NURS_347_01_SP25_Exam 3
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Items to be Ordered:
"Mr. Allen had a left knee replacement yesterday and is receiving onoxaparin for DVT prophylaxis."
"So you are ordering a stat chest X-ray and increasing oxygen to 4 L/min, correct?"
"This is Sin Le, the RN on the surgical unit, calling about Mr. Allen in room 210."
"Would you like me to obtain an EKG immediately and request a stat chest X-ray."
"Vital signs: BP 92/58 mm Hg, HR 118/min, O₂ saturation 84% on 2 L nasal cannula. Breath sounds diminished on the right side."
"The client reports sudden chest pain rated 8/10 that began 5 minutes ago."
- "Mr. Allen had a left knee replacement yesterday and is receiving onoxaparin for DVT prophylaxis."
- "So you are ordering a stat chest X-ray and increasing oxygen to 4 L/min, correct?"
- "This is Sin Le, the RN on the surgical unit, calling about Mr. Allen in room 210."
- "Would you like me to obtain an EKG immediately and request a stat chest X-ray."
- "Vital signs: BP 92/58 mm Hg, HR 118/min, O₂ saturation 84% on 2 L nasal cannula. Breath sounds diminished on the right side."
- "The client reports sudden chest pain rated 8/10 that began 5 minutes ago."
Explanation
Correct Answer:
I — Introduction: (3) "This is Sin Le, the RN on the surgical unit, calling about Mr. Allen in room 210."
S — Situation: (6) "The client reports sudden chest pain rated 8/10 that began 5 minutes ago."
B — Background: (1) "Mr. Allen had a left knee replacement yesterday and is receiving onoxaparin for DVT prophylaxis."
A — Assessment: (5) "Vital signs: BP 92/58 mm Hg, HR 118/min, O₂ saturation 84% on 2 L nasal cannula. Breath sounds diminished on the right side."
R — Recommendation: (4) "Would you like me to obtain an EKG immediately and request a stat chest X-ray."
R — Read-back: (2) "So you are ordering a stat chest X-ray and increasing oxygen to 4 L/min, correct?"
The ISBARR framework is a standardized communication tool used in healthcare to ensure clear, concise, and complete handoff of critical patient information. Introduction identifies who is calling and about whom. Situation describes the current problem prompting the call. Background provides relevant clinical context and history. Assessment presents the objective clinical data supporting the concern. Recommendation proposes the actions the nurse believes are needed. Read-back confirms the orders received from the provider to ensure accuracy and prevent errors.
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The nurse should make a copy of the safety event report and place it in the client's medical record.
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The nurse should record the incident in the client's medical record and fill out a safety event report separately.
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The nurse should await results of the x-ray before filing the report.
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The nurse should include a note on the client's chart that mentions the report.
Explanation
When a patient experiences a fall or any safety incident, the nurse must document the event objectively in the client's medical record as part of the legal and clinical record of care. Additionally, a safety event report, also called an incident report, must be completed separately as an internal quality improvement tool. These are two distinct documents that serve different purposes. The medical record captures what happened clinically, while the safety event report is used by the facility to analyze, track, and prevent future incidents.
Why the other options are incorrect:
A. The safety event report should never be placed in or referenced in the client's medical record. It is a confidential internal facility document used for quality improvement and is legally protected from discovery in many jurisdictions. Placing it in the chart could compromise its protected status.
C. Waiting for x-ray results before filing the report is incorrect. The safety event report should be filed promptly after the incident occurs, regardless of diagnostic outcomes. Delay in reporting undermines the purpose of timely incident documentation.
D. Including a note on the client's chart that mentions the safety event report is incorrect practice. The existence of an incident report should not be referenced in the medical record, as this could compromise its confidential and legally protected nature.
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Risk for Imbalanced Nutrition
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Risk for Activity Intolerance
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Risk for Infection
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Risk for Ineffective Coping
Explanation
Correct Answer: (C) Risk for Infection
HIV severely compromises the immune system by destroying CD4 T-cells, leaving the client highly susceptible to opportunistic infections. Using Maslow's hierarchy of needs and the ABCs of prioritization, physiological threats such as infection take priority over nutritional, activity, or psychosocial concerns. Preventing and managing infection is the most critical nursing priority for an HIV-positive client.
Why the other options are incorrect:
A. Risk for Imbalanced Nutrition is a valid concern in HIV clients due to poor appetite and malabsorption but is not the highest priority compared to the life-threatening risk of infection.
B. Risk for Activity Intolerance may occur as the disease progresses due to fatigue and weakness but is not the immediate priority upon admission.
D. Risk for Ineffective Coping is an important psychosocial diagnosis but falls lower in priority when physiological needs such as infection prevention are present.
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Perform digital rectal stimulation to facilitate stool passage.
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Assess for bowel sounds and palpate for distention.
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Encourage ambulation and increased oral fluid intake.
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Administer a prescribed laxative.
Explanation
Correct Answer: (B) Assess for bowel sounds and palpate for distention.
Assessment always comes first in the nursing process before any intervention is implemented. Before treating postoperative constipation, the nurse must assess bowel sounds and palpate for abdominal distention to determine the nature and severity of the problem and rule out more serious complications such as paralytic ileus or bowel obstruction. These findings will guide the appropriate intervention and ensure that treatments such as laxatives or ambulation are safe and appropriate for the patient's current condition.
Why the other options are incorrect:
A. Digital rectal stimulation is an invasive intervention that should only be performed after thorough assessment confirms it is appropriate and safe. Performing it without prior assessment is premature.
C. Encouraging ambulation and increased fluid intake are appropriate interventions for constipation but must follow assessment. They may be insufficient or inappropriate if a more serious underlying condition such as ileus is present.
D. Administering a laxative is a valid intervention for constipation but must be preceded by assessment. If the patient has a bowel obstruction, administering a laxative could be harmful.
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Alert-aware process
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Sleep-wake cycle
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Circadian rhythm
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Yo-yo theory
Explanation
Correct Answer: (C) Circadian rhythm
The circadian rhythm is the internal biological clock that regulates the natural cycle of physical, mental, and behavioral changes that follow a roughly 24-hour cycle. It governs patterns of sleep and wakefulness, hormone release, body temperature, and other vital functions in response to light and darkness in the environment. The term circadian comes from the Latin words circa meaning about and dies meaning day, reflecting its approximately daily cycle.
Why Other Options are Incorrect:
A. Alert-aware process is not a recognized scientific or medical term related to biological timekeeping or the body's internal clock.
B. Sleep-wake cycle describes the pattern of alternating sleep and wakefulness but is a broader behavioral phenomenon regulated by the circadian rhythm, not the name of the biological clock itself.
D. Yo-yo theory is not a recognized term in sleep science, physiology, or chronobiology and has no relevance to the body's biological timekeeping mechanisms.
Electrolyte Imbalance — Description of Imbalance
Hyponatremia → Calcium / Potassium / Sodium / Magnesium
Hyperkalemia → Calcium / Potassium / Sodium / Magnesium
Hypocalcemia → Calcium / Potassium / Sodium / Magnesium
Hypermagnesemia → Calcium / Potassium / Sodium / Magnesium
- Hyponatremia → Sodium
- Hyperkalemia → Potassium
- Hypocalcemia → Calcium
- Hypermagnesemia → Magnesium
Explanation
Correct Answers:
Hyponatremia → Sodium
Hyperkalemia → Potassium
Hypocalcemia → Calcium
Hypermagnesemia → Magnesium
Each electrolyte imbalance is named using Greek and Latin prefixes that directly indicate the electrolyte involved and the direction of the imbalance. Hypo means low and hyper means high. Natremia refers to sodium, kalemia refers to potassium, calcemia refers to calcium, and magnesemia refers to magnesium. Therefore, hyponatremia means low sodium, hyperkalemia means high potassium, hypocalcemia means low calcium, and hypermagnesemia means high magnesium in the blood.
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Reassess the client to determine the reasons for inadequate pain relief.
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Teach the client about the plan of care for managing pain.
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Wait to see whether the pain lessens during the next 24 hours.
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Change the plan of care to provide different pain relief interventions.
Explanation
Correct Answer: (A) Reassess the client to determine the reasons for inadequate pain relief.
According to the nursing process, when evaluation reveals that a desired outcome has not been met, the nurse must return to the assessment phase to identify why the current plan is ineffective before making changes. Reassessing the client allows the nurse to gather new data about the nature, location, intensity, and contributing factors of the unrelieved pain, which will then guide appropriate modifications to the care plan. Acting without reassessment could lead to inappropriate or ineffective interventions.
Why Other Options are Incorrect:
B. Teaching the client about the pain management plan is an implementation step, not the appropriate response when an outcome has not been achieved. Reassessment must come first to identify why pain relief is inadequate.
C. Waiting another 24 hours to see if pain lessens is inappropriate and unsafe. Unrelieved pain by the second postoperative day requires immediate reassessment and intervention, not a passive wait-and-see approach.
D. Changing the plan of care is appropriate but must come after reassessment. Modifying interventions without first identifying the reason for failure may not address the actual problem and could be harmful.
Nurse's Notes — Day 1: Temperature 37.2°C (99°F) Blood pressure 104/56 mmHg Heart rate 98/min Respiratory rate 20/min Oxygen saturation 96% on room air Client has an NG tube in the right nare, placed to intermittent low wall suction, draining moderate green-brown drainage.
respiratory acidosis / hypoxia / metabolic alkalosis
respiratory rate / glucose level / oxygen saturation / nasogastric suctioning / calcium level
- respiratory acidosis
- hypoxia
- metabolic alkalosis
- respiratory rate
- glucose level
- oxygen saturation
- nasogastric suctioning
- calcium level
Explanation
Correct Answer: (1) Metabolic Alkalosis (2) Nasogastric Suctioning
The patient has an NG tube on intermittent low wall suction, which is actively draining gastric contents. Gastric fluid is highly acidic and rich in hydrochloric acid (HCl). When this acidic fluid is continuously removed through suctioning, the body loses hydrogen ions and chloride, causing the blood pH to shift toward alkalosis. This results in metabolic alkalosis, a condition where the blood becomes too basic due to loss of acid rather than accumulation of a base.
Why the other options are incorrect:
Respiratory acidosis occurs when there is inadequate ventilation leading to carbon dioxide retention. The patient's respiratory rate of 20/min and oxygen saturation of 96% do not support this as a current risk directly tied to the NG tube.
Hypoxia is not the primary risk here. While the oxygen saturation of 96% is on the lower end of normal, the most clinically significant and directly caused risk based on the NG suctioning is metabolic alkalosis.
Respiratory rate, glucose level, oxygen saturation, and calcium level are not the cause of the developing condition in this scenario. Nasogastric suctioning is the direct causative factor leading to loss of gastric acid and the resulting metabolic alkalosis.
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An advanced surgical care consent
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An informed consent
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An advance directive
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A living will
Explanation
An advance directive is a legal document in which a person specifies their healthcare wishes and instructions to guide their medical team in the event they become unable to communicate those decisions themselves. It is a broad term that encompasses various forms of pre-planned healthcare instructions, making it the most accurate and encompassing answer for the document described in this scenario.
Why the other options are incorrect:
A. An advanced surgical care consent is not a recognized legal or medical document. This term does not exist in standard healthcare or legal practice and is therefore incorrect.
B. An informed consent is a document signed before a specific procedure or treatment, confirming that the patient has been educated about the risks, benefits, and alternatives and agrees to proceed. It is not a document that specifies future wishes when communication is impossible.
D. A living will is actually a type of advance directive, specifically addressing end-of-life care wishes such as resuscitation preferences and life-sustaining treatment. While related, it is a subset of the broader advance directive category, making option C the more complete and accurate answer.
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"We all have the same goal and that is the safety of the client, so let's do the time out after the procedure instead."
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"I understand you are very busy, so we can move on without the time-out."
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"I understand you are very busy, but we need to do the time-out prior to the procedure."
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"Whether you have time to do it or not, we will do it without you."
Explanation
Correct Answer: (C) "I understand you are very busy, but we need to do the time-out prior to the procedure."
The surgical time-out is a mandatory patient safety protocol required before any surgical procedure to verify the correct patient, correct site, and correct procedure. The circulating nurse has both a professional and ethical obligation to ensure this step is completed. Option C demonstrates assertive yet respectful communication, acknowledging the surgeon's concern while firmly upholding patient safety standards without being confrontational or dismissive.
Why the other options are incorrect:
A. Suggesting to do the time-out after the procedure defeats its entire purpose. The time-out must occur before the procedure begins to prevent wrong-site, wrong-patient, or wrong-procedure errors.
B. Moving on without the time-out is a direct violation of patient safety protocols and Joint Commission standards. No level of busyness justifies skipping this mandatory safety check.
D. While this statement is assertive, it comes across as disrespectful and confrontational toward the surgeon, which can damage the team dynamic and does not reflect professional therapeutic communication in a team setting.
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