Question 1

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply.

Accepted Answer

Repositioning and transferring clients can be delegated to unlicensed assistive personnel (UAP) when it is deemed safe and appropriate. The nurse must provide UAPs with detailed instructions, including when to move the client, which techniques to use, and when to use assistive persons or devices. The nurse must also notify UAPs of any client mobility restrictions. Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving (Option D). The client who is 8 hours postoperative total hip replacement requires assessment prior to repositioning as the client is at risk for hip dislocation. A wedge may be needed to maintain abduction; nursing judgment is required (Option A). To reduce the risk of client and staff injury, safe transfers and repositioning are achieved using the following guidelines: Use a gait/transfer belt to transfer a partially weight-bearing client to a chair (Option B). Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist (eg, comatose, medicated) (Option C). Use a full-body sling lift to move/transfer nonparticipating clients. Use 2-3 caregivers to move cooperative clients weighing less than 200 lb (91 kg). Use 3 or more caregivers to move cooperative clients weighing more than 200 lb (91 kg) (Option E). Educational objective: Client repositioning and transferring can be delegated to unlicensed assistive personnel if it is deemed safe and appropriate. The nurse must provide instructions to maintain client safety and intervene if the task is performed inappropriately or requires nurse involvement (eg, spinal cord stabilization).

Question 2

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first?

Accepted Answer

A subdural hematoma is caused by bleeding into the subdural space and is the result of blunt force head trauma. It is life-threatening, as increased pressure from the hematoma on the brain can lead to decreased cerebral perfusion and herniation (mid-line shift). Assessing for signs of increased intracranial pressure, including change in level of consciousness, Cushing triad (hypertension, bradycardia, and irregular respirations), ipsilateral pupil dilation, headache, and vomiting, is critical as surgery to evacuate the hematoma and relieve the pressure may be necessary. (Option A) Manifestations of neurogenic shock include hypotension and bradycardia. Although the client has bradycardia and requires monitoring, the client is normotensive and has normal skin color and temperature, which indicate adequate perfusion. (Option B) Headache, transient change in level of consciousness, and inability to remember the injury (retrograde amnesia) are expected manifestations of a concussion. The Glasgow Coma Scale score of 15 (range: 3-15) indicates complete orientation. (Option D) Central diabetes insipidus results from head trauma. Damage to the hypothalamus or pituitary gland leads to decreased antidiuretic hormone secretion, resulting in increased serum osmolality (>295 mOsmol/kg [295 mmol/kg]). Treatment is necessary, but polyuria (>200 mL/hr) and hypernatremia (sodium >145 mEq/L [145 mmol/L]) due to dehydration are expected manifestations. Educational objective: A subdural hematoma is caused by bleeding into the subdural space outside the brain. Surgical evacuation of the hematoma may be necessary to relieve the pressure on the brain, as increased intracranial pressure can lead to decreased cerebral perfusion, herniation (mid-line shift), and death.

Question 3

After receiving the shift report, the nurse should assess which infant first?

Accepted Answer

A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. (Option A) A normal respiratory rate for an infant is 30-60/min. This infant is currently stable. (Option C) It is normal to auscultate crackles in an infant during the first hour of life. This is because fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable. (Option D) A normal temperature range for an infant is 97.7-99.7 F (36.5-37.6 C). This infant is currently stable. Educational objective: The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus.

Question 4

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met?

Accepted Answer

The best indicators of a successful intervention (desired effect achieved) are objective criteria. This is an objective measurable result that can be correlated with the intervention. (Option B) Attending an inservice seminar for staff education is an important and necessary step for intervention implementation. However, the intervention will be successful only if the information is applied and the desired outcome achieved. (Option C) Reporting the number of written reminders given to respective clients is necessary. However, this reporting of intervention achievement is subjective as recall can be inaccurate. Even if it were an accurate recounting, it does not prove that the intervention succeeded. The appropriate focus should be on client outcomes, not nursing staff behaviors. (Option D) Although approval from surgeons provides helpful support for the intervention, an objective evaluation beyond personal opinions is required. Educational objective: The effectiveness of an intervention should be determined by objective measurable outcomes that can be correlated with the intervention. It should not be based only on personal opinion or staff activities.

Question 5

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department.  The nurse suggests the transfer of which client to the health care provider?

Accepted Answer

Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any health care setting. (Option A) Cardiac troponins are proteins released into the blood by damaged cardiac muscle (ie, myocardial infarction). Serial troponin I levels are normal (<0.5 ng/mL [0.5 mcg/L]) in clients with unstable angina as there is no muscle injury; however, cardiac ischemia is present. This client requires continual cardiac monitoring and interventions to restore blood flow to the heart. (Option B) Atrial fibrillation involves the rapid firing of irritable foci in the atria and an irregular, sometimes rapid, ventricular response. To slow the heart rate (goal <100/min), an IV infusion of the calcium channel blocker diltiazem (Cardizem) is prescribed; this requires continual cardiac monitoring. (Option C) Complete heart block is life-threatening and requires a pacemaker. This client should not be transferred. Educational objective: Clients with unstable angina experiencing chest pain and clients newly admitted with complete heart block or atrial fibrillation with a rapid ventricular response are unstable and require continual monitoring in an intensive care unit.

Question 6

Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural practices of the clients on their assigned unit. Which leadership strategy is best for the nurse manager to implement to assist the graduate nurses in developing cultural competency?

Accepted Answer

The transformational nurse manager provides a supportive culture in which learning is valued and best practices are implemented to ensure the appropriate skill level and experience of each staff member. A workshop would provide the graduate nurses with an opportunity to learn and ask questions about the cultures represented on their unit. It would also help develop cultural awareness and sensitivity, leading to respect for the diverse cultures represented on the unit. (Option A) Cultural diversity is present in every clinical unit; therefore, it is not feasible to assign the graduate nurses to a unit without cultural diversity. (Option C) To provide culturally competent care, the graduate nurses must know about the various cultures represented on their unit. Culturally competent care is first attained through education. Afterward, the graduate nurses are ready to implement best practices in the care of clients from diverse cultures. (Option D) Although researching various cultures would assist the graduate nurses in learning, the new graduates are novices and have not fully developed cultural competency; therefore, they are not the best individuals to provide an in-service on this topic. Educational objective: Nurse managers must ensure that the nursing staff can provide quality care to clients on the unit through development of the necessary skills, including cultural competency. Nurse managers can find mentoring and continuing education programs and Internet resources useful in developing the cultural competencies of staff nurses.

Question 7

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply.

Accepted Answer

Lateral violence (also known as horizontal violence) can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague. These behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming. However, other acts, such as refusing to help someone, sabotage, exclusion, and unfair assignments, also fall under the category of lateral violence. Violence in the workplace should not be tolerated or ignored by either staff or management. Actions that staff members can take if they become victims of lateral violence include: Documenting and keeping a file of all incidents (Option A) Reporting the incidents to the immediate supervisor Letting the bully know that the behavior will not be tolerated (Option E) Observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) (Option C) Seek support from within the facility or from an external source (Option B) Ignoring acts of lateral violence will perpetuate the bullying. (Option D) The chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain. Educational objective: Lateral violence in the workplace (acts of aggression by an employee toward another employee) should not be tolerated or ignored. Victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way, and seeking support.

Question 8

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply.

Accepted Answer

Potassium-sparing diuretics (eg, spironolactone, triamterene, eplerenone), ACE inhibitors (eg, lisinopril, ramipril), and angiotensin II receptor blockers (eg, losartan, valsartan, candesartan) cause hyperkalemia. Therefore, these should be held in clients with underlying hyperkalemia (Option D). Aminoglycosides (eg, gentamicin, tobramycin, amikacin) are used to treat serious infections. The nurse should monitor renal function and peak and trough levels, and report an elevated creatinine level (>1.3 mg/dL [115 µmol/L]) to the health care provider as it is a major adverse effect that can indicate reversible nephrotoxicity. An adjustment in the dose and dosing interval may be required (Option E). (Option A) Neutropenia (decreased neutrophil count) increases a client's susceptibility to infection. Filgrastim (Neupogen) is used to increase the neutrophil count in clients with certain malignancies and in those undergoing chemotherapy. Neutropenia is expected in this client and is not the most important result to report. (Option B) Acute osteomyelitis, an infection of the bone, is characterized by local and systemic manifestations of infection (eg, leukocytosis - white blood cell count >11,000/mm³ [11.0 x 10⁹/L], increased erythrocyte sedimentation rate, fever) and involves long-term antibiotic therapy. This is expected and is not the most important result to report. (Option C) Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl). Morphine can also be used; worsening pancreatitis due to an increase in sphincter of Oddi pressure has not been proven in studies. Elevated lipase level is expected and is not the most important result to report. Educational objective: ACE inhibitors (eg, lisinopril, ramipril) and angiotensin II receptor blockers ("sartans") can cause hyperkalemia (potassium >5.0 mEq/L [5.0 mmol/L]). Aminoglycosides (eg, tobramycin, gentamicin, amikacin) can cause nephrotoxicity.

Question 9

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply.

Accepted Answer

Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing (Options A and E). The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature (Option B). (Options C and D) The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information. Educational objective: The nurse's role in informed consent is to witness a client's signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions.

Question 10

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room?

Accepted Answer

Although placing pediatric clients of different sexes in a semi-private room is not ideal, the charge nurse must prioritize client room assignments based on client safety. At ages 4 and 5, the male-female pair can room together. The client in Buck traction does not have a transmittable illness. The client post laparoscopic appendectomy is also not infectious. Given the options above, this is the safest room assignment. (Option B) Children with infections requiring airborne precautions (eg, varicella, tuberculosis, measles) should be placed in a private, airborne infection isolation room (eg, negative airflow room). If required, clients infected with the same organism can be roomed together, but a private room is preferred. (Option C) Rotavirus is a viral gastroenteritis, and salmonella is a bacterial gastroenteritis. The risk for cross contamination is high, especially with caregivers sharing the facilities. (Option D) A client with sickle cell anemia is at risk for infection due to spleen dysfunction (repeated infarctions), and a client with periorbital cellulitis has an infection. Although compatible in age and sex, these clients should not share a room. Educational objective: Pediatric room placement should be based on disease process, sex, and developmental stage. When assigning children to semi-private rooms, the charge nurse must consider client safety first.

Question 11

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client?

Accepted Answer

Cellulitis is a common skin bacterial infection that is usually treated with IV antibiotics in clients with diabetes mellitus. Room 2 is the best assignment option for this client with cellulitis. The client with dementia and urinary incontinence who has an external urinary condom catheter is the least susceptible to infection compared to those in rooms 1, 3, and 4. (Option A) The client who is 1 day postoperative laparoscopic cholecystectomy (surgical procedure with small incisions) is at increased risk for infection. The client with cellulitis should not be placed in room 1. (Option C) Although this client has pulmonary embolism, the history of prior splenectomy leads to a very high lifelong risk of rapid sepsis. Splenectomy clients need vaccination against encapsulated organisms (eg, pneumococcus, meningococcus, and Haemophilus influenzaetype B). Even a low-grade fever should be taken seriously in these clients. The client with cellulitis should not be placed in room 3. (Option D) Lupus nephritis is a serious renal complication of systemic lupus erythematosus (SLE), an inflammatory autoimmune disease that can lead to end-stage kidney disease. The systemic disease and the immunosuppressant (azathioprine [Imuran]) prescribed to slow its progression increase infection risk. The client with cellulitis should not be placed in room 4. Educational objective: A client with an infection should not be assigned to a semi-private room with a client who had surgery or is immunocompromised and receiving immunosuppressants as these clients are highly susceptible to infection. Post-splenectomy clients are also at lifelong risk for rapid sepsis.

Question 12

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

Accepted Answer

11ecbb05_cbbc_eeec_b433_9df1ab20734c_MD0009_00 During a mass casualty event, the goal of the nurse is to triage rapidly and provide the greatest good for the greatest number of people. Clients are commonly triaged using a color-coded system and placed into four categories. When prioritizing clients for treatment, emergent needs should be managed first followed by urgent and nonurgent needs. If no clients are identified as having emergent needs, clients with urgent needs (eg, open fractures with palpable pulses) should be treated first (Option B). (Options A and C) Clients who are expectant due to the severity of their injuries (eg, severe neurological trauma, full-thickness burns >60% total body surface area) are the lowest priority for treatment. However, the nurse should provide palliative care, if possible, while addressing the needs of others. (Option D) Clients with nonurgent needs (eg, minor lacerations) should receive treatment after emergent and urgent clients. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged rapidly using a color-coded system that ranks them from highest medical priority to lowest: red (emergent), yellow (urgent), green (nonurgent), and black (expectant).

Question 13

The nurse receives news of a local mass shooting.  Stable clients need to be discharged to make room for newly admitted clients.  Which client would the nurse identify as safe to recommend for discharge?

Accepted Answer

Disaster events cause a sudden increase in admissions to local hospitals. The nurse identifies clients who are safe to recommend for discharge to make room for newly admitted clients. A client with acute asthma exacerbation may require treatment in the emergency department or hospitalization for oxygen, inhaled bronchodilators, and corticosteroids. The client can likely be discharged home when respiratory status has stabilized and continue the previous home regimen of inhaled bronchodilators and corticosteroids (Option B). (Option A) Clients who have received chemotherapy may be immunocompromised due to neutropenia. An immunocompromised client is at greater risk of sepsis from an infection. Close monitoring and antibiotic therapy are required. (Option C) Clients with diabetes may develop diabetic ketoacidosis (DKA) during illness or infection. Features of DKA (eg, lethargy, abdominal pain, hyperglycemia, urine ketones) are a medical emergency. Untreated DKA may progress to loss of consciousness and coma. Treatment includes frequent laboratory monitoring and IV insulin, fluids, and potassium. (Option D) Clients with ulcerative colitis are at risk for developing toxic megacolon (ie, severe inflammatory colon distension). Symptoms include fever, nausea, vomiting, pain, and abdominal distension. Clients require close monitoring, nasogastric tube for decompression, IV fluids, and antibiotics. Emergency surgery may be required. Educational objective: In response to a local disaster, the nurse identifies clients who can be safely discharged to make room for newly admitted clients. A client with acute asthma exacerbation can be safely discharged home when respiratory status has stabilized.

Question 14

Which issue would a unit quality improvement committee address?

Accepted Answer

A unit quality improvement committee assesses process standards (guidelines, systems, and operations) and clinical issues on a specific unit that affect delivery of client care and client outcomes. The committee implements a process to improve performance if the standards are not being met. Examples requiring unit quality improvement include the following: Medications prescribed STAT are not available in a timely manner Catheter-associated bacterial infections are increasing within the unit (Option C) (Option A) The issues addressed by a unit quality improvement committee should be related to standards and clinical factors involving the specific unit rather than client perception. (Option B) Individual practice issues or concerns (eg, individual performance, financial reimbursement) would be addressed by the nurse's manager or appropriate hospital committee (eg, peer review committee). (Option D) Although workplace hostility can potentially affect staff perceptions and performance, personnel issues should be addressed by the specific department manager (eg, laboratory personnel management) or human resources. Educational objective: A unit quality improvement committee assesses clinical issues arising on a unit (eg, increased infection rate) and problems with the systems and standards (eg, late delivery of medications from pharmacy) created to ensure delivery of quality care. This committee is not concerned with administrative or management issues (eg, client satisfaction surveys, individual performance reviews).

Question 15

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

Accepted Answer

The key aspects related to radiation exposure are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction, and manifests later on. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. (Option A) Nerve agents used as biological weapons (eg, sarin) inhibit acetyl-cholinesterase, and their effects are caused by the resulting excess acetylcholine. Common symptoms are miosis, rhinorrhea, copious secretions, shortness of breath, and flaccid paralysis. Treatment is with suction and support ventilation and circulation. However, these symptoms are not related to radiation contamination. (Option C) Damage from radiation affects the most radiosensitive cells first; these are the hematopoietic, digestive, central nervous system, and cutaneous cells. The presence of severe symptoms indicates extensive internal damage and that the victims are less salvageable in the long term. (Option D) Neurologic symptoms such as symmetrical descending flaccid paralysis with cranial nerve palsies (ptosis, diplopia, dysphagia, dysphonia) are classic of botulism, which is caused by toxins from the spore-forming anaerobic bacillus Clostridium botulinum. Treatment includes ventilator assistance and the heptavalent botulism antitoxin. Educational objective: In triaging victims from a radiation contamination disaster, nurses should assist clients who are farthest away from the source and have the least symptoms as most damage is internal and will not be apparent initially. Nerve agents (eg, sarin) cause excess acetylcholine with copious secretions. Neurologic symptoms are classic for biological threats such as botulinum toxin.

Question 16

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client?

Accepted Answer

Surgical debridement of an unstageable pressure injury involves using a scalpel to remove necrotic (eschar) or infected tissue from the wound to promote healing. The most appropriate room assignment for this client is Room C, as the client with a gastrointestinal bleed and nasogastric tube is the least susceptible to infection compared with the clients in Rooms A and B (Option C). (Option A) Multiple myeloma is a cancer that involves proliferation of malignant plasma cells (monoclonal antibodies), which are ineffective in providing protection against infection and suppress normal bone marrow cell production (eg, erythrocytes, platelets, leukocytes). This client in Room A is especially vulnerable to infection due to immunosuppression related to the disease process and to drug therapy with corticosteroids. (Option B) The postoperative client should not be assigned to Room B with a client who has osteomyelitis, an infection of bone. (Option D) The client with influenza requires droplet precautions and would likely require a private room (Room D). Clients with severe disease (ie, requiring hospitalization) should receive antiviral medication (eg, zanamivir, oseltamivir) as they are at high risk for complications. Educational objective: A client undergoing an extensive surgical debridement for an infected pressure injury should not be assigned to a room with a client who is vulnerable to infection (eg, immunocompromised) or who has an active infection.

Question 17

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action?

Accepted Answer

The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option C). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option D). (Option A) Although taking vital signs when a client reports pain is appropriate, evidence indicates that vital signs are unreliable physiologic indicators for pain. (Option B) The UAP is instructed to ask the client if they are having pain and then report back to the nurse. However, the registered nurse is responsible for pain assessment and should not delegate this task to the UAP. Educational objective: A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait.

Question 18

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home?

Accepted Answer

Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information (Option D). Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. When a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially in situations where sensitive information needs to be communicated (Option C). Children should not be used as translators except in an emergency situation when there are no other options. (Option A) This client's parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child's care at home. (Option B) Providing written materials without verbal teaching does not give the client (or the client's legal guardian) the chance to ask questions, nor does it give the nurse the opportunity to assess the client's understanding of the given information. Educational objective: When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes.

Question 19

The risk management nurse is reviewing client records.  Which nursing intervention could have contributed to a sentinel event?

Accepted Answer

A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. (Option A) Flumazenil is the appropriate antidote for a benzodiazepine overdose. (Option B) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option D) Nitroprusside is a potent vasodilator often used for hypertensive urgencies. Educational objective: The target International Normalized Ratio (INR) for most conditions in which warfarin is used is normally 2-3 and is occasionally 3.5. The risk of bleeding increases as the INR rises.

Question 20

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply.

Accepted Answer

The best indication of moving air in a client with asthma is peak flow. The results are categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal best and caution), and red (<50% of personal best - a medical alert). This client is currently in good control. Other findings to note include effortless breathing, no cough or wheeze, and sleeping well all night (Option C). Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness in skeletal muscles, especially in the bulbar region that involves eye movement, swallowing/speaking, and breathing. Such clients become more exhausted as the day progresses. The client can be discharged home as ptosis is an expected finding (Option E). (Option A) Normal Glasgow Coma Scale is 15; a score of 12 indicates impairment requiring further care. (Option B) The varices oozing blood are at risk for rupture and/or increasing ammonia (from the digestion of protein in the blood). This client needs treatment. (Option D) Normal platelet count is 150,000-400,000/mm³ (150-400 × 10⁹/L). A potential complication of heparin therapy is thrombocytopenia. The client is at risk for paradoxical thrombosis (eg, stroke, arterial clots) and, rarely, bleeding. Educational objective: Clients with an acute head injury and a Glasgow Coma Scale of 12, thrombocytopenia while on heparin, or oozing varices in cirrhosis are not stable for discharge.

Exam 5: Leadership & Management

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply.

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first?

After receiving the shift report, the nurse should assess which infant first?

A nursing unit implements a quality improvement process of written reminders to ameliorate incentive spirometer (IS) use in postoperative clients. What is the best indicator that the client goal for this process has been met?

The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate another acutely ill client from the emergency department. The nurse suggests the transfer of which client to the health care provider?

Several graduate nurses tell the nurse manager that they are unfamiliar with the various cultural practices of the clients on their assigned unit. Which leadership strategy is best for the nurse manager to implement to assist the graduate nurses in developing cultural competency?

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply.

The nurse reviews the serum laboratory results of assigned clients. Which results are most important to report to the health care provider? Select all that apply.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply.

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room?

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client?

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first?

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?

Which issue would a unit quality improvement committee address?

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination?

The charge nurse must assign a room for a client who was transferred from a long-term care facility and is scheduled for extensive surgical debridement to remove infected tissue from an unstageable pressure injury. Which room assignment is the most appropriate for this client?

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action?

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event?

There has been a community disaster with multiple victims. Stable clients must be released to make room for the victims. Which clients would the nurse recommend as stable for discharge? Select all that apply.