Nursing Management, Delegation and Prioritization 2

EXPLANATION

✔Correct answer:

Assess neurovascular status of the affected limb. The first action Nurse Clara should perform is to assess the neurovascular status of the affected limb. This assessment is critical to ensure that blood flow and nerve function to the extremity have not been compromised due to the fracture. Neurovascular compromise can result in serious complications such as ischemia or permanent nerve damage if not identified and treated promptly. Key elements of a neurovascular assessment include checking for pain, pallor, pulse, paresthesia (sensation), and paralysis, often referred to as the "5 Ps." Immediate identification of neurovascular compromise is essential to prioritize interventions and notify the healthcare provider if necessary.

The ABCs (Airway, Breathing, Circulation) and Maslow’s Hierarchy of Needs guide prioritization. Assessing circulation (blood flow) to the limb and ensuring nerve function aligns with these principles. Without a thorough neurovascular assessment, the nurse cannot safely proceed with other interventions, such as pain management or immobilization.

Assessing neurovascular status is like checking if power lines are still functional after a storm damages a pole. Before repairing the pole (immobilizing the fracture) or addressing secondary issues, you must confirm that the wires (circulation and nerves) are intact to prevent further damage.

Nurse Clara should include the following steps when assessing and addressing the child’s condition:

• Assess for signs of neurovascular compromise: pain unrelieved by medication, pallor, diminished or absent pulses, paresthesia, paralysis, and coolness of the extremity compared to the unaffected side.
• Document findings thoroughly and notify the healthcare provider immediately if there are any indications of neurovascular compromise.
• After completing the neurovascular assessment, proceed with other interventions, such as pain management and immobilization.
• Ensure frequent neurovascular checks, especially after interventions like splinting or traction, to monitor for changes in the child’s condition.

✘Incorrect answer options:

Administer prescribed pain medication to the child. While pain management is important and should be addressed promptly, it is not the first priority. Assessing the neurovascular status ensures that there is no immediate risk of limb ischemia or nerve damage, which would require urgent intervention beyond pain relief.

Immobilize the femur using appropriate splinting or traction. Immobilization is an essential step in fracture management to prevent further injury and reduce pain. However, it should not be performed before completing a neurovascular assessment, as improperly applied splinting or traction could worsen existing neurovascular compromise.

Notify the healthcare provider of potential child abuse concerns. Fractures in non-ambulatory infants can be a red flag for potential child abuse and require reporting in accordance with legal and ethical guidelines. However, this is not the immediate priority compared to ensuring the child’s neurovascular integrity and addressing the physical condition of the fractured femur.

EXPLANATION

✔Correct answer:

Marking the endotracheal tube 1 cm from where it meets the incisor tooth or nares. The correct marking of the endotracheal tube (ETT) is a critical aspect of ensuring proper placement and patient safety. The ETT should be marked at the level where it meets the patient's incisor teeth (oral intubation) or the nares (nasal intubation), but the tube should not be marked 1 cm away from these reference points. This action is incorrect because it introduces a margin of error, potentially leading to improper tube placement (either too shallow or too deep) during monitoring or repositioning.

Incorrect markings can compromise patient safety by increasing the risk of extubation or endobronchial intubation (where the tube is advanced into one bronchus, often the right mainstem bronchus), which could result in hypoxemia or lung injury. Nurse Evelyn must intervene immediately to ensure the tube is marked precisely and accurately at the point where it meets the anatomical landmark.

Imagine you're hanging a picture on a wall and marking the nail's exact position. If you mark the spot 1 cm away instead of where the nail should go, the picture could end up crooked or unstable. Similarly, marking the endotracheal tube inaccurately creates confusion about its proper position, increasing the risk of improper placement and complications for the patient.

Nurse Evelyn should ensure that the new RN is aware of best practices for endotracheal tube care and monitoring, emphasizing the importance of accurate marking and placement confirmation.

• Verify that the ETT is marked where it meets the incisor teeth (or nares for nasal intubation) and document the correct depth (e.g., "ETT at 22 cm at the teeth").
• Ensure regular monitoring of the ETT depth to detect unplanned movement (e.g., accidental extubation or advancement into the right bronchus).
• Provide education about the risks of inaccurate marking, such as hypoxemia, aspiration, or barotrauma.
• Use additional methods to confirm placement, including bilateral breath sound assessment, capnography, and chest X-ray.

✘Incorrect answer options:

Checking for bilateral breath sounds and symmetrical chest rise. This is a standard and necessary step in confirming correct endotracheal tube placement. If breath sounds are absent on one side (often the left), the tube may be in the right mainstem bronchus, and repositioning is required. Symmetrical chest rise confirms proper placement in the trachea rather than a bronchus. This action does not require intervention.

Listening over the stomach to rule out esophageal intubation. Auscultating over the stomach is an essential step to ensure the tube is not placed in the esophagus. If the tube is incorrectly placed in the esophagus, gurgling sounds will be heard during ventilation. This is an appropriate action and does not require intervention.

Requesting a chest X-ray to confirm proper placement of the tube. Requesting a chest X-ray is a standard procedure to confirm the endotracheal tube's position. The tip of the ETT should be 2–3 cm above the carina (the bifurcation of the trachea). This is a safe and necessary step and does not require intervention.

EXPLANATION

✔Correct answer:

Keep the head of the bed elevated at a 30–45 degree angle. Elevating the head of the bed to a 30–45 degree angle is one of the most effective interventions to reduce the risk of ventilator-associated pneumonia (VAP). This position helps prevent aspiration of gastric secretions, which can occur when the patient is lying flat. Aspiration is a major risk factor for VAP, a serious complication in mechanically ventilated patients caused by the invasion of pathogens into the lower respiratory tract.

This intervention is part of the evidence-based "Ventilator Bundle," which includes a set of practices recommended to reduce VAP risk. Keeping the head of the bed elevated also promotes better lung expansion and drainage of secretions, reducing the risk of pooling secretions in the lower airways that can lead to infection.

Think of the lungs like a drainage system. If the system is lying flat, water (secretions) can pool, creating a breeding ground for bacteria. Elevating the system allows gravity to help keep the "pipes" (airways) clear and prevents the buildup of harmful bacteria.

Nurse Carla should prioritize strategies to reduce the risk of VAP by focusing on prevention. The following actions should be included in patient care:

• Maintain the head of the bed at a 30–45 degree angle unless contraindicated (e.g., unstable hemodynamics).
• Perform regular oral care with antiseptic solutions (e.g., chlorhexidine) to reduce oral bacterial colonization.
• Assess the need for daily sedation interruption to evaluate readiness for extubation, which decreases the duration of mechanical ventilation.
• Minimize ventilator circuit disconnections to reduce the risk of introducing pathogens into the system.
• Use sterile technique when suctioning the airway to prevent contamination.

✘Incorrect answer options:

Administer prescribed antibiotics on schedule. While administering antibiotics as prescribed is important in treating existing infections, it does not reduce the risk of developing VAP. Preventive measures such as proper positioning, oral care, and sterile suctioning are more effective in minimizing the risk of VAP.

Provide hyperoxygenation prior to suctioning. Hyperoxygenation is an important practice during suctioning to prevent hypoxemia, but it does not directly prevent VAP. Suctioning removes secretions already in the airway but does not address the risk of aspiration, which is a key factor in VAP development.

Suction the airway when coarse crackles are noted. Suctioning is necessary to maintain a patent airway and remove excess secretions, but it is not a preventive measure for VAP. Inappropriate or excessive suctioning can irritate the airway and increase the risk of infection, so it should only be performed when clinically indicated.

EXPLANATION

✔Correct answer:

"Instruct the patient to pinch the soft part of their nose and lean forward slightly." The most effective first-line management for anterior epistaxis involves instructing the patient to pinch the soft part of their nose (just below the nasal bone) and lean forward slightly. Pinching applies direct pressure to the site of bleeding, and leaning forward prevents blood from flowing down the throat, which could lead to nausea, aspiration, or vomiting. This technique helps control bleeding while reducing complications.

Controlling a nosebleed is like turning off a faucet. Pinching the soft part of the nose is like closing the valve at the right spot to stop the flow, while leaning forward prevents water (blood) from spilling into unwanted areas.

Nurse Jamie should guide the RN in performing proper interventions for anterior epistaxis and monitor the patient for any signs of complications.

• Teach the RN to monitor the patient for continued bleeding, observing for signs such as swallowing or spitting blood, which may indicate posterior epistaxis requiring further intervention.
• Ensure the RN educates the patient to avoid blowing their nose, sneezing forcefully, or bending over for 24–48 hours after the bleeding stops to reduce the risk of recurrence.
• Document the duration and severity of the epistaxis, interventions performed, and the patient's response to treatment.

✘Incorrect answer options:

"Apply a cold compress to the back of the patient's neck and have them lie flat."  This is incorrect because lying flat can cause blood to drain down the throat, increasing the risk of aspiration or nausea. Cold compresses are best applied to the bridge of the nose, not the neck, to encourage vasoconstriction and help reduce bleeding.

"Pack the patient's nostrils tightly with gauze soaked in saline to control bleeding." This is not appropriate as a first-line intervention for anterior epistaxis. Packing should only be done under the direction of a physician or by a trained healthcare provider when bleeding cannot be controlled with simple measures like pinching the nose. Incorrect packing may worsen bleeding or damage nasal tissues.

"Encourage the patient to blow their nose forcefully to expel clots and stop the bleeding."  This is incorrect because blowing the nose can dislodge clots that have formed, potentially worsening the bleeding. Patients should be instructed to avoid forceful actions like blowing or sneezing during and after treatment for epistaxis.

EXPLANATION

✔Correct answer:

The child is swallowing frequently. Frequent swallowing in a child who has recently undergone a tonsillectomy is a red flag that could indicate postoperative bleeding in the surgical site, which is a serious complication. Children may not always verbalize or express symptoms of bleeding, but frequent swallowing is often a subtle but critical sign, as they may be swallowing blood trickling down the back of their throat. Post-tonsillectomy hemorrhage can lead to hypovolemia, airway obstruction, or aspiration, requiring immediate follow-up to confirm bleeding and provide intervention.

This finding warrants immediate action by Nurse Sarah to assess for bleeding. She should inspect the throat using a light to check for active bleeding, monitor vital signs for signs of hypovolemia (e.g., tachycardia, hypotension), and notify the physician promptly for further evaluation and management.

Imagine a leak in a water pipe hidden behind a wall. At first, you may only notice small signs like a faint dripping sound or wet spots on the floor, but if left unchecked, the leak can cause major damage. Similarly, frequent swallowing in a post-tonsillectomy child is a subtle sign of bleeding that, if not addressed quickly, can lead to serious complications like hypovolemia or airway obstruction. Acting immediately can prevent the situation from escalating.

Nurse Sarah must act quickly to address potential postoperative bleeding while continuing to monitor for other complications.

• Inspect the throat for signs of active bleeding or clots, using a flashlight if necessary.
• Monitor the child’s vital signs closely for tachycardia, hypotension, or restlessness, which may indicate hypovolemia or shock.
• Keep the child in a side-lying position or sitting upright to minimize the risk of aspiration if bleeding occurs.
• Notify the physician immediately if bleeding is confirmed or strongly suspected.
• Educate caregivers to observe for signs of bleeding at home, such as frequent swallowing, vomiting bright red blood, or pallor.

✘Incorrect answer options:

Hypotonic bowel sounds are present. Hypotonic (or decreased) bowel sounds are not uncommon after surgery due to the effects of anesthesia or reduced oral intake. While this finding should be monitored, it does not require immediate follow-up compared to signs of postoperative bleeding.

The child complains of a sore throat. A sore throat is an expected finding following a tonsillectomy and can be managed with prescribed pain medications and comfort measures like ice chips. It does not require urgent intervention unless pain is severe or accompanied by other concerning symptoms such as difficulty breathing or swallowing.

The heart rate is 112 beats per minute. A heart rate of 112 beats per minute is within the normal range for a 3-year-old child (normal range: 80–120 bpm). While tachycardia can indicate distress or hypovolemia in certain situations, it is not an immediate concern in isolation unless accompanied by other symptoms of bleeding or shock.

EXPLANATION

✔Correct answer:

A client with a blood glucose level of 60 mg/dL reporting lightheadedness. Nurse Ben should prioritize seeing the client with a blood glucose level of 60 mg/dL who is reporting lightheadedness. A blood glucose level below 70 mg/dL indicates hypoglycemia, which can rapidly progress to serious complications, including confusion, seizures, loss of consciousness, or even death if not treated promptly. The client’s report of lightheadedness further supports the need for immediate intervention to prevent worsening symptoms. The nurse should prioritize administering a source of glucose, such as juice or glucose tablets, and reassess the client’s condition after treatment.

Using the ABCs (Airway, Breathing, Circulation) and the Maslow's Hierarchy of Needs, physiological needs—such as addressing hypoglycemia, which affects the body's ability to function—are prioritized above other issues, such as pain management, education, or mild fever.

Hypoglycemia is like a car running out of fuel. It needs an immediate refill (glucose) to continue running safely, or it will break down (serious complications).

When addressing hypoglycemia, Nurse Ben should take the following steps:

• Provide a rapid source of glucose, such as 15-20 grams of carbohydrate (e.g., 4 ounces of juice, 1 tablespoon of honey, or glucose tablets).
• Recheck the client’s blood glucose level 15 minutes after treatment to ensure it has increased to a safe range.
• Monitor the client for persistent symptoms or recurring hypoglycemia and escalate care if necessary.
• Investigate the cause of hypoglycemia (e.g., skipped meals, insulin administration) to prevent future episodes.
• Document the intervention and communicate findings to the healthcare provider if needed.

✘Incorrect answer options:

A client scheduled for discharge later in the day who needs final medication teaching. Although medication teaching is important, it is not a priority over a client with a potentially life-threatening condition, such as hypoglycemia. Discharge teaching can wait until urgent physiological needs are addressed.

A client recovering from surgery who is requesting pain medication. Pain management is important, but it is not immediately life-threatening. The nurse can attend to this client after stabilizing the hypoglycemic client, as untreated pain is unlikely to lead to serious complications in the short term.

A client receiving IV antibiotics for pneumonia who has a mild fever. A mild fever is expected in a client with pneumonia and does not pose an immediate threat. This client’s care can be deferred until the hypoglycemic client’s condition is stabilized.

EXPLANATION

✔Correct answer:

Assist the patient into a sitting position to optimize lung expansion. Assisting the patient into a sitting position is an appropriate task to delegate to a nursing assistant (NA) because it is within their scope of practice. Positioning a patient to enhance lung expansion is a non-complex intervention that requires no advanced clinical judgment or assessment, making it safe and effective for delegation. Optimizing lung expansion is essential for patients with pneumonia because it facilitates better ventilation and improves the ability to cough effectively by allowing the diaphragm and intercostal muscles to work more efficiently.

Positioning the patient in a sitting or semi-Fowler’s position can help open the airway by reducing pressure on the diaphragm, promoting better airflow, and improving the ability to clear secretions. This task is an essential supportive measure that aligns with the nursing assistant’s role.

Think of the lungs as balloons that need room to inflate fully. Sitting upright is like stretching the balloon's opening so air can flow in freely, whereas lying flat can compress the opening, making it harder to fill.

Nursing assistants can contribute to the care of pneumonia patients by focusing on tasks that support respiratory health while the nurse performs more complex duties like assessment and education.

• Ensure the patient is in a semi-Fowler's or upright position during meals and coughing exercises to prevent aspiration and improve lung function.
• Remind the patient to use an incentive spirometer if prescribed and encourage deep breathing exercises.
• Assist with repositioning every 2 hours to promote lung drainage and prevent atelectasis.
• Monitor and report changes in the patient’s comfort level or breathing patterns to the nurse.

✘Incorrect answer options:

Teach the patient how to perform diaphragmatic breathing exercises. Teaching requires advanced nursing knowledge, clinical judgment, and the ability to evaluate the patient’s understanding and response. This task falls within the scope of practice for registered nurses (RNs) and cannot be delegated to a nursing assistant.

Encourage the patient to increase fluid intake to thin secretions. While increasing fluid intake is a vital intervention for pneumonia, encouraging and monitoring fluid intake requires assessment and understanding of the patient’s fluid balance and potential contraindications (e.g., heart failure or renal impairment). This intervention is better suited for RNs or licensed practical nurses (LPNs).

Monitor the patient’s oxygen saturation during coughing exercises. Monitoring oxygen saturation is a task requiring the ability to interpret findings and act upon changes in clinical status. Nursing assistants are not trained to analyze oxygen saturation readings or determine when interventions like supplemental oxygen are necessary, so this task must remain within the RN’s scope of practice.

EXPLANATION

✔Correct answer:

A lack of trust in the abilities of the healthcare team members. The most likely reason for the new nurse's hesitation to delegate tasks is a lack of trust in the abilities of the healthcare team members. Delegation requires confidence in the competency and reliability of others, and new nurses may struggle with this due to limited experience in assessing team members' skills. Without trust, the new nurse may worry about whether tasks will be completed correctly or safely, leading to hesitation in assigning responsibilities. Additionally, new nurses may feel personally responsible for ensuring patient outcomes, making them reluctant to relinquish control.

Delegation is a critical skill in nursing that involves assigning tasks appropriately while maintaining accountability. A lack of trust can stem from the new nurse’s unfamiliarity with the team, inadequate knowledge of team members’ roles and competencies, or a fear of negative consequences if delegated tasks are not completed properly.

Delegating tasks is like being the captain of a soccer team. If the captain doesn’t trust their teammates’ abilities to pass or score, they might try to do everything themselves, leading to inefficiency and missed opportunities.

Nurse Emma, as the preceptor, can take steps to help the new nurse develop confidence and delegation skills:

• Provide opportunities for the new nurse to observe effective delegation in action, demonstrating how tasks can be safely assigned based on team members' skills and scope of practice.
• Encourage the new nurse to communicate openly with team members, asking about their competencies and comfort levels with specific tasks.
• Review the principles of delegation, such as ensuring tasks align with the scope of practice, providing clear instructions, and following up to ensure completion.
• Support the new nurse in building trust with the team by highlighting the expertise and reliability of other healthcare members, such as nursing assistants or LPNs.
• Foster a supportive environment where the new nurse feels comfortable asking for guidance and reflecting on their delegation experiences.

✘Incorrect answer options:

Behaviors demonstrated by the preceptor as a role model. While role modeling is important, hesitation to delegate is more likely rooted in the new nurse’s personal lack of trust and experience. If the preceptor demonstrates appropriate delegation skills, this would encourage, not discourage, the new nurse.

The guiding principles taught at the new nurse’s nursing school. Nursing school emphasizes the importance of delegation in providing efficient, safe care. While new nurses may be cautious about delegation due to theoretical concerns, reluctance is more often linked to a lack of practical experience and trust in others’ abilities.

The orientation program provided to the new nurse. Although the quality of the orientation program can influence the new nurse’s confidence, it is less likely to be the direct cause of hesitation. Most orientation programs are designed to teach delegation principles, not to discourage them.

EXPLANATION

✔Correct answer:

Cleaning the inner cannula while following universal precautions. Cleaning the inner cannula of a tracheostomy tube requires sterile technique, not just universal precautions. Sterile technique is essential to prevent introducing pathogens into the airway, which could result in a life-threatening infection like tracheitis or pneumonia. Universal precautions (using gloves and other basic protective measures) are not sufficient for this procedure because of the high risk of infection in a patient with a tracheostomy.

If Nurse Angela observes the student nurse using universal precautions rather than sterile technique for cleaning the inner cannula, she must immediately intervene, provide correction, and reinforce the importance of maintaining a sterile field during tracheostomy care.

Cleaning the inner cannula with universal precautions is like cleaning surgical tools with regular dishwashing soap instead of sterilizing them—you’re leaving room for harmful microbes to cause infections.

Nurse Angela should ensure that the student nurse is aware of proper procedures for tracheostomy care and the importance of aseptic practices.

• Reinforce the need to use sterile gloves, sterile water or saline, and a sterile cleaning brush when cleaning the inner cannula.
• Instruct the student to establish and maintain a sterile field while performing tracheostomy care.
• Educate the student about the risks of infection associated with improper technique, particularly for patients with a direct airway to their lungs.
• Demonstrate the correct method for cleaning the inner cannula and stoma site if needed, ensuring the student fully understands the procedure.
• Encourage the student to ask questions and seek clarification if unsure about sterile procedures.

✘Incorrect answer options:

Suctioning the tracheostomy tube prior to starting tracheostomy care. Suctioning the tracheostomy tube is appropriate before beginning care if the patient has secretions or is experiencing respiratory distress. Suctioning clears the airway and ensures the patient can breathe adequately during the procedure. This action does not require intervention.

Taking off old dressings and wiping away excess secretions. Removing soiled dressings and cleaning visible secretions is a necessary step in tracheostomy care. It prevents skin breakdown and infection around the stoma site. This action is appropriate and does not require intervention.

Replacing the inner cannula and carefully cleaning the stoma site. Replacing the inner cannula is a routine and critical part of tracheostomy care. Cleaning the stoma site helps prevent infection and promotes healing. If this is performed using sterile technique, it does not require intervention.

EXPLANATION

✔Correct answer:

Deep vein thrombosis (DVT). In the immediate postoperative period following bariatric surgery, the prevention of deep vein thrombosis (DVT) is the priority due to the high risk of this life-threatening complication. Clients with morbid obesity are at increased risk for DVT due to decreased mobility, the effects of surgery on blood flow, and their baseline risk of venous stasis. A DVT can progress to a pulmonary embolism (PE), which is a medical emergency. Therefore, preventing DVT through interventions such as early ambulation, the use of sequential compression devices (SCDs), and administering anticoagulants as prescribed is critical.

The prioritization of care is guided by Maslow’s Hierarchy of Needs and the potential for immediate harm. DVT poses a more immediate and life-threatening risk than other complications such as vitamin deficiencies or poor adherence to dietary changes, which are longer-term concerns.

Preventing a DVT after surgery is like ensuring a car’s brake system works before driving—it’s a critical safety measure that must be addressed before focusing on non-urgent maintenance like changing the air filter (managing long-term complications).

Nurse Carla should implement the following interventions to reduce the risk of DVT:

• Encourage early ambulation as soon as it is safe and feasible to promote circulation and prevent venous stasis.
• Apply sequential compression devices (SCDs) or anti-embolism stockings to improve venous return in the lower extremities.
• Administer prophylactic anticoagulants (e.g., low-molecular-weight heparin) as prescribed, unless contraindicated.
• Educate the client on leg exercises they can perform in bed, such as ankle pumps and leg flexion, to enhance blood flow.
• Monitor for signs of DVT, such as unilateral leg swelling, warmth, redness, or pain, and notify the healthcare provider immediately if symptoms occur.

✘Incorrect answer options:

Vitamin and mineral deficiencies. While vitamin and mineral deficiencies (e.g., vitamin B12, iron, calcium) are common after bariatric surgery due to malabsorption, they are long-term complications rather than immediate postoperative risks. Addressing deficiencies involves ongoing dietary education and supplementation, but this is not the highest priority during the acute recovery period.

Wound infection at the surgical site. Preventing wound infection is an important postoperative goal, but the risk of infection typically develops later in the recovery process. Early prevention of DVT is a higher priority because of the immediate risk of a potentially fatal pulmonary embolism.

Poor adherence to dietary changes. Adherence to dietary changes is critical for long-term success after bariatric surgery, but it does not pose an immediate threat to the client’s health during the acute postoperative phase. Education on dietary adherence can occur later as the client stabilizes.

EXPLANATION

✔Correct answer:

The patient was recently involved in a motor vehicle accident.  A recent motor vehicle accident strongly supports the likelihood of a pulmonary embolism (PE) because of the potential for prolonged immobility, trauma, or injury, which are key risk factors for deep vein thrombosis (DVT), the most common cause of PE. Following an accident, injuries to the extremities or blood vessel walls, as well as the patient being immobilized during recovery, can increase clot formation. When a blood clot forms in a deep vein (usually in the legs) and travels to the lungs, it results in a PE, which is a life-threatening condition.

This scenario aligns with Virchow's triad, which identifies three factors that contribute to thrombosis:

1. Venous stasis (e.g., immobility after an accident).
2. Endothelial damage (e.g., trauma to blood vessels).
3. Hypercoagulability (e.g., from injuries or systemic inflammation).

In this case, the history of a motor vehicle accident places the patient at a high risk for developing a clot that could lead to a PE.

Imagine a blocked pipe in a water system due to debris that accumulated after a storm. The debris represents a blood clot that formed due to the trauma (storm) and poor water flow (immobility). If this blockage travels to a vital part of the system (the lungs), it can cause severe damage, just as a clot causes a pulmonary embolism.

For a patient suspected of having a PE, Nurse Alex should act quickly to assess, monitor, and coordinate care. Key steps include:

• Monitor vital signs, particularly respiratory rate, oxygen saturation, and heart rate, for signs of respiratory or cardiac compromise.
• Assess for symptoms of PE, such as sudden onset dyspnea, chest pain, tachycardia, hemoptysis, or anxiety.
• Initiate diagnostic tests as ordered, such as D-dimer, chest CT angiography, or ventilation-perfusion (V/Q) scan to confirm PE.
• Ensure the patient remains on bed rest to prevent clot dislodgement or worsening of the condition until stabilized.
• Administer anticoagulants or thrombolytics as prescribed to prevent further clot formation and dissolve existing clots.
• Educate the patient about PE prevention strategies, especially if immobility or future trauma is anticipated.

✘Incorrect answer options:

The patient has been participating in a 6-month aerobic exercise program. Aerobic exercise improves circulation and reduces the risk of blood clots. Regular physical activity is protective against conditions like DVT and PE, rather than contributing to them.

The patient delivered her youngest child one year ago. While pregnancy and the postpartum period are risk factors for thromboembolism, the risk decreases significantly after the first six weeks postpartum. A delivery one year ago would not significantly increase the likelihood of a PE unless other risk factors are present.

The patient remained on bed rest for 6 hours following a diagnostic procedure. While prolonged immobility can contribute to venous stasis, a six-hour period of bed rest is insufficient to significantly increase the risk of a DVT or PE unless additional risk factors (e.g., clotting disorders) are present.

EXPLANATION

✔Correct answer:

Take and document vital signs and pulse oximetry readings every 4 hours. Delegation to a nursing assistant must align with the principles of safe and effective care. Nursing assistants are trained to perform routine tasks such as measuring and documenting vital signs (e.g., blood pressure, temperature, heart rate) and pulse oximetry readings, provided they are stable and non-complex. These activities are within the nursing assistant's scope of practice and do not require advanced nursing judgment or decision-making.

In the context of a mechanically ventilated patient, vital signs and pulse oximetry are critical components of monitoring the patient’s status. However, any abnormal findings or significant changes must be reported immediately to the nurse, who is responsible for interpreting these findings and taking further action.

Think of a nursing assistant as a weather observer reporting temperature and rainfall measurements (vital signs). They collect the data, but it’s up to the meteorologist (nurse) to analyze the information and determine if a storm (clinical issue) is approaching.

When delegating tasks, Nurse Jamie must ensure proper supervision and communication while focusing on tasks that require critical thinking or clinical decision-making. Consider the following guidelines:

• Ensure the nursing assistant is competent in obtaining accurate vital signs and pulse oximetry readings and documenting them correctly in the patient’s record.
• Instruct the nursing assistant to report any abnormal values (e.g., pulse oximetry below 92%, significant blood pressure changes) to the nurse immediately.
• Verify that the nursing assistant understands the scope of their role and the importance of communicating promptly about any changes in the patient’s condition.
• Perform follow-up assessments or interventions based on the nursing assistant’s documented findings, ensuring patient safety and appropriate care.

✘Incorrect answer options:

Perform a respiratory status assessment every 4 hours. Respiratory assessments, especially for patients on mechanical ventilation, involve advanced clinical skills, such as evaluating lung sounds, respiratory effort, and ventilation parameters. These tasks require the nurse's expertise and cannot be delegated to a nursing assistant.

Verify that the ventilator settings align with the prescribed parameters. Checking ventilator settings and ensuring they match the prescribed parameters (e.g., tidal volume, respiratory rate, and oxygen concentration) is a critical nursing responsibility. It requires knowledge of the ventilator’s functions and the ability to identify and respond to potential problems. This task cannot be delegated to a nursing assistant.

Monitor the patient for signs indicating the need for suctioning every 2 hours. Monitoring for signs of airway obstruction (e.g., visible secretions, decreased oxygen saturation, audible gurgling) requires clinical judgment and the ability to initiate appropriate interventions, such as suctioning. This is beyond the scope of a nursing assistant’s practice and must be done by a licensed nurse.

EXPLANATION

✔Correct answers:

• "Identify and avoid triggers such as allergens and smoke."
• "Monitor your peak flow readings regularly."
• "Take your controller medication even when you feel well."

Effective asthma management focuses on reducing exacerbations, preventing symptoms, and maintaining optimal lung function. These key points are crucial for a comprehensive teaching plan:

• Identify and avoid triggers: Recognizing and avoiding triggers like allergens, smoke, pollution, or strong odors is essential for preventing asthma attacks. Education about common triggers and how to minimize exposure is a cornerstone of asthma management.
• Monitor peak flow readings regularly: Regular peak flow monitoring helps patients assess their lung function and detect early signs of worsening asthma. Patients should learn how to use a peak flow meter and recognize patterns that require action, such as using a rescue inhaler or contacting their healthcare provider.
• Take controller medication daily, even when symptom-free: Controller medications (e.g., inhaled corticosteroids) reduce airway inflammation and prevent symptoms. Patients must understand that these medications are not for immediate relief but for long-term control, and they must be taken consistently to be effective.

Managing asthma is like managing a car: avoiding triggers is like steering clear of potholes, checking peak flow readings is like monitoring your fuel gauge, and taking controller medication daily is like getting regular maintenance—even if the car seems to be running fine.

Nurse Rachel should provide clear instructions, demonstrations, and written materials to ensure the patient understands these key points.

• Teach the patient how to use their rescue and controller inhalers correctly, including when and how to use each type.
• Explain how to use a peak flow meter and help the patient set a personal action plan based on their readings (e.g., green, yellow, and red zones).
• Encourage the patient to keep a diary of asthma symptoms and triggers to share with their healthcare provider during follow-up visits.
• Provide information about smoking cessation resources if applicable, as smoking worsens asthma symptoms and control.

✘Incorrect answers:

"Use your rescue inhaler daily to prevent asthma attacks."  Rescue inhalers (e.g., short-acting beta agonists like albuterol) are intended for acute symptom relief, not for daily use to prevent attacks. Overuse of a rescue inhaler indicates poor asthma control and the need for reassessment of the treatment plan.

"Only use your inhaler if you experience severe symptoms." This is incorrect because rescue inhalers should be used at the first sign of symptoms, not only during severe episodes. Waiting until symptoms become severe can lead to delayed relief and potentially worsen the condition. Controller medications should also be taken proactively, not only during symptoms.

EXPLANATION

✔Correct answer:

The patient’s blood pressure is 100/48 mm Hg and heart rate is 102 beats per minute. A blood pressure of 100/48 mm Hg accompanied by a heart rate of 102 beats per minute indicates potential hypotension and tachycardia, which are concerning findings after a thoracentesis. Removing a large volume of pleural fluid (1800 mL in this case) can cause a sudden shift in intrathoracic pressure, leading to cardiovascular instability, such as hypovolemia or re-expansion pulmonary edema. These changes can impair venous return to the heart and reduce cardiac output, potentially resulting in hypotension, tachycardia, and even respiratory distress. Nurse Lauren should report these findings to the physician immediately, as they may require urgent interventions such as fluid replacement, further evaluation, or close monitoring.

Imagine a dam holding back a reservoir of water. If too much water is released too quickly, the river downstream can flood, causing instability and damage. Similarly, removing a large volume of pleural fluid too rapidly during a thoracentesis can disrupt the body's balance, leading to a "flood" of cardiovascular instability, such as hypotension and tachycardia, which requires immediate attention to prevent complications.

Nurse Lauren should be vigilant for signs of hemodynamic instability and respiratory complications following a thoracentesis, particularly when a large amount of fluid has been removed.

• Monitor the patient’s vital signs closely, especially blood pressure, heart rate, and oxygen saturation.
• Assess for signs of re-expansion pulmonary edema, such as dyspnea, hypoxemia, or crackles on auscultation.
• Position the patient appropriately, usually in a semi-Fowler’s position, to promote lung expansion and comfort.
• Notify the physician of any significant changes in hemodynamic or respiratory status to initiate timely treatment.
• Educate the patient about reporting symptoms such as chest pain, dizziness, or difficulty breathing immediately.

✘Incorrect answer options:

The patient becomes emotional, crying, and expressing difficulty continuing treatment. While emotional distress is valid and should be addressed, this is not an urgent medical issue requiring immediate reporting to the physician. Emotional support, therapeutic communication, and potentially a referral to counseling or a support group are appropriate interventions.

The patient reports sharp, stabbing chest pain with deep breaths. Chest pain after a thoracentesis can occur due to pleural irritation or inflammation. While it should be monitored and treated (e.g., with analgesics), it is not as urgent as signs of hemodynamic instability unless accompanied by other symptoms such as severe respiratory distress or hypoxia.

The dressing at the thoracentesis site shows 1 cm of bloody drainage. A small amount of bloody drainage at the thoracentesis site is expected and can be managed with routine dressing changes and monitoring for excessive bleeding or infection. This does not require immediate reporting unless the drainage becomes excessive or the site shows signs of infection.

EXPLANATION

✔Correct answer:

Deliver oxygen via nasal cannula to improve oxygenation. The nurse's first priority in this scenario is to improve the client's oxygenation by administering oxygen via a nasal cannula or another appropriate oxygen delivery device. The client's signs and symptoms—dyspnea, chest pain, syncope, tachypnea, hypotension, and fear of death—are concerning for a life-threatening condition, such as a pulmonary embolism, acute coronary syndrome, or other cardiac or respiratory emergencies. In such situations, ensuring adequate oxygenation is critical and aligns with the ABCs (Airway, Breathing, Circulation) framework for prioritizing care. Oxygen delivery improves oxygen saturation, alleviates dyspnea, and helps prevent hypoxia while the underlying condition is further evaluated and treated.

The symptoms described suggest a state of inadequate oxygenation and perfusion, which could be due to impaired oxygen delivery to tissues. Administering oxygen helps increase the availability of oxygen in the bloodstream, stabilizing the client while further interventions, such as fluid therapy, diagnostics, or medications, are initiated.

Imagine a fire (acute medical crisis) that’s depriving people of oxygen in a room. Your first action would be to provide oxygen (immediate relief) before determining the fire's exact cause and addressing other factors like structural damage (underlying condition).

Nurse actions should focus on stabilizing the client’s oxygenation and identifying the underlying cause of the symptoms:

• Deliver oxygen via nasal cannula, non-rebreather mask, or another appropriate method, based on the severity of the hypoxia and clinical judgment.
• Assess oxygen saturation levels using pulse oximetry, and monitor for improvements after oxygen therapy.
• Perform a focused assessment of respiratory and cardiovascular status, including lung sounds, heart rate, and skin color.
• Prepare for additional interventions, such as diagnostic testing (e.g., ABGs, ECG, or imaging) to determine the cause of the symptoms.
• Communicate the client’s status promptly to the healthcare provider and anticipate further orders, such as IV fluids, medications, or advanced monitoring.

✘Incorrect answer options:

Provide pain relief by administering prescribed medications. While pain management is important, it is not the first priority in this scenario. Addressing the client’s oxygenation and stabilization takes precedence, as untreated hypoxia could lead to rapid deterioration or death.

Initiate IV fluid therapy to address potential hypovolemia. Hypotension and tachycardia may suggest hypovolemia; however, the priority is to first stabilize oxygenation. Fluid therapy can follow once oxygen delivery is addressed and the underlying cause of the hypotension (e.g., shock, pulmonary embolism) is identified.

Administer dopamine to improve cardiac output. Dopamine may be used to support blood pressure and cardiac output in cases of shock, but it is not the first-line intervention in this situation. The client's oxygen needs must be met before considering vasopressor therapy. Administering dopamine without addressing oxygenation could worsen the client’s condition.

EXPLANATION

✔Correct answer:

Encouraging, monitoring, and documenting the patient’s nutritional intake. Encouraging, monitoring, and documenting nutritional intake is an appropriate task to delegate to the nursing assistant (NA) as it falls within their scope of practice. Nutrition plays a crucial role in recovery after surgery, particularly for patients with Activity Intolerance, as proper nutrition provides the energy needed for healing and gradual increases in physical activity. Nursing assistants are trained to provide support in monitoring patients' food and fluid intake, encouraging patients to eat, and documenting intake for the nurse to review.

This task does not require advanced clinical judgment or critical thinking, making it suitable for delegation. Nurse Kevin can then focus on more complex tasks, such as assessing the patient's tolerance for activity or developing a care plan.

Think of nutrition as the fuel needed to power a car (the patient). The nursing assistant's role is like a gas station attendant—they ensure the tank is being filled, while the nurse (like a mechanic) focuses on ensuring the car runs smoothly and safely.

While the NA assists with nutritional intake, Nurse Kevin should ensure a coordinated approach to the patient’s recovery, focusing on interventions to address Activity Intolerance.

• Review the documentation of the patient’s nutritional intake to assess adequacy and identify potential issues such as poor appetite.
• Encourage small, frequent meals if the patient has reduced appetite or limited energy for eating postoperatively.
• Monitor the patient’s overall energy levels and gradually increase activity as tolerated to reduce fatigue and improve strength.
• Evaluate the patient's physical and cardiorespiratory responses during activity to adjust care as needed.

✘Incorrect answer options:

Teaching the patient to balance rest and activity periods. Teaching requires advanced nursing knowledge, assessment skills, and the ability to tailor education to the patient's individual needs. This task requires critical thinking and is beyond the scope of practice for a nursing assistant.

Observing the patient’s cardiorespiratory response during activities. Observing and interpreting cardiorespiratory responses (e.g., changes in heart rate, respiratory rate, and oxygen saturation) during activity involves clinical judgment, which falls within the nurse’s responsibilities. NAs are not trained to monitor or assess these physiological changes.

Scheduling activities during times when the patient is most energetic. Scheduling activities requires assessing the patient’s energy levels, preferences, and tolerance, which is a task for the nurse. The NA may assist with specific delegated tasks during scheduled activity times but cannot independently plan or schedule activities.

EXPLANATION

✔Correct answer:

The patient struggles to recall her husband’s first name. This finding indicates a potential neurological deficit, which could be caused by a cerebrovascular event such as an ischemic or hemorrhagic stroke. Since the patient is on enoxaparin, a low-molecular-weight heparin (anticoagulant), there is a risk of complications such as excessive bleeding, including intracranial hemorrhage. Confusion or memory problems are red flags for a possible stroke or central nervous system (CNS) event, requiring immediate evaluation. Neurological symptoms like difficulty recalling familiar information, confusion, or sudden changes in cognitive status warrant urgent reporting to the physician, as these could signal a life-threatening condition.

Patients taking anticoagulants are at an increased risk of bleeding, and any signs of altered neurological function must be addressed promptly to prevent further complications.

Imagine your brain as a computer. If the power source (blood flow) is disrupted or a component is damaged (due to bleeding), the computer might not function properly, causing memory errors or shutdowns. This is why neurological symptoms like confusion need immediate attention.

When neurological symptoms are observed in a patient on anticoagulant therapy, nurses should act quickly to assess, report, and prevent further complications.

• Perform a focused neurological assessment, including evaluating orientation, speech, memory, and motor function.
• Assess for other signs of bleeding, such as severe headache, visual changes, or loss of motor coordination.
• Immediately notify the physician to ensure prompt diagnostic testing (e.g., CT scan or MRI) and treatment if needed.
• Monitor the patient's medication regimen and ensure proper dosing of enoxaparin to minimize bleeding risks.
• Educate the patient and family about recognizing and reporting signs of bleeding or neurological changes.

✘Incorrect answer options:

The patient reports that her right leg aches throughout the night. Leg pain is a common symptom after DVT, especially during the recovery phase, due to lingering inflammation or venous insufficiency. While this should be monitored, it is not an immediate cause for alarm unless accompanied by other signs of a new clot, such as severe swelling or redness.

The right calf feels warm and appears larger than the left calf. While these findings could indicate a new or recurrent DVT, the patient is already on enoxaparin, which reduces the likelihood of clot formation. This finding should be reported, but it does not take precedence over signs of a neurological emergency, such as confusion.

The patient has several bruised areas on her arms. Bruising is a common side effect of anticoagulant therapy and is typically benign unless accompanied by excessive or unexplained bleeding. While this should be documented and discussed with the physician to evaluate the patient’s anticoagulant dose, it is not as critical as neurological symptoms that suggest a CNS complication.

EXPLANATION

✔Correct answer:

A respiratory rate of 8 breaths per minute.  A respiratory rate of 8 breaths per minute is a critical finding in a patient with emphysema and requires immediate attention. This rate indicates respiratory depression, which can be life-threatening. Patients with chronic obstructive pulmonary disease (COPD), including emphysema, are at risk of carbon dioxide retention (hypercapnia) due to impaired gas exchange. Oxygen therapy at high flow rates (e.g., 5 L/min via nasal cannula) can suppress the hypoxic drive that stimulates breathing in these patients, leading to respiratory depression and even respiratory arrest.

Emphysema patients rely primarily on hypoxia (low oxygen levels) rather than hypercapnia (high carbon dioxide levels) to drive their respiratory effort. Administering excessive oxygen can blunt this hypoxic drive, further decreasing respiratory rate and causing a dangerous retention of CO2. Nurse Jenna must act immediately to address this by reducing the oxygen flow rate and notifying the healthcare provider.

Imagine a car engine designed to run on a specific balance of fuel and air. If you flood the engine with too much fuel (oxygen in this case), the engine stalls and stops running. Similarly, patients with emphysema rely on a delicate balance of oxygen and carbon dioxide to drive their breathing. Too much oxygen "floods the system," suppressing their natural drive to breathe, leading to respiratory depression.

Nurse Jenna should prioritize interventions to stabilize the patient and prevent further complications:

• Immediately reduce the oxygen flow rate to the prescribed level, typically 1–3 L/min via nasal cannula, for patients with emphysema.
• Closely monitor the patient’s respiratory rate, oxygen saturation, and arterial blood gases (ABGs) to assess for signs of respiratory acidosis or further hypercapnia.
• Place the patient in a high Fowler’s position to optimize lung expansion and ease breathing.
• Notify the healthcare provider immediately about the patient’s condition and potential oxygen-induced respiratory depression.
• Prepare for possible interventions, such as noninvasive positive pressure ventilation (e.g., BiPAP) or emergency intubation if respiratory failure worsens.

✘Incorrect answer options:

The presence of fine crackles at the lung bases. Fine crackles are typically associated with fluid in the alveoli and may suggest conditions such as heart failure or pneumonia. While concerning, this finding does not require immediate intervention in a patient with emphysema unless accompanied by acute respiratory distress or hypoxemia.

The patient sitting upright and leaning over the night table. This posture, known as the tripod position, is a common compensatory mechanism used by patients with emphysema to optimize breathing. While it indicates ongoing respiratory difficulty, it is not an acute or life-threatening finding in this context.

A large, barrel-shaped chest appearance. A barrel chest is a characteristic finding in chronic emphysema due to lung hyperinflation and prolonged air trapping. This is a long-term adaptation and does not represent an acute issue requiring immediate intervention.

EXPLANATION

✔Correct answer:

Check to see if the client is responsive. The first action Nurse Jenna should take is to assess whether the client is responsive. This is crucial for determining the severity of the situation and prioritizing care. If the client is unresponsive, Nurse Jenna may need to initiate emergency protocols, such as calling a rapid response team or beginning CPR. If the client is responsive, Nurse Jenna can proceed with further assessments and interventions based on the client's condition. Ensuring the client’s immediate safety and evaluating their level of consciousness is a fundamental step in any fall or emergency situation.

According to the ABCs (Airway, Breathing, Circulation) of emergency care, the nurse must assess the client’s responsiveness to determine whether life-threatening conditions are present. Once responsiveness is confirmed, further actions can be planned to address the situation appropriately.

If you come across a car accident, your first step would be to check if the driver is conscious and alert before attempting to move them or ask questions about what happened.

Nurse Jenna should follow these steps to manage the situation safely:

• Assess the client’s level of responsiveness by calling their name and gently tapping their shoulder.
• If the client is unresponsive, initiate emergency protocols such as calling for help, checking for breathing and a pulse, and beginning CPR if necessary.
• If the client is responsive, perform a quick assessment to determine the presence of injuries, such as bleeding, fractures, or signs of head trauma.
• Reassure the client and ensure their safety by preventing further movement until help arrives or injuries are ruled out.
• Document the incident thoroughly, including the client’s condition, actions taken, and any subsequent findings or interventions.

✘Incorrect answer options:

Call for assistance to help get the client back into bed. While calling for assistance may be necessary, it is not the first action Nurse Jenna should take. The priority is to assess the client’s condition and responsiveness before moving or repositioning them, as moving an injured client without proper evaluation could cause further harm.

Help the client safely return to bed. Moving the client back to bed should not be done until their condition has been assessed and any injuries have been ruled out. Prematurely moving a client who may have sustained a head, neck, or spinal injury could exacerbate their condition.

Ask the client to explain what happened. While gathering information about the incident is important, it is not the first priority. The nurse must first ensure the client’s safety by assessing their responsiveness and physical condition before seeking details about the fall.

EXPLANATION

✔Correct answer:

Assess the patient’s level of consciousness. The first step in responding to a patient found on the floor with a head injury is to assess their level of consciousness (LOC). This assessment is crucial in determining the severity of the injury and prioritizing interventions. The level of consciousness provides critical information about the patient's neurological status and whether they are responsive, which may guide further actions, such as stabilizing the airway or initiating cardiopulmonary resuscitation (CPR).

According to the ABCs (Airway, Breathing, Circulation) of emergency nursing care, evaluating a patient's responsiveness aligns with ensuring airway patency (if unconscious) and preparing to address life-threatening conditions. Any delay in assessing the patient's LOC may result in missing critical findings, such as a compromised airway or worsening head trauma.

Imagine finding a smartphone that is damaged and not functioning. Before fixing it or calling for help, you first need to check if the phone still turns on. Similarly, assessing a patient’s level of consciousness is like checking if their "system" is still responding before moving to other steps.

Nurse Mia must quickly evaluate the situation while ensuring the safety of both the patient and herself. The following steps are critical:

• Ensure the scene is safe to approach the patient (e.g., no hazards such as spilled liquids or sharp objects).
• Assess the patient's level of consciousness using verbal stimuli (e.g., calling their name) and physical stimuli (e.g., tapping their shoulder if safe).
• Determine the patient’s airway, breathing, and circulation status as part of the primary assessment.
• Only move the patient if necessary to protect their airway or if they are in immediate danger (e.g., choking or in an unsafe location).
• Call for assistance or activate the emergency response system as soon as the patient’s condition is evaluated.

✘Incorrect answer options:

Use the call button to summon help immediately. While summoning help is important, it should not take precedence over assessing the patient's condition. Determining the patient's LOC and ABCs is the first step, as it guides whether immediate life-saving actions are needed. Without knowing the patient’s status, summoning help alone may delay critical interventions.

Carefully turn the patient face up to evaluate their condition. Turning the patient may worsen their injury, especially if there is a potential spinal injury from the fall. The priority is to assess their LOC without moving them unnecessarily. Moving the patient should only occur if the airway is compromised or if it is unsafe to leave them in their current position.

Step into the hallway to ask a nursing assistant to stay with the patient while contacting the physician. Leaving the patient unattended is not appropriate in this scenario. The nurse should remain with the patient to assess their condition and ensure their safety until further help arrives.

EXPLANATION

✔Correct answer:

Persistent bubbling observed in the water seal chamber. Persistent bubbling in the water seal chamber of a chest tube system typically indicates an air leak. This is a serious issue that requires the nurse's urgent attention, as it may signify that air is entering the pleural space from the lung or the tubing system. In a patient with a thoracotomy and chest tube, resolving air leaks is essential to re-establishing normal intrapleural pressure and promoting lung expansion.

A properly functioning water seal chamber should show intermittent bubbling during expiration or coughing, which is normal as air exits the pleural space. Persistent or continuous bubbling, however, is abnormal and requires immediate investigation. The nurse should assess the chest tube connections, tubing, and insertion site for signs of a disconnection or air leak, and notify the physician promptly if the issue cannot be resolved at the bedside.

Think of a chest tube system like a sealed vacuum bag. If there's a persistent bubbling in the water seal, it’s like having a hole in the bag, allowing air to escape. This prevents the vacuum (negative pressure) from working properly, making it harder for the lung to re-expand.

Nurse Lisa should guide the nursing student on how to identify and address an air leak. Immediate action is necessary to prevent further complications like a tension pneumothorax or impaired gas exchange.

• Check the chest tube connections to ensure they are secure and that no disconnections or loose fittings are causing the air leak.
• Inspect the insertion site for signs of air leakage, such as crepitus (subcutaneous emphysema), and ensure the dressing is intact.
• If the air leak persists, clamp the chest tube briefly near the insertion site (if ordered and appropriate) to determine whether the leak originates from the patient or the tubing system.
• Notify the physician immediately for further evaluation if the air leak cannot be resolved or if the patient’s respiratory status worsens.
• Monitor the patient’s oxygen saturation, respiratory rate, and work of breathing to assess for signs of respiratory distress.

✘Incorrect answer options:

Chest tube drainage measuring 10 to 15 mL/hr. This drainage amount is within normal limits, especially in the postoperative phase. Nurses are typically concerned if drainage exceeds 70–100 mL/hr or if there is a sudden increase in bloody or serosanguinous drainage, as this may indicate hemorrhage.

The patient reporting pain at the chest tube site. Pain is a common postoperative finding, especially around the chest tube site. While it should be managed appropriately with analgesics and nonpharmacologic interventions, it does not require urgent reporting unless it is severe or accompanied by other signs of complications, such as crepitus or infection.

A chest tube dressing labeled with yesterday’s date. While changing chest tube dressings daily or as needed to maintain sterility is important, a dressing labeled with yesterday’s date does not represent an urgent finding. This should be addressed promptly but does not take priority over the possibility of an air leak.

EXPLANATION

✔Correct answer:

A client with heart failure who is short of breath and has bibasilar crackles on auscultation.  The client with heart failure who is short of breath and has bibasilar crackles should be Nurse James’ first priority. These findings suggest fluid overload and worsening heart failure, which could quickly progress to pulmonary edema, a life-threatening condition. Shortness of breath indicates impaired oxygenation, and crackles (fluid in the lungs) signal poor gas exchange. Prompt assessment and interventions, such as oxygen therapy, diuretics (if prescribed), and positioning the client upright, are critical to stabilize the client’s respiratory and cardiac status.

This decision aligns with the ABCs (Airway, Breathing, Circulation) framework, as addressing respiratory distress and oxygenation takes precedence over other issues. Failure to manage this client’s symptoms promptly could result in respiratory failure or cardiac arrest.

 Imagine a water leak (fluid overload) filling a basement (lungs). You need to stop the flooding and remove the water (manage shortness of breath and crackles) immediately before dealing with less urgent issues like tidying up furniture (pain relief or teaching).

Nurse James should focus on stabilizing the client’s respiratory and cardiac status:

• Elevate the head of the bed to improve lung expansion and reduce the work of breathing.
• Administer oxygen as prescribed to improve oxygenation.
• Perform a focused respiratory and cardiovascular assessment, including pulse oximetry, respiratory rate, heart rate, and blood pressure.
• Anticipate orders for diuretics (e.g., furosemide) to reduce fluid overload and improve symptoms.
• Monitor for worsening respiratory distress, such as accessory muscle use, cyanosis, or declining oxygen saturation, and notify the healthcare provider promptly.

✘Incorrect answer options:

A client who had a myocardial infarction 2 days ago and is requesting pain medication for chest discomfort rated 4/10. Chest discomfort in a client post-myocardial infarction is concerning, but a pain level of 4/10 suggests mild to moderate discomfort. This client is stable compared to the client with heart failure and respiratory distress. Nurse James can assess this client after addressing the more urgent needs of the client with shortness of breath.

A client with atrial fibrillation who reports feeling lightheaded but has a heart rate of 80 beats per minute. Lightheadedness may indicate reduced cardiac output; however, a heart rate of 80 beats per minute suggests the atrial fibrillation is controlled. This client’s condition is not as acute as the client with heart failure and can be addressed after stabilizing the client with respiratory distress.

A client who is scheduled for a stress test in 30 minutes and needs pre-procedure teaching. Pre-procedure teaching is important but not urgent. This client is stable and can wait until Nurse James has addressed more critical clinical issues.

EXPLANATION

✔Correct answer:

The Pneumococcal vaccine.  The pneumococcal vaccine is critically important for older adults, particularly those aged 65 and older, and those with chronic conditions such as cerebrovascular disease. Pneumococcal disease, caused by Streptococcus pneumoniae, can result in severe infections like pneumonia, meningitis, and bacteremia, all of which older adults and those with comorbidities are at heightened risk for. Clients with cerebrovascular disease may have compromised immune systems or decreased lung capacity, further increasing their vulnerability to respiratory infections.

The CDC recommends two pneumococcal vaccines for adults over 65: the pneumococcal conjugate vaccine (PCV15 or PCV20) and the pneumococcal polysaccharide vaccine (PPSV23). These vaccines can prevent severe complications and reduce hospitalization rates in vulnerable populations.

Think of the pneumococcal vaccine as a shield for the elderly against a storm of potential infections. Just like a storm is more likely to damage an older, weaker house, infections like pneumonia are more likely to severely impact someone with underlying health conditions. The vaccine helps strengthen the client’s defenses.

Nurse Lisa should provide education about the importance of the pneumococcal vaccine while addressing any questions or concerns the caregiver may have. Key considerations include:

• Explain the recommended pneumococcal vaccine schedule for individuals over 65 years old and the importance of preventing serious infections.
• Assess the client’s vaccination history to determine if they have received the PCV15, PCV20, or PPSV23, and if additional doses are necessary.
• Address common misconceptions about vaccines, including safety and efficacy, and provide evidence-based information.
• Encourage adherence to other recommended vaccines for older adults, such as the influenza and shingles vaccines, as part of comprehensive care.
• Document vaccination status and communicate the need for future doses to the client and caregiver as appropriate.

✘Incorrect answer options:

The Hepatitis A vaccine. The Hepatitis A vaccine is not a priority for older adults unless they are at specific risk due to factors such as international travel to areas where hepatitis A is endemic or exposure to contaminated food or water. It is not routinely recommended for the general elderly population.

The Lyme disease vaccine. A vaccine for Lyme disease is not currently available for humans. Lyme disease is primarily a concern for individuals living in or traveling to areas with high tick populations, and preventive measures such as tick repellents and protective clothing are more relevant.

The Hepatitis B vaccine. While the Hepatitis B vaccine is important for individuals at high risk for infection (e.g., healthcare workers, those with liver disease, or individuals with high-risk sexual behaviors), it is not routinely recommended for all older adults unless specific risk factors are present.

EXPLANATION

✔Correct answer:

Presence of a pneumothorax. Pneumothorax is a critical complication that can occur in neonates with respiratory distress syndrome (RDS) receiving nasal continuous positive airway pressure (CPAP) ventilation. CPAP delivers positive pressure to keep alveoli open, improving oxygenation and reducing atelectasis. However, the pressure can sometimes cause overdistension of the alveoli, leading to alveolar rupture and air leakage into the pleural space, resulting in a pneumothorax.

A pneumothorax in a newborn can present with sudden deterioration, including increased respiratory distress, hypotension, and decreased oxygen saturation. Early recognition and intervention, such as needle aspiration or chest tube placement, are vital to prevent further complications like hypoxemia and cardiac compromise.

Newborns with RDS are particularly vulnerable because their underdeveloped lungs, surfactant deficiency, and fragile alveolar structure increase the risk of barotrauma from CPAP therapy.

Imagine inflating a fragile balloon (the newborn’s alveoli) with a constant stream of air (CPAP). If too much pressure is applied, the balloon may burst (pneumothorax). Careful monitoring helps prevent overinflation and keeps the system safe.

Nurse Clara should focus on detecting early signs of a pneumothorax and preventing barotrauma while ensuring the newborn receives adequate respiratory support.

• Closely monitor the infant’s respiratory status, including respiratory rate, effort, and oxygen saturation levels.
• Watch for sudden changes in vital signs such as hypotension, bradycardia, or increased work of breathing.
• Assess for asymmetrical chest expansion or decreased breath sounds, which may indicate a pneumothorax.
• Ensure that the CPAP settings are appropriate to avoid excessive pressure that can cause barotrauma.
• Be prepared to assist with interventions like transillumination to confirm pneumothorax or emergency procedures such as needle decompression.

✘Incorrect answer options:

Development of a pulmonary embolism. Pulmonary embolism (PE) is rare in newborns, as their immobility and lack of venous stasis reduce the likelihood of clot formation. PE is not a recognized complication of CPAP therapy in neonates.

Signs of bronchitis. Bronchitis, an inflammation of the bronchial tubes, is uncommon in neonates and is not associated with CPAP therapy. Respiratory distress in a newborn is more likely related to structural or functional lung immaturity, as seen in RDS.

Symptoms of pneumonia. While neonates can develop pneumonia, it is usually caused by infections rather than CPAP therapy. CPAP may actually help reduce the risk of pneumonia by improving ventilation and clearing secretions, rather than contributing to its development.

EXPLANATION

✔Correct answer:

Notify the nursing supervisor to address the issue promptly. In this situation, Nurse Taylor's priority is to ensure that the client receives timely and appropriate care. If another nurse has repeatedly failed to assess a client despite reports of abdominal pain—a symptom that could indicate a serious condition such as appendicitis, bowel obstruction, or perforation—escalating the issue to the nursing supervisor is the most effective course of action. This ensures that the matter is addressed immediately and appropriately at the leadership level.

The nursing supervisor is equipped to handle professional accountability concerns and will take the necessary steps to ensure the client’s needs are met while addressing the potential negligence. Escalating this issue also ensures documentation and appropriate follow-up, as neglecting to assess a patient can lead to severe clinical outcomes and legal implications.

Imagine a customer at a restaurant reports to a server multiple times that their meal is undercooked, but the server ignores them. The manager must intervene to ensure the issue is resolved quickly and to address the server’s behavior. Similarly, Nurse Taylor must involve the nursing supervisor to prioritize the client’s care and resolve the underlying issue with the other nurse.

Nurse Taylor must act to ensure that patient safety is prioritized and the issue is appropriately managed. Consider the following steps:

• Verify the nursing assistant's report and ensure all relevant details (e.g., the client’s condition, symptoms, and previous attempts to address the issue) are clear and documented.
• Notify the nursing supervisor immediately to intervene and take appropriate action regarding the care of the client and the accountability of the nurse in question.
• Reassure the client that their concerns are being addressed and ensure they are stable while waiting for the appropriate nurse to attend to them.
• Document the incident, including what was reported, steps taken, and when the nursing supervisor was informed, to ensure continuity of care and accountability.

✘Incorrect answer options:

Offer assistance to the other nurse to see if help is needed. While offering assistance may seem collaborative, it does not address the underlying concern of professional accountability. The other nurse has already failed to act on repeated requests, and the client’s condition requires immediate attention. Simply offering help may delay necessary intervention and does not resolve the neglect of duty.

Personally assess the client and inform the other nurse of the necessary actions. Although assessing the client may seem like an immediate solution, it is not Nurse Taylor’s responsibility to assume the other nurse’s duties unless specifically delegated by the supervisor. This approach could unintentionally enable the other nurse’s negligence without addressing the root issue, potentially putting other clients at risk.

Speak directly to the client to gauge satisfaction with their care. Speaking to the client may provide useful feedback, but it does not address the immediate clinical and ethical concern. Client satisfaction is important, but the priority here is to ensure their safety and that appropriate care is provided.