Use SBAR to communicate hand-off information
S- SituationThe ED admitted Mr. Jones at 4:30 AM for SOB and weakness. After treatment, he is transferring
... [Show More] to the telemetry unit.B - Background60 year old African-American male with a history of peripheral vascular disease, type 2 diabetes, chronic kidney disease, coronary artery disease, and atrial fibrillation. A provider recently discharged him from the facility after he treated Mr. Jones for atrial fibrillation and a type 2 diabetic ulcer of the right foot. Mr. Jones did not complete prescribed antibiotics after his discharge. He is non compliant in managing his diabetes. He smokes one pack of cigarettes a day and uses alcohol 3 to 5 times a week.A - AssessmentMr. Jones is awake, alert, and orientated x3. Current vitals are: BP 112/70, P: 158, R: 34, T: 99.1, and O2 sat 91% on 2 L via nasal cannula. ECG indicates atrial fibrillation; placed on telemetry. Chest x-ray: opacities greater in the right lung than left lung. Altered lab values include: sodium 128, potassium 5.1, BUN 44, creatinine 3.0, and glomerular filtration rate 25. His total bilirubin was 2.8, calcium 8.7, WBCs 16.1, hemoglobin 9.3, hematocrit 28.2, and blood glucose 71. We did a digoxin level, which was 0.6. He has a soiled dressing on his right foot and is a stage III ulcer. A #20 gauge IV catheter was inserted peripherally in his left forearm and a nurse gave him 1,000 mL of 0.9% sodium chloride. Intake: 1,000 mL Output: None. No family present.
Nurse Allyson is preparing to perform a sterile dressing change to Mr. Jones's foot. After removing the exam gloves, performing hand hygiene, and gathering the needed supplies, what are the next steps Nurse Allyson should take for the dressing change?
1. Apply clean gloves.
2. Remove dressing and place in moisture-proof bag.
3. Remove clean gloves.
4. Wash hands.
5. Apply sterile gloves.
6. Cover with sterile gauze.
7. Secure dressing.
Nurse Allyson is preparing to call the provider about Mr. Jones's difficulty breathing. Which of the following orders should she recommend to the provider?
A. albuterol 1.25 mg via nebulizer
B. decrease IV fluid rate o 50 mL/hr
C. furosemide (Lasix) 20 mg IV
D. repeat chest x-ray
C. furosemide (Lasix) 20 mg IV
Mr. Jones's total urinary output is 50 mL. His total IV fluid intake since admission is 1550 mL. Which of the following is an appropriate nursing intervention at this time?
A. massage mr. jones bladder
B. obtain a bladder scan
C. have mr. jones stand at the bedside to void
D. obtain an order for urinary cath
B. obtain a bladder scan
Nurse Allyson is going to perform a bladder scan on Mr. Jones. Where should the transducer be placed on his abdomen?
midline below umbilicus
Nurse Allyson is planning care for a set of clients. Which of the following should be her priority action?
A. implement the provider's new prescriptions
B. check on the client who is reporting chest pain
C. obtain a phone report on the newly assigned client
D. ask the AP to attend to the client whose call light is sounding
B . check on the client who is reporting chest pain
The telemetry technician notified Nurse Allyson that Mr. Jones is having arrhythmia. Which of the following is the priority nursing intervention at this time?
A. perform a focused assessment
B. assess mr. jones temp
C. perform head-to-toe
D. admin an antiemetic med
A. perform a focused assessment
Mr. Jones's heart monitor displays this rhythm strip. Which of the following is an appropriate nursing action?
A. obtain a 12-lead ECG
B. call rapid response team
C. give metoprolol (Lopressor) 5 mg IV bolus stat
D. admin mag sulfate 10 mg IV bolus stat
B. call the rapid response team
rationale: unstable ventricular tachycardia is rapidly fatal if not successfully ended within 3-5 min
The provider gave Nurse Allyson new prescriptions to implement. Based on Mr. Jones's current symptoms, which of the following medications should she give him at this time?
A. Sodium polystyrene sulfonate (Kayexalate) 30 g PO once now
B. regular insulin 10 units IV bolus once now
C. calcium gluconate 10% (10mL) IV bolus once now
D. 1,000 mL of 0.9% sodium chloride with 20 mEq KCl at 100 mL/hr
A. Sodium polystyrene sulfonate (Kayexalate) 30 g PO once now
rationale: Sodium polystyrene sulfonate (Kayexalate) is a resin that allows for sodium and potassium exchange in the GI system ; potassium is excreted through feces, not urine
Nurse Allyson is preparing to administer furosemide (Lasix) 40 mg IV. Available is furosemide 80 mg/5 mL. How many mL should she administer?
A. 1.5 mL
B. 2.0 mL
C. 2.5 mL
D. 3.0 mL
C. 2.5 mL
Nurse Allyson and the provider are reviewing chronic kidney disease information with Mr. Jones. Which of the following statements made by Mr. Jones indicates he understands the information?
A. "i will need to drink 3 L a day"
B. "i will need to weigh myself weekly"
C. "i will need to eat a low-protein diet"
D. "i will need to eat a high-potassium diet"
C. "I will need to eat a low-protein diet"
Nurse Allyson is planning care for Mr. Jones, who has clinical manifestations of phlebitis. Which of the following is the priority action the nurse should take?
A. apply heat to the IV site
B. remove IV cath
C. elevate the affected extremity
D. restart a new IV in the other extremity
B. remove IV cath
Nurse Allyson is planning care to Mr. Jone's central line. Which of the following should Nurse Allyson include in Mr. Jones's plan of care?
A. use a 3mL syringe for admin of IV meds
B. Use a sterile technique to change the dressing
C. obtain consent before central line placement
D. measure and document the exposed catheter daily
E. Change the catheter cap every 3 to 7 days
B. Use a sterile technique to change the dressing
C. Obtain consent before central line placement
E. Change the catheter cap every 3 to 7 days
Nurse Allyson gave a report about Mr. Jones to the home health nurse. Which of the following data is in the appropriate section of the SBAR to facilitate appropriate and comprehensive communication?
A. S: mr. jones vs are BP 126/78, pulse 100, RR 22, and temp 98.4
B. B: mr. jones has a central line cath located on the upper right chest
C. A: mr. jones has chronic kidney disease and type 2 DM
D. R: Upon discharge, Mr. Jones is scheduled to receive cefepime 2 g IV daily for the next 2 weeks.
D. R: Upon discharge, Mr. Jones is scheduled to receive cefepime 2 g IV daily for the next 2 weeks. [Show Less]