Exit Exam (BSN 366)

The correct answer is:

An adult client with no postoperative drainage in the Jackson Pratt drain with the bulb compressed.

Explanation:

The Jackson Pratt (JP) drain is designed to drain excess fluid and prevent the accumulation of blood or other fluids in a wound. If the bulb is compressed, it indicates that the drain is working to create suction. The absence of drainage in the JP drain is not necessarily alarming, especially if the wound is not producing excessive fluid. As long as there are no signs of infection or complications, this scenario is less urgent and the client can be assessed last. The focus should be on monitoring other more acute issues that could pose a greater risk to the patient's health.

Why the Other Options Are Incorrect:

An older client with a distended abdomen and no drainage from the nasogastric tube:

Abdominal distention in an older client can be a sign of a serious issue such as a bowel obstruction, ileus, or peritonitis. The absence of drainage from the nasogastric tube may suggest a blockage, impaired gastrointestinal function, or a surgical complication. This requires immediate attention, as it could indicate a life-threatening condition.

An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac:

Dark red drainage on the dressing could indicate active bleeding, a serious concern after surgery. The absence of drainage in the Hemovac might indicate a blockage or clot, which can lead to a hematoma or infection. Immediate intervention is needed to address potential complications such as excessive bleeding or infection.

An adult client with a rectal tube draining clear, pale red liquid drainage:

While clear, pale red drainage may be normal postoperatively, it can also indicate complications such as bowel injury or infection. This requires timely evaluation, though it is not as immediately life-threatening as other complications like active bleeding or bowel obstruction. However, it still warrants a prompt assessment to ensure proper care.

The correct answer is:

Push the undiluted dextrose slowly through the currently infusing IV.

Explanation:

In the case of insulin shock, or hypoglycemia, rapid administration of glucose is necessary to raise blood sugar levels quickly. The administration of 50% dextrose is a standard treatment, as it provides a concentrated and immediate source of glucose. The proper method for administration is to slowly push the undiluted dextrose through the currently infusing IV. This allows for fast action in correcting hypoglycemia while minimizing the risk of complications, such as vein irritation or a sudden spike in blood glucose levels.

Why the Other Options Are Incorrect:

Dilute the dextrose in 1 L of 0.9% normal saline solution

Diluting the dextrose would lower its concentration and slow the infusion rate, making it less effective in treating the acute condition of hypoglycemia. The primary goal in this emergency is to rapidly increase blood glucose levels, and diluting the dextrose would hinder that goal.

Make the dextrose in a 50 mL piggyback for a total volume of 100 mL

This option introduces an unnecessary step. Administering the dextrose in a piggyback infusion would slow down the delivery of the treatment, delaying the response. A quicker infusion of the undiluted 50% dextrose through the current IV is more efficient and effective in rapidly raising blood glucose levels.

Ask the pharmacist to add the dextrose to a TPN solution

Total parenteral nutrition (TPN) is used for long-term nutritional support and is not appropriate for an immediate hypoglycemic emergency. Adding dextrose to a TPN solution would delay the necessary intervention, as TPN solutions are not designed for rapid glucose infusion in emergencies. The priority in this case is to deliver a concentrated dose of dextrose as quickly as possible to address the hypoglycemia.

Correct Answers:

Provide rescue breaths with a manual ventilation bag

Call for rapid response

Apply oxygen via nasal cannula

Give naloxone 2 mg IV

Explanation:

The client is receiving IV morphine, which poses a risk for respiratory depression. Signs like slow or shallow breathing, low oxygen saturation, or decreased responsiveness signal a medical emergency. Rapid intervention is critical to restore breathing and prevent further decline.

Provide rescue breaths with a manual ventilation bag ensures immediate oxygenation if the client’s respirations are too slow or absent, preventing hypoxia while other treatments are initiated.

Call for rapid response allows the rapid response team to provide immediate, advanced interventions to stabilize the patient.

Apply oxygen via nasal cannula helps improve oxygen saturation and supports respiratory function while naloxone begins to work.

Give naloxone 2 mg IV because naloxone is an opioid antagonist that reverses the effects of morphine, helping to restore adequate breathing and consciousness.

Why the Other Options Are Incorrect:

Perform chest compressions is only appropriate if the client is in full cardiac arrest (no pulse). If the client still has a pulse but is experiencing respiratory depression, rescue breathing—not compressions—is the proper first response.

Print an electrocardiogram (ECG) strip is not a priority in this situation. Although cardiac monitoring is useful, printing an ECG strip does not address the immediate respiratory issue and does not contribute to resolving the acute situation.

Correct Answer: Survivors of violence that occurred at least 5 years ago.

Rationale:

Designated healthcare funding is often directed toward populations that experience ongoing effects from past trauma or significant health disparities. Survivors of violence, even if the event occurred several years ago, are considered a vulnerable population due to the long-term physical, mental, and emotional health challenges they may face. These challenges could include chronic pain, mental health conditions like PTSD, and social difficulties, all of which require targeted healthcare interventions. As such, they are eligible for funding aimed at addressing these needs, especially when they might not have access to comprehensive healthcare or specialized services.

Excluded Options:

African-American women who are 30 to 35 years of age: While African-American women may face health disparities, this group is too broad and general to be automatically designated for specialized funding unless there are other specific, vulnerable factors (e.g., survivors of violence, chronic health conditions).

Active armed forces reserve unit returning from Europe: Members of the armed forces may be eligible for specific healthcare programs, especially those related to trauma, injuries, or mental health conditions. However, the group in this option does not meet the specific criteria for designated funding aimed at vulnerable populations unless specific health concerns (such as PTSD or physical injuries) are being addressed.

Full-time students who are attending public colleges: College students, while they may have specific healthcare needs, do not generally qualify as a vulnerable population unless they fall into other categories (e.g., low-income, homeless, or with specific health issues). Typically, this group is not the primary focus for healthcare funding for vulnerable populations.

Selected Priorities:

A, B, D, E, G, J

A) Feed immediately. Early feeding (breast or formula) is the first-line treatment for neonatal hypoglycemia. At BG 35, the infant needs glucose now – feeding can often raise blood sugar into safe range. It’s noninvasive and critical to do right away.

B) Monitor for respiratory distress. IDMs are at risk for Respiratory Distress Syndrome, plus this baby’s RR was 80 (tachypnea). Continuous observation for grunting, flaring, retractions is vital so interventions (oxygen, CPAP) can be started promptly if needed. Monitoring breathing is a high priority in any newborn showing possible distress.

D) Keep in warmer with bili lights. The infant’s temp is 96°F (hypothermic) – placing the baby under a radiant warmer stabilizes temperature. The mention of “bili lights” suggests using a warmer that also has phototherapy, anticipating possible jaundice (bilirubin was 7 mg/dL, slightly high). Warmth is critical to prevent cold stress, which can worsen hypoglycemia. So yes, keep baby in a warmer (and phototherapy can run as needed).

E) Monitor temperature every 30 min. Given the baby’s low temp, frequent checks are needed to ensure re-warming efforts are effective. Temp q30min until stable is appropriate to avoid under- or overheating. This frequent monitoring is a priority to track improvement.

G) Contact RT for ABG and O₂ therapy. In a jittery, tachypneic IDM, there’s concern for respiratory issues. Getting Respiratory Therapy involved for an arterial blood gas and possible oxygen support ensures we address any RDS quickly. An ABG can assess oxygenation and acid-base status. If RR is 80 and maybe grunting, starting some O₂ or getting RT to evaluate is prudent. Early RT involvement is better than late if distress is present.

J) Check blood glucose level (re-check) after interventions. We fed the baby; now we must follow up BG to see if it improved. Monitoring glucose is an ongoing priority until stable. A repeat BG (likely 30 min to 1 hr after feeding) tells us if additional interventions (like dextrose gel or IV glucose) are needed. So continuing to measure BG is crucial.

These six actions address the baby’s acute issues: hypoglycemia (feed, re-check BG), hypothermia (warmer, temp monitoring), and risk of RDS (monitor breathing, involve RT). They align with the case’s expected priorities for an IDM who is symptomatic.

Why other orders are lower priority:

C) Apply dextrose gel in cheek: Buccal dextrose gel is second-line if feeding fails to correct BG. We would try feeding first (as we did in A). If BG remains low, then gel can be used. It’s important, but after seeing if feeding works. So it’s slightly lower priority than initial feed and re-check.

F) IV bolus of D10W 2 mL/kg: IV dextrose is indicated for severe or refractory hypoglycemia. At BG 35 with some symptoms (jittery), we attempt feed (and gel) first. If those fail, or if baby was very symptomatic or BG <20–25, then IV would be urgent. In this case, baby is jittery but not seizing or unconscious, so we can try lesser invasive measures first. Thus, the IV bolus is held in reserve if BG doesn’t improve.

H) Echocardiogram: While IDMs can have cardiomyopathy, an immediate echo is not typically an emergency unless signs of cardiac distress exist. It’s not a priority in the first hour of life compared to warmth, glucose, breathing. It might be done later if baby has a murmur or poor perfusion. But not a “priority” order right now.

I) Transfer to NICU: You’d transfer if the baby remains unstable or needs aggressive intervention (like ventilator or ongoing IV glucose). Initially, we try to stabilize in the newborn nursery. If we can’t, then NICU transfer happens. It’s not automatic unless these measures fail. So I is not first-line unless baby decompensates despite our interventions.

Summary:

Neonatal hypoglycemia management calls for immediate feeding and glucose monitoring. Thermoregulation (use of warmers) is crucial at 96°F to prevent further metabolic stress. RDS risk in IDMs necessitates vigilant respiratory monitoring and readiness for oxygen/ventilation support. The prioritized orders (A, B, D, E, G, J) cover these bases. Buccal gel and IV glucose are contingency steps if feeding doesn’t suffice. NICU transfer and echo are higher-level interventions if initial stabilization isn’t achieved.

Correct Answers:

N-95 tuberculosis standard

The N-95 tuberculosis standard is a federally regulated safety protocol designed to protect healthcare workers from inhaling airborne particles that may contain the tuberculosis bacteria. Tuberculosis (TB) is a contagious respiratory disease, and the N-95 respirator is specifically mandated by OSHA and the CDC to prevent exposure during care of patients with TB. This standard is vital in healthcare settings to prevent transmission of TB among staff and patients.

Blood-borne pathogen standard

This standard, also mandated by OSHA, protects healthcare workers from exposure to infectious materials such as blood and bodily fluids, which may contain viruses like HIV, hepatitis B, and hepatitis C. The Blood-borne pathogen standard requires the use of personal protective equipment (PPE), proper disposal of sharps, and stringent hygiene practices to reduce the risk of transmission. This is critical for safeguarding healthcare workers handling contaminated materials in their daily duties.

As Low as Reasonably Allowable standard (ALARA)

The ALARA standard is applied to minimize radiation exposure in healthcare environments, especially for healthcare professionals working with radiological equipment. It focuses on keeping radiation exposure levels as low as possible while still achieving the required medical outcomes. This standard is essential for healthcare workers in radiology, helping to protect them from the harmful effects of ionizing radiation while performing necessary diagnostic procedures.

Why the Other Options Are Incorrect:

Standard precautions

Standard precautions are essential infection control practices to prevent the transmission of infectious agents, but they are not specifically a federally regulated biological practice in the same way as the N-95 tuberculosis standard, blood-borne pathogen standard, or ALARA. Standard precautions are guidelines for general infection control, whereas the other options address specific biological threats with clear federal regulations.

Biological product exposure limit (BPEL)

BPEL is not a federally regulated biological practice for healthcare workers. While it addresses limits on exposure to biological products in the workplace, it does not directly pertain to healthcare worker safety regarding infectious disease or radiation exposure. BPEL is more related to regulatory measures on biological product handling rather than specific protocols for biological safety in healthcare.

Resource Conservation and Recovery Act (RCRA)

RCRA regulates the management and disposal of hazardous waste, including medical waste, but it is not a biological safety practice specifically for healthcare workers. While important for waste management, RCRA does not directly regulate the safety practices required to protect healthcare workers from biological hazards, infections, or radiation exposure.

Correct Answer:

Re-dress the abdominal incision.

Explanation:

The primary concern in this scenario is infection prevention. The abdominal dressing is no longer occlusive, exposing the surgical wound to potential contamination, which could lead to infection and delayed healing. Clients with dementia, especially those who are confused at night, may exhibit behaviors like picking at dressings or IV sites, which increases the risk of complications. Re-dressing the wound with sterile technique immediately is crucial to protecting the wound from bacteria, ensuring a clean healing environment, and preventing possible infections that could delay recovery.

Why the Other Options Are Incorrect:

Leave the lights on in the room at night:

While leaving the lights on may help orient confused clients, this is not the priority intervention in this case. The more pressing concern is preventing infection at the surgical site, which is exposed due to the dressing being loose. Adjusting the lighting may be helpful but should be considered after the wound is properly covered and protected.

Apply soft bilateral wrist restraints:

Restraints should only be used as a last resort, especially when other non-invasive options have not been effective. In this case, less restrictive interventions such as providing distractions, redirecting the client, or using mittens to prevent the client from touching the dressing are preferable. Applying restraints should be avoided unless the client is at risk of serious harm or injury, which is not the case here.

Replace the IV site with a smaller gauge:

The IV site described as "pink" likely indicates mild irritation, but this is not an urgent issue. Replacing the IV site with a smaller gauge is not necessary unless there are signs of more severe complications, such as infection, phlebitis, or infiltration. The priority is to ensure the surgical wound is protected, and the IV site can be monitored for further issues if needed.

Correct Answer: Stop the irrigation flow.

Explanation:

When there is a discrepancy between the expected and actual output of a continuous irrigation system, the first step the nurse should take is to stop the irrigation flow. A significant decrease in output (from 1000 ml/hour to 200 ml) may indicate a blockage, clot, or kink in the catheter, which is impeding proper drainage. If the irrigation is continued without addressing the obstruction, it could lead to bladder distention, which can cause additional pressure on the bladder or urethra, increasing the risk of injury. By stopping the flow, the nurse prevents further complications and can investigate and manage the underlying cause, such as a catheter blockage or kink.

Why the other options are incorrect:

Notify the healthcare provider:

While it may be important to notify the healthcare provider later if the situation does not improve or worsens, the immediate priority is to stop the irrigation flow. Continuing the irrigation could lead to further complications, and the nurse must address the immediate concern first. Notifying the provider should occur after stopping the flow and assessing the situation.

Document the finding and continue to observe:

Although documenting the finding and monitoring the patient are important steps, the nurse should not wait to act. If the output is significantly lower than expected, a blockage could worsen, leading to complications such as bladder distention. Immediate action to stop the irrigation and assess the situation is needed to prevent further harm to the patient.

Irrigate the catheter with a large piston syringe:

Irrigating the catheter may be necessary if a blockage is confirmed, but this should only be done after stopping the irrigation flow. Continuing the irrigation flow before addressing the potential blockage could worsen the problem and cause injury. If a blockage is suspected, the nurse should stop the flow, confirm the issue, and then decide whether irrigating the catheter is appropriate.

The correct answers are:

Perform daily surgical dressing change for a client who had an abdominal hysterectomy.

Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus.

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

Explanation:

Practical nurses (PNs) are trained to perform various tasks within their scope of practice, such as wound care, administering certain medications (excluding most IV push medications), and conducting routine assessments. The tasks listed here are appropriate for delegation to a PN under the supervision of a registered nurse (RN).

Perform daily surgical dressing change for a client who had an abdominal hysterectomy:

PNs are qualified to perform routine wound care and surgical dressing changes, assuming there are no complications like severe infection or wound dehiscence. This task falls within their scope of practice as long as the RN provides guidance.

Administer a dose of insulin per sliding scale for a client with type two diabetes mellitus:

PNs are trained to administer subcutaneous injections, including insulin, based on established protocols such as a sliding scale. In some cases, the insulin dose may need to be verified by an RN before administration, but the actual injection can be carried out by the PN.

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty:

Routine vital sign monitoring is well within the scope of a PN's role. After surgery, PNs routinely assess vital signs to ensure the client’s recovery is progressing appropriately.

Why the Other Options Are Incorrect:

Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperatively:

Initiating a PCA pump requires the specialized skills of an RN due to the complexities involved, such as programming the pump correctly, monitoring for complications (e.g., respiratory depression), and ensuring patient safety. While a PN can assist with monitoring, only an RN can initiate a PCA pump.

Start the second blood transfusion for a client 12 hours following a below-knee amputation:

Blood transfusions must be initiated by an RN due to the need for proper protocol adherence, careful monitoring for transfusion reactions, and clinical assessment. Although PNs can assist with monitoring during a transfusion, only an RN can start the process.