Author Question: A nursing student is newly assigned to care for a client transferred from the intensive care unit ... (Read 69 times)

penza · **on:** Jul 17, 2018

A nursing student is newly assigned to care for a client transferred from the intensive care unit from another hospital who needs pain medication.

The student noticed that the client's identification wristband is not present, and there is a client identification band taped to the client's foot of his bed, which looks different from other bands the nursing student has seen in the hospital. Which action should the nurse take next?
A) Ask the client to state his first and last name and date of birth and, if it matches the computerized chart, skip scanning the band and go ahead and administer the medication
B) Ask the client to state his first and last name and date of birth and compare the information with the wrist band taped to the bed and, if it matches, administer the medication
C) Ask the client's primary care nurse to properly identify the client and place a client identification wristband on the client before administering medication
D) Ask the client if he is John Jones and born November 15, 1970, and if affirmed, place the wristband at the end of the bed on the client's wrist and repair it with tape, and administer the med

Question 2

A licensed practical/vocational nurse (LP/VN) is caring for clients on a rehabilitation unit.

The nursing supervisor announced that a tornado has been spotted nearby and is headed toward the nursing facility, and the clients need to be placed into safety immediately. The staff are instructed, since they are on the first floor of a four-story building, to place anyone able to walk into the bathrooms, which are on the inside of the building without windows. If anyone has to stay in the room, place them as close to the center of the building as possible and cover them with pillows and blankets and pull the wood blinds and curtains. Which actions should the LP/VN provide to achieve protecting her clients in the timeliest fashion? Select all that apply.
A) Ask nursing assistant (NA) to pull blinds and curtains in rooms of clients who cannot be moved, rooms 4 and 6; place pillows over client's body with face free, and cover with three blankets from head to toe; move bed as close to door as possible with ventilator staying plugged into the essential red socket.
B) Ask unlicensed assistive personnel (UAP) to pull blinds and curtains in rooms of clients who cannot be moved, rooms 4 and 6; place pillows over client's body with face free, and cover with three blankets from head to toe; move bed as close to hall door as possible with ventilator staying plugged into the essential red socket.
C) Ask NA to transfer clients in rooms 5A and 5B to their wheelchairs and take them to the hall bathroom.
D) Ask UAP to transfer client in room 5A and 5B to their wheelchairs and take them to the hall bathroom.
E) The LP/VN quickly tells clients in rooms 1, 2, and 3 to go to the hall bathroom and stay there because a tornado has been sited.
F) The LP/VN quickly checks that all clients have been evacuated or are made as safe as possible and that the NA and UAP and the LP/VN enter the hall bathroom.

Kedrick2014 · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

Ans: C
Feedback:
The nursing student should make the primary care nurse aware that the client's wrist identification band is not present, so the client needs to be properly identified and a new band placed. The student may state that there is a client identification band taped to the end of the bed, which does not look like the hospital's band. The nursing student should not assume that the band taped at the end of the bed is correct because the client was transferred from another hospital and the band may be from that hospital. The student should not bypass safety features of the medication administration system by identifying the client without using the proper hospital-approved identification band. The nursing student should not read the information of name and birthdate to a client and ask to affirm it because if the client was confused or did not hear the student correctly, the client may state yes and the nurse could make a medication error by administering the med to the wrong client.

Answer to Question 2

Ans: B, C, E, F
Feedback:
The LP/VN should delegate tasks according to the qualifications of the staff, so the NA has the most training and experience with transferring a client to a wheelchair and transporting clients. The UAP has the least training and experience and the nurse needs to provide specific instructions and may use this staff member to help with tasks such as pulling the blinds and placing pillows over the client. The LP/VN should quickly round starting with the ambulatory clients and direct them to the safe place, and then make sure all delegated tasks have been performed properly, and all clients are safe, and make sure the staff is safe.