Ethics, Processing, and Care - NCLEX-PN

Molding, or the elongation of the infants head during labor and delivery, is a normal adaptation allowing the relatively large skull to traverse the narrow space of the birth canal. It generally resolves in 1-5 days.

Meconium is a sticky, dark-green to black stool that is the first stool passed by neonates after birth. It is composed of the content of the infant's digestive tract before it has begun drinking milk - primarily water, mucus, bile, lanugo, and intestinal epithelial cells. A newborn that has begun to feed on breastmilk or formula should pass a normal stool (yellow to mustard-green and creamy rather than sticky) within 24 hours.

All of these are important professional roles of the nurse in a healthcare setting.

A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.

Washed red blood cells are the product of blood that has been stripped of plasma, leukocytes, antibodies, cytokines, and platelets, in addition to any other blood proteins.

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.

Before administration, plasma products must be checked for ABO compatibility and Rh compatibility.

ABO blood type does not have to be an exact match, but blood types must be compatible. An Rh positive individual, for example, is compatible with either Rh negative blood or positive blood, while an Rh negative individual is only compatible with Rh negative blood.

Whenever possible, fresh frozen plasma should be transfused immediately (or as soon as possible) after thawing. However, if this is not possible, it may be refrigerated for as long as 24 hours after thawing.

Common signs of transfusion reaction include urticaria, itching, or swelling, pallor or cyanosis, anxiety, and myalgia, tingling, or numbness, in addition to diaphoresis, tachycardia, headache, and gastrointestinal distress.

Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm.

Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.

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.