The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Revise clinical practice guidelines.

Engage staff in evidence based practice.

Evaluate effectiveness of the change.

Consult with a clinical nursing expert.

Answer and Explanation

The Correct Answer is C

A.   Revising clinical practice guidelines might be necessary in the long term if the new approach becomes widely accepted and proven effective. However, this action is typically part of a broader, organizational process that follows initial implementation and evaluation.
B.   Engaging staff in evidence-based practice is crucial for successful implementation of the new approach. This involves educating and training staff on the new methods, ensuring they understand and support the change, and integrating the new practices into daily routines.
C.   Evaluating the effectiveness of the change is a critical next step. After implementing a new approach, it is essential to assess whether it achieves the desired outcomes and improves client care. This evaluation involves monitoring and analyzing results to determine if the change is beneficial and meets the intended goals.
D.   Consulting with a clinical nursing expert can be helpful for advice and guidance during the implementation process. However, this action is typically part of the initial planning and decision-making stages rather than the immediate next step after gathering evidence.

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Correct Answer is D

Explanation

A. This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B. Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C. Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D. This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

A. Tell the client to use larger bags that expand with gas. B. Teach the client how to burp the bag to relieve the gas. C. Ensure that the pin holes are made at the top of the bag. D. Inform the client about bags that have gas release valves.

Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

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The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

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