Case Study - Suicide Sentinel Event PDF

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Incorrect Question 1 of 28

As the nurse documents the client’s assessment, the nurse is correct to question which activity of a client with type II diabetes mellitus?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Client’s frequency for checking blood glucose. Too much glucose in the system can cause long-term complications such as heart disease. Understanding how the client manages his diabetes can provide helpful insight on the treatment plans and how to prevent further complications.

Quantity of Ensure taken per day. Reviewing the amount of nutrition shakes the client consumes daily helps the nurse discern if proper caloric intake is taking place as well as assess the client’s nutritional status.

Reason for lack of appetite. If a person taking insulin fails to consume adequate carbohydrates, a drop in glucose levels is possible, causing hypoglycemia (low blood glucose). Symptoms of hypoglycemia include headache, disorientation, weakness, perspiration, shallow breathing, nervousness, visual disturbances, and vertigo, and it sometimes leads to unconsciousness. Christensen, Barbara L.(2010). Foundations of Nursing, 6th Edition. Mosby, page 639.

Amount of water and other fluids taken daily.

Clients with diabetes require more fluid intake to avoid dehydration because high levels of glucose can lead to dehydration. Rebar, C., Ignatavicius, D., Workman, M. L. (2018). Medical-Surgical Nursing: concepts for nterprofessional collaborative care, (9th ed.) St. Louis, MO, p. 195.

Last blood glucose result obtained by client. This would be the least concern because the nurse is going to take the client’s blood glucose as part of the initial assessment.

Question 2 of 28

The client mentions that he feels “blue” lately because his wife died one year ago, and his children live out of state and seldom visit. The nurse knows that the greatest risk for major depression includes which event? Being retired from the military. Retirement can be a source of depression but is not the greatest risk.

The realization of growing older. Adapting to old age depends on personality traits and coping strategies and is not considered the greatest risk for depression. Ignatavicius, D., Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (7th ed.), Saunders, St. Louis, MO, Elsevier, Inc., p. 15.

Inability to attend church regularly. Inability to participate in spiritual activities that were once enjoyed can sometimes negatively affect an elderly person. The client has not mentioned the inability to participate in activities he once enjoyed.

Becoming widowed within the past year.

The combinations of sadness, loneliness from losing a loved one in widowhood, and hopelessness leads to social withdrawal. Those feelings place an older adult at greater risk of suffering from major depression because older adults are reluctant to adapt to changes. Ignatavicius, D., Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care, (7th ed.), Saunders, St. Louis, MO, Elsevier, Inc., p. 15.

Question 3 of 28

The HCP prescribes 1000 mL dextrose 5% with normal saline 0.9% and 20 mEq/L potassium chloride (KCl) to infuse at 100 mL/hr. The nurse is correct to question which additive to this infusion prescription? Normal saline (NS) and Potassium chloride (KCl). The combination of potassium and calcium in the IV fluids assists to replenish electrolytes in the body.

Normal saline (NS). Normal saline is prescribed to replete volume not to treat a glucose.

Dextrose (D5). Solutions that contain dextrose are not recommended for client with diabetes because they can result in the rise of insulin, which will cause a decreased level of potassium in the blood. Dextrose may be prescribed for a client with diabetes to prevent low blood sugar during surgery. As a result of the many treatment and approaches to diabetes, it is important for the nurse to clarify the drug and intravenous fluid prescriptions with the HCP.

Potassium chloride (KCl). There appears to be a link between levels of potassium and glucose.

Question 4 of 28

The HCP prescribes 1000 mL normal saline 0.45% with 20 mEq/L potassium chloride (KCl) to infuse at 125 mL/hr. The nurse calculates that it will take how many hours for the infusion to be complete? (Enter numeric value only. If rounding is required, round to the whole number.) Total volume infused/mL per hour = infusion time. 1000 mL/125 mL = 8 hours

Question 5 of 28

The client is febrile with temperature of 101.5°F (38.6°C). Based on this information, which intervention should the nurse implement first? Contact the lab and request blood cultures be drawn. Blood culture specimens are always drawn before giving acetaminophen or starting antibiotic therapy because the antibiotic usually interferes with the organism's growth in the laboratory. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508.

Administer acetaminophen per hospital protocol. To maintain the accuracy of a clinical picture, blood cultures are generally obtained prior to medicating clients. Acetaminophen is an antipyretic and is withheld because it lowers the body’s temperature and suppresses some of the body’s natural responses to infection, affecting the blood culture results. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508.

Contact the HCP for a prescription for an antibiotic. The initiation of antibiotic treatment is always withheld until after the blood culture is drawn because the accuracy of the results may be affected.

Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508.

Retake temperature with a tympanic thermometer. The temperature is usually retaken to measure the efficacy of the antipyretic. Christensen, B. L. (2011). Foundations of Nursing, (6th Edition), St. Louis, MO, Elsevier, Inc., P.508.

Question 6 of 28

The HCP prescribes clindamycin 900 mg in 100 mL over 30 minutes. The IV tubing drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many drops per minute? (Enter numeric value only. If rounding is required, round to the nearest Use the formula: volume over time in minutes X the drop factor 100 mL/hr / 30 minutes X 15 gtt/mL = 49.9 = 50 gtts/min

whole number.)

Question 7 of 28

The nurse knows that before drawing arterial blood gases, which interventions are the most important to be performed?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Perform Allen’s Test. The Allen’s test is performed prior to drawing an arterial blood test. It involves the nurse compressing both radial and ulnar arteries at the same time. The client’s hand should become white as a result of the occlusion. The client’s hand color should return as soon as the nurse releases both arteries.

Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180.

Use sterile technique. Sterile technique must be maintained during venipuncture. Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180.

Utilize clean technique. Medical asepsis is used in many daily activities, such as hand hygiene and changing clients’ bed linens. Sterile technique, not clean technique, is always used in an invasive procedure.

Check two client identifiers. The two client identifier is part of the Joint Commission’s National Patient Safety Goals and requires the nurse to verify two identifiers prior to performing any procedure to ensure the right client and procedure. Black, J. M. (2009) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 180.

Draw blood gas after applying oxygen. Arterial blood gas (ABG) findings interpret the client’s oxygenation and acid-base balance. The result of the ABG will measure if the applied oxygen is actually helping the client, if there is a need to obtain an order for bicarbonate.

Question 8 of 28

When monitoring the client’s respiratory status, which symptom provides the nurse with the earliest indication of respiratory difficulty? Hypoxia. Hypoxia is an early sign of respiratory distress. The nurse assesses respiratory depth, rate, and effort and listens for abnormal breath sounds that suggest breathing difficulty. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient—centered care, (8th ed.), St. Louis, MO, Elsevier, Inc. p. 570.

Dusky nail beds and lips. Dusky nail beds and lips are late signs of respiratory distress.

Decreased pulse rate. The pulse rate will increase with respiratory difficulty.

Cyanosis. Cyanosis is a late sign of respiratory distress.

Question 9 of 28

The nurse prepares to contact the HCP with lab results, knowing that all lab information must be collected prior to reporting. Which lab results does the nurse need to report first to the HCP? Arterial Blood Gases (ABGs), O2 saturation, White Blood Cell Count (WBC). Normal values for adults are pH 7.35 to 7.45 , PaCO2 35 to 45 mmHg (4.6 - 5.9 kPa), PaO2 80 to100 mmHg (>10.6 kPa), HCO3 22 to 26 (22-26 mmol/L), O2 saturation 96% to 100%. The labs for the client are abnormal. As COPD worsens, oxygen in the blood decreases and carbon dioxide increases, resulting in chronic respiratory acidosis. Once baseline ABG values are obtained and communicated to the HCP, treatment and monitoring can begin. The WBC count is high and is indicative of possible infection which should be reported to the HCP. Ignatavicius, D., Workman, M. L. (2016). Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO, Elsevier, Inc., p. 188.

Potassium (K+), Chloride (Cl), Creatinine (Cr). These labs are normal and there is no need to report the results.

Glucose, HCO3, Blood Urea Nitrogen (BUN). The blood glucose is abnormal but the HCP is already aware of this from Mr. Fearon’s initial assessment and is not the most important lab to report. The other lab values are normal and there is no need to report them.

Platelets, Sodium (Na+), Hemoglobin (HG)/Hematocrit (Hct).

These lab values are normal and there is no need to report the results.

Question 10 of 28

The nurse should interpret which finding as expected limits for the client with COPD? 87% O2 saturation. A client with COPD who retains CO2 has adapted to high blood CO2, and relies on low PaO2 to stimulate breathing. A high concentration of O2 may raise the PaO2 level so that the client’s stimulus to breathe is lost and respiratory depression may result. Not all clients with COPD rely on hypoxic drive; retention of CO2 must be confirmed by blood gas analysis. Reference: Linton, A. (2012). Introduction to Medical-Surgical Nursing, (5th Edition). St. Louis, MO, Elsevier, Inc. p. 557.

96% O2 saturation. This result is within the normal range and not an expected finding from a client with COPD.

100% O2 saturation. This result is within the normal range and not an expected finding from a client with COPD.

75% O2 saturation. This result is below the range for any client and requires immediate oxygenation intervention.

Question 11 of 28

The HCP orders additional diagnostic tests. Which test would the nurse anticipate the HCP will order for the client? Magnetic Resonance Image (MRI). A magnetic resonance image (MRI) is used to view anatomical structures and detect abnormalities. It gives the clinician a 3-d image, however, bones are not well-identified in MRI images. MRI is a noninvasive examination that does not expose the client to radiation and produces precise, clear images of tumors.

Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 547.

Positron Emission Tomography (PET). A position emission tomography (PET) utilizes a radioactive tracer that allows the clinician to detect diseases and proper organ function. Exposure to radiation is greater than an MRI and takes longer to perform, 3-4 hours. Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 550.

Computerized Tomography (CT). A computerized tomography (CT) is the diagnostic imaging of choice during emergent situations because it produces accurate images of solid organs and bones that can reveal soft tissue masses. It is considered more harmful due to the side effects of radiation exposure. Linton, A. (2012). Introduction to Medical-Surgical Nursing, 5th Edition. (8th ed.) St. Louis, MO, Elsevier, Inc., p. 547.

Diagnostic Imaging X-ray (DIX). This is not a legitimate test that would be ordered for the client.

Question 12 of 28

What are the nurse’s responsibilities when preparing the client for the CT scan?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Verify the client’s identity with two types of identifiers. The client is identified with two types of identifiers before any procedure is performed. https://www.jointcommission.org/NPSG.01.01.01

Determine if the client has any known allergy to iodine or shellfish.

It is the nurse’s responsibility to always assess the client for allergies to the iodine dye before it is administered. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.) St. Louis, MO., Elsevier, Inc. p. 479.

Ask the client when his last dose of metformin was taken. If the client usually takes metformin, the drug is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function has been established.

Explain the post procedure and the recovery time. There is no post procedure to explain for this procedure.

Instruct the client to remain NPO 4 to 8 hours before the procedure. It is not necessary for a client to be NPO prior to this procedure. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.) St. Louis, MO., Elsevier, Inc. p. 479.

Question 13 of 28

A client care technician arrives to transport the client to the CT scan. The nurse knows that communication breakdown can occur during transfer. Which statements about effective handoff communication are true?(Select all that apply. One, some, or all options may be correct.) Select all that apply

Background noise and interruption seldom affect the exchange of information because nurses can multitask. Background noise and interruption always affect the exchange of information and can lead to miscommunications that cause medical errors. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67.

There is no need to give a verbal report if the situation, background, assessment recommendation (SBAR) tool is used. Verbal communication is a two-way conversation between two providers, which minimizes misunderstandings and potential client medical errors. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67.

Communication and tradition differences between people of different backgrounds can be a barrier to handoff. To improve communication between staff members and healthcare agencies, procedures for handoff communication were established. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67.

A situation, background, assessment recommendation tool form must be completed prior to the client’s transfer. An effective procedure used in many agencies today is called SBAR (pronounced S-Bar). SBAR is a formal method of communication between two or more members of the healthcare team. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67.

A situation, background, assessment recommendation (SBAR) tool is used only between the nurse and the HCP to obtain orders for client care. The SBAR communication method is used between all interdisciplinary care providers to ensure accurate and safe communications about client care. Ignatavicius, D., Winkelman, C. (2016). Clinical Companion for Medical-Surgical Nursing: patient-centered collaborative care. (8th ed.), St. Louis, MO., Elsevier, Inc. p. 67.

Question 14 of 28

When preparing the client for the bronchoscopy, it isessentialfor the nurse to take which action first? Instruct the client to be NPO for 4 to 8 hours before the procedure.

Abstaining from food or liquids hours before a procedure can decrease the risk of pulmonary aspiration but is not the first action. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479.

Premedicate the client with the prescribed benzodiazepine prior to the procedure. If there is a prescription to premedicate the client prior to a procedure, the consent form must be signed first and the client must understand the procedure prior to administration of the medication. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479.

Provide detailed information about the procedure to the client. Educating a client regarding the care prior to and after a procedure can ease concerns a client may have about the procedure. The nurse is not responsible for providing detailed information about the procedure but is to clarify facts that have been presented to the client by the healthcare provider. Christensen, B. L. (2011). Foundations of Nursing. (6th ed.), St. Louis, MO, Elsevier, Inc., Page 479.

Verify that the consent form is signed by the client and witness the signature. By witnessing the client sign the informed consent, the nurse can confirm that the client has all of his concerns addressed and that he understands the procedure and risks associated with it. It is essential to obtain informed consent before sedation for surgery or a procedure is performed and is the first action taken by the nurse. The nurse is to verify that the consent form is signed and serve as a witness to the signature[FS(1] . Ignatavicius, D., Workman, M. L. (2018). Medical-Surgical Nursing: patient-centered collaborative care, (8th Edition), St. Louis, MO., Elsevier, Inc. p. 239.

Question 15 of 28

Which legal document ensures that the client’s treatment preferences are

followed in the event that he is unable to make decisions regarding his own care? Advance Directives. An advance directive is a document that allows clients to name someone they trust to act on their behalf if they are ever unable to make healthcare decisions for themselves.

Living will. A living will is a legal document that allows clients to designate in advance, which treatments they want in specific situations.

Durable Power Of Attorney. The Durable Power of Attorney allows clients to designate in advance, one person to make treatment decisions when clients are not able to make decisions for themselves. A...