100 C LIENT M ANAGEMENT AND L EADERSHIP S UCCESS

COMPREHENSIVE EXAMINATION ANSWERS AND RATIONALES

1. 1. Fosamax should be administered in the morning on an empty stomach to increase absorption, but it is not priority over the client’s sitting up for 30 minutes. The client should main upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion.

2. The client with peptic ulcer disease may be more a risk for esophageal erosion, but the HCP should have assessed this prior to pre- scribing this medication for the client. 3. The client with osteoporosis should be

encouraged to walk to increase bone den- sity, but this is not pertinent when adminis- tering the medication.

4. Fosamax should be administered on an empty stomach with a full glass of water to promote absorption of the medication. The client should remain upright for at least 30 minutes to prevent regurgitation into the esophagus and esophageal erosion.

2. 1. This is an example of autonomy. The client needs all pertinent information prior to making an informed choice.

2. This is an example of fidelity. Fidelity is the duty to be faithful to commitments and involves keeping information confi- dential and maintaining privacy and trust.

3. This is an example of veracity, the duty to tell the truth.

4. This is an example of nonmalfeasance, the duty to do no harm. This avoids telling a client facing surgery that he has cancer.

3. 1. The client’s international normalized ratio (INR) is 3.4. The therapeutic range is 2 to 3 for a client diagnosed with atrial fibrillation. This client is at risk for bleeding. The nurse should hold the medication and discuss the warfarin with the HCP.

2. Metoclopramide is used to stimulate gastric emptying. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication.

3. Docusate is a stool softener. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication.

4. Atorvastatin is a lipid-lowering medication. Nothing in the stem or the MAR indicates a problem with administering this medication. The nurse would administer this medication.

4. 1. The first step in cardiopulmonary resusci- tation according to the AHA guidelines is to establish unresponsiveness by “shaking and shouting.” If the client does not respond to being shaken, then the nurse can proceed to the next step, which is to “look, listen, and feel” for breaths. This is assessment and, according to AHA guide- lines, the UAP could perform this func- tion if alone. However, the nurse should assess the client before a UAP.

2. Administering two rescue breaths comes after establishing unresponsiveness and lack of respiration.

3. The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time.

4. The nurse should place the client in the recumbent position before attempting to perform chest compressions; the nurse should send the UAP for help and the crash cart.

5. 1. The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client’s heart quits beating.

2. The information about the DNR status is already inside the chart. It may need to be placed on the outside of the chart and a special arm band or other notification made to other health-care personnel.

3. The client has a DNR order, but this does not imply that there may be 6 months or less life expectancy for the client. (Hospice care may be requested for clients with less than a 6-month life expectancy.) An order for hospice must be written by the attending health-care provider before making this referral. 4. The client should be allowed as many

visitors as the hospital policy allows.

6. 1. An elevated amylase would be expected in a client diagnosed with acute pancreatitis. The nurse would not need to call the HCP immediately.

2. An elevated WBC would be expected in a client diagnosed with a septic (infection) leg wound. The nurse would not need to call the HCP immediately.

3. The urinalysis report showing many bacteria is indicative of an infection. Clients receiving chemotherapy are at high risk of developing an infection. The nurse should notify the HCP immediately.

4. This blood glucose level is above normal range but would not be particularly abnor- mal for a client diagnosed with type 1 dia- betes. The nurse would not need to call the HCP immediately.

7. 1. The client has not complained of claustro- phobia. The client has some type of neuro- logic abnormality.

2. A vest restraint will not keep the client’s head still during the MRI.

3. The nurse should make sure that the client does not have any medical device implanted that could react with the magnetic field created by the MRI scan- ner. An implanted ECG device could prevent the client from having an MRI, depending on the age of the pacemaker and the material with which it was made.

4. Family members are requested to stay out- side of the area where the MRI is performed.

8. 1. The nurse needs as much information as possible in order to provide care for the client. The client may or may not have a significant other to be contacted. This is not the best way to try to get information on the client.

2. The ambulance workers will only be able to give a cursory report based on the limited information that was provided to them. This is not the best place to try to get information on the client.

3. The nursing home should send a trans- fer form with the client that details cur- rent medications and diagnoses as well as hygiene needs. Previous hospital records will include a history and physi- cal examination and a discharge sum- mary. This is a good place to start to glean information regarding the client.

4. The HCP orders may contain a current diagnosis but will not contain any informa- tion about the client’s medical history. This is not the best place to try to get informa- tion on the client.

9. 1. The nurse asked the client her name, and the client replied that she was a different person.

2. The step the nurse did not take was to verify the client’s arm band against the MAR. Checking the identification band

against the MAR would have prevented the error.

3. This is not the step that was overlooked. 4. This is not the step that was missed.

10. 1. The nurse should implement the least restrictive measures to ensure client safety. Restraining a client is one of the last measures implemented.

2. Moving the client near the nursing sta- tion where the staff can closely observe the client is one of the first measures in most fall prevention policies.

3. This is considered medical restraints and is one of the last measures taken to pre- vent falls.

4. Four side rails are considered a restraint. Research has shown that having four side rails up does not prevent falls and only gives the client farther to fall when the client climbs over the rails before falling to the floor.

11. 1. The nurse cannot testify to what preceded the client’s fall because the nurse was not on duty at the time.

2. The nurse was not on duty to assess the client’s injuries, so any information about the injuries received from the fall would have to be hearsay or obtained from the chart.

3. The nurse cannot testify to the client’s mental status prior to the fall because the nurse was not on duty at the time.

4. The nurse initiated a policy that is designed to prevent falls from occur- ring. This is all the nurse can testify to. 12. 1. The LPN is qualified to perform a

sterile procedure, such as inserting an indwelling catheter before surgery. This is an appropriate assignment.

2. Turing and repositioning a client can be delegated to a UAP.

3. Emptying a client’s bedside commode and recording the amount of urine can be del- egated to a UAP.

4. The nurse should feed the client who gagged during the last meal to assess the client’s ability to swallow. This client is unstable and cannot be assigned/delegated.

13. 1. The registered nurse, experienced or not, can be assigned nursing duties of assess- ment, planning, teaching, and other duties that cannot be delegated or assigned. The charge nurse only has two RNs for 35 clients. This nurse should not be requested to stay home.

2. An experienced LPN will be needed by the unit to care for the many IV lines and medications.

3. The UAP cannot administer medica- tions or IVs and has requested to be allowed to stay home. This is the best staff member to request to stay home.

4. This UAP may be less experienced on the floor but has not worked long enough to receive any paid time off, and this could greatly affect the UAP’s pay.

14. 1. The resident’s WBC count is within nor- mal limits and indicates an ability to resist infection. The nurse should not place this resident in reverse isolation.

2. The resident’s H&H is slightly lower than normal but not low enough to cause dys- pnea during activity. The resident does not need oxygen.

3. The resident’s platelet count is very low and could cause the resident to bleed. The nurse should initiate bleed- ing precautions that include not using sharp blades to shave the resident and using soft bristle toothbrushes.

4. The client is not at risk for developing an infection. The client does not need the temperature checked every 4 hours.

15. 1. The charge nurse does not have a right to interfere with two consenting adults having a relationship. Doing nothing is the correct action for the charge nurse. If one of the residents involved is inca- pable of giving consent to a relationship, then the charge nurse might need to get involved.

2. Two consenting adults have a right to form a bond. The family does not have a right to interfere with the expression of a basic human need, to form an intimate relationship with another human being. 3. The residents have the right to compan-

ionship. They should be allowed to partic- ipate in any activity that they wish, when they wish.

4. This is a normal situation, and no care plan meeting is needed.

16. 1. The argument should already be in a pri- vate area because the argument ensued during report. Report should always be held in a confidential area.

2. The CNO should evaluate the con- cerns of each charge nurse and then make a decision as to a plan of care for the resident. The CNO is the next in

command over the charge nurses in an extended care facility.

3. This argument does not involve the fam- ily. If, after listening to both sides, the CNO thinks there is a need for family member’s input, then the CNO could contact the family, but a decision should be made until this can occur.

4. The nurses each have a concern over a resident. This situation should be resolved before continuing report.

17. 1. Calling a time-out when a discrepancy is noted on the surgical permit is an appro- priate action to prevent an error during a surgical procedure.

2. The Joint Commission requires two iden- tifiers be utilized prior to administering medications. Most hospitals use the client’s date of birth for the second identifier. This is an appropriate action to prevent an error during a medication administration.

3. A quiz during orientation is given to assess whether the new employee understands the information being taught. Giving the answers to the quiz completes the required documentation for the employee’s files but does not ensure the new hire understands how to utilize the IV pump. This is a viola- tion of the Patient Safety Goals.

4. Initiating a fall prevention program for an elderly client to prevent falls is an appropri- ate action to attempt to ensure client safety.

18. 1. The therapeutic PTT level should be 11_/

2to 2 times the control. Most con-

trols average 36 seconds, so the thera- peutic levels of heparin would place the control between 54 and 72. With a PTT of 92, the client is at risk for bleeding, and the heparin drip should be held. The nurse should assess this client first.

2. A client diagnosed with pneumonia would be expected to have a fever. This client can be seen after the client diagnosed with a DVT.

3. Cystitis is inflammation of the urinary bladder, and burning on urination is an expected symptom.

4. Pancreatitis is a very painful condition. Pain is a priority but not over potential for hemorrhage.

19. 1. Digoxin can be administered later because it is a routine medication.

2. Lasix can be administered within the 1-hour leeway (30 minutes before and after); it does not need to be administered first.

3. Darvon is not due yet; the nurse should assess the client and determine whether nonpharmacologic interventions to relieve pain can be implemented, but this medica- tion cannot be administered for 2 hours.

4. Tylenol is administered for mild- to-moderate pain. By the time the nurse obtains the medication and per- forms all of the steps to administer a medication correctly, it will be time for the client to receive the Tylenol. This medication should be administered first.

20. 1. The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client’s age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the

question that should be asked because many clients may be embarrassed to bring up the subject.

2. The client should not drive a motor vehi- cle until released to do so by the HCP. This is not an appropriate question at this time.

3. The client should be discharged with a prescription for oral pain medications to be taken as directed by the surgeon. The nurse should not encourage the client to use old medications the client may have at home. This is not an appropriate question.

4. The nurse is providing discharge instruc- tions and should tell the client when to call the HCP. This is not an appropriate question.

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Rehabilitation Nursing