NU270 PrepU Week 8 (Safety & Security Preparedness)

Which client being treated for anorexia displays assessment values that warrant hospitalization?

A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL - A 25-year-old whose weight is 70% of ideal and who has a serum glucose of 58mg/dL should be hospitalized because both values are troublesome. The values of the other clients do not meet the criteria for hospitalization.

A medication is prescribed for a pediatric client. The nurse is ensuring the dosage is correct. What factor would the nurse use to calculate the dosage is correct for this client?

Body surface area (BSA) - Pediatric doses are calculated according to the infant's or child's weight in kilograms or the BSA. The BSA formula provides the most accuracy in calculating pediatric dosages because it considers both weight and height.

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to

Ensure that the mother does not have access to car keys or drive an automobile. - A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met?

Grab bars are installed in a client bathroom to facilitate safe showering. - According to Maslow, safety and security needs follow basic physiologic needs; therefore, grab bars in a bathroom helps ensure safety in the client's shower. Enrolling in an art class would meet love and belonging, self-esteem, or self-actualization needs. Arranging for a teenager to have friends visit would help in meeting love and belonging needs. Identifying strengths in a client demonstrates self-esteem needs.

Which principle should a nurse consider when administering pain medication to a client?

Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. - Administering sustained-release oral formulations around the clock provides better relief of chronic pain by keeping blood levels within therapeutic range. Opioid combination drugs and nonopioid medications are most effective in the treatment of mild to moderate pain. I.V. medications usually act within 1 hour of administration. Morphine and hydromorphone are drugs of choice for severe pain.

When a hospitalized client is in contact precautions, which action is necessary?

The client should be placed in a private room when possible. - When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed and doors do not need to be closed.

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set - After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume cycled - With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?

Wear protective clothing. - A nurse must wear two layers of chemotherapy-approved disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. Reconstituted oral forms of chemotherapy, such as powders, should be prepared in the pharmacy and delivered in a sealed syringe. The nurse should use two layers of chemotherapy-approved gloves and a sterile gauze pad when priming IV tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or performing other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, IV tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:

assess the client's safety. - Toileting often is associated with falls; the nurse must ensure the client's safety.

A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately?

blurred vision - During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

use caution when driving an automobile. - The client is describing hypersomnia and is at increased risk for a motor vehicle accident when drowsy while driving an automobile. The client is to avoid alcohol, caffeine, and late-night activities.

Which client would not be able to undergo a magnetic resonance imaging scan (MRI)?

A client with a pacemaker - Clients with pacemakers or metal implants, such as heart valves or orthopedic devices, cannot undergo an MRI. There are not contraindications for obese clients can to undergo an MRI. Clients who are claustrophobic or those with anxiety can have an MRI but may need special intervention such as sedation.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers." - The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home." - By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

A nurse is educating a client's family on Alzheimer's disease. Which statement by the nurse would cause the charge nurse to intervene?

"Routine administration of donepezil at the same time every day can cure the disease." - Alzheimer's is a degenerative and irreversible disorder of the cerebral cortex. Medications should be administered as ordered, but there is no cure for this disease. Labeling items and using large-numbered clocks and calendars help promote memory and recall. Clients with Alzheimer's are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment is important. Alzheimer's disease places clients at risk for metabolic complications such as dehydration and malnutrition. Offering finger foods and fluids can prevent these complications.

During a private conversation, a client with borderline personality disorder asks a nurse to "keep this secret," then displays multiple, self-inflicted, superficial lacerations of the forearms. What is the nurse's best response?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." - This response informs the client of the nurse's planned actions and allows time for the client to discuss the actions. Saying the client will be placed on suicide precautions or stating that the physician will be notified puts the client on the defensive and may lead to a power struggle. Asking what instrument the client used to make the cuts ignores the psychological implications of the client's actions.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse - The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit. - Take medications exactly as directed and do not stop the medication if symptoms are relieved unless advised to do so by the physician. Sunlight tends to exacerbate the disease. Because fatigue is a major issue, allow for adequate rest, along with regular activity to promote mobility and prevent joint stiffness. Maintain a well-balanced diet and increase fluid intake to raise energy levels and promote tissue healing.

Which motor disorder of sleep can be life threatening?

Obstructive apnea - Obstructive apnea causes poor ventilation, poor quality sleep, and daytime sleepiness—at best. At worst, it can contribute to depression, auto- and work-related accidents, cardiac dysrhythmias, and hypertension. Severe apnea can lead to pulmonary hypertension, polycythemia, or cor pulmonale. Periodic limb movement disorder and restless legs syndrome, although distressing and possibly indicative of disease, are not of themselves life threatening. Narcolepsy is not a motor disorder of sleep.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma. - While catheterization is done for a postpartum complication of urinary retention, it isn't routinely done to protect the bladder from trauma. The other options are appropriate measures to include in the care plan during the fourth stage of labor, which begins with placental expulsion and extends through the next 1 to 2 hours.

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching. - Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of the child's discharge.

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration - The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the client and the type of food eaten.

As part of a community class, student nurses are developing curriculum to teach expectant parents the importance of having their child properly secured in a child safety seat. During the class, the students are going to have a safety officer examine the car seats that the parents have installed in their vehicle. This is an example of which type of prevention?

Primary prevention - Primary prevention is directed at keeping disease from occurring by removing risk factors. Some primary prevention is often mandated by law, like child safety seats. Secondary prevention focuses on screening and early disease identification, whereas tertiary prevention is directed at interventions to prevent complications of a disease.

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. - Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing. Standard precautions don't adequately protect staff and other clients from bacterial meningitis.

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?

Reinforce the need to perform leg exercises every hour when awake - The nurse should reinforce the need to perform leg exercises every hour when awake. If signs and symptoms of thrombophlebitis appear, the client should maintain bed rest. The nurse should not massage the client's calves or thighs. The nurse should instruct the client not to cross the legs or prop a pillow under the knees.

The toddler needs elbow restraints to keep his hands away from a facial wound. What will the nurse do to best ensure their safe use?

Remove one restraint at a time on a regular basis to check for skin irritation. - Removing one restraint at a time provides for control of both hands. A long-sleeve shirt under the elbow restraints also protects the skin, and is a better choice than lotion since lotion will soften the skin and not be protective. The restraints should not extend into the axilla. Movement would create pressure and irritation. The parent can help monitor the restraints, but the nurse is responsible for the safety of their use.

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood?

Reports having a cold 1 month ago that resolved quickly - Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a history of viral hepatitis, report a blood transfusion within 12 months, and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease.

A client in the emergency department has self-inflicted wounds on both arms. Assessment reveals that the client was diagnosed with borderline personality disorder 6 months ago, for which the client has been receiving outpatient treatment. The client tells the nurse that the client recently found out the client's therapist is moving and will no longer be able to work with the client. What is the priority nursing diagnosis for this client?

Self-mutilation - Although all the above are problems for this client, the highest priority nursing diagnosis is self-mutilation. If left untreated, self-mutilation can lead to suicide attempts.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention

Wear a face mask during dressing changes. - The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.

Which complication is common in neonates who receive prolonged mechanical ventilation at birth?

bronchopulmonary dysplasia - Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation.

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use. - Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued.

A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?

keeping a pillow between the client's legs at all times - After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn't be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler's position should be avoided.

The nurse understands that client education related to antihypertensive medication should inform the client:

to avoid over-the-counter cold and sinus medications - Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Many over-the-counter preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended. Patients with hypertension must make considerable effort to adhere recommended lifestyle modifications.

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning. - A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.

Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills?

determining if the client's physical condition is life-threatening - If the client's physical condition is life-threatening, the priority is to treat the medical condition. Any compromise to the client's airway, breathing, or circulation must be addressed immediately. It's also imperative to determine the time of ingestion because this may determine treatment. The psychiatric evaluation, which includes intent to harm oneself, adequate support system, and history, can be performed after the client is medically stable.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

Client's level of consciousness - A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.

A nurse is caring for a client receiving heparin therapy who has developed heparin-induced thrombocytopenia. Which nursing intervention does the nurse anticipate?

Discontinuation of heparin therapy - In persons with drug-associated thrombocytopenia, there is a rapid fall in the platelet count within 2 to 3 days of resuming a drug or 7 or more days after starting a drug for the first time. The platelet count rises rapidly after the drug is discontinued. The anticoagulant drug heparin has been increasingly implicated in thrombocytopenia and, paradoxically, in thrombosis. The complications typically occur 5 days after the start of therapy and result from heparin-dependent antiplatelet antibodies that cause aggregation of platelets and their removal from the circulation. The antibodies often bind to vessel walls, causing complications such as deep vein thrombosis, pulmonary embolism, myocardial infarction, and stroke. The treatment of heparin-induced thrombocytopenia requires the immediate discontinuation of heparin therapy and the use of alternative anticoagulants to prevent thrombosis recurrence.

A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?

Moderate lithium toxicity - Side effects associated with moderate lithium toxicity include severe diarrhea, dry mouth, nausea and vomiting, mild to moderate ataxia, lack of coordination, dizziness, slurred speech, tinnitus, blurred vision, increasing tremors, muscle rigidity, asymmetric deep tendon reflexes, and increased muscle tone.

A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications. - Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next?

Rinse their eyes with water, report the incident, and go to Employee Health. - Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.

Immediately following administering a medication by enteral tube, the nurse will:

flush the tube with water. - It is important to flush the tube to ensure all of the medication reaches the child's digestive tract and to prevent occlusion of the tube. Right (not left) side-lying position will aid in stomach emptying, although it was not specified that the enteral tube was located in the stomach. Elevating the head of the bed is done prior to placing material in the gastrointestinal tract. Checking for signs of nausea and vomiting is always important but does not have to be done immediately following enteral tube medication administration.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia - Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy.

The nurse covers the myelomeningocele of a neonate with a sterile dressing. Which statements direct the nurse's action?

preventing infection - The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Conserving energy is not a concern for neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs. - The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.