Ethics, Processing, and Care - NCLEX-PN

The correct answer is "immediately inform the covering physician." This is the correct choice because in this case, a medical error was committed, and the most appropriate immediate course of action is to let the patient's covering physician know, so that they can determine what effect this may have on the patient, assess the patient, and determine what, if any, immediate intervention needs to be performed to ensure that the adverse effect on the patient is minimized.

While it is possible in this case, given that the patient has congestive heart failure, and that they may have been fluid overloaded by the administration of excess fluids, that they will need to be diuresed with furosemide, this medication cannot be administered without the order of the covering physician, and it would be inappropriate to administer furosemide without their orders.

While your hospital's safety oversight committee may ultimately need to be informed of this incident, the most immediate priority is patient safety, and as such, the patient's physician should be notified of the medical error before anyone else so that they can best manage any immediate consequences of the error.

It would be highly inappropriate to not inform anyone of the error, as an unintended dose of IV fluids was administered and this can be dangerous in a patient with congestive heart failure. Any delay, whether due to not telling anyone, or to conferring with co-nurses, in informing the supervising physician would be inappropriate and potentially dangerous to the patient.

Of the nursing types listed, only nurse practitioners are can be authorized to write prescriptions for pharmaceutical drugs.

Communicating patient values, preferences and expressed needs to other members of health care team is an example of patient-centered care, which is defined as the act of recognizing the full agency of the patient by providing compassionate and coordinated care based on respect for patient preferences, values, and needs.

Using tools such as algorithm flow charts and cause-effect analyses to make processes of care more explicit is an example of quality improvement, which is defined as the use of data to monitor the outcomes of treatment practices and other efforts to continuously improve the quality and safety of health care systems.

Asking for help from a co-worker or superior is an example of teamwork and collaboration, which is defined as the ability to function effectively within nursing or integrated teams. Skills should include the ability to have open, mutually respectful communication, shared decision making, and a focus on patient care.

Using a checklist for tasks when doing an in-home visit is an example of saftey, which is defined as employment of practices that minimize the risk of harm to patients and providers both by individual performance and the use of systems (such as checklists) to avoid errors.

When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.

The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below in a non-diabetic patient. The symptoms of hypoglycemia include altered consciousness, tremors, weakness, vertigo, headaches, heart palpitations, and a bounding pulse.

A temperature of is not considered abnormal as it may reflect a normal variation in body temperature.

His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.

It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.

Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.

Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.

The four main categories of shock are as follows:

• Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
• Hypovolemic: Due to loss of fluids or hemorrhage.
• Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
• Anaphylactic: Systemic inflammatory response to an allergen.

Varicella requires airborne precautions. Staff caring for patients with varicella should be immune. One's immunity to varicella can be confirmed by a blood test.

Standard precautions should be utilized in the care of every patient. Hand hygiene before and after patient contact is always required. Clean, functioning, equipment should always be available. The use of personal protective gear when there is potential to blood or bodily fluid exposure is critical. This includes the proper disposal of soiled materials such as linens. However, it is not necessary for patients to be housed in private rooms unless they are affected by an infectious disease. If private rooms for infectious individuals are unavailable, it is acceptable to place patients in cohorts of the same infectious disease.

Washed red blood cells are generally prepared for patients with a history of severe allergic reaction to blood transfusion. Washed red blood cells are not generally required in patients with kidney disease, patient who are immunocompromised, or patients with metastatic disease.

The normal range for hemoglobin in an adult female is . Hemoglobin levels above that range may be indicative of chronic low blood oxygen, while lower levels of hemoglobin are seen in anemia.

The normal range for hemoglobin levels in an adult male is . Hemoglobin levels above that range may be indicative of chronic low blood oxygen, while lower levels of hemoglobin are seen in anemia.

When percussing the seventh intercostal space along the right midclavicular line, you should expect to hear a dull note, as this is directly over the solid mass of the liver.

The border of the liver can be found by percussing in a descending line along the intercostal spaces of the right midclavicular line, starting at the clavicle. The superior border of the liver can be measured at the point where percussion transforms from resonant or hyperresonant (indicating the air-filled lung) to dull (indicating the solid mass of the liver).

A healthy and normal abdominal aorta will measure between 2.5-3cm in diameter. An abdominal aorta over 3cm and under 5cm in diameter is considered to be enlarged, and surgery to prevent abdominal aortic aneurism is generally performed on abdominal aortas that surpass 5cm in diameter in females or 5.5cm in diameter in males.

A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.

Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.