1137 Safety

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. -Call the supervisor and ask what to do. -Hold the medications. -Call the healthcare provider and provide a report of the events and vital signs. -Give the medications and check vital signs later. -Give the scheduled medications.

-Hold the medications. -Call the healthcare provider and provide a report of the events and vital signs.

A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? -20G, 1½″ -20G, 1″ -22G, 1½″ -22G, 1″

22G, 1″

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first? -Obtain an order for blood cultures. -Assess heart sounds. -Raise the head of the bed. -Prepare for a paracentesis.

Raise the head of the bed.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? -Draw a circle around the moist spot and note the date and time. -Notify the physician. -Remove the dressing, clean the site, and apply a new dressing. -Remove the catheter, check for catheter integrity, and send the tip for culture.

Remove the dressing, clean the site, and apply a new dressing.

Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? -Reposition the nasogastric tube. -Place client in supine position. -Stop the feeding. -Aspirate stomach contents.

Stop the feeding.

A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She's been in bed for a week and is not eating or showering. She told me that she didn't want to kill herself, but it's not like her to do nothing for herself. She won't even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason? -Refusing to talk to the grandson alone indicates a major problem. -The behaviors may reflect passive suicidal thoughts. -Seeing the grandson and grandmother together will be helpful. -The behaviors reflect altered role performance.

The behaviors may reflect passive suicidal thoughts.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply? -decreasing environmental stimulation -providing adequate hygiene -orientating the client to the unit activities -asking the client to go eat a meal in the day room

decreasing environmental stimulation

The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: -apply a warm soak to the site. -irrigate the needle with normal saline. -stop the flow of solution temporarily. -discontinue the infusion.

discontinue the infusion.

A nurse is administering daunorubicin to a patient with lung cancer. Which situation requires immediate intervention? -the laboratory reports a white blood cell (WBC) count of 1,000/mm3. -the I.V. site is red and swollen. -the client begins to shiver. -the client states they are nauseous.

the I.V. site is red and swollen.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? -"I removed all the throw rugs from the house." -"I use an electric razor to shave." -"I floss my teeth every morning." -"I take a stool softener every morning."

"I floss my teeth every morning."

The nurse is preparing to infuse a unit of packed red blood cells. What safety precautions will the nurse follow? Select all that apply. -Confirm the client is wearing a name band. -Notify the pharmacist of infusion order. -Obtain the client's weight. -Review hemoglobin and hematocrit levels. -Note client allergies.

-Review hemoglobin and hematocrit levels. -Note client allergies. -Confirm the client is wearing a name band.

When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which safety points? Select all that apply. -Syrup of ipecac should be administered following all ingestions of poisonous substances. -Toddlers should be adequately supervised at all times. -All poisonous substances should be kept out of the reach of children and stored in a locked cabinet if necessary. -The difference between pediatric and adult dosages of medicines is significant, and adult dosages given to children can have serious, harmful effects. -Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment.

-Toddlers should be adequately supervised at all times. -All poisonous substances should be kept out of the reach of children and stored in a locked cabinet if necessary. -The difference between pediatric and adult dosages of medicines is significant, and adult dosages given to children can have serious, harmful effects. -Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment.

The client is ordered heparin IV and the nurse questions if the dose of heparin is safe according to the client's age and weight. What actions should the nurse implement? Select all that apply. -Withhold the dose at this time. -Administer half the medication and document concerns. -Administer the IV heparin as ordered. -Call the health care provider and discuss concerns. -Administer the IV as ordered, but document concerns.

-Withhold the dose at this time. -Call the health care provider and discuss concerns.

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply. -free access to the client for immediate family -a thorough explanation of the isolation procedures -a communication plan for the family and client -discontinued isolation procedures at the family's request -acknowledgement of the family's concerns

-a communication plan for the family and client -a thorough explanation of the isolation procedures -acknowledgement of the family's concerns

A client is prescribed doxorubicin for Hodgkin's disease. The nurse includes interventions in the plan of care for reducing what complications of doxorubicin? Select all that apply. -ocular toxicity -neurotoxicity -cardiac toxicity -pulmonary toxicity -ototoxicity

-cardiac toxicity -pulmonary toxicity

A client takes diazepam while establishing a therapeutic dose of antidepressants for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. -to avoid eating cheese and other tyramine-rich foods -not to use alcohol while taking the drug -to stop taking the drug if he experiences swelling of the lips and face and difficulty breathing -to take the medication on an empty stomach -to consult with his health care provider before he stops taking the drug

-to consult with his health care provider before he stops taking the drug -not to use alcohol while taking the drug -to stop taking the drug if he experiences swelling of the lips and face and difficulty breathing

The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. -Verify the client has signed an informed consent. -Position the client in a side-lying position. -Apply ice to the biopsy site. -Clean the skin with an antiseptic solution.

1. Verify the client has signed an informed consent. 2. Position the client in a side-lying position. 3. Clean the skin with an antiseptic solution. 4. Apply ice to the biopsy site.

The mobile crisis unit of a large city receives an emergency call from an adolescent who states, "My life is worthless. I do not want to live anymore." The mobile crisis unit is on its way to the home. The nurse's best first response would be which of the following? -Provide reassurance that life is not that bad. -Ask the client if they ever felt like this before. -Attempt to calm and support the client. -Do not tell the client that the police will accompany the crisis team.

Attempt to calm and support the client.

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag? -Dispose of the plastic basin. -Wash the basin in hot, soapy water. -Spray the basin with a disinfectant agent. -Clean the basin with an antiseptic agent.

Dispose of the plastic basin.

A nurse is counseling a married woman who has two children under 4 years of age and is a victim of spousal abuse. Before the client leaves the clinic, what is the most important thing the nurse should do? -Discuss the abuser's behaviors with the client. -Teach the client about the cycle of violence. -Give the client the name of a domestic violence shelter. -Help the client develop a safety plan.

Help the client develop a safety plan.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? -Increase the frequency of client observation. -Administer a sedative. -Ask family members to stay with the client. -Contact the health care provider, and request a prescription for soft wrist restraints.

Increase the frequency of client observation.

A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. What should the nurse do in order to obtain admission information from the client? -Obtain a trained medical interpreter. -Ask one of the unlicensed assistive personnel (UAP) to serve as an interpreter. -Ask the client's daughter to serve as an interpreter. -Use the limited knowledge of the client's language learned in high school along with nonverbal communication.

Obtain a trained medical interpreter.

An older adult is taking eight medications to manage hypertension, diabetes, and arthritis and reports having nausea, diarrhea, tremors, and unusual thoughts. When investigating the cause of these symptoms, the nurse should consider which reason for underestimating adverse drug reactions in older adults? -Adverse reactions rarely have an atypical presentation. -Physical or psychological symptoms are attributed to the effects of aging. -Excess sedation is difficult to assess in the older adult. -Cognitive impairment is an expected finding in the older adult client.

Physical or psychological symptoms are attributed to the effects of aging.

The nurse should dispose of a used needle and syringe by: -Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room. -Recapping the needle and placing the needle and syringe in the universal precaution container in the client's room. -Separating the needle and syringe and placing both in the precaution container in the client's room. -Cutting the needle at the hilt in a needle cutter before disposing of it in the universal precaution container in the client's room.

Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? -The injection will provide immunity against the chickenpox. -The client should avoid contact with children diagnosed with rubella. -The vaccine prevents a future fetus from developing congenital anomalies. -Pregnancy should be avoided for 4 weeks after the immunization.

Pregnancy should be avoided for 4 weeks after the immunization.

A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 325 mg enteric coated aspirin to be given via the feeding tube once daily. How should the nurse give this medication? -Request an alternate formulation -Give the tablet by mouth -Crush the tablet, mix with a small amount of water, and infuse into the feeding tube, followed by a flush -Add the tablet to the feeding tube whole, followed by a flush

Request an alternate formulation

Parents of a preschooler with chickenpox ask the nurse about measures to make their child comfortable. The nurse instructs the parents to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? -rheumatic fever -Reye's syndrome -Guillain-Barré syndrome -scarlet fever

Reye's syndrome

A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I'm pregnant. She's willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? -The client did not say that the father of the baby was excited about this. -Symptom management will be difficult in early pregnancy without medications. -The mother is not likely to provide enough help for what the client needs. -The client will have difficulty financially supporting the baby.

Symptom management will be difficult in early pregnancy without medications.

Which finding in a client's history would be the most likely to increase the client's risk for renal calculi? -The client drinks one to two glasses of fluid daily. -The client runs 5 miles three times a week. -The client eats a diet that meets the daily requirements for calcium. -The client takes large doses of vitamin E.

The client drinks one to two glasses of fluid daily.

A client is admitted to the hospital after sustaining a fracture of the femur sustained while intoxicated. The client's condition is stable; however, the client is shaky, irritable, and anxious. The next day the nurse finds the client restless and perspiring, with an elevated pulse. The client cries, "There are bugs crawling on my bed. I've got to get out of here," and begins to thrash about. What knowledge does the nurse use to manage the client's immediate care? -The client is experiencing withdrawal delirium. -The client is attempting to manipulate staff. -The client may have sustained a head injury. -The client is having an episode of psychosis.

The client is experiencing withdrawal delirium.

A young adult is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? -Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. -The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. -The health care provider (HCP) will get a consultation from another health care provider and proceed with placement of the ICP catheter until the family arrives to sign the consent. -The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married.

The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.

.A parent tells the nurse that the primary discipline method used in the home is corporal punishment. What should the nurse tell the parent about corporal punishment? -Use can result in children becoming accustomed to spanking. -It does not physically harm the child. -It reinforces the idea that violence is not acceptable. -Use can be beneficial in teaching children what they should do.

Use can result in children becoming accustomed to spanking.

Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)? -pain during sexual activity -a change in the pattern of the chest pain -pain during an argument -pain during or after a physical activity

a change in the pattern of the chest pain

The nurse on the postpartum unit is planning to complete assessments during the last half hour of the shift. Which assessment should be accomplished first? -a postpartum couplet with the infant who has had transient tachypnea of the newborn (TTN) at birth and now has a respiratory rate of 60 breaths/minute -a newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours -a couplet with baby born at 36 weeks' gestation; the 5-lb (2,268-g) infant had initial blood glucose of 35 mg/dL (1.9 mmol/L) and when taken to the room had a glucose of 46 mg/dL (2.6 mmol/L) -a mother who had a cesarean birth and is 6 hours after birth with the baby in special care nursery; the mother has not yet seen her baby

a newly admitted postpartum client who is receiving magnesium sulfate at 3 g an hour initiated 10 hours ago for preeclampsia; her infant ate poorly previously and has not eaten for 4 hours

A nurse is caring for a confused client and develops a plan of care based on a least restraint policy. Which intervention would be most appropriate for the nurse to implement based on this policy? -vest-type restraint -locking waist restraint -chair with locking lap tray -alarm-activating wrist bracelet

alarm-activating wrist bracelet

The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications? -abdominal muscle strengthening exercises every 8 hours -expressing breast milk every 3-4 hours -passive range of motion leg exercises every 2 hours -deep breathing and coughing exercises every 2 hours

deep breathing and coughing exercises every 2 hours

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? -phenytoin -heparin sodium -dexamethasone -methyldopa

heparin sodium

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority? -assessing vital signs -massaging the uterus -assisting client to left lateral position -assisting client to empty her bladder

massaging the uterus

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect? -agranulocytosis -extrapyramidal effects -neuroleptic malignant syndrome -anticholinergic effects

neuroleptic malignant syndrome

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client -to the bathroom. -to a standing position so they can urinate. -to the bedside commode. -onto the bedpan.

onto the bedpan.

When teaching a client when to take glipizide in order to maximize the effectiveness of the drug, the nurse should instruct the client to: -take glipizide four times a day at evenly spaced intervals. -take glipizide as indicated by blood glucose values. -take glipizide immediately after meals. -take glipizide 30 minutes before breakfast.

take glipizide 30 minutes before breakfast.

A nurse is teaching the parents of a 7-year-old child about the use of protective restraints in the car to help avoid spinal cord injuries in car accidents. The child weighs 20 kg (44 lb). Which of the following information should the nurse emphasize in the teaching? -using a lap seatbelt -using a lap and shoulder belt -using a booster seat -using a rear-facing car seat

using a booster seat