Nokea
The nurse conducts safety rounds within the nursing unit. Which observation requires followup? Select all that apply.
- A. The client's armband was affixed to the bedside table.
- B. The client's telephone number and name were used as identifiers.
- C. Multiple blood specimen tubes are labeled before specimen collection.
- D. A room number is used as an identifier during medication administration.
- E. Verifies client's name, date of birth, consent, site, and procedure during a time out process.
Correct Answer: A,B,C,D
Rationale: Armbands on tables, using telephone numbers, pre-labeling tubes, and room numbers as identifiers risk errors. Verifying name, date of birth, and procedure details is correct.
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The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl (14.29 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1215 the CBG was 288 mg/dl (15.984 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1730 the CBG was 254 mg/dI (14.097 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should do which of the following at 1730?
- A. Administer 8 units of regular insulin
- B. Administer 6 units of regular insulin
- C. Notify the primary health care provider (PHCP)
- D. Withhold the prescribed insulin
- E. Modify the client's prescribed diet to low sodium
Correct Answer: B,C
Rationale: Per the sliding scale, 254 mg/dL requires 6 units of insulin, and three consecutive CBGs >250 mg/dL require notifying the PHCP.
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Implement seizure precautions
- C. Read back the result for verification
- D. Recollect the laboratory specimen
Correct Answer: C
Rationale: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply.
- A. Increase the number of verbal orders given from primary healthcare providers
- B. Nurse-to-nurse bedside handoff reporting
- C. Handoff reporting using the ISBAR framework
- D. Ensure staff are taking uninterrupted breaks
- E. Increase the lighting around the medication dispensing machines
Correct Answer: B,C,D,E
Rationale: Bedside handoffs, ISBAR framework, breaks, and better lighting reduce errors. Verbal orders increase error risk.