LEADERSHIP AND MANAGEMENT Flashcards
A five-year-old has been hospitalized for 24 hours. He is on skeletal traction for the treatment of a right femur fracture. You walk into the room and find him crying. His right foot is pale, and you feel no pulse. What is your priority nursing intervention?
A. Reassess the foot in twenty minutes.
B. Readjust the traction.
C. Administer the ordered as needed pain medication.
D. Notify the physician.
Explanation
Choice D is correct. The assessment findings indicate circulatory compromise to the right foot. This may be secondary to arterial injury distal to the fracture or compartment syndrome. It is an emergency and the nurse should notify the physician immediately to obtain appropriate orders for evaluation and intervention.
Choice A is incorrect. Although reassessment is important, any sign of circulatory compromise should be addressed immediately.
Choice B is incorrect. While readjustment of traction may be necessary, notifying the physician regarding the signs of circulatory impairment is of utmost importance. Physicians may decide on appropriate further interventions.
Choice C is incorrect. The nurse should give analgesics to address the child’s pain. However, the administration of pain medication will not resolve the issue of circulatory impairment and it is not the priority nursing action that should be taken.
NCSBN Client Need
Topic: Physiological Integrity;Subtopic: Physiological Adaptation
Reference:
Kozier and Erb’s Fundamentals of Nursing; Health assessment; musculoskeletal impairment.
Which of the following is an improper technique for correcting written documentation? Select All That Apply.
A. Draw a line through the error, write the date, time, and reason for the error, and add your initials
B. Use correction tape and write over the error so there is no confusion
C. Write over the error in darker ink
D. Completely black out the error with a black marker
Explanation
Choices B, C, and D are correct. All of these practices are inappropriate methods of correcting written documentation. Using a tape, writing over the sentence using a black ink, and blacking out using black marker are attempts to conceal the original documentation and may be considered illegal in a court. In a court of law, the court needs to see the underlying data that were corrected. No effort should be made to obliterate the error.
Choice A is incorrect. It is not illegal for medical professionals to make the necessary updates to records, as long as they follow proper methods and do not obscure information. Choice A, in fact, is the correct technique for correcting the written documentation.
NCSBN Client Need I Topic: Health Promotion and Maintenance
Reference: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer); Chapter 4: Documentation and Interprofessional Communication; Lesson: Accuracy and Completeness
The nurse is caring for a client who has the following clinical data as shown in the Exhibit. Which action should the nurse take based on the 14:00 vital signs?Click the Exhibit button for additional information.
A. Reassess the client’s vital signs (VS) in one-hour.
B. Notify the primary healthcare physician (PHCP).
C. Perform a physical assessment.
D. Stop the infusion of prescribed D5W
Explanation
Correct Answer is B. At 11:00, the client was given intravenous haloperidol, which subsequently increased the client’s pulse and temperature. These changes reflect neuroleptic malignant syndrome (NMS). NMS is brought upon by atypical and typical antipsychotics and is manifested by muscle rigidity, tachycardia, and a fever. The nurse needs to report the 14:00 findings to the provider because of hypertension, progressive tachycardia, and fever.
Choice A is incorrect. The client is showing signs of NMS. Priority action is to contact PHCP. The monitoring of the client can follow later.
Choice C is incorrect. Performing a physical assessment is not necessary at this time as the nurse has sufficient reason to notify the provider.
Choice D is incorrect. Priority action is to report to the PHCP. Stopping the D5W infusion is not immediately necessary.
The nurse is caring for a patient following the placement of a gastrostomy tube. The Unlicensed Assistive Personnel (UAP) reports thin, pale, and yellow-green drainage with sour odor and a small amount of blood. Which is the best action for the nurse to take?
A. Obtain specimen for culture.
B. Assess the drainage.
C. Instruct UAP to obtain full set of patient’s vitals.
D. Assess patient’s temperature for fever.
Explanation
B is correct. The nurse should assess the patient’s drainage to confirm it is within the reasonable expectations for the patient’s condition. Up to 1500mL/day of thin, pale, yellow-green drainage with sour odor and a small amount of blood would be expected for this patient.
A is incorrect. There would be no reason to culture this drainage since it is within expectations for the patient’s condition.
C is incorrect. This would not be an indication to collect a unique set of vitals since this drainage is expected with the placement of a gastrostomy tube. If there is any doubt, the nurse should visualize and assess the patient, not delegate this task to the UAP.
D is incorrect. There would be no reason to expect the patient would be febrile since this drainage is usually scheduled with the gastrostomy tube.
NCSBN Client Need:
Topic: Management of care; Sub-Topic: Assignment/Delegation
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 378)
The primary objective of identification of similarities and differences among the cultural beliefs of the patients by the nurse is to:
A. Communicate with the family
B. Make sure the proper diet is ordered
C. Perform a spiritual consult
D. Avoid making assumptions
Explanation
Choice D is correct. Making assumptions or generalizations about a patient’s spiritual needs based on ethnic or religious affiliation is almost sure to be an oversimplification. The nurse should be able to identify similarities and differences among the cultural beliefs of the patients. Just because a patient belongs to certain culture or ethnicity, it is incorrect to generalize their spiritual needs.
Choices A, B, and C are incorrect. Ordering a specific diet as per the patient’s specific cultural or religious preference is certainly warranted. However, generalizations can not be made here either and knowing patient’s specific preference will help the nurse cater to patient’s dietary or spiritual needs. Communicating with the family and performing a spiritual consult should also be done at the patient’s request. While identification of cultural similarities and differences among the patients can help guide these processes, these are not the primary objectives. The primary objective is to avoid making assumptions.
NCSBN Client Need: Topic: Psychosocial Integrity
Resource: Nursing Health Assessment: A Best Practice Approach (Wolters/Klewer); Chapter 10: Cultural Assessment; Lesson: Characteristics of Culture
What tool, or graphic display, that is shown in the Exhibit can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory?
A. Histogram
B. A Scatter-gram
C. Genogram
D. Ecomap
Explanation
The Correct Answer is D.The tool, or graphic display that is shown above is an ecomap or an ecogram. Ecomaps can assist the nurse in understanding the interrelationships of the family with the environment, as consistent with systems theory Ecomaps show the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Histograms and scattergrams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Choice A is incorrect. Histograms show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact the individual, family, and community.
Choice B is incorrect. Scatter grams show statistical data and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
Choice C is incorrect. Genograms show medical information and risk factors in a realistic manner and not the interrelationships of individuals, families, and communities with their external environment and the forces and relationships that impact on the individual, family, and community.
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
A. Ask the physician for clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
B. Ensure that a working IV pump is set up at the patient’s bedside.
C. Order a STAT arterial blood gas.
D. Pad the side rails of the patient’s assigned bed.
Explanation
Choice D is correct. The patient presented with alcohol withdrawal seizures. The priority nursing action is to pad the bed’s side rails to prevent injury since the patient is at high risk of a recurrent seizure. In an acute care setting, side rails are often used as a medical assistive device and not a restraint. Side rails are considered a restraint only if the intent is to prevent the patient’s free access and keep them in bed. In the setting of seizure precautions, side rails are raised, and the bumper pads are used as a medical assistive device.
Choice A is incorrect. While clonazepam may help with the anxiety associated with alcohol withdrawal, it is not the drug of choice in managing alcohol withdrawal. Instead, diazepam, lorazepam, and chlordiazepoxide are used most frequently to treat or prevent alcohol withdrawal. Furthermore, providing the patient with this medication is not the priority action in patient safety.
Choice B is incorrect. Since the patient will be admitted to a non-medical psychiatry floor, continuous intravenous infusion is not permitted while on that unit. However, necessary injections, oral medications, or other non-invasive procedures performed while on the non-medical unit.
Choice C is incorrect. Ordering a STAT arterial blood gas is not necessary when the patient arrives at the psychiatry unit. Before the patients are sent to the non-medical psychiatry floor, they are already deemed clinically stable and medically cleared.
NCSBN client need | Topic: Safety and Infection Control, Injury Prevention
Reference: Volpicelli, MD, Ph.D., Teitelbaum, MD S. Management of moderate and severe alcohol withdrawal syndromes.
During a holiday party in your long-term care facility, you take unplanned and surprise candid photographs of residents enjoying the festivities for the monthly newsletter. What have you done?
A. You have appropriately facilitated reminiscence therapy with photographs.
B. You have violated federal law.
C. You have effectively facilitated group cohesiveness with these photographs.
D. You have violated state law.
Explanation
The correct answer is B. You have violated the federal law entitled the Health Insurance Portability and Accountability Act of the federal government. The Health Insurance Portability and Accountability Act mandates confidentiality and protects the clients’ right to confidentiality. Taking photographs without resident consent is a violation of the federal Health Insurance Portability and Accountability Act.
Choice A is incorrect. You have not appropriately facilitated reminiscence therapy with these photographs. These surprise group photographs are NOT appropriate.
Choice C is incorrect. You have not appropriately facilitated group cohesiveness with these photographs. These surprise group photographs are NOT appropriate.
Choice D is incorrect. You have not violated state law, but you have violated federal law. Health Insurance Portability and Accountability Act is governed by federal law.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Due to an absent staff nurse, the postpartum unit is assigned a nurse from the “medical” ward as a floater. Which of the following patients should the charge nurse assign to the float nurse?
A. A 20-hour postpartum client who will be discharged the following morning.
B. A 16-hour postpartum client who had eclampsia during delivery.
C. A 10-hour postpartum client who has soaked 4 perineal pads in one hour.
D. A 5-hour postpartum client whose fundus is still not at the midline.
Explanation
Correct Answer is B. This client can be assigned to the float nurse. The nurse is floating from the medical unit to the postpartum unit. Eclampsia is a complication of preeclampsia and is characterized by high blood pressure and seizures. This client remains at risk for a seizure. The goals of management of Eclampsia involve controlling seizures and controlling hypertension. Medical unit nurses understand and are experienced in taking care of clients having a seizure.
“Float Nurse” refers to someone who is permanently assigned to a specific unit but is asked to cover another group because of staffing needs temporarily. Some hospitals have
“float pools” where the nurses float from one to another, based on staffing needs (sick calls, increased census, etc.). Nurses in “float pools” are well versed with a variety of scenarios and are often able to handle many assignments with ease. However, their experience tends to be “generalized” rather than “specialized.” To adequately use the strengths of a “float” nurse, appropriate patient assignments should be made.
A charge nurse should consider a few issues before making patient assignments to a float nurse. More general diagnoses are better suited for the float nurses because such determinations have more standardized plans of care. Regarding unit-specific patients, the float nurses may not have specialized experience to care for such specific diagnoses. These unit-specific patients are better assigned to experienced nurses who are trained for those particular aspects of the patients’ diagnoses and who are more familiar with those complicated care plans.
Choice A is incorrect. The client is being discharged from the postpartum unit. She needs to be assessed whether she has the capacity to take care of her baby once at home. She also needs to be educated by the nurse about newborn care. A specialized nurse with postpartum unit-specific experience should be assigned to this client.
Choice C is incorrect. This client seems to be having primary Post-Partum Hemorrhage (PPH). Uterine atony is one of the leading causes of PPH. Specialized interventions (uterine massage, starting Pitocin drip, etc.) may be needed to control PPH. Therefore, a dedicated nurse with postpartum unit-specific experience should be assigned to this client.
Choice D is incorrect. Soon after delivery, the uterine fundus (upper portion of the uterus), is midline and at 1 to 2 hours post-partum, it is palpable halfway between the symphysis pubis and the umbilicus. About 12 hours post-partum, the fundus is at the level of the umbilicus. In this scenario, at 5 hours postpartum, the client’s fundus is not yet at the midline. This means the fundus is displaced, and the most frequent cause of a displaced fundus is a full bladder. A full bladder may predispose to postpartum hemorrhage because it interferes with normal involution (contraction) of the uterus. The client should be asked to void. The medical nurse is usually not specialized in palpating the fundus, and therefore, this client should be assigned to a unit-specific experienced nurse.
NCSBN client need
Topic: Management of care; Sub-topic: Assignment, Delegation, and Supervision.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003
Which legislative initiative is the most closely related to information technology utilized in healthcare organizations?
A. The Health Insurance Portability and Accountability Act (HIPAA).
B. The state scopes of practice for the Informatics Nurse.
C. The Confidentiality and Information Security rule.
D. The Joint Commission for the Accreditation of Healthcare Organization’s ( JCAHO) standards.
Explanation
The correct answer is C.The Confidentiality and Information Security rule under the Health Insurance Portability and Accountability Act (HIPAA) is the legislative initiative that is the most closely and specifically related to information technology that is utilized in healthcare organizations. This rule specifically addresses the need for data security and protection.
Choice A is incorrect. The Health Insurance Portability and Accountability Act (HIPAA) is not the legislative initiative that is the most closely and specifically related to information technology that is utilized in healthcare organizations. There is another legislative initiative that is more specific to information technology than this.
Choice B is incorrect. The state scopes of practice for the Informatics Nurse are not legislative initiatives that are the most caring and specifically related to information technology utilized in healthcare organizations. Job descriptions for the Informatics Nurse may entail specifics about information technology and its security, but job descriptions are not legislated.
Choice D is incorrect. The Joint Commission for the Accreditation of Healthcare Organization’s ( JCAHO) standards address information technology and security; however, these are regulatory standards and not legislative initiatives.
Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.
Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981?
A. Either irreversible cessation of circulatory and respiratory functions OR irreversible cessation of all functions of the entire brain including the brain-stem.
B. Both irreversible cessation of circulatory and respiratory functions AND irreversible cessation of all functions of the entire brain including the brain-stem.
C. Irreversible cessation of circulatory and respiratory functions only.
D. Irreversible cessation of all functions of the entire brain including the brain-stem only.
Explanation
Choice A is correct.
Important Fact:
The Uniform Determination of Death Act of 1981 defines death as either irreversible cessation of circulatory and respiratory functions OR the irreversible cessation of all functions of the entire brain, including the brainstem.
Choice B is incorrect because the Uniform Determination of Death Act of 1981 does not require both the cessation of circulation and respiratory functions AND irreversible end of all functions of the entire brain, including the brain stem.
Choices C and D are incorrect. Although C or D could constitute a death call, the Uniform Determination of Death Act of 1981 states that death is defined as EITHER option “C” or option “D” above. Hence, C and D are incorrect because these options use the term “Only.”
NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Physiological Adaptation
Reference:
Fundamentals of Nursing/ Theories, Concepts, and Applications (Wilkinson/Treas/Barnett/Smith); Chapter17: Loss, Grief, and Dying; Lesson: Death and Dying
As you are taking the “staff only” elevator, you see a nurse who is now taking care of a client, Mr. B, who you cared for the week before. You ask the nurse how Mr. B is doing and the nurse tells you how significantly his condition has deteriorated over the last week. You have:
A. Violated the confidentiality of client information.
B. Asked an inappropriate question in the elevator.
C. Shown compassion for Mr. B.
D. Shown your caring about Mr. B.
Explanation
Correct Answer is B. You have asked an inappropriate question in the elevator. You have primarily set the other nurse up for a violation of the need for confidential client information because client information can only be shared, orally, and in writing, with others who are providing direct or indirect care to the client, and they have a need to know this information. As based on the information in this question, you are no longer taking care of Mr. B. Therefore; you should never have asked these questions.
The nurse who gave you the information violated Mr. B’s right to confidentiality. Although you asked this question because you are a compassionate and caring nurse, it was not an appropriate question.
Choice A is incorrect. You have not violated the confidentiality of client information because you did not share any client information with anyone.
Choices C and D are incorrect. Although you may have asked this question because you are a compassionate and caring nurse, this is not an appropriate question since you are no longer involved in the client’s care.
References: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice and Sommer, Johnson, Roberts, Redding, Churchill et al.
The nurse is preparing medications for the shift. Which of the following clients should be prioritized for immediate medication administration?
A. Digoxin to a client with an apical pulse of 50.
B. Furosemide to a client with a serum potassium level of 3.0 mEq/L.
C. Magnesium sulfate to a client with Torsades de pointes
D. Verapamil to a client with blood pressure of 100/60 mm Hg.
Explanation
Choice C is correct.
Torsades de pointes, a form of ventricular tachycardia, is a life-threatening condition. The nurse should immediately administer the medication to the client to prevent the disease from progressing into ventricular fibrillation.
Choice B is incorrect. Furosemide is a loop diuretic used to treat congestive heart failure and edema. The drug predisposes the client to hypokalemia. In this case, the client already has a low serum potassium level. Therefore, the nurse needs to notify and question the prescribing physician whether he/she should still proceed with administering the medication.
Choice A is incorrect. When the nurse is administering digoxin, she should check the patient’s apical pulse and withhold the dose if the pulse falls below 60 beats per minute.
Choice D is incorrect. The blood pressure of the client is at 100/60 mm Hg. Verapamil is a calcium channel blocker and is often used to treat high blood pressure and angina. It can be administered as ordered. Typically, physicians order blood pressure medications to be held at a systolic blood pressure of 90 mm Hg or below. However, the nurse should prioritize administering magnesium to the client with Torsades de pointes.
Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier.
The nurse is triaging a group of clients in the emergency department (ED). Which client should the nurse triage as emergent? Select only one option
A. 36-year-old complaining of pleuritic chest pain with a productive cough.
B. 81-year-old complaining of nausea and vomiting for two days.
C. 50-year-old presenting with malaise and an isolated area of reddened vesicles.
D. 68-year-old presenting with ataxia and dysarthria.
Explanation
Choice D is correct. A client presenting with ataxia and dysarthria is likely to have a cerebrovascular accident (CVA). This client is presenting with life-threatening symptoms and should be triaged as emergent. If the client is confirmed to have an ischemic stroke, the physician is likely to order reperfusion therapy (tPA)within a 3 to 4.5-hour window. Therefore, this presentation is an emergency.
Choice A is incorrect. The client with pleuritic chest pain and productive cough is likely presenting with pneumonia. There is no mention of unstable vitals. Such a client would be triaged as urgent. Per guidelines, such clients should receive antibiotics within 2 hours of presentation in the ED. This client should be attended after the client in Option D.
Choice B is incorrect. The elderly client with nausea and vomiting would be triaged as urgent. Such clients are prone to dehydration and renal failure. There is no mention of unstable vitals. The client should be attended after the client in option D.
Choice C is incorrect. The client with malaise and an isolated area of reddened vesicles is likely to have Shingles or Herpes Zoster. This client is triaged as non-urgent and should be attended to after other clients in options D, B, and A are attended.
During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP) working with her. After charging, which of the following is the nurse’s primary responsibility?
A. Document the completion of the task
B. Make a list of tasks not yet completed to pass on to the next shift
C. Observe the UAP for the duration of the task
D. Follow-up with the UAP to ensure completion of the task, evaluating the outcome.
Explanation
D is correct. The nurse should follow-up with the UAP to ensure completion of the task, evaluating the outcome. The ultimate responsibility for any job will always remain with the person who delegated it. Therefore, after delegating a task, the nurse’s primary responsibility will be to follow up with the UAP.
A is incorrect. The nurse’s primary responsibility after delegating a task will be to follow up with the UAP. The nurse cannot document the completion of the job until the follow-up has been performed.
B is incorrect. It is unnecessary to make a list of tasks not yet completed to pass on to the next shift. The nurse’s primary responsibility after delegating a job will be to follow up with the UAP.
C is incorrect. If delegating correctly, the nurse must delegate a task within the scope of practice of the UAP and therefore does not need to observe the UAP for the duration of the job. The nurse’s primary responsibility after delegating a task will be to follow up with the UAP.
NCSBN Client Need:
Topic: Effective, safe care environment; Subtopic: Infection control and safety
Subject: Fundamentals; Lesson: Prioritization, delegation, and leadership
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
ou are a nurse working in a medical unit with a trained aide. You have admitted a new patient and have received the following orders.You know that the correct prioritization for performing these tasks is: ( Please arrange in correct sequential order)
Vital Signs every 4 hours.
Insulin 2 units Humulin Subcutaneous now.
CBC, electrolytes, urinalysis, and 2 sets of blood cultures.
Amoxicillin 250 mg by mouth first dose now and then every 6 hours.
Explanation
Correct Sequence is in the following order:-
Insulin – 2 units Humulin Subcutaneous NOW. CBC, Electrolytes, urinalysis, and 2 sets of blood cultures Amoxicillin 250 mg by mouth first dose now, and then every 6 hours Vital Signs every 4 hours
While prioritizing the orders from physician, the nurse should look for the orders that specify urgency – such as “STAT” or “as soon as possible” or “now.”
A “now” prescription for insulin should be done as soon as possible after the patient arrives on the floor. The nurse should understand that insulin lowers the patient’s blood sugar and can help to prevent sequelae associated with high blood sugar. Since the patient is being initiated on antibiotics, it appears there is a suspicion of infection. In patients with suspected infection, glycemic control is helpful in achieving good outcomes.
Collecting the labs is the second task that should be completed since blood cultures have been ordered. Blood cultures must always be collected BEFORE the administration of an antibiotic so that the antibiotic does not interfere with the results. Obtaining cultures after antibiotics may give false negative results.
As soon as the blood cultures are drawn, the nurse should administer the amoxicillin since it is ordered “now”, and every 6 hours. In almost any infection including sepsis, guidelines allow 1 to 2 hours window from the time of patient arrival before which antibiotics can be administered. Blood cultures must be obtained before antibiotics.
Finally, vital signs are the lowest priority for the nurse since this is a task that can be delegated to the aide following an initial assessment. It can be executed after the above orders are completed.
NCSBN Client Need
Topic: Management of Care;Sub-Topic: Establishing Priorities
Subject: Adult Health;Lesson: Prioritization
The nurse checks the history of several pre-operative patients before their scheduled surgeries. Which of the following patients should the nurse be most concerned with and alert the doctor about the elevated risk of surgical complications? Select all that apply.
A. The epileptic patient who took carbamazepine early in the morning
B. The diabetic patient with a blood glucose of 250 mg/dl.
C. The patient with anemia and a hemoglobin level of 6.5mg/dl.
D. The patient who suffers from insomnia.
E. The patient who reports a history of trouble being anesthetized
Explanation
Choices B and C are correct. The most concerning patients are diabetic patients with uncontrolled hyperglycemia and those with severe anemia. Both conditions significantly increase the patients’ risk of developing surgical complications and should be managed before surgery.
Hyperglycemia is an independent marker of poor surgical outcomes in both diabetic and non-diabetic patients. The random glucose test in an average adult normally ranges between 80mg/dl to 140mg/dl. A random blood sugar greater than 180 to 250 mg/dl is considered severe hyperglycemia. Uncontrolled hyperglycemia increases the risk of infections, delays surgical wound healing, prolongs hospital stay, and increases postoperative mortality. The physician must be notified, and the blood sugars must be optimized before surgical intervention. A desirable goal in most perioperative patients is to maintain blood glucose in the range of 140 to 180 mg/dl. In cases of severe hyperglycemia (greater than 250 mg/dl), surgery should be postponed by a few hours to obtain good glycemic control.
Severe anemia must be corrected before the patient undergoes surgery. Surgical blood loss may further worsen the pre-existing anemia. Severe anemia increases the risk of postoperative mortality. In patients with underlying cardiovascular disease, the risk of post-operative death significantly increases when preoperative hemoglobin is 10 g/dL or less. The physician should be alerted, so the cause of anemia is investigated, and transfusions are given as needed. In patients with no symptoms from anemia and no history of ischemic heart disease, hemoglobin above 7gm% is considered reasonable to undergo surgery. Those patients who are symptomatic from their anemia should be transfused as needed.
Choice A is incorrect. While many medications should be held before surgery, anti-convulsant such as carbamazepine should not be withheld. Post-operative electrolyte imbalances such as hypomagnesemia can increase the seizure potential in a patient with epilepsy. Anti-convulsant must never be withheld peri-operatively. If the patient ends up having a seizure intra-operatively or post-operatively, surgical outcomes may worsen.
Choice D is incorrect. Insomnia is not an absolute contraindication to performing surgery. Good sleep may help promote wound healing, and therefore, measures to improve sleep can be deployed after surgery.
Choice E is incorrect. While the nurse should inform the doctor regarding the prior history of the patient’s difficulty being anesthetized, this by itself does not increase the risk of surgical complications.
NCSBN client need
Topic: Reduction of Risk Potential: Potential for Complications for Surgical Procedures and Health Alterations.
Reference:
Lewis S, Dirksen S, Heitkemper M, Bucher L, Harding M. Medical-Surgical Nursing.
A 23-year-old college student seeks medical help at the infirmary complaining of severe fatigue. She reports exertional dyspnea, and her skin appears pale. Aplastic anemia is suspected. Laboratory values reflect anemia, and the client is advised for a bone marrow biopsy. The client refuses to sign the consent and states, “Come on, just get the doctor to give me a transfusion and let me go. Spring break begins this weekend, and I’m leaving for Florida.” The nurse’s most significant concern at this time would be:
A. The possibility that the client may contract infection from being exposed to large crowds at spring break
B. The client does not understand the full impact of her condition
C. The client may need transfusion before leaving for spring break
D. The causative agent needs to be identified and the treatment should be started
Explanation
Choice B is correct. The possibility of an infection is a concern but not the most pertinent issue at this point. The most significant concern at this point is the fact that the client does not fully grasp the gravity of her condition. She must be educated and be allowed to verbalize her feelings about her situation.
A transfusion is only a temporary measure because the causative agent has not been identified. For treatment to commence, a bone marrow biopsy needs to be done first, but before that, the client’s feelings regarding her condition need to be addressed for care to continue. The correct answer is option B. Options A, C, and D are incorrect.
Reference:
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier
The nurse and the Licensed Practical Nurse (LPN) are assigned to a busy medical unit. Which of the following tasks would be appropriate for an LPN to take? Select all that apply.
A. Reinforcing newborn care education to a 24-year-old first-time mother.
B. Adjustment of a 68-year-old stable patient’s cervical traction as ordered by the provider.
C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis.
D. An assessment of a 36-year-old man newly admitted for chest pain.
Explanation
Choices A, B, and C are correct. Initial teaching does not fall within the scope of practice of an LPN. A registered nurse always performs initial instruction. However, LPNs can “reinforce” education (Choice A) to a client. Generally, the tasks that require “critical thinking” should not be delegated to an LPN. Tasks such as obtaining stool samples for occult blood (Choice B) and following health care provider’s orders to adjust cervical traction (Choice C) are all within the scope of practice of an LPN and do not require critical thinking process. LPNs can also apply and remove the cervical collar on stable spinal patients.
If the cervical traction is being applied for neck fractures, RNs or LPNs should not remove or add the traction weight since such patients have spinal instability. For an unstable client in traction, an RN should assess the neurovascular status, and document as ordered. Assessment or caring for unstable clients is not within the scope of LPN practice. However, cervical traction may also be applied for other reasons such as osteoarthritis, etc. In a client with stable clinical status and predictable outcomes, adjusting cervical traction as ordered by the provider falls within the scope of LPN practice. Choice B does not mention any unstable findings that fall outside the scope of an LPN.
For any question regarding delegation to LPNs, please make sure you determine the complexity and predictability of the client.
A Registered Nurse (RN) is responsible for determining the level of complexity and predictability of a client’s presentation. The RN documents this in an established plan of care. The LPNs accountability for the outcomes of care and independence of practice depends mostly on the predictability and complexity of the client presentation. Please note that the scope of practice is based on decisions around a task, not the job itself.
Predictability involves assessment of how effectively a health condition is managed, the changes likely to occur, and whether the type and timing of change can be predicted (College of Nurses of Ontario,1997, p.6). Complex or unstable situations are those where the patient’s status is fluctuating with unexpected responses resulting in an elaborate plan of care.
In cases where there is a high degree of complexity and a low degree of predictability, RNs are solely accountable for outcomes of care (“unstable” situations). In these cases, custody is determined by frequent assessments. The LPN practice in these cases is DIRECTED by the RN in that decisions of care are made by the RN only. Interventions change often, and patients’ responses to intrusions may be unexpected or high risk. In acute cases where there are equal degrees of complexity and predictability, RNs and LPNs share accountability for the outcomes of care. LPN practice is COLLABORATIVE with the RN in that decisions of responsibility are made by the RN and LPN together. In stable situations where there is a low degree of complexity and a high degree of predictability, the plan of care can be readily established. It can be managed with interventions that have predictable outcomes. Here, LPNs are solely accountable for the results of care. LPN practice is INDEPENDENT of the RN. The LPN is responsible for determining that the skills are appropriate for the patient.
Planning is not within the scope of an LPN. LPNs cannot formulate a care plan but may collaborate with an RN’s care plan.
In short, one may remember a popular mnemonic “DO NOT DELEGATE WHAT YOU EAT (LPNs cannot Evaluate, Assess, Teach).”
Choice D is incorrect. LPNs can perform focused assessments. However, initial and comprehensive assessments should always be performed by a registered nurse or an attending physician. The client with chest pain may involve a high degree of complexity and a low degree of predictability. Such assessment and planning require the critical thinking process.
Here is a 5-minute refresher video on the LPN Scope of Practice:
https://www.youtube.com/watch?v=EkYe7rSsJkk
The nurse is caring for a 2-year-old client who is intubated and mechanically ventilated. Two hours into the shift, the hospital receives a tornado warning. What is the priority action the nurse should take?
A. Clock out, her shift is over and she is not responsible.
B. Remove the child from the ventilator and carry her to a tornado shelter.
C. Move the patient as close to the interior of the room as possible
D. Close all of the doors
Explanation
Choice C is correct.
The priority action for the nurse is always to “best protect her patient.” During a tornado warning, the appropriate nursing action is to move patients away from windows and as close to the room’s interior as they can safely be. This action best protects them in the event of a tornado.
Choice A is incorrect. It is not appropriate to clock out because her shift is over. The nurse is always responsible for her patients’ safety, and clocking out does not best protect her patient.
Choice B is incorrect. It is inappropriate to remove the child from the ventilator because it could result in serious harm and even death if the child is dependent on mechanical ventilation.
Choice D is incorrect. Closing all of the doors will not protect the patient during a tornado. This is an appropriate action in some fire events depending on the fire’s location, but never for a tornado.
NCSBN Client Need:
Topic: Effective, safe care environment;Subtopic: Infection control and safety
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
A patient has completed a living will stating that he does not want intubation, mechanical ventilation or artificial nutrition/ hydration should he become unable to communicate his preferences related to medical care. However, the patient’s adult children have expressed their opposition to the patient’s wishes. Which are appropriate nursing actions? Select allthat apply.
A. Notify the patient’s physician, the nursing supervisor, and the risk manager.
B. Explain to the patient’s family that the living will cannot be changed at this point.
C. Encourage the family to discuss their feelings to try to resolve this issue.
D. Request a consult with the facility ethics committee if needed.
E. Advise the patient to just go along with the wishes of his adult children.
Explanation
Correct answers are A, C, and D. Should such a conflict be observed, the nurse should notify the patient’s physician, the nursing supervisor and the risk manager, and encourage the family to discuss the issue among themselves, and with the above individuals, to resolve the conflict. A consult with the ethics committee may also be indicated.
Choice B is incorrect. The patient may revoke or change an advance directive at any time, either orally or in writing.
Choice E is incorrect. By law, the patient has a right to autonomy and self-determination, including the right to choose and refuse treatment.
Blooms Taxonomy - Analyzing
References:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8th Edition. Elsevier Mosby St Louis 2013.
Lippincott’s Nursing Procedures 5th Edition. Lippincott Williams & Wilkins. 2009
The nurse is providing patient care working in a unit that uses the total patient care model for delivering nursing care. The nurse recognizes which of the following as an aspect of this nursing care delivery model?
A. The RN assumes responsibility for a caseload of patients
B. The RN supervises team members providing direct patient care
C. The RN provides care for the same patients during their hospital stay
D. The RN is responsible for all aspects of care during a shift of care
Explanation
Correct Answer is D. Characteristics of the total patient care model include; the RN being responsible for all aspects of care during a shift of care, care can be delegated, and the RN works directly with the patient, family, and health care team members.
Choices A and C are incorrect.The RN having responsibility for a caseload of patients and providing care for the same patients during their hospital stay are characteristics related to the primary nursing model.
Choice B is incorrect. In team nursing, team members provide patient care under the supervision of the RN team leader.
Bloom’s Taxonomy: Analyzing.
Reference:
Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing 8th Edition. Elsevier Mosby St Louis 2013.
The patient is presenting with a fever, nausea, and dysuria. Which action would the nurse take first?
A. Administer as needed antipyretic.
B. Call physician to obtain an antibiotic order for a suspected UTI
C. Collect midstream, clean-catch urine specimen
D. Collect STAT blood cultures
Explanation
C is correct. The nurse should recognize that this patient is presenting with symptoms of urinary tract infection (UTI) or pyelonephritis. The most appropriate first action would be to assess the patient and check the urine for infection.
A is incorrect. In a patient who is not in distress or severe pain, the nurse should not administer medication until the assessment is complete.
B is incorrect. The nurse should finish assessment prior to calling physicians since there is no data to support a medical emergency scenario to immediately notify physician without a complete assessment. Besides, urine specimen should be collected before administering an antibiotic in a suspected UTI.
D is incorrect. The patient’s symptoms are consistent with urinary tract infection and would not necessarily warrant blood cultures. A complicated UTI may evolve in to sepsis. If signs of sepsis are present, blood cultures would be appropriate.
NCSBN Client need:
Topic: Establishing priorities, system-specific assessment
Reference: (DiGiulio & Keogh, 2014, p. 368);Subject:Adult health;Lesson:Renal/urinary
The nurse on a medical floor receives a report on four patients. Which patient should the nurse see first?
A. A client with pulmonary embolism on anticoagulation, dyspnea, and pCO2 of 30mmHg
B. A client with atrial fibrillation on Warfarin, history of prior rectal bleeding and an INR of 6.0
C. A client Congestive Heart Failure and Brain Natriuretic Peptide of 640 pg/mL
D. A client with Acute pancreatitis and serum calcium of 8.9 mg/dL
Explanation
Choice B is correct. While answering prioritization questions, it is essential to determine which findings are unexpected and which pose an immediate risk of complications to the client. The target International Normalized Ratio (INR) for atrial fibrillation is 2.0-3.0. A supra-therapeutic INR of 6.0 is too high for this patient and puts the patient at high risk for bleeding. Additionally, given his prior history of gastrointestinal bleeding, he is more prone to recurrent bleeding in the setting of coagulopathy. The nurse should hold warfarin, assess the patient for signs of bleeding and notify the physician of abnormal results to determine if vitamin K should be administered to counter the effects of warfarin.
Choice A is incorrect. The client has an established diagnosis of Pulmonary Embolism (PE) and is on therapeutic anticoagulation. Dyspnea and elevated D-dimer are expected results in patients with known PE. D-dimer reflects thrombin and plasmin activity and is usually positive in hospitalized patients with thrombotic events. Low pO2 (Hypoxia) and low pCO2 (Respiratory alkalosis) are expected findings in patients with PE. Normal PCO2 is 35-45 mmHg, so 30 mmHg is small but not critical (<20 mmHg).
Choice C is incorrect. Brain Natriuretic Peptide is a marker for Congestive Heart Failure (CHF) because it correlates with left ventricular pressure. High Left ventricular pressures and high BNP levels are expected findings in patients with heart failure. A BNP more top than 100 pg/mL is abnormal. The client has an established diagnosis of CHF, and a report of BNP at 640 pg/mL does not require immediate action.
Choice D is incorrect. Acute pancreatitis can cause decreased calcium levels (hypocalcemia). Severe hypocalcemia may be seen in acute pancreatitis and can present with neurological as well as cardiovascular manifestations. However, since the normal range for serum calcium level is 8.6-10.2 mg/dL, this patient’s result of 8.9 mg/dL is within normal range and would not warrant any intervention.
NCSBN Client Need:
Subject: Leadership/management; Lesson: Prioritization
Reference: (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 578-579)
The nurse is studying the role of referrals in coordinating the client’s care. The primary purpose of referrals is to:
A. Ensure that the continuum of care is a seamless transition.
B. Ensure the completeness and appropriateness of the client care.
C. Establish the registered nurse as the center of client care.
D. Establish the client or the group as the center of client care.
Explanation
Correct Answer is B.The primary purpose of referrals is to ensure the completeness and appropriateness of the client care. Although there are many clients’ needs that the nursing team can address, there are also client needs that can be met by others in the multidisciplinary healthcare team.
Choices A, C, and D are incorrect. Although the continuum of care must be a seamless transition, and referrals are an essential component of client movement along the continuum of care, it is not the primary purpose of references.
Lastly, the client is the center of the client care, not the registered nurse. Although clients participate in the referral process, establishing the client or the group as the center of client care is not the primary purpose of referrals.
Reference: Ellis, Janice Rider, and Celia Love Harley (2012). Nursing in Today’s World: Trends, Issues, and Management (10th Edition). Philadelphia, PA: Lippincott Williams and Wilkins.
The nurse is taking care of a client receiving a D5LR intravenous infusion. Suddenly, the client complains of chest pain and difficulty breathing. On exam, there is cyanosis and tachycardia. The nurse also notices an empty IV bottle. What is the initial intervention of the nurse?
A. Replace the empty IV bottle with a new one.
B. Replace the IV line and attach a new IV bottle.
C. Stop the IV infusion and turn the client on his left side with the head of the bed lowered.
D. Stop the IV infusion and notify the physician.
Explanation
Choice C is correct. The nurse should suspect “air embolism” because the patient is presenting with characteristic symptoms in a setting where the fluid infusion is complete and the IV drip set is still open. An empty IV “bottle” offers this clue. Manifestations of an air embolism include tachycardia, hypotension, chest pain, the difficulty of breathing, and cyanosis. Air embolism may cause blockage of small pulmonary vessels compromising the gas exchange, obstruction of ventricular pumping, and arrhythmias. In practice, replacement of IV infusion bottles with collapsible air bags has largely minimized the risk of air embolism during IV infusions.
The nurse’s initial action would be to turn off the infusion system, place the client on his left side with the head lowered (left Trendelenburg position), and notifying the physician. Left-sided Trendelenburg position will help the air bubble float in the right ventricle/ right atrium and prevents it from causing right ventricular outlet obstruction.
Choice A is incorrect. Replacing the IV bottle is not an appropriate intervention in this situation since the client is already presenting with signs and symptoms of air embolism. To prevent air embolism, the nurse should have replaced the IV bottle before it is empty. At this time, the nurse should turn off the infusion system and place the client in left-Trendelenburg position.
Choice B is incorrect. Replacing the IV line and hooking up a new IV bottle does not address the air embolism.
Choice D is incorrect. A nurse should never delay a lifesaving intervention which is within the scope of his/her practice. After stopping the infusion, the next immediate action for the nurse would be to place the client on his left side with the head lowered to trap the air in the right atrium. Following this, the nurse must notify the physician.
Reference
Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO
Which of the following components should the nurse know to include in her handoff at the end of her shift?
A. List of p.r.n (as needed) medications administered
B. Normal assessment findings for the shift
C. A complete history of lab results and interventions since admission
D. All scheduled medications the client receives.
Explanation
Choice A is correct. Medications administered as needed should be included in the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. It is important to include important information about the client about what has occurred over the previous change, and if any “as needed” (p.r.n) medications were administered.
B is incorrect. Normal assessment findings for the shift are not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. Reviewing all normal assessment findings would not only take too long but is not necessary information. Any changes in assessment findings, abnormal findings, and current problems should be included, but normal assessment findings are not required to cover.
C is incorrect. A complete history of lab results and interventions since admission is not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. Going over a complete history of lab results and interventions since admission would not only take too long but would not be pertinent.
D is incorrect. All scheduled medications the client receives is not a necessary component of the nursing handoff. Nursing handoff should review the client’s condition during the past shift accurately, but quickly. As needed medications, changes in the client’s situation, interventions, and the client’s response to such interventions are part of the nursing handoff.
NCSBN Client Need:
Topic: Effective, safe care environment; Subtopic: Coordinated care
Subject: Fundamentals; Lesson: Prioritization, delegation, and leadership
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
While working in an adult cardiac telemetry unit, you see each of the following rhythms on the monitor. Which of the following is your immediate priority? A . 3RD-DEGREE BLOCK B . SINUS BRADYCARDIA C . SUPRAVENTRICULAR TACHYCARDIA D . NORMAL SINUS RHYTHM
Explanation
Choice A is correct. This Electrocardiogram (ECG) shows a third-degree heart block, otherwise known as a complete heart block. This rhythm is fatal without intervention. If you notice this, you must notify the physician immediately so appropriate interventions can be implemented.
A complete heart block may lead to fatal symptomatic bradycardia with a heart rate of less than 40/min, hypotension, seizures, cerebral ischemia, or cardiac arrest, and sudden cardiac death. It, therefore, is considered a fatal rhythm, and hence, this patient is a top priority.
To understand a complete heart block, you must first understand a normal EKG. The image shown below indicates a normal EKG where there is a clear relationship between a “P” wave and “QRS” complex. P-R interval is regular. “P” wave indicates SA (sinoatrial node) node firing, whereas QRS indicates Ventricular contraction. PR interval is the time interval from Sinus node firing to the time it reaches ventricle and results in shrinkage. “T” wave indicates ventricular repolarization, and it marks the beginning of ventricular relaxation.
In a 3rd degree or complete heart block, there is no atrioventricular conduction, so no impulses from the supraventricular nodes (sinus impulses) are conducted to the ventricles whatsoever. This results in erratic heart rates where the sinus node and the atrioventricular nodes are beating independently. This leads to a junctional rhythm where there is no correlation between P-waves and QRS complexes. The atrial rhythm will be regular (P to P interval regular). Ventricular rhythm is steady (R-to-R range is consistent). However, the P-R interval will be variable. These are the typical characteristics of a 3rd degree AV block.
Choice B is incorrect. This ECG shows sinus bradycardia. There are a regular P-R interval and the proper relationship between P waves and QRS complexes. But the heart rate is lower. The price of impulses arising from the sinoatrial (SA) node is more economical than expected. The average adult heart rate, resulting from the SA node, is usually 60 to 100 beats per minute. Sinus bradycardia is defined as a sinus rhythm with a rate below 60 beats per minute. While sinus bradycardia can sometimes be concerning, it is not a fatal rhythm that requires immediate attention in the absence of symptoms. This may even be an average heart rate for the patient, depending on their baseline. Athletes who are very well conditioned tent to have low baseline heart rates, such as a heart rate in the 40s. Therefore, it is so important to know what is normal for your patient.
Choice C is incorrect. This ECG shows supraventricular tachycardia or SVT. While this is a concerning rhythm that will need attention, it is not your priority given that you have a patient in third-degree heart block that could suffer sudden cardiac death. SVT is often tolerated by patients for long periods and can be challenging to break. The typical treatment is adenosine or cardioversion to convert the patient back into normal sinus rhythm.
Choice D is incorrect. This ECG shows normal sinus rhythm or NSR. This is the baseline rhythm that we expect to see in all patients, so this patient would not be your priority. You would need to see all the other patients on your above list first, as they all have irregular rhythms.
NCSBN Client Need:
Topic: Physiological Integrity; Subtopic: Physiological adaptation
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
You are taking care of an 80-year-old patient who is post-op day one from abdominal surgery. Upon assessment, you notice bowel protruding through her incision and quickly determine that evisceration has occurred. Place the following actions in order of priority:
Prepare the patient for immediate surgery
Take vital signs and monitor for and signs of shock
Call for help and stay with the patient
Document the incident.
Cover the wound with a sterile normal saline dressing
Correct Answer is:
Call for help and stay with the patient
Cover the wound with a sterile normal saline dressing
Take vital signs and monitor for and signs of shock
Prepare the patient for immediate surgery
Document the incident.
Explanation
The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, and the surgeon must be notified STAT.
After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler’s position ( no more than 20 degrees bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension.
After these two actions, the next nursing action is to check the patient’s vital signs and monitor for shock while waiting for the health care providers.If signs of shock such as tachycardia and hypotension are noted, there is a medical emergency, and the health care provider/ rapid response needs to be called to the bedside immediately.
After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident.
NCSBN Client Need
Topic: Physiological Adaptation Subtopic: Medical Emergencies
Reference:
Ignatavicius D, Workman ML: Medical-surgical nursing: Patient-centered collaborative care, ed 7, Philadelphia.
The nurse receives a call from her mother who tells her that her father is having sudden and severe chest pain but is refusing to go to the hospital. What should be the nurse’s initial action?
A. Tell her mother to call 911.
B. Ask her mother to let her father chew an aspirin.
C. Ask what her father ate recently.
D. Ask her mother if she can talk to her father.
Explanation
Choice B is correct. An acute myocardial infarction (MI) should always be suspected while considering a differential diagnosis of new-onset chest pain in an elderly man. Often, the pathophysiology of acute myocardial infarction or unstable angina involves thrombus (clot) formation and propagation. The patient should be given an aspirin to chew on first to decrease platelet aggregation and prevent the thrombus from getting any bigger. The patient is obviously in distress and intervention should be initiated. The benefits of early aspirin administration outweigh the risks. Several clinical trials have strongly suggested that the early administration of aspirin can significantly reduce the size of the myocardial infarction and improve survival. Studies have shown that aspirin administration within one hour of emergency room presentation by a patient with an acute MI or unstable angina is associated with a substantial reduction in 30-day mortality when compared to those given aspirin an hour after the presentation. Therefore, the nurse should certainly advise her mother to give her father an aspirin. Also, the patient should be instructed to chew aspirin rather than swallowing it at once. Chewed aspirin works faster compared to swallowing it at once.
Generally, if a patient experiences a new onset chest pain, the recommended sequence of action is to call 911 or local emergency first and then take an aspirin. Often, it is the 911 operator who first evaluates the patient’s symptoms and advises the patient to take an aspirin. Once dispatched, the paramedics can give oxygen and medications and move the patient fast to the ER. If the patient is indeed having a heart attack, early intervention with thrombolytics or angioplasty can limit the damage. Therefore, calling 911 is crucial. In this case, the patient’s wife has already called her daughter who is a nurse. The wife also mentioned that the patient is unwilling to go to the hospital. Being a nurse, it would be an appropriate and responsible action for the daughter to advise her mother to give the aspirin right away. Following that, the daughter can talk to her father to alleviate his anxiety, convince him to call 911, and go to the hospital.
Choice A is incorrect. Had the mother not already reached out to her daughter who is a nurse, the recommended course of action would be to call 911 and then give her husband an aspirin. However, the mother has reached out to a nurse. In the role of a nurse, it is appropriate for the daughter to advise her mother to give her father aspirin right away and then call 911.
Choice C is incorrect. Obtaining more history will certainly help to narrow down the differential diagnoses of new-onset chest pain. Asking what her father ate could give the nurse additional information about the potential cause of the chest pain; if it is related to a gastrointestinal or cardiac etiology. However, the patient is in distress and the first intervention should be to give an aspirin. The benefits of early aspirin administration outweigh the risks.
Choice D is incorrect. The nurse can talk to her father to alleviate his anxiety and get more history while her mother is getting the aspirin. The priority action should be to give aspirin to her father.
Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes, Nebraska: Elsevier.
