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. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

A. Before changing assignments, determine which staff members have fitted particulate filter masks. B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. C. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care.

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.

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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

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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