper transfer procedures all ensure continuity of care.

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The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Select all that apply.

A. A sterile object is held below the table surface and returned to the sterile field.
B. The outer inch of the sterile towel hangs over the side of the table.
C. A partially emptied container of sterile betadine is replaced within the sterile field.
D. Sterile packages are opened with the first edge away from the technician.

Correct Answer: A,B,C

Rationale: Holding a sterile object below the table surface, allowing the towel to hang over the edge, and replacing a partially used container all compromise sterility. Opening packages with the first edge away from the technician is correct technique.

Nurses are expected to understand the principles of triage when caring for multiple clients. The ICU charge nurse is reviewing assignments. Based on the principles of triage, to which client would the charge nurse give priority for treatment? Select all that apply.

A. a client on a ventilator who has an alarm sounding
B. a client who has just returned from an open appendectomy
C. a client ready to transfer to the floor after the nurse calls report
D. a client who has been talking with family and is now unresponsive
E. a client receiving a new antibiotic who complains of tingling in the mouth

Correct Answer: A,D,E

Rationale: A ventilator alarm, unresponsiveness, and tingling (possible anaphylaxis) indicate immediate threats to life, requiring priority in triage.

The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?

A. a client with gout in the large toe
B. a client with fever, vomiting, and diarrhea
C. a client with MRSA
D. a client with severe dementia with a tendency to wander

Correct Answer: A

Rationale: The gout client has a non-infectious condition, minimizing infection risk for the immunocompromised necrotizing fasciitis client.

A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?

A. Clients have the right to view their medical records but may not copy any of the information contained in the records.
B. Clients wavenumber be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance.
C. Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan.
D. It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information.

Correct Answer: C

Rationale: Clients have the right to a fair review of complaints, as per the Patient's Bill of Rights. The other options contain inaccuracies.

A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?

A. Work closely with the UAP during the shift and observe for any signs of impairment.
B. Complete the bed bath without comment. The unit is already short one staff member.
C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.

Correct Answer: D

Rationale: The smell of alcohol suggests potential impairment, which poses a safety risk to clients. Reporting to the charge nurse ensures client safety and follows protocol. Options A, B, and C fail to address the potential risk adequately.