EAQ Safety

A client is agitated and threatening staff and other clients with physical harm. The nurse prepares to administer the prescribed as-needed (PRN) haloperidol after other means to deescalate the behavior have failed. The prescription calls for the administration of 5 mg of haloperidol intramuscularly PRN for severely agitated/aggressive behavior. The haloperidol is available in a vial labeled 2 mg/mL. How many milliliters of solution will the nurse administer?

2.5mL

An 18-year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam. The nurse knows that flunitrazepam is often used for what? As a date rape drug To control symptoms of psychosis To control symptoms of bipolar mania To treat hangover symptoms after excessive alcohol consumption

As a date rape drug Flunitrazepam, illegal in the United States, has been used in date rapes; the victim is attacked after consuming a drink spiked with the drug. Flunitrazepam is not used to treat psychosis, mania, or hangover symptoms.

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? Chest x-ray Flushing the line with heparin Withdrawing blood to ensure patency Chest fluoroscopy

Chest x-ray The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.

A urine specimen is needed to test for the presence of ketones in a diabetic client. What should the nurse do when collecting this specimen from a urinary catheter? Disconnect the catheter, and drain the urine into a clean container. Clean the drainage valve, and remove the urine from the catheter bag. Wipe the catheter with alcohol, and drain the urine into a sterile test tube. Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine. The urinary catheter and drainage bag should always remain a closed, sterile system; urine should be drawn only from the catheter port, not the collection bag. Cleaning the drainage valve and removing the urine from the catheter bag will not yield a fresh specimen indicating present acetone levels. The system should remain closed so that fewer microorganisms enter the urinary tract.

During which stage of pregnancy would a teratogen cause neural tube defects? Fetal period Presomite period Embryonic period Preimplantation period

Embryonic period Neural tube defects may occur due to the exposure to a teratogen during the embryonic period (3 to 8 weeks). Exposure to a teratogen during the fetal period (9 to 38 weeks) may cause learning deficits and behavioral abnormalities. Exposure to teratogens during the presomite and preimplantation period (1 to 2 weeks) may cause a spontaneous abortion.

The disaster management team is working to manage the aftermath of an accidental explosion in a fertilizer plant and has started evacuating the injured and uninjured victims from danger as first line of action. Which team member most likely engages in this action? Nurse Paramedic Volunteers Firefighter

Firefighter During a disaster, firefighters and other first responders such as police officers are most likely to be involved in removing the injured and uninjured victims from danger. Nurses are typically not involved in this process, as they require special rescue training. Paramedics are responsible for providing initial care to the victims. Volunteers are supervised by nurses to provide care for the victims injured in disaster.

An underweight client has autoimmune hemolytic anemia that has been unresponsive to corticosteroids, and a splenectomy is scheduled. For what complication should the nurse assess the client in the immediate postoperative period? Dehiscence Hemorrhage Wound infection Abscess formation

Hemorrhage

A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin? It is used to suppress hunger in individuals trying to lose weight, so the client should stop taking the medication. It is often used to treat migraines associated with hormonal changes and should be safe for continued use as needed. It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. It is an atypical antipsychotic, and the woman needs to make an immediate appointment with her mental healthcare provider to discuss alternative medications.

It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately.

While caring for victims of a hurricane, a nurse is teaching hygiene practices and symptoms of various infections. Which phase of disaster management is the nurse executing? Mitigation Response Evaluation Preparedness

Mitigation Mitigation is the attempt to limit a disaster's impact on human health and community functions. Educating the client about the rapid spread of infectious diseases and various hygiene methods that can be adopted in such conditions will help limit the impact of the disaster. Response is the actual implementation of the disaster plan. Evaluation involves identifying successes and failures of the response effort in order to prepare for the future. Preparedness is the protective plan designed before the occurrence of a disaster to assess the risk and evaluate the potential damage.

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take? Obtain vital signs Clamp the NG tube Instill 30 mL of iced normal saline into the NG tube Record the observations and continue monitoring the client

Obtain vital signs Large amounts of blood or excessive bloody drainage 12 hours postoperatively indicate that the client is hemorrhaging. Vital signs should be taken. Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. The primary healthcare provider must prescribe instilling 30 mL of iced normal saline into the nasogastric tube. Continuing to monitor the drainage and record the observations is an unsafe intervention at this time; action must be taken to address and stop the hemorrhaging.

Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? Pulse rate Blood pressure Respiratory rate Body temperature

Respiratory rate

The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. What should the nurse include in the instructions? Anticipate that nausea and vomiting will continue until the infection is no longer present. The infection causes diarrhea accompanied by flatus and abdominal discomfort. Consume a diet that is high in fiber and low in fat. Other than routine hand washing, it is not necessary to perform special disinfection procedures.

The infection causes diarrhea accompanied by flatus and abdominal discomfort. The main clinical manifestation of C. difficile is diarrhea accompanied by excessive flatus and abdominal discomfort. Nausea and vomiting are not associated with this infectious disease. Clients should follow a nutritionally balanced diet high in fiber and low in fats with no specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread of the infection because the C. difficile spore is relatively resistant.

While caring for survivors of a massive tsunami, the nurse makes an initial assessment of a client's condition and assigns a yellow tag. What is the likely role of the nurse? Triage officer Public information officer Medical command physician Hospital incident commander

Triage officer A triage officer is expected to evaluate clients quickly, determine treatment needs, and tag the clients accordingly. A public information officer serves as a liaison between the health care facility and the media. The medical command physician assesses the probable in-client admissions and the expected resource needs of the client. Leadership for implementing the emergency plan is assumed by the hospital incident commander.

The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? "I should see whether the insulin is expired." "I should keep a daily logbook of times of insulin injection." "I should keep my medication in its original labeled container." "I should administer insulin only if there are any symptoms."

"I should administer insulin only if there are any symptoms." The client should administer insulin throughout his or her lifetime and should maintain the dose and daily schedule as ordered by the primary healthcare provider. Before administering insulin, the client should check the expiration date. The client should maintain a daily logbook of insulin injections. The client should keep the medication in its original labeled container and refrigerate if needed.

A client who has delivered her infant by cesarean birth because of active genital herpes is transferred to the postpartum unit. Which type of isolation precautions does the nurse plan to institute? Enteric Droplet Contact Airborne

Contact Contact precautions include a gown, mask, and gloves to protect the nurse from the virus; the client should be in a private room. The Centers for Disease Control and Prevention guidelines for isolation precautions do not include enteric precautions as a category. Droplet and airborne precautions are not necessary for a person with genital herpes.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? Have the prescription renewed every 48 hours. Assess the client's condition per hospital protocol. Provide range of motion to the client's elbows every shift. Document output from the tube and catheter every two hours.

Assess the client's condition per hospital protocol. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every two hours. Generally, output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

A nurse in the prenatal clinic is assessing a woman at 34 weeks' gestation. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action? Arranging transportation to the hospital Obtaining a prescription for an antihypertensive Rechecking the blood pressure within 30 minutes Obtaining a prescription for acetaminophen to relieve the headache

Arranging transportation to the hospital The client has severe preeclampsia, which develops suddenly with a blood pressure of 160/110 mm Hg or higher and proteinuria of +2 to +3 or more. Severe headache and blurred vision are typical symptoms. The client needs immediate treatment to prevent eclampsia. There is no time to obtain or administer antihypertensive medication. This is an emergency situation; waiting 30 minutes to recheck the blood pressure will put both client and fetus in further danger. Having acetaminophen prescribed to relieve the headache is unsafe and places both client and fetus in jeopardy.

While triaging clients after an earthquake that has caused mass casualties, the nurse notes that a client with a massive head injury does not respond to stimulation and cannot breathe independently. Which color tag would be given to the client? Red tag Black tag Green tag Yellow tag

Black tag In an incident that has caused mass casualties, a military form of triage is performed to provide the best care for the most people. In such instances, clients who may otherwise have been resuscitated are often classified as expectant. Therefore a client with a massive head injury who is unable to respond to any kind of stimulus and is unable to breathe independently would be classified with a black tag. Clients needing emergency medical care are identified with red tags. Green tags are given to the clients who sustained minimal injuries in the disaster. Yellow tags are given to clients whose treatment can be delayed for a short time.

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? Mask Clean gloves Sterile gloves Shoe covers

Clean gloves Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.

A nurse finds that his or her surgical mask has become moist before going to a surgery. What should the nurse do? Dispose of the mask Wait until the mask gets dry and then enter the operating room Do not cough or sneeze while wearing the mask Talk less after wearing the mask to minimize respiratory airflow

Dispose of the mask The nurse should dispose of a mask if it gets moist or wet because the mask might have been contaminated. The nurse should not wait till the mask gets dry; instead, the mask should be changed. Coughing or sneezing should be avoided when the nurse is in a sterile area. The nurse should talk less after wearing a dry or sterile mask to minimize respiratory airflow.

Which instruction should the nurse give a client who is on oral extended-release ciprofloxacin therapy for urinary tract infection? Chew the medication along with food Take a walk in morning sunlight Stop the drug after symptoms subside Refrain from taking the tablet immediately after an antacid

Refrain from taking the tablet immediately after an antacid Ciprofloxacin is an antibiotic used in treating urinary tract infections. The nurse should instruct the client to refrain from consuming ciprofloxacin within 2 hours of taking an antacid. Most antacids contain aluminum or magnesium, which interferes with the absorption of ciprofloxacin. The client should be instructed to swallow the tablet and not chew it because chewing it negates the extended-release action of the drug. Clients on ciprofloxacin therapy should avoid sunlight because the medication increases sensitivity to sun and could result in sunburn. The prescribed drug regimen should be followed even if symptoms subside. Premature cessation of medication can lead to recurrence of infection or bacterial resistance.

The home health care nurse discards outdated and leftover medications from previous prescriptions at the home of an elderly client. Which Quality and Safety Education for Nurses (QSEN) competency does this intervention involve? Safety Quality Improvement Evidence-based practice Teamwork and collaboration

Safety The nurse ensures the safety of the client by discarding medications that are outdated. It is important to prevent harm to the client who may unintentionally take a medication that is no longer required. Quality improvement requires the nurse to use data to monitor the outcomes of care processes. The nurse ensures evidence-based practice by integrating the best current evidence with clinical expertise, client, and family values for delivery of optimal health care. The nurse functions effectively within nursing and interprofessional teams to promote open communication and mutual respect while applying teamwork and collaboration competency.

A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer?

mL=2mgx(mL/10mg)=0.2mL