NURSING 335 HESI CASE STUDY ANSWERED
PERFECTLY!!
The Emergent Care ClinicThe Emergent Care Clinic is a fast-paced, 20-bed, free-
standing, acute care facility. The Emergent Care interdisciplinary team includes
registered nurses (RN), practical nurses (PN), unlicensed assistive personnel
(UAP), physicians, advanced practice registered nurses (APRN), and other
collaborative care team members. The facility is located in an urban area and is
open for business 24 hours a day, 7 days a week.
Management of Care
The first action of the charge nurse for the day shift in the Emergent Care Clinic is
to prepare the assignments for the day shift. In addition to the charge nurse, three
RNs, one PN, and two UAPs are scheduled from 7 am to 7 pm.
Which client should the charge nurse assign to the PN?
Answers :A 20-year-old female who complains of pain to the right lower leg with
swelling after tripping on the sidewalk.
Because this client is the least acute, she is the most appropriate assignment for the
PN.
Mr. Jackson, the 45-year-old male client reporting left arm pain and
gastrointestinal upset, is assigned to an RN. It is most important for the RN to
admit Mr. Jackson to which room in the Emergent Care Clinic?
Answers :A room with a continuous cardiac telemetry monitor.
Reports of left arm pain may indicate myocardial ischemia, and monitoring the
ECG ECG is critical
The RN admits Mr. Jackson to a clinic room and connects him to the continuous
cardiac telemetry monitor so that his heart rhythm can be monitored in the room
and at the nurse' station.
Previous Section
, Management of Care: Delegation
The UAP assists the RN in getting Mr. Jackson admitted.
Which tasks should the RN delegate to the UAP?
Answers :Enter the obtained vital signs in the medical record.
The RN can delegate this task to the UAP.
Place a bedside commode in the room.
The UAP obtains Mr. Jackson's vital signs and reports the results to the RN.
Reported vital signs for Mr. Jackson are as follows:
T 98.8° FP 94 beats/minR 30 breaths/minBP 158/88 mmHg
Which action should the RN delegate to the UAP next?
Answers :Apply a continuous pulse oximeter monitor to the client.
The increased respiratory rate indicates that continuous monitoring is the primary
concern for this client. The oxygen saturation level also needs to be monitored
continuously. The pulse oximeter may be applied by the UAP, but the monitoring
and assessment is done by the RN.
The UAP applies the continuous pulse oximeter to Mr. Jackson's finger. The
client's Oxygen saturation is 90%. The RN applies an automated blood pressure
cuff to assess his BP every 15 minutes.
Reduction of Potential Risk
Mr. Jackson also reports dull, aching pain from his left shoulder radiating to his left
arm. He states the pain comes and goes, and he rates the pain as 5 on a pain scale
of 0 to 10. The RN applies electrodes from the ECG machine to obtain a tracing of
Mr. Jackson's heart function and then analyzes Mr. Jackson's ECG strip, which
shows a normal sinus rhythm.
Which prescription should the RN plan to implement first for Mr. Jackson?
PERFECTLY!!
The Emergent Care ClinicThe Emergent Care Clinic is a fast-paced, 20-bed, free-
standing, acute care facility. The Emergent Care interdisciplinary team includes
registered nurses (RN), practical nurses (PN), unlicensed assistive personnel
(UAP), physicians, advanced practice registered nurses (APRN), and other
collaborative care team members. The facility is located in an urban area and is
open for business 24 hours a day, 7 days a week.
Management of Care
The first action of the charge nurse for the day shift in the Emergent Care Clinic is
to prepare the assignments for the day shift. In addition to the charge nurse, three
RNs, one PN, and two UAPs are scheduled from 7 am to 7 pm.
Which client should the charge nurse assign to the PN?
Answers :A 20-year-old female who complains of pain to the right lower leg with
swelling after tripping on the sidewalk.
Because this client is the least acute, she is the most appropriate assignment for the
PN.
Mr. Jackson, the 45-year-old male client reporting left arm pain and
gastrointestinal upset, is assigned to an RN. It is most important for the RN to
admit Mr. Jackson to which room in the Emergent Care Clinic?
Answers :A room with a continuous cardiac telemetry monitor.
Reports of left arm pain may indicate myocardial ischemia, and monitoring the
ECG ECG is critical
The RN admits Mr. Jackson to a clinic room and connects him to the continuous
cardiac telemetry monitor so that his heart rhythm can be monitored in the room
and at the nurse' station.
Previous Section
, Management of Care: Delegation
The UAP assists the RN in getting Mr. Jackson admitted.
Which tasks should the RN delegate to the UAP?
Answers :Enter the obtained vital signs in the medical record.
The RN can delegate this task to the UAP.
Place a bedside commode in the room.
The UAP obtains Mr. Jackson's vital signs and reports the results to the RN.
Reported vital signs for Mr. Jackson are as follows:
T 98.8° FP 94 beats/minR 30 breaths/minBP 158/88 mmHg
Which action should the RN delegate to the UAP next?
Answers :Apply a continuous pulse oximeter monitor to the client.
The increased respiratory rate indicates that continuous monitoring is the primary
concern for this client. The oxygen saturation level also needs to be monitored
continuously. The pulse oximeter may be applied by the UAP, but the monitoring
and assessment is done by the RN.
The UAP applies the continuous pulse oximeter to Mr. Jackson's finger. The
client's Oxygen saturation is 90%. The RN applies an automated blood pressure
cuff to assess his BP every 15 minutes.
Reduction of Potential Risk
Mr. Jackson also reports dull, aching pain from his left shoulder radiating to his left
arm. He states the pain comes and goes, and he rates the pain as 5 on a pain scale
of 0 to 10. The RN applies electrodes from the ECG machine to obtain a tracing of
Mr. Jackson's heart function and then analyzes Mr. Jackson's ECG strip, which
shows a normal sinus rhythm.
Which prescription should the RN plan to implement first for Mr. Jackson?
