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Which situation represents the primary nursing care delivery model?
- A. The registered nurse (RN) performs all tasks needed by the individual client to optimize health.
- B. The RN provides care to 4 clients, while the unlicensed assistive personnel (UAP) is assigned to care for 2 clients.
- C. The RN develops a plan of care for each client and collaborates with other staff members assigned to the same group of clients.
- D. The UAP is assigned to make beds and fill water pitchers. The RN is assigned to administer medications.
Correct Answer: A
Rationale: In primary nursing, option 1, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. Option 2 does not follow the guidelines for any specific type of nursing care delivery approach. Team nursing, option 3, is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members.
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The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers should the nurse include in this review? Select all that apply.
- A. Ensure that crib sides are up.
- B. Place large, soft pillows in the crib.
- C. Use large, soft toys without small parts.
- D. Attach a pacifier to a stretchable piece of ribbon and pin to the infant's clothing.
- E. Allow a toddler who is toilet training privacy in the bathroom to promote autonomy.
- F. Ensure that an infant or toddler is never left unattended while lying on a changing table.
Correct Answer: A,C,F
Rationale: To promote safety for infants and toddlers, crib sides should never be left down because the child could roll and fall. Large, soft toys without small parts should be used because small parts can become dislodged and choking and aspiration may occur. For this same reason, an infant or toddler is never left unattended while lying on a changing table. Pillows, stuffed toys, comforters, or other objects should not be placed in the crib because the child can become entwined in these items and suffocate. Pacifiers should not be attached to string or ribbon because of the risk associated with choking. The child is never left alone in the bathroom, in the tub, or near any other water source because of the risk of drowning.
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.
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 medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN?
- A. Asking the client to take sips of water
- B. Asking the client to lie down on his right side
- C. Asking the client to look up at the ceiling for 30 seconds
- D. Instructing the client to void before taking the medication
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication.