The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

The unlicensed assistive personnel tied the confused client to a chair with a sheet.

The unlicensed assistive personnel escorted the client downstairs to smoke a cigarette.

The unlicensed assistive personnel assisted the client in ambulating to the dayroom area.

The unlicensed assistive personnel bought the client a carbonated beverage from the cafeteria.

Answer and Explanation

The Correct Answer is A

This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.

Choice A rationale

Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.

Choice B rationale

While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.

Choice C rationale

Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.

Choice D rationale

Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

The nurse must identify the client's highest risk factors for perioperative complications. While the client is currently in the preoperative area for a hip arthroplasty due to osteoarthritis, their specific medical history places them at an elevated priority for the development of a Deep vein thrombosis (DVT). Total hip arthroplasty is a high-risk procedure for venous thromboembolism (VTE), and this client's history of recurring clots significantly increases the likelihood of a repeat event during or after surgery.

Rationales:

Deep vein thrombosis: This is the priority condition for monitoring and prophylaxis in this scenario. The client has a documented history of DVT on two separate occasions. Surgery, particularly orthopedic surgery on the lower extremities, causes venous stasis and vessel injury, which combined with the client's history, creates a high-risk profile for VTE.

History of DVT: This is a direct indicator of the client's predisposition to venous clotting. Previous episodes of DVT are the strongest predictor for future occurrences, especially when undergoing a major surgery like a total hip arthroplasty that involves significant immobility.

History of multiple DVTs: The fact that the client has a history of two separate DVTs reinforces the priority of this condition. It suggests a chronic or recurring susceptibility to clotting that requires aggressive perioperative management, such as mechanical prophylaxis (sequential compression devices) and pharmacological anticoagulation.

Pulmonary embolus: While a pulmonary embolus is a life-threatening complication of DVT, there is no evidence in the notes (such as acute chest pain or shortness of breath) to suggest it is currently occurring. It is a potential consequence rather than a condition evidenced by the current preoperative notes.

Osteoarthritis flare: While the client has painful hip osteoarthritis, this is the reason for the surgery, not a priority complication to be identified from the medical history for perioperative safety.

GERD exacerbation: The client's GERD is controlled with an antacid PRN. While important for preoperative fasting (NPO) considerations, it is not a priority condition compared to the risk of vascular complications like DVT.

Chest pain and Dyspnea: These are symptoms of an active pulmonary embolism or cardiac event. Neither is mentioned in the 0630 nurses' notes, so they cannot serve as evidence for the client's current status.

Recent surgery: The client is currently preparing for surgery. While past surgeries are noted, "recent surgery" typically refers to the immediate postoperative period as a risk factor, rather than the historical hysterectomy or appendectomy.

Smoking history: While a 52-pack-year history is significant for respiratory and vascular health, the client quit 2 years ago. While it contributes to general risk, it is less specific to the immediate priority of DVT than the direct history of having had multiple clots.

Immobility risk: The client's BMI of 30.1 and the nature of hip surgery contribute to immobility, which is a risk factor. However, the history of previous DVTs is a more specific piece of "evidence" from the notes that points to the priority condition of recurrent DVT.

Anticoagulant use: The notes mention hypertension and cholesterol meds but do not explicitly list current anticoagulant use. If they were on them, it would be a management factor, but it is not listed as evidence in the provided note.

A. I will call the provider for chest pain. B. I will gradually increase activity. C. I will utilize a diet rich in polyunsaturated fats. D. I will use increasing upper body weights to build muscle. E. I will take medications as prescribed.

Correct Answer is ["A","B","C","E"]

Explanation

Post-myocardial infarction discharge teaching focuses on secondary prevention and cardiac rehabilitation. Knowledge of cardiovascular physiology, lifestyle modification, and pharmacology is necessary to ensure the client understands how to reduce cardiac workload and prevent further coronary artery occlusion or heart failure.

Choice A rationale

Reporting chest pain is critical as it indicates potential myocardial ischemia. Early intervention can prevent further muscle damage. Clients must understand that any recurrence of angina requires immediate medical evaluation to assess coronary artery patency and perfusion.

Choice B rationale

Gradual activity increase is a hallmark of cardiac rehabilitation. It allows the heart muscle to adapt to increased demands without causing excessive strain or rupture. Controlled exercise improves cardiovascular efficiency and lowers the resting heart rate over time.

Choice C rationale

Polyunsaturated fats help lower low density lipoprotein cholesterol, reducing the risk of further atherosclerosis. A heart healthy diet limits saturated fats and trans fats, which are known to contribute to plaque formation within the coronary arteries.

Choice D rationale

Heavy weightlifting or isometric exercises can significantly increase systemic vascular resistance and blood pressure. This places excessive afterload on the healing myocardium. Clients are usually advised to avoid heavy lifting or straining during the initial recovery phase.

Choice E rationale

Adherence to medications such as beta blockers, antiplatelets, and statins is vital for long term survival. These drugs reduce blood pressure, prevent clot formation, and stabilize plaques, directly impacting the prevention of a secondary cardiac event.

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit. Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

The nurse provides discharge teaching to a client who had a myocardial infarction. Which statements by the client indicate an understanding? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit.
Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?