The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U
waves on a client's cardiac monitor screen. Fill in the correct missing information by
choosing from the lists of options in the drop-down menus. - ANSWER The nurse
should suspect
Your Answer: hypokalemia Correct Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves
and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in a
flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse
should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is
increased in hypokalemia. The nurse should immediately assess the client's vital signs and
cardiac status for signs of hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care provider to report the
findings and obtain prescriptions to treat the hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a
religious medal on a chain around the neck. What should the nurse do with regard to this
personal item? Click to highlight the correct answer from the options provided. -
ANSWER The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
1
,Rationale:Before certain diagnostic procedures, it is typical to have a client remove personal
objects that are worn on the body because of client safety and the possibility of
compromising test results. Therefore, the nurse should ask the client about the significance
of such an item and its removal because it may have cultural or spiritual significance. If so,
the nurse should ask the client if the item can be either removed temporarily or placed on
another part of the body during the procedure if appropriate.
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I
have changed my mind. I don't want this surgery." Click to highlight the correct answer from
the options provided. - ANSWER The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can respond.
Rationale:If the client indicates that he or she does not want a prescribed therapy,
treatment, or procedure such as surgery, the nurse should further investigate the client's
request. If the client indicates that he or she has changed his or her mind about surgery, the
nurse should assess the client and explore with the client his or her concerns about not
wanting the surgery. The nurse would then withhold further surgical preparation and contact
the surgeon to report the client's request so that the surgeon can discuss the consequences
of not having the surgery with the client. Further assessment and follow-up related to the
client's request need to be done. It is the client's right to refuse treatment; however, further
investigation is needed so the interventions can be tailored to specific needs.
The nurse notes that there has been an increase in the number of intravenous (IV) site
infections that developed in the clients being cared for on the nursing unit. How should the
2
, nurse proceed to implement a quality improvement program?For each action, click to
specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the client, but the action
would not be likely to address the problem
Contraindicated: an action that could harm the client and should not be taken -
ANSWER Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance improvement, focuses on
processes or systems that significantly contribute to client safety and effective client care
3
waves on a client's cardiac monitor screen. Fill in the correct missing information by
choosing from the lists of options in the drop-down menus. - ANSWER The nurse
should suspect
Your Answer: hypokalemia Correct Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves
and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in a
flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse
should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is
increased in hypokalemia. The nurse should immediately assess the client's vital signs and
cardiac status for signs of hypokalemia. The nurse should also check the client's most recent
serum potassium level and then contact the primary health care provider to report the
findings and obtain prescriptions to treat the hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a
religious medal on a chain around the neck. What should the nurse do with regard to this
personal item? Click to highlight the correct answer from the options provided. -
ANSWER The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
1
,Rationale:Before certain diagnostic procedures, it is typical to have a client remove personal
objects that are worn on the body because of client safety and the possibility of
compromising test results. Therefore, the nurse should ask the client about the significance
of such an item and its removal because it may have cultural or spiritual significance. If so,
the nurse should ask the client if the item can be either removed temporarily or placed on
another part of the body during the procedure if appropriate.
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I
have changed my mind. I don't want this surgery." Click to highlight the correct answer from
the options provided. - ANSWER The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can respond.
Rationale:If the client indicates that he or she does not want a prescribed therapy,
treatment, or procedure such as surgery, the nurse should further investigate the client's
request. If the client indicates that he or she has changed his or her mind about surgery, the
nurse should assess the client and explore with the client his or her concerns about not
wanting the surgery. The nurse would then withhold further surgical preparation and contact
the surgeon to report the client's request so that the surgeon can discuss the consequences
of not having the surgery with the client. Further assessment and follow-up related to the
client's request need to be done. It is the client's right to refuse treatment; however, further
investigation is needed so the interventions can be tailored to specific needs.
The nurse notes that there has been an increase in the number of intravenous (IV) site
infections that developed in the clients being cared for on the nursing unit. How should the
2
, nurse proceed to implement a quality improvement program?For each action, click to
specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the client, but the action
would not be likely to address the problem
Contraindicated: an action that could harm the client and should not be taken -
ANSWER Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance improvement, focuses on
processes or systems that significantly contribute to client safety and effective client care
3
