Evolve Case Study: Management of Surgical Unit

Change of Shift Report The charge nurse for the previous night shift is giving a verbal report to Ms. Hatch and the oncoming staff nurses. During the report, one of the UAPs interrupts to state that a client is vomiting. 1. How should Ms. Hatch respond to this situation? A) Ask the UAP to remain with the client until the report has been completed. Feedback: INCORRECT A vomiting client requires more expert assessment than the UAP is qualified to perform. B) Go with the UAP to the client's room to evaluate the client's condition. Feedback: INCORRECT This interrupts the shift report, impacting the work of all of the nursing staff. C) Stop the report to allow the night shift charge nurse to assess the client's needs. Feedback: INCORRECT This interrupts the shift report, impacting the work of all of the nursing staff. D) Request that a night shift staff RN go to the room to evaluate the situation. Feedback: CORRECT A night shift staff nurse has the most recent experience with the client, and is qualified to assess and respond to the situation. Additionally, this assignment allows the report to continue without delay. Points Earned: 1.0/1.0 Correct Answer(s): D After the UAP leaves the report area, the night charge nurse states, "That UAP is incompetent. She can't figure out anything on her own." 2. As the day shift charge nurse, how should Ms. Hatch respond? A) "She is doing her job. She should report problems to you." Feedback: INCORRECT While it is the responsibility of the UAP to report problems to the nurse, this statement closes communication lines. In addition, it does not model an effective way to resolve staff problems. B) "Perhaps she needs additional orientation and training." Feedback: INCORRECT Because this response may encourage the night charge nurse to continue to discuss staff members during report, it is not the most effective strategy to deal with the situation. C) "Your concern needs to be addressed with the unit manager." Feedback: CORRECT The night charge nurse should not express personal feelings about staff members during report. To ensure confidentiality, Ms. Hatch should direct the charge nurse to the unit manager.    D) "It is your responsibility to deal with staff problems on your shift." Feedback: INCORRECT This statement closes communication lines. In addition, it does not model an effective way to resolve staff problems. Points Earned: 0.0/1.0 Correct Answer(s): C Initial Client Care Assignments After receiving report, Ms. Hatch makes client care assignments for the nursing staff. 3. In making initial client care assignments, which client can be assigned to a PN, rather than an RN? A) The vomiting client, who has a nasogastric tube set to low intermittent suction. Feedback: INCORRECT This client has a problem that requires a high level of expertise to assess and implement a plan of care. Therefore, this client should not be assigned to a PN. B) A two-day postoperative client with an abdominal incision and a Jackson-Pratt drain. Feedback: CORRECT This client requires routine postoperative care which can be completed by the PN. C) A client who is scheduled to be discharged after receiving instruction about colostomy care. Feedback: INCORRECT The RN is the person qualified to complete discharge teaching and evaluate the client's ability to perform the needed care. D) A client with diabetes who reports pain two days after an above-the-knee amputation. Feedback: INCORRECT This client requires a high level of expertise to accurately assess the problem, and to plan nursing care. Therefore, this client should not be assigned to a PN. Points Earned: 0.0/1.0 Correct Answer(s): B 4. An additional client with which care need should be assigned to the same PN? A client: A) Receiving peritoneal dialysis while awaiting a kidney transplant. Feedback: INCORRECT Because peritoneal dialysis can cause significant complications, it should be performed by the RN, rather than the PN. B) Fearful about undergoing a pneumonectomy for lung cancer which is scheduled for the following day. Feedback: INCORRECT This client needs the expertise of the RN to provide emotional support, additional teaching, and effective therapeutic communication. C) Experiencing hypoactive bowel sounds on the second postoperative day after a colon resection. Feedback: CORRECT This is an expected finding at this stage of postoperative recovery. This is the correct assignment for the PN since this client requires routine postoperative care and has no identified problems requiring a higher level of expertise. D) Exhibiting pain that is being managed with an epidural infusion of hydromorphone (Dilaudid). Feedback: INCORRECT The administration of an opioid epidural infusion should be monitored by the RN, who has a higher level of assessment expertise than the PN. Points Earned: 1.0/1.0 Correct Answer(s): C Ms. Hatch learns that one of the day shift nurses will be thirty minutes late. 5. How should that nurse's client care assignments be managed until the nurse arrives? A) Ask the most experienced RN to assume the additional responsibility. Feedback: INCORRECT This places an unfair workload on one staff member and increases the risk for the provision of unsafe care. B) Advise the UAP to monitor those clients until the nurse arrives. Feedback: INCORRECT The UAP cannot be assigned the responsibility of client care without a nurse providing supervision. C) The charge nurse will assume care of the clients until the nurse arrives. Feedback: INCORRECT The charge nurse needs to be available to oversee the management of the entire unit. D) Assign an additional client to each of the day shift staff nurses. Feedback: CORRECT This assignment provides the most equitable distribution of responsibility among the RNs, and allows the charge nurse to be available to her staff and the clients on the unit.    Points Earned: 1.0/1.0 Correct Answer(s): D Establishing Priorities 6. When making initial rounds, the charge nurse should see which client first? A) A postoperative client with a tracheostomy who has signs of a tracheoesophageal fistula. Feedback: CORRECT A fistula between the trachea and esophagus can result in a compromised airway, so this client must be assessed immediately. B) A postoperative client with a continuous bladder irrigation system that is draining pale pink urine. Feedback: INCORRECT This is a normal finding and does not require immediate assessment by the charge nurse. C) A preoperative client with a history of syncope who is scheduled for carotid endarterectomy. Feedback: INCORRECT A history of syncope is an expected finding in a client scheduled for a carotid endarterectomy. D) A preoperative client with a prolonged PTT who was receiving anticoagulants. Feedback: INCORRECT This situation does require prompt evaluation prior to the client's scheduled surgery, but another situation is of more immediate priority. Points Earned: 0.0/1.0 Correct Answer(s): A Before she is able to start rounds, Ms. Hatch learns from the PN that the client with a history of syncope is threatening to get out of bed alone to go to the restroom and that the client with the possible tracheoesophageal fistula has an oxygen saturation level of 80%. Besides the charge nurse and PN, a UAP assigned to work with the PN is also available. 7. How should the charge nurse respond to this information? A) Assess the client with the possible fistula while the UAP assists the other client to the restroom. Feedback: INCORRECT Another assignment will ensure client safety more effectively. B) Assist the client to the restroom while the PN obtains vital signs on the client with the possible fistula. Feedback: INCORRECT Another assignment will ensure client safety more effectively. C) Assess the client with the history of syncope while the UAP obtains vital signs on the client with the possible fistula. Feedback: INCORRECT Another assignment will ensure client safety more effectively. D) Assess the client with the possible fistula while the PN assists the other client to the restroom. Feedback: CORRECT The RN has the expertise to assess the client with a compromised airway while the practical nurse can assist a client at risk for falls to the restroom more safely than the UAP.    Points Earned: 1.0/1.0 Correct Answer(s): D Delegation of Care Once the immediate priorities are managed, Ms. Hatch assesses the client with continuous bladder irrigation and notes that the drainage bag is full, but there is no urine return in the tubing. The client's bladder is distended, and the client reports severe bladder pain.   8. How should Ms. Hatch delegate tasks to respond to this situation? A) While the UAP manually irrigates the tubing, the RN can palpate the client's bladder. Feedback: INCORRECT Manual irrigation of an obstructed urinary drainage system is beyond the expertise of the UAP. B) While the UAP empties the urine drainage bag, the RN can calculate the client's intake and output. Feedback: INCORRECT These interventions will not resolve the immediate problem. C) While the RN manually irrigates the tubing, the UAP can empty the urine drainage bag. Feedback: CORRECT Manual irrigation of the tubing is needed and requires the expertise of the RN. The UAP can be assigned to empty the drainage bag. Once the blockage in the tubing is relieved, urine should flow easily into the empty drainage bag and the client's bladder distension should be relieved. D) While the RN calculates the client's intake and output, the UAP can palpate the client's bladder. Feedback: INCORRECT The UAP does not have the expertise to perform physical assessment. Points Earned: 1.0/1.0 Correct Answer(s): C Continuing to make rounds, Ms. Hatch observes that the preoperative client with a prolonged PTT is lethargic with pale, diaphoretic skin. The client's blood pressure is 70/40. 9. When assisting the nurse to care for this client, the UAP should be assigned which task? A) Increase the IV flow rate as directed. Feedback: INCORRECT IV fluids are considered medications, and UAPs are not qualified to administer medications. B) Position the client as directed. Feedback: CORRECT Under the direction of the RN, the UAP can assist with placement of the client in a shock position as warranted.  C) Measure the client's temperature. Feedback: INCORRECT Although the UAP is qualified to measure vital signs, there is no reason to take the client's temperature at this time. D) Monitor the client's pedal pulse volume bilaterally. Feedback: INCORRECT This physical assessment cannot be performed by the UAP. Points Earned: 0.0/1.0 Correct Answer(s): B The healthcare provider prescribes an immediate transfusion of two units of packed red blood cells. 10. After the nurse obtains the first unit of blood, what task can be delegated to the UAP? A) Check the client identification number and the number on the unit of blood with the nurse. Feedback: INCORRECT Confirming identification numbers prior to a blood transfusion must be performed by two nurses. B) Explain the need for the immediate transfusion of blood to the client and family members. Feedback: INCORRECT Client and family teaching requires the expertise of the RN. C) Obtain the client's vital signs and report the results to the nurse before the transfusion is started. Feedback: CORRECT Although the UAP can be assigned to obtain vital signs, the vital sign data must be reviewed by the RN.   D) Prepare the saline and Y-tubing for the nurse to use when starting the transfusion of packed cells. Feedback: INCORRECT The UAP does not have the expertise to assemble blood administration equipment. Points Earned: 1.0/1.0 Correct Answer(s): C Client Advocacy A female client is scheduled for surgery in four hours. The breakfast trays arrive on the unit with a tray for the preoperative client. The primary nurse notes that there is no prescription in the client's medical record regarding NPO status.   11. What action should the nurse implement? A) Instruct the UAP to take the tray to the client's room and assist the client with the meal. Feedback: INCORRECT This does not demonstrate effective client advocacy. B) Take the tray to the room, but advise the client about the risks of eating before surgery. Feedback: INCORRECT Effective client advocacy requires that the nurse be proactive in this situation. C) Ask the client what instructions she received regarding eating before surgery. Feedback: INCORRECT This does not provide the nurse with sufficient information to make a safe decision. D) Hold the tray and contact the surgeon for clarification of the client's preoperative needs. Feedback: CORRECT This proactive decision by the nurse demonstrates effective client advocacy. Recognizing that it may be unsafe for the client to eat, the nurse should confirm the surgeon's directions before taking the tray to the room. Points Earned: 1.0/1.0 Correct Answer(s): D After the meal situation is effectively resolved, the client reports to the primary nurse that she feels uneasy about the scheduled procedure. 12. What is the best initial response by the nurse? A) "Tell me what is making you feel uneasy." Feedback: CORRECT This open-ended statement encourages further verbalization by the client, allowing the nurse to determine if any further action is needed. B) "Would you like me to review the procedure with you?" Feedback: INCORRECT Although additional teaching may be needed, this is not the best initial response. C) "Would you like to speak with the surgeon again?" Feedback: INCORRECT Offering to contact the surgeon may be an effective intervention, but is not the best initial response. D) "The charge nurse will be here to help you right away." Feedback: INCORRECT The primary nurse may wish to ask the charge nurse for assistance, but this is not the best initial response. Points Earned: 1.0/1.0 Correct Answer(s): A Assignment Changes 13. Which finding in a postoperative client warrants an immediate change in care assignments, so that an RN assumes care of that client rather than the PN who was assigned initially? A) Dyspnea and a cough that produces frothy, white sputum. Feedback: CORRECT These are manifestations of pulmonary edema, a medical emergency requiring the immediate expertise of the RN. B) Frequent incisional pain rated as a 9 on a 10-point scale. Feedback: INCORRECT Uncontrolled pain may require the assessment expertise of the RN, but this situation is of less immediacy than another situation. C) Orthostatic hypotension upon standing at the bedside. Feedback: INCORRECT This is common in the postoperative period. The PN should be able to manage this problem. D) Inflammation and tenderness surrounding the incisional staples. Feedback: INCORRECT This is not a problem that requires a change in client care assignments at this time. Points Earned: 1.0/1.0 Correct Answer(s): A Since the RN will assume care of this additional client, Ms. Hatch selects another client for the PN to provide care for. 14. Which client should be reassigned to the PN? A postoperative client: A) Preparing for discharge and needs a central venous catheter removed. Feedback: INCORRECT Because removal of a central line can place the client at risk for complications, this task should be performed by an RN with a higher level of expertise. B) With wound dehiscence who needs to have the wound re-packed. Feedback: INCORRECT Because wound re-packing requires expert judgment, this task should be performed by the RN. C) Needing an indwelling urinary catheter inserted after surgery. Feedback: CORRECT This is a good client to assign to the PN, since this routine skill does not require as high a level of expertise as do the skills in the other client situations. D) Receiving total parenteral nutrition (TPN) for prolonged malnutrition. Feedback: INCORRECT A client receiving TPN is at high risk for multiple complications and requires the expertise of the RN for assessment and management of care. Points Earned: 0.0/1.0 Correct Answer(s): C Supervision 15. What action should the charge nurse implement? A) Assign a more experienced PN to perform the procedure. Feedback: INCORRECT Changing the assignment will not provide the less experienced PN with the needed learning opportunity. B) Assign a UAP to assist the PN with the procedure. Feedback: INCORRECT The UAP may assist the PN, but the UAP does not have the expertise to supervise the performance of a procedure. C) Go with the PN to supervise the procedure. Feedback: CORRECT In performing a skill for the first time, the PN requires support and supervision to ensure correct skill performance, and effective learning.   D) Reassure the PN that the same principles apply. Feedback: INCORRECT This does not provide adequate supervision to ensure correct skill performance and client safety. The PN is reassigned to care for the preoperative client and obtains the supplies necessary for the insertion of a urinary catheter. The PN tells Ms. Hatch that she has inserted several catheters in female clients, but she has never inserted one in a male client. This preoperative client is male. Points Earned: 1.0/1.0 Correct Answer(s): C Further preoperative preparation is needed after the urinary catheter is inserted. 16. Which task can be delegated to the UAP? A) Review postoperative exercises with the client. Feedback: INCORRECT Client teaching requires the expertise of the nurse. B) Ensure that the surgical consent is signed and dated. Feedback: INCORRECT This responsibility requires the expertise of the nurse. C) Observe that the surgical site is marked correctly. Feedback: INCORRECT This responsibility requires the expertise of the nurse. D) Apply the client's antiembolism (TED) stockings. Feedback: CORRECT This is a task that can safely be performed by the UAP.    The primary nurse enters the client's room and observes that his TED stockings are down below his knees. The UAP states, "I know I applied the TED stockings correctly, he must have pulled them down while I was getting him a clean gown." Points Earned: 1.0/1.0 Correct Answer(s): D 17. How should the primary nurse respond? A) "That sounds like an excuse for not doing your work correctly." Feedback: INCORRECT This aggressive response is judgmental and confrontational, and it could lead to a defensive response by the UAP. B) "I will reapply the stockings myself. Go finish your other work." Feedback: INCORRECT This passive response by the nurse does not address the UAP's role in the application of the stockings or the reason they are below the client's knees. C) "You need to reapply the stockings. I've got a client down the hall." Feedback: INCORRECT The nurse needs to assume an active role in evaluating the UAPs ability to apply the TEDs correctly. D) "Let's work together to reapply the stockings while I talk to the client about the purpose of TEDs." Feedback: CORRECT This assertive response by the nurse promotes team building. The nurse can evaluate the UAP's ability to apply the stockings as they work together. Points Earned: 1.0/1.0 Correct Answer(s): D Ms. Hatch overhears the primary nurse assign the UAP to take the vital signs of the preoperative client and to report back any problems. 18. How should Ms. Hatch respond? A) Advise the primary nurse of the responsibility to review all vital signs obtained by the UAP. Feedback: CORRECT The charge nurse must ensure that the primary nurse understands the responsibility to review all vital signs obtained by the UAP. In addition, the instruction to report any problems is too vague. The UAP does not have the skill to evaluate the vital signs for problems. This requires the expertise of the nurse.    B) Remind the primary nurse that preoperative vital signs must be taken and recorded by a nurse. Feedback: INCORRECT The vital signs may be obtained by the UAP. C) Instruct the UAP to report any problems to the charge nurse rather than the primary nurse. Feedback: INCORRECT The primary nurse is responsible for the client, so any communication about the client should first be directed to the primary nurse. D) Observe the ability of the UAP to measure and record the preoperative vital signs correctly. Feedback: INCORRECT Supervising the ability of the UAP to take vital signs is not warranted in this situation. Points Earned: 1.0/1.0 Correct Answer(s): A Implementing Change Later in the day, the unit manager advises Ms. Hatch about the increasing incidence of postoperative infections throughout the medical center. An agency-wide policy will be instituted regarding wound care management, with all initial postoperative dressings to be changed by a wound care team rather than the unit nursing staff. Ms. Hatch recognizes that this may anger many of the staff nurses. 19. What approach should Ms. Hatch use when introducing this change? A) Remind the staff that their poor performance resulted in the need for change. Feedback: INCORRECT This action will increase staff resentment and their resistance to the change. B) Reinforce the understanding that this is an administrative mandate. Feedback: INCORRECT This action does not promote staff ownership of the problem, and it is likely to lead to increased staff resentment and resistance to the change. C) Suggest that the staff report any dissatisfaction to the unit manager. Feedback: INCORRECT This suggestion does not demonstrate proper use of the chain of command. D) Explain the need to implement this change in policy. Feedback: CORRECT Adults respond more positively to change when the reason for the change is understood. Points Earned: 1.0/1.0 Correct Answer(s): D When Ms. Hatch introduces the new policy at a staff meeting, one of the nurses expresses concern that as a primary nurse, he has the responsibility to observe his clients' surgical sites. He questions his ability to meet this responsibility if a separate team changes his clients' surgical dressings. 20. How should Ms. Hatch respond? A) "I agree, but we will just have to wait and see how it works over time." Feedback: INCORRECT This is a passive response that is not proactive in responding to a potential problem. B) "I will bring your concern to the attention of the wound care team." Feedback: CORRECT This proactive response acknowledges a legitimate concern by the staff nurse. The charge nurse demonstrates respect for the nurse by taking action in response to his concern. C) "You need to accept this change and figure out how to make it work." Feedback: INCORRECT This response is aggressive and may increase staff resistance to the change. D) "A negative attitude is not beneficial for improving client care." Feedback: INCORRECT The staff nurse expressed a legitimate concern that should be addressed. Points Earned: 1.0/1.0 Correct Answer(s): B Conflict Resolution After the staff meeting, Ms. Hatch makes afternoon rounds on the unit and observes a postoperative client with a cold pack. The skin under the cold pack is pale, and the client reports that the cold pack has been in place for over four hours.   21. After removing the pack, what action should Ms. Hatch take next? A) Consult with the primary nurse caring for the client. Feedback: CORRECT Before making assumptions about the situation, the charge nurse should first gather all the needed information, starting with a consultation with the primary nurse responsible for the care of the client. B) Complete an adverse occurrence (variance) report. Feedback: INCORRECT While an adverse occurrence report may need to be completed, another action should be taken first. C) Notify the healthcare provider. Feedback: INCORRECT Although the charge nurse will notify the healthcare provider about the first incident, another action is warranted. D) Ask the UAP assigned to the client when the pack was applied. Feedback: INCORRECT Although the charge nurse may want to speak to the UAP about the application of the cold pack, another action is warranted first.   Ms. Hatch meets with the primary nurse and the UAP involved in the situation. The UAP states that she was told to apply the cold pack but was not given instructions about removing the pack. The primary nurse responds that UAPs should know when to remove cold packs since that is one of their job responsibilities. Points Earned: 1.0/1.0 Correct Answer(s): A 22. How should Ms. Hatch respond to the nurse? A) "The UAP should have asked you when to remove the cold pack." Feedback: INCORRECT The nurse is responsible for providing adequate instruction to the UAP. B) "Your lack of adequate instruction may have caused harm to the client." Feedback: INCORRECT This judgmental approach will not be productive. There is a better way for Ms. Hatch to handle this situation. C) "You should never trust UAPs to do their job correctly." Feedback: INCORRECT UAPs can be trusted to perform their jobs, but they require adequate instruction. D) "You are responsible for monitoring tasks delegated to the UAP." Feedback: CORRECT The primary nurse must understand the responsibilities related to supervision of the UAP. These responsibilities include adequate instruction and monitoring. Points Earned: 1.0/1.0 Correct Answer(s): D Both staff members appear angry about the situation and continue to insist the other is at fault. 23. What action should Ms. Hatch implement to aid in the resolution of the conflict between the UAP and the primary nurse? A) Assign the UAP to work with another primary nurse for the rest of the day. Feedback: INCORRECT This will not resolve the conflict. B) Instruct the UAP and primary nurse that they must learn to work together. Feedback: INCORRECT This aggressive intervention is likely to increase resentment and defensiveness by both staff members. C) Encourage both staff members to practice effective communication with one another. Feedback: CORRECT A positive, encouraging attitude promotes trust and respect. The charge nurse should offer a constructive approach such as practicing effective communication to help resolve the conflict.  D) Schedule a private meeting with each staff member to discuss the conflict. Feedback: INCORRECT This is likely to lead to further blame rather than promoting a positive outcome. Points Earned: 1.0/1.0 Correct Answer(s): C Client Transfer Since the surgical unit is full, Ms. Hatch must make arrangements for a client to be transferred to the skilled care unit so there will be a bed available for an acutely ill client who is awaiting emergency surgery. 24. The postoperative client with which condition is most safe to transfer to the skilled care unit? A) Hip surgery receiving an autologous transfusion. Feedback: INCORRECT This client is at risk for complications related to the transfusion and is therefore not the most stable client. B) Knee surgery requiring continuous use of passive motion therapy. Feedback: CORRECT This client's condition is the most stable, so this client is the best candidate for transfer to the skilled care unit. C) Permanent pacemaker surgery with continued telemetry monitoring. Feedback: INCORRECT A client requiring telemetry monitoring is at risk for cardiac dysrhythmias and is therefore not the most stable client. D) Femoral bypass surgery being monitored for suspected compartment syndrome. Feedback: INCORRECT Compartment syndrome is an acute complication requiring close monitoring to prevent complications. Points Earned: 1.0/1.0 Correct Answer(s): B 25. How should the charge nurse best utilize available staff during the process of transferring one client to the skilled care unit while admitting another client awaiting emergency surgery? A) The UAP can assist the PN in transferring the client to the skilled care unit while the RN admits the client awaiting emergency surgery. Feedback: CORRECT The expertise of the RN is needed to admit the acutely ill client. The client being transferred is stable and can be safely managed by the PN.  B) The UAP can begin admitting the client awaiting emergency surgery while the RN and PN transfer the client to the skilled care unit. Feedback: INCORRECT The UAP does not have the expertise to begin admitting an acutely ill client without the guidance of the nurse. C) The PN and UAP can work together to admit the client awaiting emergency surgery while the RN transfers the client to the skilled care unit. Feedback: INCORRECT This assignment does not provide the needed expertise for the admission of the acutely ill client. D) The charge nurse can admit the client awaiting emergency surgery while the UAP, PN, and RN transfer the client to the skilled care unit. Feedback: INCORRECT This is not the most efficient use of the available staff. Points Earned: 0.0/1.0 Correct Answer(s): A Case Outcome The client transfer is completed safely, and the client awaiting emergency surgery has been admitted. The nursing staff has worked the past twelve hours to provide care for twenty surgical clients, implement a new policy to reduce postoperative infections, learn new skills, and resolve conflicts to ensure safe, effective care.