NCLEX PN ARCHER REVIEW

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NCLEX PN ARCHER REVIEW

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The nurse is preparing to change a central venous catheter dressing using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used.

• Apply CHG patch over catheter insertion cite and cover with a sterile transparent dressing
• Cleanse the site with CHG for at least 30 seconds using friction; allow to air-dry completely
• Discard the clean gloves perform hand hygiene, and apply sterile gloves
• Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves
• Remove old dressing and CHG-impregnated patch; inspect insertion site

CORRECT ANSWER: 4, 5, 3, 2, 1

Central line dressing changes are sterile procedures and must be performed correctly to prevent infection. Steps should be performed in the

following order:

• Perform meticulous hand hygiene.• Don a surgical mask and apply a mask to the client (or ask the client to turn the head away from the dressing). Apply clean gloves (Option 4).• Remove the old dressing, including the chlorhexidine gluconate (CHG) - impregnated patch, making sure not to touch the insertion site (Option 5).• Inspect the site for drainage, erythema, heat, or inflammation.• Discard the clean gloves, perform hand hygiene, and apply sterile gloves (Option 3).• Cleanse the site with antimicrobial solution (eg, CHG), in a back-and-forth motion using friction, for at least 30 seconds; allow to air-dry completely (Option 2).• Apply the CHG-impregnated patch over the catheter insertion site and cover with the sterile transparent dressing (or use a CHG gel transparent dressing), making certain the edges of the dressing adhere well (Option 1).• Sign, date, and initial the dressing.• Document the procedure.

The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and pulseless. The nurse calls the health care provider at 2 AM, and the HCP begins to yell at the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is the best response by the nurse?

• "I'm concerned that this client may lose a leg unless something is done immediately."
• "I'm sorry to bother you. Is there someone else you'd like me to call?"
• "It's my job to report critical findings, just like it's your job to come see my client right now."
• "Yelling is unprofessional. I'll need to file a report with my supervisor once the client is stable."

CORRECT ANSWER: 1

The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for clients. In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's needs, especially in situations that may result in client injury Option 1 is correct).(Option 2 is wrong) Offering to call a different provider fails to address the urgency of the situation. The priority is for the nurse to advocate for the client's needs, as the client is experiencing a serious limb-threatening postsurgical complication.(Option 3 is wrong) Confrontational statements are more likely to provoke a fight rather than result in appropriate intervention for the client.(Option 4 is wrong) Incidents of bullying and workplace violence should be reported to a nursing supervisor, but the priority is to ensure that the client's needs are addressed.The nurse is caring for a client with multiple renal calculi. Which of the following interventions should the nurse anticipate? Select all that apply.

• Administer analgesics at regularly scheduled intervals
• Encourage fluid intake of up to 3 L/day
• Instruct client to stay on bed rest
• Provide massage to the client's flank
• Strain all urine for the presence of stones

CORRECT ANSWER: 1, 2, 5

The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2 are correct).To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5 is correct). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge.(Option 3 is wrong) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi.(Option 4 is wrong) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable.

The nurse receives laboratory reports on four clients. Which report is most concerning and should be reported to the health care provider?

• Client admitted with pneumonia who has a PaCO2 of 32 mm Hg
• Client receiving warfarin for atrial fibrillation who has an IN of 2.5
• Client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL
• Client with chronic obstructive pulmonary disease who has a Pa02 of 85 mm Hg

CORRECT ANSWER: 3

Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL is very low (normal adult male: 14-18; normal adult female: 12-16). This client should be assessed for active bleeding and for signs associated with severe anemia (eg, tachycardia, shortness of breath). The health care provider should be notified as soon as possible (Option 3 is correct).(Option 1 is wrong) Although a normal PaCO2 is 35-45 mm Hg, clients with pneumonia, as well as those with asthma, panic attacks, and pulmonary embolism, have tachypnea. Rapid breathing causes more carbon dioxide gas (CO2) to be exhaled, thereby reducing the amount of CO2 in the blood (ie, PaCO2).(Option 2 is wrong) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation. To prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's INR is therapeutic.(Option 4 is wrong) A PaO2 greater than 80 mm Hg is a normal finding. In clients with chronic obstructive pulmonary disease (COPD), CO, becomes trapped in the lungs due to blocked airways. The body adjusts to elevated CO2 levels (which trigger increased respiratory rate in clients without COPD) and then uses the amount of oxygen in the blood (eg, PaO2) to regulate breathing.The nursing unit has implemented a quality-improvement program to improve client pain management. Which is the best indicator of improved pain management?

• Better client pain control as reported by a survey of the unit's nurses
• Improved clients' self-reported pain scores on chart audits
• Increase in number of PRN analgesics administered to clients
• Increase in positive feedback on a client satisfaction survey

CORRECT ANSWER: 2

Measurements for quality improvement should be client-centered and objective (quantifiable), rather than subjective. An evidence-based data collection method (eg, numeric pain scale) should be used, if applicable (Option 2 is correct). When evidence-based criteria are measured, survey results can be used as objective, retrospective measurements of a positive change.(Option 1 is wrong) Subjective, second-hand perceptions of client pain control reported by nurses may not reflect the actual adequacy of client pain relief. Objective, client-reported measurement tools should be used instead.(Option 3 is wrong) Increased analgesic administration could be attributed to many factors, including fluctuations in the number of clients on the unit or diversion of medication by staff (eg, theft. In addition, clients may obtain pain relief by nonpharmacologic means, and these measures are not reflected by measuring the number of analgesics administered.(Option 4 is wrong) Positive commentary on client satisfaction surveys is a subjective criterion. Overall client satisfaction is related to all aspects of care, including those unrelated to pain relief.