EAQ Safety

A healthcare provider prescribes 20 mEq potassium chloride to be given to a client over an 8-hour period by IV drip in 1000 mL of D5W. The IV equipment is calibrated at 10 drops per milliliter. At how many drops per minute should the nurse regulate the IV? Record your answer using a whole number. ___ drops/minute

21 drops/minute

What would be the level of the client with a hip fracture due to a mass disaster according to the emergency service index (ESI)? 1. Level 1 2. Level 2 3. Level 3 4. Level 4

3. Level 3 According to the ESI, a client with hip fracture is categorized under level 3, as this condition is not life threatening and the client is stable. In level 1, the client is not stable and has a life-threatening condition. Level 2 clients are at high risk for life-threatening complications. Level 4 clients are stable with minor injuries such as skin lacerations.

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? 1. Restricting gross motor activity 2. Preventing further deterioration 3. Keeping the client oriented to time 4. Managing the client's unsafe behaviors

4. Managing the client's unsafe behaviors Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil may help delay deterioration in some clients. It may not be possible to keep the client continuously oriented.

After surgery, a client received a prescription for 8 mg of morphine sulfate to be given by injection. The vial on hand is labeled 1 mL = 10 mg. How much solution should the nurse administer? Record your answer using one decimal place and include a leading zero if applicable. ___ mL

0.8 mL

A 5-year-old child in renal failure who has undergone creation of an arteriovenous fistula access begins hemodialysis three times a week. The nurse teaches the mother the specific care her child needs. What statement indicates that further teaching is necessary? 1. "I'll offer more drinks in warm weather." 2. "I should call the clinic if he vomits or has diarrhea." 3. "I'll check his pulse at the wrist on each arm every day." 4. "It's OK to take his blood pressure on the arm with the fistula."

4. "It's OK to take his blood pressure on the arm with the fistula." Taking the blood pressure on the arm with the arteriovenous fistula is contraindicated because the pressure of the inflated cuff may disrupt the integrity of the fistula. Consumption of more fluids is desirable because inadequate fluid intake can result in dehydration and an acid-base imbalance. Calling the clinic is desirable because vomiting or diarrhea may lead to dehydration and an acid-base imbalance. Not only should the pulse be monitored to assess vascular function distal to the arteriovenous fistula, but it should be done on both extremities and the results compared.

A laboring client expresses concern about the effect that an intravenous analgesic may have on her fetus. What is the best response by the nurse to reassure the client? 1. "I'll dilute the medication so it won't have an immediate impact on the baby." 2. "I'll just give a half-dose of the medication while the uterus is in its relaxed phase." 3. "It will be administered during a contraction, when the uterine blood vessels are constricted." 4. "It will be administered in the proximal port of your IV so that you have immediate pain relief."

3. "It will be administered during a contraction, when the uterine blood vessels are constricted." Giving the medication during a contraction, when the uterine vessels are constricted, keeps the medication within the maternal vascular system for several seconds and decreases the impact on the fetus. The other options are incorrect because none of these responses involves administration during a contraction.

The mother of a 2-year-old child calls her neighbor, who is a nurse, exclaiming that her child just ate some automatic dishwasher powder. What should the nurse tell the mother to do first? 1. Give syrup of ipecac. 2. Wash the child's lips. 3. Call the Poison Control Center. 4. Offer burnt toast with some milk.

3. Call the Poison Control Center. Dishwashing powder is a caustic chemical that requires a specific antidote, and the personnel at the Poison Control Center are best qualified to advise the mother. Syrup of ipecac, which induces vomiting, is contraindicated in children. Washing the child's lips may provide comfort, but it will not prevent injury. Neither burnt toast nor milk is recommended as an antidote for poisoning caused by dishwasher powder.

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1. Young adult who is acutely psychotic 2. Adolescent who was recently sexually abused 3. Older single man just found to have pancreatic cancer 4. Middle-age woman experiencing dysfunctional grieving

3. Older single man just found to have pancreatic cancer Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems.

A nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. What information is most important for the nurse to include in the teaching plan? 1. Maintenance of a low-potassium diet 2. Avoidance of foods high in cholesterol 3. Signs and symptoms of digoxin toxicity 4. Importance of an adequate intake and output

3. Signs and symptoms of digoxin toxicity The risk of digoxin toxicity increases when the client is receiving digoxin and furosemide, a loop diuretic; loop diuretics can cause hypokalemia, which potentiates the effects of digoxin, leading to toxicity. Digoxin toxicity can result in dysrhythmias and death. When a client is receiving a loop diuretic, the diet should be high in potassium. Although teaching the need to avoid foods high in cholesterol may be included in the teaching plan, it is not the priority. Although it is important to maintain adequate intake and output because potassium chloride should not be taken when there is a decreased urinary output, the priority is monitoring for signs of digoxin toxicity

Triage officers are tagging clients with disaster triage tags at the site of an earthquake. Which client's tag requires replacement? A. Closed femur fracture - Green B. Airway obstruction - Red C. Closed tibial fracture - Black D. Minor open fracture with distal pulse - Yellow

C. Closed tibial fracture - Black Clients with closed fractures may be given green disaster triage tags. Therefore the black tag on client with a closed tibial fracture should be replaced with a green tag. The client with a closed femur fracture has correctly been given a green tag. Clients with life-threatening conditions such as airway obstruction or shock are applied with red disaster triage tags. Therefore, the client B is correctly given a red tag. Clients with open fractures with a distal pulse are given yellow tags. Therefore the client D is correctly tagged.