Case Study 3 Multiple Clients on a Medical Surgical Unit Questions and Answers

Case Study 3 Multiple Clients on a Medical Surgical Unit Questions and Answers The charge nurse is delegating and assigning patient care to his or her team members for the shift. Staff members are listed in the left-hand column. In the right-hand column, right in the number for the best member of the patient care team for each intervention. Note that all responses may be used more than once. 1. check and record vital signs for each patient 2. administer docusate sodium, 50mg orally to a patient passing hard stool 3. Bathe bedridden confused patient 4. Complete an assessment on a newly admitted patient for altered level of consciousness 5. measure output and empty patients urinary catheter bag at end of shift 6. place a urinary catheter as ordered by the health care provider 7. teach a rehab patient to call for help when getting out of bed to the bathroom 8. Check finger stick blood glucose and administer sliding scale insulin as ordered if glucose is elevated 1. AP 2. LPN/LVN 3. AP 4. RN 5. AP 6. LPN/LVN 7. RN 8. LPN/LVN During the shift change report, the night RN informs the team that Ms. S is to be transferred back to her long term care facility after lunch. What action should be taken for this patient? a. Instruct the AP to awaken her for vital signs and breakfast b. allow her to sleep for an hour or two while the other patients are assessed c. assign the LPN/LVN to immediately pack up the patient's belongings d. call the nursing home to find out if the transfer can wait until tomorrow b. allow her to sleep for an hour or two while the other patients are assessed Which patients should the team leader assign to the LPN/LVN for nursing care under the RN's supervision? Select all that apply a. Mr. C (unstable angina) b. Ms. J (chest pain) c. Mr. R (stroke) d. Ms. S (heart disease and dementia) e. Mr. B (decrease urine output, altered level of consciousness) f. Mr. L (SOB and chronic emphysema) a. Mr. C (unstable angina) c. Mr. R (stroke) d. Ms. S (heart disease and dementia) f. Mr. L (SOB and chronic emphysema) Which patient should the RN assess first? a. Mr. C (unstable angina) b. Ms. J (Chest pain) c. Mr. B (decrease during output, altered level of consciousness) d. Mr. L (SOB and chronic emphysema) b. Ms. J (Chest pain) The RN is assessing Ms. J's chest pain. Which questions would the RN be sure to ask the patient? Select all that apply a. "when did you first notice the chest pain?" b. "Did your pain start suddenly or gradually?" c. "How long has the chest pain lasted?" d. "Have you experienced confusion or loss of memory with pain?" e. "Can you grade your pain on a scale of 0 to 10, with 10 being the worst pain ever?" f. "What were you doing when the chest pain started?" a. "when did you first notice the chest pain?" b. "Did your pain start suddenly or gradually?" c. "How long has the chest pain lasted?" e. "Can you grade your pain on a scale of 0 to 10, with 10 being the worst pain ever?" f. "What were you doing when the chest pain started?" The HCP's prescribed actions for Ms. J, who is currently experiencing chest pain, are as follows. Which intervention should be completed first? a. Administer nitroglycerin 0.6mg sublingually as needed for chest pain b. administer morphine 2mg IV push as needed for chest pain c. check blood pressure and heart rate d. complete lab tests including cardiac markers and daily electrocardiogram c. check blood pressure and heart rate Which tasks should the nurse delegate to the newly hired AP? Select all that apply a. asking Ms. S memory testing questions b. teaching Ms. J about treadmill exercise testing c. checking vital signs on all six patients d. recording oral intake in urine output for Mr. B e. assisting Mr. L to walk to the bathroom f. helping Mr. R with morning care c. checking vital signs on all six patients d. recording oral intake in urine output for Mr. B e. assisting Mr. L to walk to the bathroom f. helping Mr. R with morning care Which key point would the nurse be sure to include when teaching Mr. C about the post procedural care for cardiac catheterization? a. "There are no restrictions after the procedure" b. "you will be able to get out of bed within two hours after the procedure" c. "you will have to stay almost flat in bed with the limited position changes for four to six hours" d. "family visitors will be restricted until the next day" c. "you will have to stay almost flat in bed with the limited position changes for four to six hours" The cardiac lab calls to have Ms. J sent for her graded exercise test (GXT). What is the nurse's best action? a. Instruct the AP to put the patient in a wheelchair and take her to the lab b. Call the cardiac lab and ask to delay the test until later in the day c. contact the HCP to ask if the patient should still have the GXT d. ask the patient if she is continuing to have the chest pain c. contact the HCP to ask if the patient should still have the GXT The AP is delegated the task of measuring morning vital signs for all six patients. Which finding would the nurse instruct the AP to report immediately? a. Oral temperature higher than 102°F b. blood pressure higher than 140 / 80 c. heart rate lower than 65 beats minute d. respiratory rate lower than 18 breaths/min a. Oral temperature higher than 102°F The AP asks the RN why it is important to notify someone whenever a patient with heart problems reports chest pain. What is the RN's best response? a. "It's important to keep track of the chest pain episodes so we can notify the HCP" b. "the patient may need morphine to treat the chest pain" c. "chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment" d. "our unit policy includes specific steps to take in the treatment of patients with chest pain" c. "chest pain may indicate coronary artery blockage and heart muscle damage that will need treatment" The HCP's prescribed interventions for Mr. R, who had a stroke four days ago, include assisting the patient with meals. Which staff member would be best to assign this task? a. Physical therapist b. AP c. LPN/LVN d. occupational therapist b. AP The LPN/LVN reports to the RN that Mr. R was unable to take his oral medications because of difficulty swallowing. The RN assesses Mr. R and finds that he is having dysphagia. What is the RN's best instruction for the LPN/LVN? a. "Keep Mr. R NPO, and I will contact his HCP." b. "Try giving his medications with applesauce or pudding." c. "Check with the pharmacy to find out if they have liquid forms of Mr. R's medications" d. "remind the patient to cough and deep breathe" a. "Keep Mr. R NPO, and I will contact his HCP." The AP reports to the RN that Mr. L, the patient with chronic emphysema, says he is feeling short of breath after walking to the bathroom. What action should the RN take first? A. Notify the HCP B. increase oxygen flow to 6L/min via nasal cannula C. assess oxygen saturation by pulse oximetry D. remind the patient to cough and deep breathe C. assess oxygen saturation by pulse oximetry The oral temperature of Mr. B, the patient newly admitted from a long term care facility with decreased urine output and altered level of consciousness, is now 102.6°F. What is the nurse's best action? a. Notify the HCP b. administer acetaminophen 2 tablets orally c. assign the LPN/LVN to give an acetaminophen Suppository d. remove extra blankets from the patient's bed a. Notify the HCP Which factor does the nurse suspect most likely precipitated Mr. B's elevated temperature? a. Bladder infection b. increased metabolic rate c. kidney failure d. nosocomial Pneumonia a. Bladder infection The RN in is working on the care plan for Mr. B. Which care intervention is most appropriate to delegate to the AP? a. Checking the patient's level of consciousness every shift b. assisting the patient with ambulation to the bathroom to urinate c. teaching the patient the side effects of antibiotic therapy d. administering sulfamethoxazole-trimethoprim orally every 12hrs b. assisting the patient with ambulation to the bathroom to urinate The AP reports that Mr. L's heart rate, which was 86 beats/min in the morning, is now 98 beats/min/ what would be the most appropriate question for the nurse to ask Mr. L? a. "Have you just returned from the bathroom?" b. "Did you recently use your albuterol inhaler?" c. "Are you feeling short of breath?" d. "How much do you smoke?" b. "Did you recently use your albuterol inhaler?" The LPN/LVN reports to the RN that Ms. S will not leave the chest leads for her cardiac monitor in place and asks if the patient can be restrained. What is the RN's best response? a. "Yes, this patient had a heart attack and we must keep her on the cardiac monitor." b. "Yes, but be sure to use softer strength so that the patient circulation is not compromised." c. "No, we must have an HCP's order before we can apply restraints in any situation." d. "No, but try covering the lead wires with the sheet so that the patient does not see them" d. "No, but try covering the lead wires with the sheet so that the patient does not see them" Mr. C has returned from the cardiac catheterization lab and requires close monitoring after the procedure. Which post procedural tasks would be best assigned to the LPN/LVN? Select all that apply a. Check bilateral pedal pulses every 15 minutes during the first hour b. check rock groin area for bleeding every 15 minutes during the first hour c. continue IV fluids normal saline at 50mL/hr d. assist patient to bathroom as needed during first six hours after the procedure e. administer morphine sulfate 2 mg IV push as needed for pain f. give patients daily multivitamin and stool softener on return to medical unit a. Check bilateral pedal pulses every 15 minutes during the first hour b. check rock groin area for bleeding every 15 minutes during the first hour c. continue IV fluids normal saline at 50mL/hr f. give patients daily multivitamin and stool softener on return to medical unit Near the end of the shift, the LPN/LVN reports that the AP has not totaled the patient's intake and output for the past eight hours. What is the nurse's best action? a. Confront the AP and instruct him to complete this assignment at once b. assign the task to the LPN/LVN c. ask the AP if he needs assistance completing the intake and output records d. notify the nurse manager to include this on the AP's evaluation c. ask the AP if he needs assistance completing the intake and output records