Questions and Answers
Which lab results are most concerning for patient Ellen Thomas?
What are the correct steps for inserting a straight catheter?
- Explain the procedure to the client. 2. Perform hand hygiene and don clean gloves. 3. Help to dorsal recumbent position with thighs externally rotated. 4. Open catheterization kit using sterile technique. 5. Apply sterile gloves. 6. Gently separate labia to expose the urethral meatus. 7. Cleanse the urethral meatus from top to bottom. 8. Hold catheter 3-4 inches from the tip. 9. Insert catheter until urine flows out. 10. Collect urine in the appropriate receptacle.
Who can the RN delegate an intermittent urinary catheter to?
Considering the same patient with the same lab results, which conditions might the nurse be concerned with?
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Of the doctor's orders, which ones are appropriate for patient Ellen Thomas?
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Identify each action by the team as appropriate or inappropriate.
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Study Notes
Lab Results and Patient Concerns
- Elevated sodium level (149 mEq/L) indicates possible hypernatremia.
- High BUN (38 mg/dL) suggests dehydration; normal creatinine (1.1 mg/dL) rules out renal failure.
- Elevated WBC count (10,200 mm³) may indicate infection or inflammation.
- Albumin level is low (2.9 g/dL), potentially signifying malnutrition.
- Frequent headaches and low mood raise concerns about mental health and possible underlying conditions.
Catheterization Procedure
- Explain the procedure to the patient for comfort and understanding.
- Ensure proper hygiene through clean gloves and sterile technique.
- Position the patient appropriately (dorsal recumbent with thighs rotated).
- Perform catheterization correctly to ensure patient safety and minimize discomfort.
Delegation Rights and Responsibilities
- UAP can obtain orthostatic blood pressures; RN must interpret results.
- LVN/LPN can perform straight catheterizations, while UAP cannot conduct assessments.
- Delegation should consider right task, circumstances, person, supervision, and communication.
Additional Patient Condition Concerns
- Possible conditions include:
- Dehydration, evidenced by low BP and tachycardia.
- Hypernatremia associated with elevated serum sodium.
- Signs of depression due to mood changes and lack of appetite.
- Other common conditions ruled out: diabetes, constipation, stroke, heart attack, renal failure, and dementia.
Appropriate Doctor's Orders
- Appropriate interventions include IV fluids, strict monitoring of intake/output, and obtaining a urinalysis.
- Continuing home medications is essential for CAD and depression management.
- Low sodium diet is appropriate considering the patient's health status.
- Question the need for furosemide due to signs of dehydration; assess appropriateness of neurological consultations.
Fall Assessment and Response
- Inappropriate actions included family notification by UAP and calling the healthcare provider by the LPN.
- Appropriate actions by the RN involved performing neurological assessments, applying pressure to wounds, and documenting the incident.
- Vital signs must be assessed by a trained professional, with the RN being responsible for response to acute situations.
- Adverse event reporting must be handled appropriately to ensure accountability and improve patient safety.
Considerations for Future Care
- Addressing the prevention of falls through proper patient handling and risk assessments.
- Reflect on the possible long-term outcomes for the patient regarding their mental and physical health after the fall incident.
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Description
This quiz covers essential nursing skills related to interpreting lab results, performing catheterization, and understanding delegation in nursing. Test your knowledge on patient assessments, hygiene protocols, and the roles of healthcare team members. Perfect for nursing students and professionals seeking to enhance their clinical competencies.
