A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse use?
Provider's prescription
Maslow's hierarchy of needs
Evidence-based practice
Critical pathway
Surgical record
The Correct Answer is C
Choice A reason: A provider's prescription is not a resource for developing a standard for removal of indwelling urinary catheters. A prescription is a specific order for a particular client, not a general guideline for a group of clients.
Choice B reason: Maslow's hierarchy of needs is not a resource for developing a standard for removal of indwelling urinary catheters. Maslow's hierarchy of needs is a theory of human motivation that ranks the basic needs of individuals from physiological to self-actualization. It does not provide specific information on how to perform nursing interventions.
Choice C reason: Evidence-based practice is a resource for developing a standard for removal of indwelling urinary catheters. Evidence-based practice is the integration of the best available research evidence, clinical expertise, and client preferences and values into clinical decision making. It helps to ensure that the nursing care is effective, safe, and consistent.
Choice D reason: A critical pathway is not a resource for developing a standard for removal of indwelling urinary catheters. A critical pathway is a tool that outlines the expected course of treatment and outcomes for a specific diagnosis or procedure. It does not provide detailed instructions on how to perform nursing interventions.
Choice E reason: A surgical record is not a resource for developing a standard for removal of indwelling urinary catheters. A surgical record is a document that records the details of a surgical procedure, such as the type of surgery, the anesthesia used, the operative findings, and the complications. It does not provide information on the postoperative care of the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This client does not need an interdisciplinary conference because their condition is not complex or chronic. The nurse can manage the client's care by monitoring their vital signs, fluid intake and output, and hydration status. The nurse can also educate the client on how to prevent orthostatic hypotension by changing positions slowly and wearing compression stockings.
Choice B reason: This client does not need an interdisciplinary conference because their condition is well-controlled and self-managed. The nurse can manage the client's care by checking their blood glucose levels, administering insulin as prescribed, and providing dietary and lifestyle education. The nurse can also collaborate with the diabetes educator or the endocrinologist if needed.
Choice C reason: Although this client is at risk for pressure ulcers, their albumin level is within the normal range, indicating adequate nutritional status. Low albumin levels are often associated with poor wound healing and increased risk of skin breakdown, but in this case, nutrition does not appear to be a concern. Preventive measures, such as regular repositioning, skin assessments, and pressure-relieving devices, can be implemented by nursing staff without requiring an interdisciplinary meeting.
Choice D reason:This client is the most appropriate candidate for an interdisciplinary conference. The activated partial thromboplastin time (aPTT) is a critical lab value for monitoring heparin therapy, and a level of 34 seconds is below the therapeutic range. A subtherapeutic aPTT increases the risk of clot formation, indicating that the heparin dose may need to be adjusted. An interdisciplinary team, including the physician, pharmacist, nurse, and laboratory personnel, should collaborate to ensure safe and effective anticoagulation management. This conference would allow for a discussion on dosage adjustments, potential medication interactions, and continued monitoring to prevent complications such as deep vein thrombosis or pulmonary embolism.
Correct Answer is C
Explanation
Choice A reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use decimals or trailing zeros when writing doses, as they can be misread or mistaken for larger doses. For example, 10.0 mg could be read as 100 mg.
Choice B reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MSO4 could be confused with magnesium sulfate (MgSO4).
Choice C reason: This is the correct way to transcribe a verbal prescription. The nurse should write the full name of the drug, the dose, the route, the frequency, and the indication for use. The nurse should also use standard abbreviations that are clear and unambiguous. For example, IV means intravenous, q4h means every 4 hours, and prn means as needed.
Choice D reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MS could be confused with morphine sulfate or magnesium sulfate. The nurse should also use standard abbreviations for the route and frequency, not words like every or prn.
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