Management of a Medical Unit

Management of a Medical Unit RN Case Study The nurse manager is the 7:00 a.m. to 7:00 p.m. charge nurse on a general medical unit that includes five telemetry-monitored rooms. The nursing staff includes experienced nurses, newly-licensed nurses, practical nurses (PNs), unlicensed assistive personnel (UAPs), and a unit secretary. Each newly-licensed nurse has an assigned staff nurse as a preceptor. In addition to the nursing staff, a respiratory therapist, case manager, and pharmacist are assigned to the unit. 1. Which client situation requires the most immediate intervention by the charge nurse? A. New onset ST segment elevation in a client admitted with angina B. A client with hyponatremia is becoming increasingly confused, disoriented, and agitated. C. The WBC of a client with cellulitis increases from 8k to 15k D. A client starting treatment for tuberculosis develops a productive cough of mucopurulent sputum A. New onset ST segment elevation is observed on the telemetry monitor of a client admitted with angina. ECG finding indicates ischemic changes that require immediate client assessment and mgmt to prevent myocardial damage ED needs to give report on a client to be admitted to the medical unit asap. 2. What action should Mr. Young take? A. Return to the nursing unit desk to obtain report B. Take the report over the telephone C. Request that another staff RN obtain the report. D. Advise the unit secretary to write down the report. Request that another staff RN obtain the report. Another RN can obtain the report, while the charge nurse gives his full attention to assessment of the unstable client. The client with ECG changes reports that he just experienced an episode of chest pain and took a dose of nitroglycerin he brought from home. The UAP enters and informs Mr. Young that the client with hyponatremia is attempting to climb over the bedrails. 3. How should the charge nurse respond to this situation? A. Instruct the client with angina to call if further assistance is needed and help with the confused client. B. Remain with he client who has angina and assign a PN to monitor the confused client while the UAP obtains a bed alarm. C. Assess the confused client and assign the UAP to the client with angina D. Implement fall precautions for the ocnfused client and assign the PN to assess the client with angina Remain with he client who has angina and assign a PN to monitor the confused client while the UAP obtains a bed alarm. The client w/ angina and ECG changes remains unstable and requires the expertise of the charge nurse to assess and manage his care. The PN, assisted by the UAP, can safely monitor a confused client to prevent injury The vital signs of the client with cellulitis are T 102*F, P 112, R 28, and BP 84/42 4. Who should the charge nurse assign to care for this client? A. An experienced PN B. The newly licensed nurse, assisted by an experienced UAP C. The newly licensed nurse and staff nurse preceptor. D. The newly licensed nurse alone The newly licensed nurse and staff nurse preceptor. The client is exhibiting manifestations of septic shock, a potentially fatal problem. The newly licensed nurse doesn't yet have the expertise to respond to this situation independently Mr. Young assigns a PN to provide care to a client with pneumonia caused by MRSA. Airborne precautions are required. The PN requests a change in assignment, stating that due to her pregnancy, she is concerned about entering isolation rooms. 5. How should the charge nurse respond? A. As a staff member, you have to... B. No one likes to care for clients in isolation... C. What concerns do you have about your pregnancy... D. I will change your assignment What concerns do you have about your pregnancy and this client care situation? The charge nurse should first determine what concerns the PN has related to the situation before making a decision. The PN states: "I know that my fear is ungrounded if I follow isolation precautions, but..." 6. When adhering to the ethic of caring in a leadership role while still maintaining client safety, what is the best action for the charge nurse to implement? A. Assign another PN to care for the client and reassign the pregnant PN to other clients. B. Advise the PN that the UAP can do the majority of the client care in the room C. Continue to reassure the PN it's safe D. Assume primary care of the client so the PN doesn't need to go in the room Assign another PN to care for the client and reassign the pregnant PN to other clients. Since the PN is not refusing the assignment, and because her request is not based on discrimination or lack of knowledge, the charge nurse may choose to respond to the PN's concern in a caring manner by changing the assignment. Another PN agrees to assume care of the client in isolation 7. Which diagnosis and upcoming procedure can best be assigned to this PN, rather than an RN? A client with: A. unstable angina scheduled for a cardiac catheterization B. osteoporosis scheduled for a bone mineral density test that day C. hepatic encephalopathy scheduled for a liver biopsy D. DVT scheduled for a vena cava filter insertion Osteoporosis scheduled for a bone mineral density test that day. This client is the most stable and the test requires minimal client teaching and prep. Additionally a high level of expertise is not needed to monitor the post-procedure condition 8. Which task can be delegated to the UAP who is assisting the PN and RN in the care of these 4 clients? A. Notify the RT about the O2 needs of the client with COPD B. Deliver and prepare the meal tray of the client who is in isolation with MRSA-induced pneumonia. C. Measure, record the abdominal circumference of the client w/ cirrhosis D. Review teaching materials about foods high in Ca2+ Deliver and prepare the meal tray of the client who is in isolation with MRSA-induced pneumonia. THE UAP is trained in the precautions needed to provide basic care to clients in isolation The O2 sat of the client in isolation has decreased to 88% 9. Which action should the respiratory therapist take? A. Write a prescription for an inhaled bronchodilator B. Increase the rate of oxygen being administered. C. Evaluate the sputum culture D. Turn and position the client every 2 hours Increase the rate of oxygen being administered. The RT can evaluate the need of the client and adjust O2 administration within defined parameters The client with cirrhosis is preparing for discharge. 10. Mr. Young consults with the case manager about which aspect of the client's care? A. Evaluating the client's risk of liver failure after discharge B. Providing discharge teaching about the meds to be taken at home. C. Initiating a referral for durable medical equipment and home health care. D. Est the plan of care to be implemented by the home care nurses Initiating a referral for durable medical equipment and home health care. The case manager initiates referral and helps the client to manage resources effectively. A newly licensed nurse is assigned care of a client with an IV heparin infusion. The client's dosage should be increased by 200units/hr 11. It is best for the newly licensed RN to collaborate with which team member to ensure that the dosage is adjusted correctly? A. The med unit charge nurse B. The pharmacist C. The RN who is precepting the newly licensed nurse. D. The RN who cared for the client the previous day. The RN who is precepting the newly licensed nurse. The staff nurse preceptor has the time, expertise, and responsibility to assist. 12. When changing client care assignments, Mr. Young knows that it is important to assign the client on which medication/solution to the care and expertise of another RN rather than a PN? A. Clopidogrel (Plavix) B. Lactated RInger's C. Pantoprazole (Protonix) D. An insulin/potassium infusion An insulin/potassium infusion to treat diabetic ketoacidosis (DKA) This client is the most physiologically unstable and is most likely to experience complications 13. Which one of the RN's clients can best be assigned to the PN? A. A 56-year-old female client with anemia due to long-term chronic renal failure who is scheduled for a hemodialysis treatment that afternoon. B. A 47-year-old male client who is receiving meperidine (Demerol) via PCA to treat lower back pain C. A 62-year-old female client with newly diagnosed emphysema who needs instruction on breathing techniques and inhaler use D. A 42-year-old male client with coronary artery disease who just returned following cardiac catheterization and stent placement. A 56-year-old female client with anemia due to long-term chronic renal failure who is scheduled for a hemodialysis treatment that afternoon. This client is stable and is the best choice In prep for hemodialysis, the nurse prepares to administer minocyline (Minocin) 75mg in 500mL D5W. The minocyline comes in the dilution 100mg/10mL 14. How many mL should be added to the 500 mL bag? 7.5 mL A UAP is assisting in caring for the client with low back pain, receiving morphine via PCA pump 15. Which instruction should the nurse convey to the UAP? "Notify me if... A. the client's pain becomes excessive B. the client doesn't use the PCA correctly C. the PCA is providing adequate pain control D. any changes in mental status, such as disorientation Report any changes in mental status, such as disorientation. 16. Which action should the nurse implement? Assist the client in returning to a supine position in the bed. 17. In reviewing the situation with the UAP and RN assigned to the client, Mr. Young needs to emphasize which problem? Insufficient instruction and supervision by the RN. 18. The client with which telemetry pattern is best to consider for transfer? Sinus arrhythmia with rate fluctuation during respiration. 19. After identifying the client that is the safest to transfer from the telemetry area, what action should Mr. Young take next? Contact the healthcare provider for a prescription to remove the telemetry and transfer the client. 20. It is most important for the preceptor to supervise which nursing intervention performed by the newly licensed RN? Interpretation of the cardiac rhythm. The client has uncontrolled a fib and is scheduled for cardioversion. The RN wants to observe the procedure. 21. What is the best response by the preceptor? A. You are no longer in school. You should not expect to see every procedure... B. As a staff nurse, you must learn to be responsible... rather than leave the unit C. Because observation of the procedure will help you provide better care, I will manage our assigned clients while you go. D. You seem uncomfortable about the care required by this procedure. Tell me more Because observation of the procedure will help you provide better care, I will manage our assigned clients while you go. 22. In planing a client care assignment independent of the preceptor for the next day, which client is best to assign to the new RN? SELECT ALL THAT APPLY -Experiencing dysphagia following a CVA, which necessitates the use of total parenteral nutrition via a central line. -2 DAY post op hip fracture A mandatory inservice program on use of insulin pens. Nursing staff will also be responsible for teaching clients how to use them. 23. To ensure that all the staff are competent in the use of the new equipment, which action is most important for Mr. Young to implement? Schedule time for each nurse on the unit to practice using the insulin pens. One of the PNs is having difficulty manipulating the insulin pen 24. How should Mr. Young respond? A. Ask the PN is she attended the inservice B. Offer to repeat a demonstration and allow the PN additional practice time. C. Remind the PN that only RNs should administer insulin D. Advise the PN to continue using only insulin syringes Offer to repeat a demonstration and allow the PN additional practice time. Several clients have experienced difficulty using the insulin pens. A staff nurse requests that syringes be made available for client teaching 25. Which action should MR. Young implement first? Go with the nurse to observe the difficulty the clients are experiencing with the pens. Mr. Young discovers that inaccurate insulin doses is occurring with the pens, and requests a further study be initiated. A quality improvement team meets to develop a plan to further evaluate the problems. 26. In preparing a study of this problem, which goal statement is best for the team to identify? All clients using insulin pens will measure an accurate dose 100% of the time. 27. What additional information is most important for the quality improvement team presenting a recommendation to the administration about teaching clients how to use insulin pens? The inability of these clients to measure an accurate dose with a syringe. 28. In preparing the recommendation, it is most valuable to obtain input from which member of the healthcare team? Unit pharmacist.