Nursing Comprehensive Exam 1

Use the following formula for calculating medication dosages: Desired divided by Available multiplied by 1 Capsule = Capsule(s) per dose; 100 mg divided by 50 mg multiplied by 1 Capsule = 2 Capsules

Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in specified areas, or the nurse can prove the lack of knowledge for the performance of an assigned task. When encountered with this situation, the nurse should set priorities and identify potential areas of harm to the client. All pertinent facts related to client care problems and safety issues should be documented. The nurse should perform only those tasks in which training has been received. It is the nurse’s responsibility to clearly describe these tasks.

Syringes should never be recapped in any circumstances because of the risk of getting pricked with a contaminated needle. Used syringe should always be placed in a sharps container immediately after use to avoid individuals getting injured. A syringe should not be swept up, because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe

Early ambulation should not exceed the client’s tolerance. The client should be assisted before sitting. The client is assessed to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client’s side to provide physical support and encouragement.

Following administration of an IM injection, the nurse would massage the site to assist in medication absorption. Then the nurse assists the client to a comfortable position. The uncapped needle is discarded in a puncture-resistant container, gloves are removed and hands are washed. A needle is never recapped. Of the options provided, the nurse would perform the option D first.

A potential organ donor must meet age eligibilty requirements, which vary by organ. For example, age must not exceed 65 years for kidney donation, 55 years for pancreas or liver donation, and 40 years for heart donation. The client should be free of communicable disease, such as human immunodeficiency virus, hepatitis, or syphilis and the involved organ must not be diseased. Another contraindication is malignancy, with the exception of noninvolved skin and cornea.

Since the telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door should be closed or the room curtains pulled around the bathing area.

Defamation takes place when something untrue is said (slander) or written (libel) about a person. Resulting injury to that person’s good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for specific professional group.

The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and an order needs to be obtained from the physician. The physician’s order protects the nurse from liability. The nurse should explain carefully to the client and family about the reasons that the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied a restraint on a client who was refusing it, the nurse could be charged with battery. Compromising with the client is unethical.

A tort is a wrongful act intentionally or unintentionally committed against a person or his or her property. The nurses’ inaction in the situation described is consistent with the definition of a tort offense. Option B is an offense under criminal law. Option C describes case law that has evolved over time via precedents. Option D describe laws that are enacted by state, federal, or local governments.

The RN must remember that even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that another LPN observe the procedure does not ensure that the procedure will be done correctly. Since this is a new procedure for this LPN, the RN should accompany the LPN, provide guidance and answer questions following the procedure.

In accordance with the agency's policies, nurses are required to file incident reports when a situation arises that could or did cause client harm. The nurse also contacts the physician. If a dose of 0.125 mg was prescribed, and a dose of 0.25 was administered, then the client received too much medication. Additional medication is not required and in fact could be detrimental. The client should be informed when an error has occurred, but in a professional manner so as not to cause great fear and concern. In many situations, the physician will discuss this with the client.

Participative leadership suggests a compromise between authoritarian and democratic style. In participative leadership, the leader represents his and her own analysis of the problems and proposal for action to members of the team, inviting critics and comments. The participative leader then analyzes the comments and makes final decision. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, and supervision. The autocratic style of leadership is task oriented and directive. In the situational leadership style, the style employed depends on the situation and events.

Oxygen is a highly combustible gas, although it will not spontaneously burn or cause explosion. It can easily cause a fire to ignite in a client’s room if it contacts a spark from a cigarette, burning candle, or electrical equipment. Options A, C and D are appropriate oxygen safety measures.

Electrical equipment should be grounded. The third longer prong in an electrical plug is the ground. Theoretically, the ground prong carries any stray electrical current back to the ground, hence its name. The other two prongs carry power to the piece of electrical equipment. In this situation the nurse obtains three-prong grounded plug adapter, attaches it to the cord, and plugs it into the wall. Option A, B, and C are unsafe actions.

Area rugs and runners should not be based on stairs. Any carpeting on the stairs should be secured with carpet tacks. Injuries from the home frequently result from objects, including small rugs on the stairs and on the floor, wet spots on the floor, clutter on the bedside tables, on closet shelves, on the top of refrigerator, and on bookshelves. Care should always be taken to ensure that the tables are secure and have stable straight legs. Nonessential items should be placed in drawers to eliminate clutter.

Restraints should never be applied tightly, because it could impair the circulation. The restraint should be applied securely to prevent the client from slipping through the restraint and endangering himself/herself. A hitch knot may be used on the client because it can easily be released in an emergency over 2 hours (or per agency policy) to inspect the skin for abnormalities. The call light must always be within the client’s reach in case the client needs assistance

To reduce the risk of falls, all obstacles must be removed from the home. Not all pets are trip hazards (fish, birds, guinea pigs). Grab bars in the bath tub or shower will not necessarily assist the client while walking with crutches. Shoes with nonslip soles should be worn.

Sputum specimens for culture should be labeled and transported at the laboratory immediately. Identification of the organism is critical in determining the appropriate treatment for the client. If the sputum sample is not transported immediately for culture, organisms will collect and the potential for contamination of the sample exists, which will then alter results. Options A, B, and D are important but option C identifies the priority action.

A client must be alert, able to communicate and competent to sign an informed consent. If the client is unable to, the family can sign the consent. A living will lists the medical treatment a person chooses to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advance directives are forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves.

Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to have a violent episode. Walking up behind the client may cause the client to become startled and react violently. Remaining at the entrance of the room may make the client feel alienated. If the client’s agitation is not addressed, it will only increase. Therefore waiting for the agitation to subside is not an appropriate option.

Clients known or suspected of having TB should wear a mask when out of the room to prevent the spread of the infection to others. A gown or gloves are not necessary.

Chlamydia is a sexually transmitted disease, and is frequently called non-gonococcal urethritis in the male client. It requires no special precautions other than universal precautions. Caregivers cannot acquire the disease during administration of care, and using universal precautions is the only measure that needs to be used.

A urine specimen in not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening system.

Variances are actual deviation or detours from the critical path. Variances can be either positive or negative, avoidable, or unavoidable and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken. Option C is the only option that identifies the need for further action.

A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents for the client to sign that relate the client’s responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request the client to wait and speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.

The incident report is confidential and privileged information and should not be copied, placed in the chart or have any reference made to it in the client’s record. The incident report is not a substitute for complete entry in the client’s record concerning the incident

The client has the right to donate her or his own organs for transplantation. Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent’s organs.

Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. Thus, the nurse prepares to infuse IV fluids as prescribed, and continues to monitor urine output. Options A, C and D will not maintain viability of the kidneys.

To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims’ positions are inappropriate positions for this procedure.

Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is involved, and the client is sitting on the edge of the bed, position the wheelchair next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.

Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal directed, individualized client care. Option A identifies functional nursing. Option B identifies a component of case management. Option D identifies team nursing.

Defamation occurs when information is communicated to a third party that causes damage to someone else's reputation either in writing (libel) or verbal (slander). Common examples are discussing information about a client in public areas, or speaking negatively about co-workers. The situation identified in the question can cause emotional harm to the client and the nurses could be charged with slander. This situation also violates the client’s right to confidentiality.

The catheter’s balloon is behind the opening at the insertion tip. The catheter is inserted to 2.5 to 5 cm after urine begins to flow in order to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could produce trauma.

When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.

When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four point of the walker two feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it.

Safe nursing actions intended to prevent injury to the client include keeping the side rails up, the bed in low position, use of a night-light, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Communicating with the client via an intercom does not meet the client's need to prevent potential injury.

Warm water should be used for hand washing, because it increases the sudsing action of the soap. Hands should be kept downward to enable the unsanitary material to fall off the skin. The faucet should be turns off by using towels to prevent the hands from getting recontaminated.

For negligence to be proven, there must be a duty, then a breach of duty; the breach of duty must cause the injury, and damages or injury must be experienced. Options B, C and D do not fall under the criteria for negligence. Option A is the only option that fits the criteria of negligence.

Standard precautions involves body substance and universal precautions. The nurse would wear a mask and goggles when suctioning the client. Sterile gloves are worn. A mask would offer full protection of the nose and the mouth. Goggles would protect the eyes from getting injured. A gown would protect the nurse’s uniform and a cap would protect the nurse hair, but these items are not required for suctioning a client.

Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and for the same reason, the drainage tubing is not placed or looped under the client’s leg. The tubing must drain freely at all times.

With the client’s elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and crutches placed approximately 15 cm (6 inches) anterolateral from the toes, the nurse should be able to place two fingers comfortably between the axillae and axillary bars. Crutches are adjusted if there is too much or too little space for the axillary area. The client is advised never to rest the axillae and the axillary bars because this could injure the brachial plexus (the nerve in axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of numbness or tingling in the hands or arms.

Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. A urine output of 45 mL / hr indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues.

Basic rules for handling evidence include limiting the number of people with access to the evidence; initiating a chain of custody log to track handling and movement of evidence; and careful removal of clothing to avoid destroying evidence. This usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.

The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as delayed, requiring intervention within 30 to 60 minutes. A green or minimal designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant would be applied to the client with massive injuries and minimal chance of survival. This client would be color coded black in the triage process. The client who is color-coded black is given supportive care and pain management, but is given definitive treatment last.

Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing optimal outcome care. It manages the client care by managing the client care environment.

Work that is delegated to others must be done consistent with the individual’s level of expertise and licensure or lack of licensure. In this case, the least appropriate activity for a nursing assistant would be assisting with feeding profoundly developmentally disabled child. The child is likely to have difficulty in eating, and therefore has a high potential for complications such as choking and aspiration. The remaining three options do not include situations to indicate that these activities carry any risk.

A sterile solution such as normal saline should be used for perineal care using an aseptic syringe or a water pick. This should be done regularly at least twice a day and after each voiding and BM. The wound is intermittently exposed to air to permit drying and prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.

Restraints do not necessarily prevent falls. Restraints are devices used to restrict client’s movement in situations when it is necessary to immobilize a limb or other body part. They are applied to prevent self-inflicted injury or from injuring others; from pulling out intravenous lines, catheters, or tubes; or from removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. Restraints should not be used as a form of punishment.

The nurse removes the goggles first. The nurse unties the gown at the waist and then removes the goggles and discards them. The nurse then removes and discards the mask, unties the neck strings of the gown and allows the gown to fall from the shoulders. The gown is removed without touching the outside of the gown and discarded. The hands are then washed.