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After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol's effectiveness?
- A. Compare the number of falls that occurred before and after protocol implementation
- B. Analyze data that reflects the unit's costs incurred due to the new protocol
- C. Conduct a chart review on the unit to determine the number of clients at risk for falling
- D. Consult with the physical therapist to evaluate the benefits of the new fall protocol
Correct Answer: A
Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.
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The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant's plan of care?
- A. Initiate infant sepsis protocol
- B. Implement seizure precautions
- C. Refer to protective child services
- D. Formula feed every 3 hours
Correct Answer: B
Rationale: The infant's symptoms, such as a high heart rate, continuous crying, irritability, and hyperreactivity, suggest possible withdrawal effects due to maternal cocaine use. These symptoms can lead to seizures. Therefore, the priority intervention is to implement seizure precautions to ensure the infant's safety. Initiating the infant sepsis protocol is not indicated based on the symptoms presented. Referring to protective child services is important but not the immediate priority. Formula feeding every 3 hours is a routine care measure but does not address the urgent need to prevent potential seizures.
After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor for signs of depression
- B. Apply sequential compression stockings
- C. Provide a wide variety of meal choices
- D. Observe for signs of depression
Correct Answer: D
Rationale: Observing for signs of depression is crucial in this patient's plan of care as depression can impact his overall recovery and management post-surgery. Depression is common in individuals struggling with weight management, diabetes mellitus, and hypertension. Monitoring for urinary incontinence (Choice A) is not the priority in this case as the patient is undergoing gastroplasty for weight management, not a urinary issue. Applying sequential compression stockings (Choice B) is important for preventing deep vein thrombosis in immobile patients but is not the priority in this scenario. Providing a wide variety of meal choices (Choice C) is not the most crucial intervention at this stage, as post-gastroplasty dietary restrictions are essential for successful weight management.
The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
- A. The appearance of the returning dialysate fluid is cloudy
- B. The client complains of slight shortness of breath during installation
- C. The amount of the returning dialysate fluid is greater than the amount instilled
- D. The client complains of abdominal fullness and cramping during instillation
Correct Answer: A
Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.
The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?
- A. Remove old dressing using clean gloves. Discard gloves with old dressing
- B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
- C. Apply sterile gauze dressing to wound area
- D. Secure dressing with tape
Correct Answer: A
Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.
The healthcare provider prescribed furosemide for a 4-year-old child with a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?
- A. Urine specific gravity changing from 1.021 to 1.031
- B. Daily weight decrease of 2 pounds (0.9 kg)
- C. Blood urea nitrogen (BUN) increasing from 8 to 12 mg/dl (2.9 to 4.3)
- D. Urinary output decreasing by 5 ml/hour
Correct Answer: B
Rationale: The correct answer is B. A daily weight decrease of 2 pounds (0.9 kg) is the most appropriate outcome to indicate the effectiveness of furosemide in a child with a ventricular septal defect. Furosemide is a diuretic medication that helps reduce fluid retention. Therefore, a decrease in weight reflects a reduction in fluid volume, which is the desired effect of furosemide. Choices A, C, and D are incorrect because changes in urine specific gravity, blood urea nitrogen (BUN) levels, and urinary output do not directly reflect the effectiveness of furosemide in this context.