Progression Exam: Safety

A client suddenly loses consciousness. What should the nurse do first?

A nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate.

A physician orders codeine, ½ grain every 4 hours, for a client experiencing pain. How many milligrams of codeine should the nurse administer?

The nurse should administer 30 mg of codeine.

A client receives an IV dose of gentamicin sulfate. How long after the completion of the dose should the peak serum concentration level be measured?

The peak serum dose of an antibiotic is drawn 30 minutes after the completion of the IV dose of the antibiotic.

When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which position should the nurse expect to place the client during the early postoperative period?

After an appendectomy for a ruptured appendix, assuming the semi-Fowler's or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate?

Before surgery, the infant is kept flat in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect. Flexing the knees when side lying will increase tension on the sac, as will placing the infant in semi-Fowler's position, even though the chest and abdomen are elevated.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy?

Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on his/her left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will:

For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor would not allow proper visualization of the large intestine.

The mother asks the nurse why peanuts are one of the worst things a child can aspirate. What should the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts?

Peanuts swell and become soft when moistened with bronchial secretions, making them difficult to remove. Although peanuts contain a fixed oil that can cause lipoid pneumonia, begin to decompose when wet, and contain sodium, these factors do not make them particularly dangerous when aspirated

A nurse is caring for a confused client and develops a plan of care based on a least restraint policy. Which of the following interventions would be most appropriate for the nurse to implement based on this policy?

The client is at risk for injury related to confusion. The alarm bracelet allows the client to move freely within the unit, but will be activated if the client tries to leave. The other options are incorrect because they are restrictive and should not be used in this situation.

The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box, which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:

The nurse should contact the pharmacy directly and request that a properly labeled medication be provided. The nurse should not administer any drug that is not properly labeled, even if the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at this point because the client needs to receive the antibiotic as soon as possible.

The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply.

The nurse should write down the prescription, read the prescription back to the HCP, and receive confirmation from the provider that the prescription is correct as understood by the nurse. It is not necessary for the HCP to come to the hospital to write the prescription on the medical record or to have the nursing supervisor cosign the telephone prescription.

A client is receiving digoxin, and the pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should first:

The nurse's initial response should be to withhold the digoxin. The nurse should then notify the HCP if the apical pulse is 60 bpm or lower because of the risk of digoxin toxicity. The charge nurse does not need to be notified, but the nurse needs to document the notification and follow-up in the medical record.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation?

The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove herself from the situation, provided this can be achieved without incurring further risk.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order?

The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which action should the staff nurse take next?

The situation is escalating, and the nurse's priority is to protect the infant from harm. Therefore, removal of the infant from this situation should be the first action by the nurse. Reasoning at this point or asking one of the parents to leave the room would be ineffective and may serve to further escalate the situation. Calling security is necessary, but only after the nurse has removed the infant from the room.

When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of:

The supine position is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with supine positioning. Although suffocation is less likely if the neonate is supine, the primary intervention for reducing suffocation risk is removing blankets and pillows from the crib. The position for GER requires the head of the bed to be elevated.

Upon initial assessment of a postoperative client, the nurse identifies that the IV infusion is different from the solution ordered by the physician. What is the first action the nurse should take?

This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error.

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?

To administer oral medication through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Making sure not to crush sustained-release tablets or empty capsules, she then inserts the liquid into the NG tube. Heating the tablets may destroy or alter the drug's action. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and clogging the tube.

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should:

Aminoglycoside antibiotics can cause damage to the eighth cranial nerve and result in ototoxicity. If the client is already hearing impaired, the nurse should question the prescription with the health care provider, who may determine that prescribing another antibiotic would be safer. Gentamicin is an appropriate antibiotic for gram-negative infections such as peritonitis. Gentamicin does not cause visual impairment.

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?

Castor oil can initiate premature uterine contractions and other adverse effects in pregnant women. Castor oil doesn't promote sodium retention and isn't known to increase absorption of fat-soluble vitamins.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that:

Cephalohematomas don't cross the suture lines and are the result of blood vessels rupturing in the neonate's scalp during labor. Blood outside the vasculature in a neonate increases the possibility of jaundice as the neonate's body tries to reabsorb the blood. Caput succedaneum, which is soft tissue edema of the scalp, can occur in any labor and isn't limited to a prolonged second stage of labor.

After the nurse has administered droperidol, care is taken to move the client slowly based on the knowledge of droperidol's effect on the:

Because droperidol causes tachycardia and orthostatic hypotension, the client should be moved slowly after receiving this medication. Droperidol produces a tranquilizing effect and does affect the central nervous, respiratory, or psychoneurologic system, but the primary reason for moving the client slowly is the potential cardiovascular effects of hypotension.

The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which complication, if stated by the client, indicates the need for additional teaching?

Clients who are pregnant and have diabetes are not at greater risk for multifetal pregnancy and subsequent twin-to-twin transfusion unless they have undergone fertility treatments. The pregnant diabetic client is at higher risk for complications such as infection, polyhydramnios, ketoacidosis, and preeclampsia, compared with the pregnant nondiabetic client.

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?

Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to:

Food and fluid intake may be compromised in a client who is severely depressed. The nurse must ensure that the client is adequately hydrated and is receiving proper nutrition. Although the client's psychological needs are important, physiological needs are the priority in this case. Assessing the client's depression level, continuing the client's ordered medication, and maintaining the client's hygiene needs are lower priorities at this time. The nurse should be aware that family involvement may not be indicated in this client's care.

A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first:

Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP.

When preparing a teaching plan for a client about imipramine, which substance should the nurse tell the client to avoid while taking the medication?

Imipramine, a tricyclic antidepressant, in combination with alcohol will produce additive central nervous system depression. Although caffeinated coffee is safe to use when the client is taking imipramine, it is not recommended for a client with depression who may be experiencing sleep disturbances. Imipramine may cause photosensitivity, so the client would be instructed to use sunscreen and protective clothing when exposed to the sun. Reduced lacrimation may occur as a side effect of imipramine. Therefore, the use of artificial tears may be recommended.

A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

In situations in which a client is a threat to himself, the nurse can't honor confidentiality. Because this adolescent has said he has a specific plan to commit suicide, the nurse must take immediate action to ensure his safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the adolescent that she must do this, while at the same time conveying a sense of caring and understanding. The local authorities needn't be notified in this situation.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:

Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant?

The baseline laboratory data that are established before a client is started on tissue plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.

A client diagnosed with borderline personality disorder has self-inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first?

The client is at risk for suicide, and the nurse should determine how serious the client is, including if she has a plan and the means to implement the plan. While medication history may be important, the nurse should first attempt to determine suicide risk. Asking the client why she cut herself will likely cause the client to respond with insufficient information to determine suicide risk.

The nurse is checking the client's chart for possible contraindications, before administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse should hold the meperidine when she sees an order for what type of drug?

The nurse should hold the meperidine if she sees an order for an MAO inhibitor because MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation. The client shouldn't receive meperidine within 14 days after administration of an MAO inhibitor. Antibiotics, antiemetics, and loop diuretics don't cause significant drug interactions when administered concurrently with meperidine.

The nurse is providing care for a client who was prescribed escitalopram three weeks ago. What statement by the client should be of greatest concern to the nurse?

Concurrent use of St. John's wort and sustained serotonin reuptake inhibitors can lead to excessive serotonin levels. The risks associated with colon cleanses, multivitamins, and acupuncture are significantly lower, though any complementary or alternative therapy should be discussed with the provider.

The health care provider (HCP) has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse contacts the HCP to discuss the potential for:

Nitroglycerin causes vasodilation, which results in increased intraocular pressure. The vasodilatory effects of the medication can trigger an attack, causing pain and loss of vision. Hypotension is a common side effect of nitroglycerin, which dilates the blood vessels but is not a concern in the client with glaucoma.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to:

Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

A client with peripheral vascular disease, coronary artery disease, and chronic obstructive pulmonary disease takes theophylline 200 mg twice daily every day, and digoxin 0.5 mg once a day. The health care provider (HCP) now prescribes pentoxifylline. To prevent adverse effects, the nurse should monitor the client's:

Pentoxifylline can potentiate the effects of theophylline and increase the risk of theophylline toxicity. Therefore, the nurse should monitor the client's theophylline level. Pentoxifylline does not interact with digoxin. Pentoxifylline can interact with heparin, and the client's PTT would need to be monitored closely if the client were taking heparin. It does not affect cholesterol levels.

The primary goal in the plan of care for the client after cataract removal surgery is to:

Promoting safety is a priority goal for this client. The client's vision will not be clear, and the client may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting the client during ambulation, and following other safety precautions to reduce the risk of injury are required. Cardiac output and fluid volume excess are unrelated to cataract surgery. Maintaining a darkened environment is neither necessary nor safe.

A client is taking 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.

The nurse should instruct the client who is taking diazepam to take the medication as prescribed; stopping the medication suddenly can cause withdrawal symptoms. This medication is used for a short term only. The drug dose can be potentiated by alcohol, and the client should not drink alcoholic beverages while taking this drug. Swelling of the lips and face and difficulty breathing are signs and symptoms of an allergic reaction. The client should stop taking the drug and seek medical assistance immediately. The client does not need to avoid eating foods containing tyramine because interacts with monoamine oxidase inhibitors, not benzodiazepines. The client can take the medication with food.

A client informs the nurse that the venipuncture site "hurts." The nurse should assess the site for what findings? Select all that apply.

The venipuncture site must be assessed for signs of infection (redness and pain at the puncture site), infiltration (coolness, blanching, and edema at the site), and thrombophlebitis (redness, firmness, pain along the path of the vein, and edema).

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?

Vitamin K acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal flora to produce vitamin K, which is necessary for coagulation. Hypoglycemia is prevented and treated by feeding the infant. Hyperbilirubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy. Polycythemia may occur in neonates who are large for gestational age or postterm. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe.

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?

The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.

A parent asks the nurse about using a car seat for a toddler who is in a hip spica cast. The nurse should tell the parent:

The toddler in a hip spica cast needs a specially designed car seat. The one that the mother already has will not be appropriate because of the need for the car seat to accommodate the cast and abductor bar.

The nurse is caring for a client with peripheral artery disease who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse?

A change in the intensity of a pulse maybe indicative of arterial closure and warrants immediate attention; the nurse should notify the health care provider (HCP) immediately. A pain level of 2 out of 10 it is not uncommon from the catheter insertion site especially after the placement of a stent. Shiny and hairless skin is expected in clients with PAD. A client undergoing a catheterization may experience pain at the catheterization site as large bore sheaths are place in the femoral artery. Because people with PAD have poor circulation in their lower extremities, it is possible for them to develop leg ulcers. However it is unlikely that the percutaneous transluminal balloon angioplasty caused this.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor?

Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive.

A client is brought into the emergency department with abdominal cramps, salivation, flushing of the skin, nausea, and vomiting following an accidental overdose of pyridostigmine. What is the nurse's best action?

The most severe consequence of an overdose of a cholinergic drug is a cholinergic crisis. Early signs include abdominal cramps, salivation, flushing of the skin, nausea, and vomiting followed by circulatory collapse, hypotension, bloody diarrhea, shock, and cardiac arrest. It can be reversed by the administration of atropine, a cholinergic antagonist. Compazine will only resolve symptoms of nausea and may mask some symptoms such as drooling, it will not correct the underlying probem. If the crisis is resolved and the client improves, there is no need for further invasive interventions.

A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for:

All pregnant clients should be screened for pica, or the ingestion of nonfood substances, such as clay, dirt, or laundry starch. Commonly, clients who practice pica are anemic. Muscle spasms are not associated with the ingestion of laundry starch. However, they may be related to seizure disorder or seizure activity or a calcium deficiency. Lactose intolerance is not associated with the ingestion of laundry starch. Lactose intolerance would occur when the client ingests milk or milk products. Diabetes mellitus is not associated with the ingestion of laundry starch. Diabetes mellitus is associated with abnormal glucose levels, excessive thirst, and frequent voiding.

After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which client statement indicates the need for further instruction?

The client needs further instructions when she says, "I can continue to work at my job at the automobile factory until labor starts." The goal is to avoid preterm labor. Because the client is experiencing severe hydramnios, she will most likely be maintained on bed rest to increase uteroplacental circulation and reduce pressure on the cervix. Hydramnios has been associated with increased weight gain caused by increased amniotic fluid volume. Hydramnios has been associated with gastrointestinal disorders in the fetus, such as tracheoesophageal fistula with stenosis or intestinal obstruction. The client should continue to eat high-fiber foods and should avoid straining, which could lead to ruptured membranes. Stool softeners may also be prescribed. The client should report any symptoms of fluid rupture or labor.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor?

The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that she had a long labor.

Which instructions should a home care nurse provide for a client with acquired immunodeficiency syndrome (AIDS)?

AIDS is transmitted through body fluids such as blood, semen, vaginal and rectal secretions, and breast milk. Tooth brushing and shaving have the potential to cause bleeding; therefore, personal items such as a razor or a toothbrush should not be shared. Casual contact such as touching and hugging is not a means of transmission. Washing eating utensils separately is not necessary, nor is wearing a mask when in crowded places.

Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration?

Although not harmful to the client when injected, small air bubbles can actually change the dose of medication administered; therefore, the nurse should remove the air bubbles. Small air bubbles won't affect the drug's onset of action, duration, or absorption. Air bubbles may be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

Which practice should a nurse recommend to a client who has had a cesarean birth?

As for any postoperative client this client needs to be taught coughing and deep-breathing exercises to keep the alveoli open and prevent infection. Frequent douching isn't recommended for any group of women and is contraindicated in women who have just given birth. Doing sit-ups at 2 weeks postpartum could damage the healing of the incision. Side-rolling exercises aren't an accepted medical practice.

A nurse is caring for a client with a long-term central venous catheter. Which steps should the nurse include in teaching how to care for his catheter at home?

Clients should be instructed to clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or flushing each port using the same syringe would break sterile technique.

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

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.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of:

For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?

Immediately after a spontaneous rupture of the membranes, the nurse should listen to the fetal heart rate to detect bradycardia. With the fetus at -1 station, the cord may prolapse as amniotic fluid rushes out. Fetal heart rate should be monitored because it will indicate if cord prolapse or cord compression has occurred. The color, amount, and odor of the amniotic fluid should be noted. Although the optimal position for the client is side lying, this is not a priority at this time. The client is not having a precipitous birth with the fetal head at ?1 station. Therefore, preparing the client for a cesarean birth is unnecessary. Although maternal blood pressure should be monitored throughout labor, this is not a priority at this time.

What is one disadvantage of using the rectal route?

Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered, may cause orthostatic hypotension or hypersensitivity reactions. If inserted properly, drugs administered rectally won't cause rectal tears.

When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest?

Infants from birth to 20 lb (9.1 kg) and younger than age 1 must be in a rear-facing infant or convertible seat in the back seat, preferably in the middle. Infants and small children should never be placed in the front seat because of the risk of injuries from a breaking front windshield and an expanding airbag. Positioning a car seat next to the window isn't preferred.

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value?

It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing intervention should the nurse take? Select all that apply.

Labeling the vial will identify the medication, dosage and the preparer and decrease the chance of an error.Storing in safe place will also decrease medication errors. Leaving the vial in the client's room is not an acceptable. practice for any medication. Pharmacy reconstituting my not be an options since it is very practical for the nurse to prepare the dose. Medication should never be left in a client's room rather prepared or not.

A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg, and the pulse is 98 bpm. The nurse should:

Lorazepam, a benzodiazepine, is commonly used to decrease the symptoms of central nervous system irritability in the client who is experiencing early symptoms of alcohol withdrawal. An antihypertensive will not treat the underlying CNS irritability. If the lorazepam is effective, it will not be necessary to have someone sit with the client. At this point, it is not necessary to notify the health care provider (HCP).

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which safety points? Select all that apply.

Safety measures for poisonous substances include close supervision of children, safely storing toxic substances, teaching proper dosages and differences between adult and child doses, and the proper way to contact the Poison Control Center for instructions. Poison Control should be notified as soon as the poisoning has occurred and airway and circulation have been assessed. Poison Control will direct any further treatment. Syrup of ipecac is rarely used today in the treatment of ingested substances due to the potential for aspiration. It is contraindicated in cases of arsenic poisoning, seizures, and the ingestion of petroleum or corrosive substances.

When assessing an aggressive client, which behavior warrants the nurse's prompt reporting and use of safety precautions?

The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The nurse would clarify to the assistant that the catheter bag needs to be placed lower than the client's bladder so not to have backflow from the catheter tubing to the bladder. Placing the catheter on a lower portion of the wheelchair allows urine to flow through the tubing and does not encourage backflow. It is appropriate to drain the urine from the catheter bag before physical therapy and to make sure that there are no kinks in the tubing preventing urine flow to the drainage bag.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?

The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or restricted diet is acceptable.

At what time should the blood be drawn in relation to the administration of the IV dose of gentamicin sulfate?

To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next IV dose of gentamicin sulfate.

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site. Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration. Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include:

With compartment syndrome, the client can't perform active movement, and pain occurs with passive movement. A body-wide decrease in bone mass is seen in osteoporosis. A growth in and around the bone tissue may indicate a bone tumor.

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 lbs). Which of the following information should the nurse emphasize in the teaching?

A child must weigh 18 kg (40 lbs) to move from a front-facing seat to a booster seat. The booster seat is used until the child outgrows it and the lap and shoulder belt fit correctly.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has:

A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency. An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately. Constipation will not require immediate intervention.

Immediately after the return of an 18-month-old child to his room following insertion of a ventriculoperitoneal shunt, the nurse should first:

As soon as the child returns to his room, he needs to be positioned appropriately. In this case, he should be placed on the side opposite the shunt placement to avoid pressure on the operative site. Developmentally, the child at this age may or may not be able to state his name or where he is. Palpating his fontanel and checking pupils are part of the neurologic assessment that would be done once the child is positioned properly.

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?

Bending over the sink to wash the face is contraindicated after cataract surgery because it increases intraocular pressure. Walking without assistance, performing isometric exercises, and lying in bed on the nonoperative side are not contraindicated.

Which nursing action is most beneficial to prevent fungal infections in hospitalized clients?

Fungus spreads in warm, moist environments. The nurse must keep all skin folds on the warm body dry. Moisturized is needed for dry skin but does not prevent fungal infections. Bathing is appropriate but drying is key. Environmental air movement is not necessarily helpful.

A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38° C) The client also has a headache and appears flushed. In what order, from first to last, should the nurse perform the actions? All options must be used.

The client is experiencing a septic reaction to the blood transfusion. The nurse first stops the infusion and notifies the HCP and blood bank; then the nurse uses an infusion of normal saline to keep the vein open, and follows by obtaining a sample of the client's blood for a blood culture. Lastly, the nurse sends the blood bag and the administration set to the blood bank for culture.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?

The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist?

The nurse should collaborate with the respiratory therapist to make sure breathing treatments are administered and the client's respiratory status is watched closely before and after surgery, because of the increased risk of infection and post operative pneumonia. An induced sputum specimen is not necessary at this time. The nurse alone can teach the client coughing and deep breathing exercises and monitor the color and consistency of sputum specimens.

To follow standard precautions, the nurse should carry out which measure?

To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer?

Using the proportion method, the nurse solves for X and then adds the total number of milliliters together.

The nurse is caring for a multigravid client in active labor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure?

Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Compression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations.

Which nursing intervention is most appropriate for a client with multiple myeloma?

When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict his fluid intake.

When caring for a child with moderate burns from the waist down, what should the nurse do when positioning the child?

A child with moderate burns is at high risk for contractures. A position of comfort would encourage contracture formation. Therefore, splints need to be applied to maintain proper positioning and joint function, thereby preventing contractures and loss of function. Allowing the child to lie on the abdomen or with the hips and knees flexed often encourages contracture formation.

What is the main advantage of using a floor stock system?

A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, and fetal and maternal bradycardia (not tachycardia). Although the client may experience some postpartum urine retention, maternal oliguria isn't associated with epidural anesthesia.

A nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do?

Because a client who has attempted suicide could try again, the nurse should search his belongings and his room to remove any items that could be used in another suicide attempt. Expressing trust that the client won't cause harm to himself may increase the client's feelings of guilt and pain if he can't live up to that trust. The nurse should search the client's belongings because the need to maintain a safe environment supersedes the client's right to privacy. Although frequent checks by staff members are helpful, they aren't enough. The client may attempt suicide between checks.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which of the following actions should the nurse take to best ensure the safety of the client while complying with policy?

Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

A physician orders electroconvulsive therapy (ECT) for a severely depressed client who fails to respond to drug therapy. When teaching the client and family about his treatment, the nurse should include which point about ECT?

Reserved for clients with acute depression who don't respond to pharmacologic or psychiatric measures, ECT is the passage of an electrical current through the brain to induce a brief seizure. According to ECT proponents, the desirable changes the seizure causes in neurotransmitters and receptor sites are similar to those caused by antidepressant drugs. ECT is administered under a general anesthetic by a physician and an anesthetist. Although ECT may reduce the severity of depression, it doesn't necessarily cure the illness. Before undergoing ECT, the client is given a medication that provides short-term amnesia of the entire event.

A nurse is assessing a client with hyperparathyroidism. Which finding should the nurse report immediately to the physician?

The client with hyperparathyroidism has elevated calcium levels, which promotes the formation of kidney stones. Flank pain may be indicative of kidney stones. Anorexia is common with this condition and is not cause for immediate intervention. Urinary output and blood pressure are normal.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

The incident should be reported to risk management in order to evaluate care, and determine potential risks, or system problems, that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.

When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to:

A neonate undergoing cocaine withdrawal is irritable, often restless, difficult to console, and often in need of increased activity. It is commonly helpful to swaddle the neonate tightly with a blanket, offer a pacifier, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastrointestinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to only when he or she is crying will not aid the bonding process between mother and neonate. Frequent holding and touching are permissible.

When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, what should the nurse tell the parents to use to deliver the blows?

Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant's shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age.

A client treated with terbutaline (Brethine) for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client doesn't need to contact the physician if such movement occurs. The client experiencing premature labor must maintain bed rest at home.

The nurse is caring for an elderly patient who needs help with ADLs. Which of the following is most important for the nurse to understand when implementing care in order to avoid injury?

Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error?

The nurse should immediately assess the client who received the wrong medications. This assessment should include potential allergies to the medications and the side effects of the medications. The nurse should then notify the practitioner and the charge nurse. An incident report should be completed and submitted as directed by the facility's policy. The nurse should complete a set of vital signs with the assessment of the client.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?

The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

A client complains of difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take next?

The nurse should find out whether the medication is available in liquid form. Dissolving or breaking the capsule may interfere with drug action or absorption. The nurse shouldn't withhold any medication without first notifying the physician.

A client is receiving a transfusion of packed red blood cells. To safely administer the blood, the nurse should:

The nurse should stay with the client during the first 15 minutes of a blood transfusion because this is when reactions are most likely to occur. Blood products should never be refrigerated on the nursing unit. Blood that has not been infused after 4 hours should not be infused. The blood should be infused over the specific time prescribed by the health care provider (HCP). If a fever develops, the transfusion should be stopped immediately, and the blood reaction policy of the facility should be followed.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem?

When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

An 80-year-old client is admitted with nausea and vomiting. The client has a history of heart failure and is being treated with digoxin. The client has been nauseated for a week and began vomiting 2 days ago. Laboratory values indicate hypokalemia. Because of these clinical findings, the nurse should assess the client carefully for:

Nausea and vomiting, along with hypokalemia, are likely indicators of digoxin toxicity. Hypokalemia is a common cause of digoxin toxicity; therefore, serum potassium levels should be carefully monitored if the client is taking digoxin. The earliest clinical signs of digoxin toxicity are anorexia, nausea, and vomiting. Bradycardia, other dysrhythmias, and visual disturbances are also common signs. Chronic renal failure usually causes hyperkalemia. With persistent vomiting, the client is more likely to develop metabolic alkalosis than metabolic acidosis.

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?

No matter how far the client's pregnancy has progressed by the time of her first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications. The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor techniques near the end of pregnancy; signs and symptoms of pregnancy, shortly before they're anticipated, based on the number of weeks' gestation; and any tests, a few weeks before they're scheduled.

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness for surgery. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks to the client when obtaining informed consent.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor?

The new nurse requires additional teaching if she allows volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures.

An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication?

Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. The normal uterus is only able to distend to a certain point and when that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestation. The donor twin may become growth restricted and can have oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. Anemia is a common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. A maternal hemoglobin level below 11 mg/dL (110 g/L) is considered anemic.

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:

The nurse should collect the stool specimen using sterile technique and a sterile stool container. The stool may be collected for 3 consecutive days. Although a stool culture should be taken to the laboratory as soon as possible, it need not be delivered immediately (unlike stool being examined for ova and parasites). Applying a solution to a stool specimen would contaminate it; this procedure is done when testing stool for occult blood, not organisms. The nurse shouldn't store a stool culture on ice because the abrupt temperature change could kill the organisms.

During a home health visit, a nurse assesses a client's medication and notes that the client has two prescriptions for fluid retention. One prescription reads, "Lasix, 40 milligrams one tablet daily." The next prescription reads, "Furosemide, 40 milligrams one tablet daily." Which instruction should be given to the client?

The nurse understands that Lasix and furosemide are the same drug. Calling the health care provider to determine the correct dosage and frequency the nurse's role as a client advocate. Setting up medications in a medication tray, using only one pharmacy to dispense medications, and using all medications until the bottle is emptied will reduce medication errors. However, it is a priority to verify the medication orders first.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

The nurse should instruct the client with a platelet count of less than 150,000/?L (150 × 109/L) to avoid which activity?

When the platelet count is less than 150,000/?L (150 × 109/L), prolonged bleeding can occur from trauma, injury, or straining such as with Valsalva's maneuver. Clients should avoid any activity that causes straining to evacuate the bowel. Clients can ambulate, but pointed or sharp surfaces should be padded. Clients can visit with their families but should avoid any scratches, bumps, or scrapes. Clients can sit in a semi-Fowler's position but should change positions to promote circulation and check for petechiae.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

A client with appendicitis is at Risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Elderly, not middle-aged, clients are especially susceptible to appendix rupture.

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?

Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is:

Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. The call light should be placed so that it is easily accessible. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.