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A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.
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A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries requires follow-up?
- A. Client received 2 mg morphine IV at 0900 for pain rated 6/10.
- B. Client's blood pressure is normal after medication administration.
- C. Client refused morning medications; provider notified.
- D. Client's wound dressing changed at 1100 per protocol.
Correct Answer: B
Rationale: Describing blood pressure as 'normal' is vague and lacks specific data, requiring follow-up to ensure accurate and complete documentation.
A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
- A. Do you know when I will be going home?
- B. My dressing was changed earlier this morning.
- C. I have not received any of my medications today.
- D. I do not know how to make the remote control work.
Correct Answer: C
Rationale: Correct Answer: C. "I have not received any of my medications today."
Rationale: This statement is concerning as it indicates a potential oversight in medication administration, which is crucial for postoperative clients. The nurse should follow up with the PN to ensure that the client receives the necessary medications promptly.
Summary of Other Choices:
A: Asking about discharge is appropriate and does not require immediate follow-up.
B: Reporting that the dressing was changed is a positive sign of wound care management.
D: Not knowing how to use the remote control is not a priority in postoperative care.
Overall, choice C stands out as it directly relates to the client's well-being and should be addressed promptly.
A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
- A. A young adult client admitted for acute glomerulonephritis following a viral infection
- B. A dependent adult admitted for the treatment of a spiral fracture
- C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
- D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Correct Answer: B
Rationale: The correct answer is B because a dependent adult admitted for the treatment of a spiral fracture falls under mandatory reporting requirements for suspected abuse or neglect. The nurse is obligated to disclose information to an outside agency to ensure the safety and well-being of the patient. In cases of suspected abuse or neglect, it is crucial to involve external agencies to investigate and protect the vulnerable adult.
Choices A, C, and D do not necessarily involve mandatory reporting to an outside agency. A young adult with glomerulonephritis or asthma with possible IV drug abuse may not require immediate disclosure unless there is a clear indication of harm or risk to the patient. An emancipated minor with acute appendicitis wanting to leave without treatment raises ethical concerns but may not involve mandatory reporting unless there are specific legal requirements in place.