Leadership/Management Questions

Chapter 20

Leadership/Management Questions

176. The charge nurse is observing a new nursing graduate perform an ear irrigation to remove impacted cerumen from the client’s ear. The charge nurse should intervene during the procedure if the new nursing graduate performs which action?

1. Washes her hands before performing the procedure

2. Positions the client with the affected side up following the irrigation

3. Warms the irrigating solution to a temperature that is close to body temperature

4. Directs a slow steady stream of irrigation solution toward the upper wall of the ear canal

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 2

Rationale:

During the irrigation, the client is positioned sitting with an ear basin under the ear. Irrigation solutions that are not close to the client’s body temperature can be uncomfortable and may cause injury, nausea, and vertigo. A slow steady stream of solution should be directed toward the upper wall of the ear canal and not toward the tympanic membrane. Too much force and a flow directed toward the tympanic membrane could cause tympanic membrane rupture. Following the irrigation the client should lie on the affected side for a time to finish the drainage of the irrigating solution and to allow gravity to assist in the removal of the earwax and solution.

Test-Taking Strategy:

Note the words nurse should intervene. These words indicate a negative event query and that you are looking for an incorrect nursing action. Visualizing this procedure will assist in directing you to the correct option. Review: removal of cerumen from the ear.

Tip for the Beginning Nursing Student:

An ear irrigation is the instillation of water or a saline solution into the ear and is usually done to remove excess cerumen from the ear. Ear irrigations are not done if a perforated tympanic membrane is suspected. It is important for the nurse to know the procedure for performing an ear irrigation to prevent complications of the procedure, such as rupture of the tympanic membrane. You will learn about the procedure for performing ear irrigations and the role of the nurse as a teacher and supervisor in your fundamentals of nursing course or in your leadership/management course.

References

Christensen, Kockrow: Foundations (2011), pp. 527-528; Ignatavicius, Workman (2013), p. 1091.

177. The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the nurse noted the UAP performing which action(s)? Select all that apply.

1 Turning the client’s head to one side

2 Placing the client in a flat supine position

3 Using small volumes of fluid to rinse the mouth

4 Using a gloved finger to open the client’s mouth

5 Placing an emesis basin under the client’s mouth

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 2, 4

Rationale:

The client who is unconscious is at a great risk for aspiration. The client should have the head of the bed elevated because a flat supine position presents the risk of aspiration. The UAP should either place the client in a side-lying position or turn the client’s head to the side. An emesis basin is placed underneath the mouth to collect the small volumes of fluids used to rinse the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver.

Test-Taking Strategy:

Note the words nurse should intervene. These words indicate a negative event query and that you are looking for the option that is incorrect. Visualize this procedure, and remember that the nurse never places a finger into a client’s mouth or places the client in a flat position. Review: the procedure for administering mouth care to the client who is unconscious.

Tip for the Beginning Nursing Student:

Unconsciousness is a state of complete or partial unawareness or lack of response to stimuli. It can be caused by a variety of conditions, such as shock, hypoxia, or stroke (brain attack). The client who is unconscious requires complete care, including mouth care. Depending on the state of unawareness, the client may exhibit some responses to stimuli, such as bearing down with the teeth if an object is placed in the mouth. It is extremely important to remember that the flat position places the client at risk for aspiration and that you should never insert a finger into a client’s mouth regardless of the state of consciousness. You will learn about the procedure for performing mouth care and the role of the nurse as a teacher and supervisor in your fundamentals of nursing course or in your leadership/management course.

References

deWit, Kumagai (2013), pp. 493, 1022; Lewis et al (2011), pp. 1435-1436.

178. The nurse is observing a student donning a pair of sterile gloves and preparing a sterile field. The nurse should intervene if the student performs which action(s)? Select all that apply.

1 Puts the right glove on and then the left glove

2 Dons the sterile gloves without washing the hands

3 Uses the inner wrapper of the gloves as a sterile field

4 Maintains the gloved hands below the level of the waist

5 Touches the gloves on the overbed table, removes them, and dons another sterile pair

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 2, 4

Rationale:

Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The hands should be maintained above the level of the waist to keep them and the areas that need to remain sterile exposed to as few contaminated areas as possible. The inside wrapper provides an excellent area for usage because it is sterile. Gloves that touch anything unsterile must be considered contaminated, and a new package of gloves must be obtained and used. The order of placing gloves on is up to the individual as long as sterile technique is not broken.

Test-Taking Strategy:

Note the words nurse should intervene. These words indicate a negative event query and that you are looking for the option that identifies an incorrect action. Visualize each option keeping the principles of sterile technique in mind. Noting the words without washing the hands and below the level of the waist will direct you to the correct options. Review: sterile technique for donning gloves.

Tip for the Beginning Nursing Student:

Sterile technique, also known as aseptic technique, is the use of special procedures to prevent contamination of the nurse, object, or area by microorganisms. A sterile field is an area that the nurse prepares that is considered free of microorganisms. Sterile technique and a sterile field are used to perform various procedures, such as changing a wound dressing. Handwashing is always done before any procedure even if the nurse plans to don gloves. You will learn about sterile technique, the procedure for donning sterile gloves and setting up a sterile field, and the role of the nurse as a teacher and supervisor in your fundamentals of nursing course or in your leadership/management course.

References

deWit, Kumagai (2013), pp. 111, 1128; Potter et al (2013), pp. 436-437.

179. The nurse reviews the laboratory results of a client receiving chemotherapy and notes that the white blood cell count is extremely low. The nurse asks a nursing student assigned to care for the client to place the client on neutropenic precautions. The nurse determines the need to review the procedures for neutropenic precautions if the student nurse took which action?

1. The water pitcher was removed from the client’s room.

2. Fresh cut flowers were removed from the client’s room.

3. A box of face masks was placed at the entrance to the client’s room.

4. Fresh pears and apples brought to the client by a family member were left in the client’s room.

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Teaching and Learning

Content Area:

Leadership/Management

ANSWER: 4

Rationale:

In the immunocompromised client, a low-bacteria diet is necessary. This includes avoiding fresh fruits and vegetables. Thorough cooking of all food is also required. Anyone who enters the client’s room should perform strict and thorough handwashing and wear a mask. Cut flowers or any standing water is removed from the room because it tends to harbor bacteria.

Test-Taking Strategy:

Note the words the need to review. These words indicate a negative event query and that you are looking for the action that is incorrect. Recall that neutropenic precautions are implemented when a client is at high risk for contracting an infection. Next, look for the action that places the client at risk for infection. This will direct you to the correct option. Review: interventions for the client on neutropenic precautions.

Tip for the Beginning Nursing Student:

Neutropenia is an abnormal decrease in the number of neutrophils in the blood that places the client at risk for infection. Therefore neutropenic precautions are instituted. This type of precautions focuses on protecting the client from infection, and any potential source of infection is avoided in the client’s environment or in the care of the client. You will learn about neutropenic precautions and the role of the nurse as a teacher and supervisor in your fundamentals of nursing course or in your leadership/management course.

References

Christensen, Kockrow: Adult Health (2011), p. 795; Ignatavicius, Workman (2013), p. 420.

180. The nurse is observing a nursing student perform nasotracheal suctioning on an adult client. The nurse should intervene if the nursing student performs which action(s)? Select all that apply.

1 Sets the wall suction pressure at 140 mm Hg

2 Encourages the client to cough after suctioning

3 Inserts the suction catheter during client inhalation

4 Applies intermittent suction on the catheter during removal for up to 10 to 15 seconds

5 Inserts the catheter beyond the point at which the client elicits the gag reflex

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 1, 5

Rationale:

When suctioning an adult client, the wall suction should be set at 80 to 120 mm Hg (portable suction is set at 7 to 15 mm Hg). Elevated suction pressure settings can increase the risk of trauma to the mucosa and can induce greater hypoxia. The catheter should be inserted until the gag reflex is elicited, with suction being applied intermittently during withdrawal afterwards. The catheter should not be inserted beyond this point. Options 2, 3, and 4 are correct steps in performing this procedure.

Test-Taking Strategy:

Note the words nurse should intervene. These words indicate a negative event query and that you are looking for an incorrect action. Visualizing this procedure will assist in eliminating options 2, 3, and 4 because they are correct actions. Review: suctioning procedures.

Tip for the Beginning Nursing Student:

Suctioning is a procedure that is used to remove accumulated secretions from the respiratory tract when the client is unable to effectively cough them out. It is a sterile procedure and requires specific actions to prevent trauma to the mucosa of the respiratory tract and to prevent hypoxia. You will learn about the procedure for suctioning and the role of the nurse as a teacher and supervisor in your fundamentals of nursing course or in your leadership/management course.

References

deWit, Kumagai (2013), p. 272; Ignatavicius, Workman (2013), p. 574.

181. The nurse is preparing to administer a medication to a client and notes that the dose prescribed is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription, and the health care provider instructs the nurse to administer the dose as prescribed. Which action should the nurse take?

1. Call the pharmacy.

2. Contact the nursing supervisor.

3. Call the medical director on call.

4. Administer the dose as prescribed.

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 2

Rationale:

If the health care provider writes a prescription that requires clarification, it is the nurse’s responsibility to contact the health care provider for clarification. If there is no resolution regarding the prescription because the prescription remains as it was written after talking with the health care provider, or because the health care provider cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until clarification is obtained. Calling the pharmacy is a resource action that will confirm that the dose of medication prescribed is inappropriate, but this action will not resolve the problem facing the nurse. Option 3 is a premature action.

Test-Taking Strategy:

Focus on the subject, nursing responsibilities related to prescriptions requiring clarification. Eliminate option 4 first because this is an unsafe action. Option 3 is a premature action and should be eliminated next. Eliminate option 1 next because this action will not resolve the problem. Also recall that the nurse should follow the organizational chain of command and seek assistance from the nursing supervisor. Review: nursing responsibilities related to health care providers’ prescriptions and the associated ethical and legal responsibilities.

Tip for the Beginning Nursing Student:

The client’s health care provider will document specific prescriptions regarding the client’s care in the medical record, and the nurse needs to follow the prescriptions unless the nurse deems that a prescription may harm the client. If the prescription can cause harm to the client, the nurse needs to contact the health care provider to change the prescription. If the health care provider does not change the prescription or if the nurse is unable to locate the health care provider, the nurse should follow the chain of command in the health care organization. In this situation, the nurse should contact the nursing supervisor. Under no circumstances should a nurse implement a prescription that could cause harm to the client. You will learn about health care providers’ prescriptions and the associated legal responsibilities in your fundamentals of nursing course or in your leadership/management course.

References

Christensen, Kockrow: Foundations (2011), p. 701; Linton (2012), p. 39; Potter et al (2013), pp. 582-583.

182. The charge nurse is observing a new nursing graduate insert an indwelling urinary (Foley) catheter. The charge nurse should intervene if the new nursing graduate begins to perform which action(s)? Select all that apply.

1 Lubricates the catheter before inserting it

2 Positions the client in a side-lying position

3 Inflates the balloon to test patency before inserting the catheter

4 Cleans the area around the urinary meatus before inserting the catheter

5 Inflates the balloon as soon as urine begins to flow through the catheter tubing

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

Content Area:

Leadership/Management

ANSWER: 2, 5

Rationale:

Before insertion of the catheter, the client should be positioned on the back with the posterior sides of the feet touching one another with the knees bent. This allows for optimal visualization and access to the urethral meatus. After urine begins to flow, the catheter is inserted 2.5 cm (1 inch) more. Doing so ensures that the balloon is in the bladder, not in the urethra. Options 1, 3, and 4 identify correct procedure.

Test-Taking Strategy:

Note the words nurse should intervene, which indicate a negative event query and tell you that you are looking for the options that identify an incorrect action(s) by the new nursing graduate. Visualizing this procedure and reading each option carefully will direct you to options 2 and 5. Review: the procedure for inserting an indwelling urinary (Foley) catheter.

Tip for the Beginning Nursing Student:

A Foley catheter is a rubber tube with a balloon tip that is filled with a sterile liquid after it is inserted in the bladder. It is connected to a bag that collects urine draining from the bladder. Sterile technique is used to insert this catheter. This type of catheter is used when continuous drainage of the bladder is needed, such as during a surgical procedure. You will learn about this type of catheter and the procedure for its insertion in your fundamentals of nursing course. You will learn about the role of the nurse as a supervisor and teacher in your leadership/management course.

References

Christensen, Kockrow: Foundations (2011), pp. 575-576; Potter et al (2013), p. 1076.

183. A hospitalized client tells his evening nurse that he has received pain medication at 10:00 AM and again at 2:00 PM and that the medication provided no relief from the pain. The client says to the nurse, “Whenever that daytime nurse takes care of me and gives me pain medication it never works! I am so glad that you are here so that I can get some relief from this pain.” The nurse has observed this same occurrence with other clients who were cared for by this same daytime nurse and suspects that the daytime nurse is self-abusing drugs. The nurse should implement which action?

1. Report the information to the nursing supervisor

2. Talk with the daytime nurse who gave the medication to the client.

3. Call the impaired nurse organization and report the daytime nurse.

4. Report the information about the daytime nurse to the police department.

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Implementation

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Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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