SBAR framework - The nurse should use the SBAR framework to identify the situation, background, assessment, and recommendation for a specific circumstance. The nurse can focus on the client's immediate circumstances to promote clinical decision making. A nurse is teaching an assistive personnel (AP) about caring for a client who has a do-not-resuscitate (DNR) order. Which of the following statements by the AP indicates an understanding of the teaching? "I will call for the client's nurse to come to the room if I cannot detect the client's pulse." - The AP should contact the nurse for further assessment whenever a client's condition does not meet expected findings. The client who has a DNR order in place does not require resuscitation. A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures? Receiving moderate sedation - The nurse should verify that the client has given informed informed consent prior to receiving moderate sedation because this is a procedure which requires anesthesia.
A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions? "After I finish with the printout of my assignment, I'll put it in the shredder receptacle." - The nurse should shred all computer printouts and worksheets that contain clients' protected health information to maintain client confidentiality. An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a peripherally inserted central catheter (PICC) line. Which of the following actions should the case manager perform prior to discharge? Ensure that home infusion therapy has been arranged. - It is the case manager's responsibility to ensure that all necessary referrals have been made to facilitate the client's transition to home care. A nurse on a medical-surgical unit has arrived late to work multiple tiem over the past several weeks. The nurse manager is planning to use progressive discipline to address this problem. Identify the sequence the nurse should follow. 1. Issue an informal verbal reprimand. 2. Give the nurse a formal written reprimand. 3. Suspend the nurse without pay. 4. Terminate the nurse's employment. A nurse manager is auditing client charts and identifies an increase in ventilator- associated pneumonia (VAP). Which of the following actions should the nurse manager take? Notify the quality improvement team. - The nurse should report any unusual occurrences or trends such as VAP within the unit to the quality improvement team. The quality improvement team will analyze and evaluate the data to implement needed changes. A nurse is caring for four clients. Which of the following assessment findings is the priority? An adult client who has a femur fracture reports feeling short of breath - When using the urgent vs non-urgent approach to client care, the nurse determines priority finding is an adult client who has a femur fracture and reports feeling short of breath. Clients who have a fracture can develop a deep venous thrombosis, which can lead to pulmonary embolism.
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- Spring '19
- Nursing, AP, nurse make