PN Fundamentals NGN

Correct Answer: Check the medical record to verify the medication's name and strength.

Explanation of the Correct Answer:

 When a client expresses uncertainty about the medication being administered, the first step is to verify the medication. This ensures that the right drug is being given at the correct dose and that there has been no mix-up in the medication administration process. The medical record will indicate the correct medication and its prescribed strength. Verifying the medication before any further actions can prevent medication errors. 

Why the Other Options Are Incorrect:

Reassure the client that the blue tablet is the correct medication.

While it may be true that the blue tablet is correct, the PN should not simply reassure the client without verifying the medication first. It is important to confirm the medication to avoid potential errors.

Explain that the tablets are from different manufacturers.

This explanation may be true, but it is not the first step. The PN should verify the medication before assuming the discrepancy is due to different manufacturers. Clients should never be reassured without proper verification.

Withhold the medication and notify the healthcare provider.

While this may be appropriate if a medication error is confirmed, it is premature to take this action before verifying the medication. The first action is always to check the medical record to clarify the situation.

Summary:

The PN should first verify the medication in the medical record to ensure the correct drug and dose are being administered. This is the safest and most accurate approach to resolve any concerns raised by the client

The correct answer is C: You will need to hold your urine for 1 hour prior to the procedure.

Explanation of the correct answer:

C. You will need to hold your urine for 1 hour prior to the procedure.

 For a bladder scan, having a full bladder is crucial for obtaining accurate measurements. The scan is non-invasive and uses ultrasound technology to assess the volume of urine in the bladder. To ensure optimal results, the nurse will instruct the client to hold their urine for about an hour before the procedure. A full bladder allows for clearer imaging and more accurate assessment of bladder function or retention.

Why the other options are incorrect:

A. You will need to sign a consent form before we begin the procedure.

A consent form is typically not necessary for a bladder scan, as it is a non-invasive and routine diagnostic test. Consent forms are usually required for more invasive procedures, so this instruction is not needed for a bladder scan.

B. I will place a gel pad directly above your pubic area before I place the probe.

This statement is inaccurate because the nurse will apply ultrasound gel directly to the client’s skin, not in the form of a gel pad above the pubic area. The gel helps with the transmission of sound waves for the ultrasound to capture an accurate image, but it is applied directly to the skin and not as a separate pad.

D. You will receive a contrast dye through an IV catheter prior to the scan.

Contrast dye is not used in bladder scanning. A bladder scan is a simple, non-invasive ultrasound procedure, and there is no need for contrast dye or an IV. Contrast agents are used in imaging studies like CT scans or MRIs, not in ultrasound procedures for bladder assessment.

Summary: 

The correct answer is C because holding urine for an hour before the bladder scan ensures the bladder is sufficiently full for accurate assessment. The other options describe unnecessary or incorrect details about the procedure. Therefore, the correct answer is C. "You will need to hold your urine for 1 hour prior to the procedure."

The appropriate response for the nurse to make is C: I will assist you in any way I can during this process.

Explanation:

In many healthcare settings, family members may request to participate in postmortem care, which includes tasks such as washing and preparing the body. While nurses typically perform postmortem care, the nurse can assist the family if they request to participate. This response offers support and acknowledges the family's wishes in a compassionate manner.

Why the other options are incorrect:

A. You will have to sign a release form to perform the care yourself.

This response is not accurate because in most cases, a family member does not need to sign a release form to participate in postmortem care. The nurse can assist or allow the family to be involved with appropriate guidance.

B. A licensed health care worker must perform postmortem care.

While it is typically the nurse’s responsibility to perform postmortem care, this response is overly restrictive. In many institutions, family members may be allowed to participate in postmortem care under the nurse's guidance and supervision, and this response doesn’t provide support to the family's request.

D. This care takes place after the client leaves the facility.

This response is misleading, as postmortem care typically occurs after the client has died, but before the body is transferred from the facility. The care involves preparing the body for the family’s viewing or for transportation, and it is not delayed until after the body leaves the facility.

Summary:

The most appropriate response is to offer to assist the family while respecting their wishes, ensuring that they feel supported during this sensitive time.

The correct answer is A: Evaluate the client’s concerns and communicate them to the provider.

Rationale: In this scenario, the nurse’s primary role is to advocate for the client by first listening to their concerns regarding the prescribed procedure. It is crucial for the nurse to understand the client’s reasons for refusing the procedure, as this allows the nurse to provide appropriate support, education, and clarification. Once the concerns are understood, the nurse should then communicate these concerns to the healthcare provider. This ensures that the client’s autonomy and preferences are respected, and helps in facilitating shared decision-making between the client and the provider.

Why the other options are incorrect:

B. Contact the unit’s social worker to report the client’s refusal:

While social workers play a vital role in providing support and addressing emotional needs, the initial step should be for the nurse to evaluate the client’s concerns directly. Contacting the social worker too early may not address the client’s immediate need for understanding and communication with the healthcare provider. It is the nurse's responsibility to ensure the client's concerns are communicated first.

C. Ask the client’s partner to find out why the client has refused the procedure:

This would not be appropriate because the client has the right to make decisions about their care and to communicate those decisions themselves. Involving the partner without the client's permission would violate the client’s autonomy and confidentiality. The nurse should directly engage with the client to understand their reasons for refusal.

D. Explain the necessity of the procedure to the client:

While it is important for the nurse to educate the client, merely explaining the procedure may not address the underlying concerns the client has. The nurse should focus on actively listening to the client’s concerns, which could include fears, misunderstandings, or lack of information. By doing so, the nurse can more effectively communicate the client’s concerns to the provider and ensure that the client feels supported in making an informed decision.

In summary:

A is the correct response because it emphasizes the importance of advocating for the client by understanding their concerns and communicating those concerns to the provider. It ensures the client’s autonomy is respected and that their voice is heard in the decision-making process.

The correct answer is A: Stand with your feet together and your arms at your sides.

Explanation of the correct answer:

A. Stand with your feet together and your arms at your sides. 

This statement accurately describes the instructions for the Romberg test, which is used to assess balance and proprioception. The client is asked to stand with their feet together and arms at their sides, with their eyes closed. This position allows the nurse to observe for any swaying or loss of balance, which would suggest a neurological or vestibular issue. The test is positive if the client sways or loses balance with eyes closed, indicating a problem with proprioception or cerebellar function.

Why the other options are incorrect:

B. After I place the tuning fork, tell me when you no longer hear the sound.

This statement refers to a test for auditory function, specifically the Rinne or Weber test, which evaluates hearing and is not related to the Romberg test. The Romberg test focuses on balance, not hearing.

C. I'm going to stroke the lateral side of the bottom of your foot.

 This statement refers to the Babinski reflex, which assesses neurological function, specifically the response to stroking the sole of the foot. While important for assessing motor function, it is not part of the Romberg test.

D. Touch each fingertip as quickly as possible with your thumb.

This statement refers to a test for coordination, such as the rapid alternating movement test or finger-to-nose test, which assesses cerebellar function. While it evaluates motor skills, it is not part of the Romberg test.

Summary:

The correct answer is A, as it provides the proper instructions for the Romberg test, which assesses balance and proprioception. The other options refer to different neurological or sensory tests unrelated to the Romberg test. Therefore, the correct answer is A. "Stand with your feet together and your arms at your sides."

The correct answer is C: pale, scaly skin.

Explanation of the correct answer:

C. pale, scaly skin Pale, scaly skin is a common sign of malnutrition, particularly due to deficiencies in essential nutrients such as vitamins and fatty acids. These deficiencies can result from inadequate intake or absorption of nutrients, leading to impaired skin health. Malnutrition can lead to changes in the skin, including dryness, scaly patches, and pallor, which are significant indicators that further assessment and intervention are needed.

Why the other options are incorrect:

A. heart rate 89/min:

A heart rate of 89 beats per minute (bpm) is within the normal range for an adult at rest (60-100 bpm). While malnutrition can sometimes affect cardiovascular function, a heart rate within normal limits is not an indication of malnutrition. Therefore, this finding does not suggest malnutrition.

B. pink mucous membranes

Pink mucous membranes are indicative of adequate circulation and oxygenation. Healthy mucous membranes are typically pink and moist, signifying that the client is not severely anemic or experiencing significant dehydration, both of which are conditions that could arise from malnutrition. Therefore, this finding does not suggest malnutrition.

D. body mass index 23 A body mass index (BMI) of 23 is within the normal weight range (18.5-24.9). While extreme underweight or obesity may suggest potential issues with nutrition, a BMI of 23 is not indicative of malnutrition. In fact, this falls within the healthy weight range, so it does not support a diagnosis of malnutrition.

Summary:

The presence of pale, scaly skin is a common finding associated with malnutrition, particularly when due to nutrient deficiencies. It is a significant indicator that the client may be malnourished and requires further assessment and intervention. Therefore, the correct answer is C. pale, scaly skin.

The correct answer is B: tell the nurses that this conversation is not appropriate.

Explanation of the correct answer:

B. Tell the nurses that this conversation is not appropriate.

The nurse should immediately intervene and address the inappropriate conversation. Discussing patient information, even indirectly or in casual conversation, is a violation of patient privacy and confidentiality. The nurse should remind the colleagues that discussing patient details outside of a confidential setting, such as in a public space like an elevator, is unprofessional and goes against the principles of patient confidentiality. This action serves to directly correct the behavior while emphasizing the importance of maintaining confidentiality in all situations.

Why the other options are incorrect:

A. Inform the nurses that the neighbor's dog did not cause the wound.

While the content of the conversation might be incorrect, the main issue here is the discussion of patient details in a public space. Correcting the factual inaccuracy in this context is secondary to addressing the violation of confidentiality.

C. Complete an incident report upon returning to the unit.

While completing an incident report could be necessary if the nurse observes a violation of policy or law, the first action should be directly addressing the inappropriate conversation. Reporting the incident can follow after the situation has been addressed, but immediate action to stop the inappropriate behavior is more important.

D. Report the nurses' conversation to the client's provider.

Reporting the nurses' conversation to the client’s provider is not necessary at this stage. The primary responsibility is to stop the inappropriate conversation immediately and address the confidentiality breach. The provider should not be involved unless there is a more serious issue or continued violation.

Summary:

The most appropriate action is to directly intervene and tell the nurses that their conversation is not appropriate, as discussing patient information in public violates patient confidentiality. The other options involve actions that are either too delayed or not as directly related to addressing the behavior at hand.

Correct Answers: 

Show acceptance of the client's current feelings.

Ask the palliative care nurse to see the client.

Allow the client a time to continue crying.

Explanation

Show acceptance of the client's current feelings. This is an essential intervention when caring for a client who is emotionally distressed. Showing acceptance of the client's feelings demonstrates empathy and support, which are vital for establishing a therapeutic relationship. The client may be feeling a range of emotions including fear, sadness, and anger due to their diagnosis of stage IV ovarian cancer. By validating and acknowledging the client's emotions, the practical nurse (PN) helps the client feel heard and supported, which can reduce feelings of isolation.

Ask the palliative care nurse to see the client. A client with a terminal diagnosis such as stage IV ovarian cancer may benefit from the expertise of a palliative care nurse, who can provide support for end-of-life care, pain management, and emotional well-being. The palliative care team can assist in addressing the emotional, psychological, and spiritual needs of the client and provide resources to help the client cope with their diagnosis. By referring the client to the palliative care team, the PN ensures that the client has access to specialized care that is aligned with the goals of comfort and quality of life during this stage of illness.

Allow the client a time to continue crying. Crying is a natural emotional response to overwhelming situations, and it can be therapeutic for the client. Allowing the client time to cry offers an opportunity for emotional release and can serve as a cathartic process for managing grief and fear. The PN should avoid rushing the client or minimizing the emotional response. Instead, they should create a safe, non-judgmental space for the client to express their feelings. It is important to let the client feel they can openly process their emotions, which can be healing and allow for better coping.

Why the Other Options Are Incorrect:

Share a similar personal experience. While it might be tempting to share a personal experience to make the client feel less alone, this approach is not appropriate in this situation. The client may feel that the conversation is shifting away from their needs and may perceive the nurse as minimizing their emotions. The focus should remain on the client's experience, not on the nurse's personal experience. Instead of sharing personal stories, the PN should focus on active listening and providing emotional support.

Document the behavior in the client's record. While it is important for the PN to document the client’s emotional distress and reactions as part of ongoing assessment, it should not be the primary intervention in this situation. The immediate focus should be on providing emotional support and meeting the client’s psychological needs. Documentation should be secondary and follow after the PN has provided the necessary emotional and psychological support. In this case, the client's emotional expression is a normal part of the process and should be documented in context with the supportive care provided.

Summary: The PN should focus on accepting and supporting the client’s feelings (A), referring the client to the palliative care team for specialized care (D), and allowing the client time to express their emotions through crying (E). These interventions will provide emotional support and help the client navigate the difficult experience of receiving a terminal diagnosis. Sharing personal experiences and solely documenting the behavior are less appropriate and may not effectively address the client’s immediate emotional needs.

The correct answer is C: speak with the client about their condition after visitors have left.

Explanation of the correct answer:

C. Speak with the client about their condition after visitors have left

When caring for a client who is alert, the nurse must take measures to protect the client’s privacy and confidentiality, especially when it comes to sharing medical information. By waiting until the visitors have left, the nurse ensures that the client’s health information is discussed in private, respecting their autonomy and complying with HIPAA regulations. This allows the client to choose whether they want to share their condition with others. Protecting privacy in this way also builds trust between the nurse and client and aligns with ethical principles of nursing care.

Why the other options are incorrect:

A. Place the client’s medication record on the bedside table while ambulating the client

Leaving the medication record, which contains protected health information (PHI), unattended in a visible area risks unauthorized access. Anyone entering the room could potentially view sensitive details, making this a violation of confidentiality.

B. Give report about the client’s status while standing at the nurses’ station

The nurses’ station is often in a public or semi-public area. Discussing client information aloud in such settings increases the risk of being overheard by staff not involved in the client’s care or even by visitors, which is a breach of privacy.

D. Place a message board in the client’s room to post dietary information

Even though it might seem convenient, posting dietary information in the room publicly can reveal parts of the client's medical treatment plan (e.g., diabetic or renal diets). This could lead to unintentional disclosure of their health status to visitors or other individuals, which violates privacy protocols.

Summary:

When caring for an alert client in a long-term care facility, the nurse must prioritize actions that protect the client’s privacy. The most appropriate intervention is to speak with the client about their condition after visitors have left, ensuring that personal health information remains confidential and is only shared with the client or others they approve.