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. - correct answerThe nurse should suspect
Your Answer: hypokal...
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. - correct answerThe nurse should suspect
Your Answer: hypokalemiaCorrect 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. - correct answerThe 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.
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. -
correct answerThe 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 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 - correct answerCollect
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 outcomes; criteria are used
to monitor outcomes of care and to determine the need for change to improve the quality of care. If the
nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections,
the nurse should collect data about the problem. This should include information such as the primary
and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the
site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV
site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed,
the nurse should examine evidence-based practice protocols to identify the best practices for care to IV
sites to prevent infection. These practices can then be implemented and followed by evaluation of
results based on the evidence-based practice protocols used. Collecting identifying client information is
contraindicated because of confidentiality and is unnecessary in this quality improvement effort. Noting
the mental status of the clients can be done but is not likely to address the problem. Noting the types of
medications being infused can also be done, but will not address the problem of IV site infection.
Although it is helpful to know the expected duration of the IV site, this information does not change
infection control practices in managing the IV site and is therefore considered a non-essential action.
The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial
artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. How
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