Nokea
The nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs a variance analysis. Which finding should indicate the need for further assessment and analysis?
- A. A client is performing his or her own colostomy care.
- B. A 1-day postoperative client has a temperature of 98.8°F (37.1°C).
- C. A 2-day post-abdominal hysterectomy client has drainage noted from the incision.
- D. A client newly diagnosed with diabetes mellitus is preparing his or her own insulin for injection.
Correct Answer: C
Rationale: Variances are actual deviations or detours from the critical paths. Option 3 is the only option that identifies the need for further action. Variances can be either positive or negative, or avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken.
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The nurse assisting in the care of a client who is to be cardioverted should plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
- A. 50 to 100 joules
- B. 200 to 250 joules
- C. 250 to 300 joules
- D. 350 to 400 joules
Correct Answer: A
Rationale: Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. Cardioversion is usually started at 50 to 100 joules. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the primary health care provider, and the remaining options identify energy levels that are too high for cardioversion.
The nurse manager is reviewing the principles of surgical asepsis with the nursing staff. In which situations should the nurse manager communicate to the staff that it is necessary to use the principles of surgical asepsis? Select all that apply.
- A. Removing a dressing
- B. Reapplying sterile dressings
- C. Inserting an intravenous (IV) line
- D. Inserting a urinary (Foley) catheter
- E. Suctioning the tracheobronchial airway
- F. Caring for an immunosuppressed client
Correct Answer: B,C,D,E
Rationale: Surgical asepsis involves the use of sterile technique. Some examples of procedures in which surgical asepsis is necessary include reapplying sterile dressings, inserting an IV or urinary catheter, and suctioning the tracheobronchial airway. Medical asepsis, or clean technique, includes procedures to reduce and prevent the spread of microorganisms. Removing a dressing can be done by clean technique using clean gloves (although reapplying the dressing requires surgical asepsis). Caring for an immunosuppressed client requires medical asepsis techniques.
The nurse administers digoxin 0.25 \mathrm{mg by mouth rather than the prescribed dose of 0.125 \mathrm{mg to the client. After assessing the client and notifying the health care provider, which action should the nurse implement first?
- A. Write an incident report.
- B. Administer digoxin immune Fab.
- C. Tell the client about the medication error.
- D. Tell the client about the adverse effects of digoxin.
Correct Answer: A
Rationale: According to agency policy, the nurse should file an incident report when a medication error occurs to accurately document the facts. The nurse should assess the client first and then contact the primary health care provider (HCP) because in this situation the client received too much medication. The client should be informed of the error and the adverse effects in a professional manner to avoid alarm and concern. However, in many situations, the HCP prefers to discuss this with the client. Digoxin immune Fab is reserved for extreme toxicity and requires a prescription and may be prescribed depending on the client's response and the serum digoxin level.
The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention should the nurse perform to provide a safe environment for the client at this time?
- A. Place pads on the side rails.
- B. Connect the client to a bedside ECG.
- C. Remove all food or fluids within the client's reach.
- D. Place a water-seal chest drainage set at the bedside.
Correct Answer: C
Rationale: After this procedure, the client remains NPO until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse should monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.
The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?
- A. It limits movement of a limb during a painful procedure.
- B. It prevents the violent client from injuring self and others.
- C. At night it keeps the client in bed instead of wandering about.
- D. It is useful in preventing the client from pulling out intravenous lines.
Correct Answer: C
Rationale: Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A primary health care provider's prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.