Nokea
A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 89/50 mm Hg. What action by the nurse is best?
- A. Call the Rapid Response Team
- B. Document and continue to monitor
- C. Notify the primary care provider
- D. Repeat blood pressure measurement in 15 minutes
Correct Answer: A
Rationale: The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer respiratory or cardiac arrest. Since the client has experienced a significant change in blood pressure, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. Notifying the primary care provider is important but does not address the immediate need for intervention. Repeating the blood pressure measurement delays necessary action.
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A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?
- A. Provide the client's current pain level and history
- B. Administer additional pain medication as needed
- C. Document the client's pain in the medical record
- D. Schedule a follow-up visit with the physician
Correct Answer: A
Rationale: The SBAR format (Situation, Background, Assessment, Recommendation) is used for clear and concise communication with healthcare providers. Providing the client's current pain level and history is part of the Background and Assessment components of SBAR, ensuring the physician has relevant information to make informed decisions. The other options are not part of the SBAR communication process.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important for client safety?
- A. Bring a list of all medications and what they are for
- B. Keep the doctor's phone number by the telephone
- C. Write down the name of each caregiver who comes in the room
- D. Verify the surgical site with the surgeon before the procedure
Correct Answer: A
Rationale: Medication errors are the most common type of health care mistake. The Joint Commission's Speak Up campaign encourages clients to help ensure their safety. One recommendation is for clients to know all their medications and their purposes to prevent medication errors, which directly impacts client safety.
A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?
- A. Ask the hospitals there about standard nurse-client ratios
- B. Choose the hospital that has the newest technology
- C. Find a hospital that is accredited by The Joint Commission
- D. Use a facility affiliated with a medical or nursing school
Correct Answer: C
Rationale: Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on safety. Nurse-client ratios differ by unit type and change over time. New technology doesn't necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, however safety is most important.
Which action by the nurse working with a client best demonstrates respect for autonomy?
- A. Asks if the client has questions before signing a consent
- B. Gives the client accurate information when questioned
- C. Treats the client fairly compared to other clients
- D. Keeps promises made to the client
Correct Answer: A
Rationale: Autonomy is self-determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, because without full information the client cannot practice autonomy. Giving accurate information is practicing veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice.
A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best achieve this goal? (Select all that apply.)
- A. Attend hand-off rounds to coach and mentor
- B. Conduct audits of staff using a new template
- C. Hand-off rounds to coach and mentor
- D. Encourage staff to ask questions during hand-off
- E. Give raises based on compliance with reporting
Correct Answer: A,B,C,D
Rationale: A protocol for standardizing hand-off reports and other critical communication is the SHARE model. Attending hand-off rounds gives the manager opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is standardizing within the system. Encouraging staff to ask questions and think critically about the information is allowing opportunities to ask questions. Giving raises based on compliance is not part of the SHARE model.