Safety
A nurse is caring for a client prescribed an intramuscular (IM) injection. Which assessment findings may affect the absorption rate of the drug? Select all that apply.
Age and dosage Blood flow to the injection site Amount of body fat at the injection site Blood flow to the IV site affects the drug absorption. So does the age, dose, and amount of fat at the injection site. Muscle tone or muscular strength do not affect the absorption rate.
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.
Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility. The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the fall, and finally, document the event on the client's health record.
A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?
Uterine massage If uterine atony is noted, uterine massage should be performed to decrease the risk of postpartum hemorrhage. This intervention takes priority. If the uterus is displaced from midline, assist the client to empty her bladder. Vital signs should be taken every 15-30 minutes, but the priority action is to address the uterine atone. A position change is not indicated.
Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy?
activated partial thromboplastin time (APTT) APTT is used to measure the clotting status when the client is receiving heparin. The INR and PT are used to measure clotting status in a client receiving warfarin. Neither heparin nor warfarin affects thrombin time.
The nurse would question the prescription for a fetal scalp electrode on which client?
client with an HIV infection Placement of a fetal scalp electrode should be avoided when a client has HIV because it increases the risk of transmission to the fetus. The use of a fetal scalp electrode is indicated when precise tracing are needed to monitor changes associated with fetal hypoxia and satisfactory tracing cannot be obtained with external methods. The presence of decelerations, meconium stained fluid, and prolonged second stage of labor may all be indications for placing a fetal scalp electrode.
After discussing preconception needs with a nulliparous client who eats a primarily Asian diet, which client statement indicates the need for further instruction?
"If I become pregnant, I can continue to eat sushi twice a week." The client needs further instructions when she says, "If I become pregnant, I can continue to eat sushi twice a week." Raw fish, including tuna, should be avoided while the client is pregnant because of the risk of contamination with mercury and other potential teratogens. Folic acid supplements taken before the client gets pregnant and during pregnancy can help reduce the risk of neural tube defects. Steaming vegetables reduces the risk that vitamins will be lost in the cooking water. Soy products can increase the client's protein levels.
After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which statement by the parents indicates effective teaching?
"We will remove the restraints temporarily at least three times a day to check his skin, then put them right back on." Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site. The restraints are worn at all times except when they are removed to check the skin. Because of the risk for skin breakdown, the restraints are removed periodically during the day to assess the child's underlying skin. It is advisable to remove only one restraint at a time while keeping hold of the child's hand on the unrestrained side. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. The restraints should be in place at all times during sleep and play to prevent inadvertent injury to the operative site. Taping the restraints directly to the skin is not advised because skin breakdown can occur when tape is reapplied to the same area over several weeks. The restraints can be fastened to clothing to keep them from slipping.
A client at 11 weeks gestation calls the antepartum clinic nurse. She has soaked a perineal pad with fresh blood in less than 30 minutes. The uterine cramping has also become worse. What is the most appropriate response from the nurse?
"You need to seek immediate attention from your physician." Pregnancy loss during the early weeks of pregnancy may be seen as a heavy menstrual period. Blood loss of this amount with or without uterine cramping should be assessed by a physician as soon as possible. With the amount of bleeding the client is experiencing, lying down or taking no action puts the client at risk of possible hemorrhage.
A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond?
"You seem worried about this assignment." The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.
To prepare for insulin administration, the nurse disinfects the injection site. Before giving the injection, the nurse should allow the disinfected area to dry for:
1 minute. Before administering an injection, the nurse should allow the disinfected area to dry for about 1 minute. Doing so prevents introducing the potentially irritating disinfectant into the client's tissues.
A nasogastric tube is prescribed to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
Ask for the prescription to be changed to an oral gastric tube. Because a basilar skull fracture can involve the frontal and ethmoid bones, inserting a nasogastric tube carries the risk of introducing the tube into the cranial cavity through the fracture. An oral gastric tube is preferred for a client with a basilar skull fracture. The tube would not be placed into the duodenum. Gastric aspirate is not routinely tested for blood unless there is an indication to suggest bleeding, such as a falling hemoglobin or visible blood in the drainage.
A client with a history of suicidal thoughts and depression has just attended an outpatient day therapy group session. The nurse hears from the client that he/she plans to forgo lunch and the afternoon session, stating, "I just need to go home and have a nap." What would be the day therapy nurse's best response?
Ask the client to sit for a few minutes to discuss missing the afternoon session. The client is demonstrating a behavior that should be further assessed. The nurse should take the time to assess the client's thoughts, feelings, and behaviors. While the client may truly just need the rest, he/she may be upset, or employing a pattern of behavior that is part of the problem. Regardless, the nurse should investigate this and also assess for safety. Asking a closed question, such as "Are you angry?", would not assist this assessment, nor would it be therapeutic to focus on rules of the program or the client's interest or enjoyment of the food.
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?
Ask the physician to prescribe a specific laxative. 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.
A nurse is caring for a client who's in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?
Checking for the umbilical cord around the neonate's neck After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.
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.
When teaching a parent of a school-age child about signs and symptoms of fever that require immediate notification of the physician, which description should the nurse include?
Complaints of a stiff neck The nurse should discuss complaints of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, fever that disappears for 24 hours then returns, and a history of febrile seizures should be addressed by the physician but can wait until office hours.
Which performance improvement strategy helps prevent adverse reactions to blood products?
Confirming client identification with two qualified health professionals The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.
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.
While obtaining a health history, a nurse learns that a client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
Diphenhydramine A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask, gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a clear liquid diet or sodium restrictions.
A client hospitalized for depression remains extremely depressed and expresses increasing suicidal ideation to her primary nurse. What should be the nurse's priority intervention?
Ensuring that the client is not permitted to use anything that would be potentially dangerous Although grief, loss, and isolation are impacting the client's depressed state, the priority intervention is to prevent the client from self harm. All of the interventions listed are appropriate, but ensuring safety from potential danger is the priority.
A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?
Ensuring the safety of this client and other clients on the unit Ensuring the safety of this client and other clients on the unit is the nurse's immediate priority. Moving the agitated client to a less-stimulating environment, isolating him, or sedating him address the client's needs but don't address those of the other clients. Removing other clients from the area until the agitated client calms down addresses the safety of the other clients without addressing the needs of the agitated client.
A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?
Gently aspirate the I.V. catheter to check for a blood return. Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. She doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.
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?
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 is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?
Increase the frequency of client observation. The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.
The nurse develops a plan of care for a client with a t-tube. Which nursing intervention should be included?
Inspect skin around the t-tube daily for irritation. Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the t-tube be kept clean and dry. T-tubes are not routinely irrigated; they are irrigated only on prescription of the health care provider. There is no need to maintain the client in a supine position; assist the client into a position of comfort. T-tubes are never clamped without a health care provider's prescription. If prescribed to be clamped, however, t-tubes are typically clamped 1 to 2 hours before and after meals.
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.
A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should emphasize which fact?
Most toddler deaths are accidental. Most toddler deaths are accidental. Many injuries or deaths in this age-group result from fire, drowning, motor vehicle accidents, and firearms. Toddlers don't generally overdose on medications, although this situation could happen if a toddler were given too much medication in the home or hospital setting. A child must be older than age 12 months and weigh more than 20 lb (9.1 kg) to ride in a front-facing car seat. Toddlers are at higher risk for injury than adults because of their developmental level and their limited ability to distinguish right from wrong and to recognize danger signs.
Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?
Place the client in a high Fowler's position. Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating. Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed. Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.
Which goal is most important when developing a long-term care plan for a child with hemophilia?
Prevent injury during each stage of development. The priority for ongoing care for this child is to prevent injury while maintaining normal growth and interests. As with all chronic illnesses, there is a potential for self-esteem problems, but no data are presented to support this as a priority for care planning. The parents should have a good understanding of the disease process and realize the importance of obtaining regular health care for their child. The client may have episodes of acute pain, for the child who has bleeding into a joint, but this is a transient situation.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.
A client treated with terbutaline (Brethine) for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
Report a heart rate greater than 120 beats/minute to the physician. 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.
Parents of a preschooler with chickenpox ask the nurse about measures to make their child comfortable. The nurse instructs the parents to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder?
Reye's syndrome Research shows a correlation between the use of aspirin in children with flulike symptoms and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
When administering medication, the nurse ensures client safety by following the rights of medication administration. Identify the "rights of medication administration." Select all that apply.
Right client Right dose Right medication Right time Right route A nurse must always implement safe nursing practices when administering medications. Following the rights of medication administration helps protect the client from medication errors. Safe procedure includes confirming the right client, dose, medication, time, and route. Confirming the room number does not guarantee that the right client will receive the correct medication.
A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority?
Risk for injury Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow's hierarchy of needs.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?
Rubber dropper An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.
A client in the manic phase of bipolar disorder constantly belittles other clients and is demanding special favors from the nurses. Which intervention by the nurse would be most appropriate for this client?
Set limits with specific and consistent consequences for belittling or demanding behavior. Set limits with specific and consistent consequences for belittling or demanding behavior.
A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Sew thick padding into the elbows and knees of the child's clothing. As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.
A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern?
Suicide potential An unemployed client with a personal history of anorexia nervosa and a family history of affective disorders is at high risk for suicide. Although this client could be at risk for alcohol abuse, the history indicates a strong risk of depression and suicide. Avoidance behavior is characteristic of clients diagnosed with an anxiety disorder, not anorexia nervosa. Explosive outbursts are associated with posttraumatic stress disorder and impulse control disorder.
A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her children to the neighbors' house and has turned on the gas to kill herself. She is home alone and gives the nurse her address. Which action should the nurse take next?
Tell the caller that another nurse will telephone the police. The immediate priority is to save the caller's life. Therefore, the nurse should tell the caller that another nurse will telephone the police. The immediate goal is to rescue the caller because the suicide attempt has begun. Referring the caller to a 24-hour suicide hotline or instructing the caller to telephone her family for help may be appropriate as part of discharge planning. Asking the caller whether she has telephoned her HCP is not appropriate. The nurse is responsible for notifying the HCP.
A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She has been in bed for a week and is not eating or showering. She told me that she did not want to kill herself, but it is not like her to do nothing for herself. She will not even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason?
The behaviors may reflect passive suicidal thoughts. Passive suicidal thoughts, such as a wish to die or giving up on self-care, can be as much of a risk as active suicidal ideation (the idea of killing one's self directly), especially for older clients because they commonly lack the means, energy, and motivation for an active suicide attempt. Seeing the grandson and grandmother together may help later. Not talking to the grandson and experiencing altered role performance may be real issues, but these are not as critical as the risk of indirect (passive) suicide.
A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?
The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client's fiancée cannot sign the consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The HCP should insert the catheter in this emergency. He does not need to get a consultation from another HCP. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin.
When assessing an infant with suspected inguinal hernia, which finding would be most significant?
The inguinal swelling is reddened, and the abdomen is distended. Abdominal distention and a redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. A strangulated hernia necessitates immediate surgical intervention. The ability to reduce the hernia and normal stooling do not indicate it is incarcerated. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.
The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?
The use of a condom is advised for sexual intercourse. Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users. College students are at high risk for development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?
Verify that the site, side, and level are marked. As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.
A nurse should question an order for a heating pad for a client who has:
active bleeding. Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.
A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:
advance both crutches. The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.
To prevent back injury, the nurse should instruct the client to:
avoid prolonged sitting and standing. Prolonged sitting and standing should be avoided because they strain the lower back. Pushing objects rather than pulling them will help decrease back strain. Clients should select a semi-firm to firm mattress to provide back support. When sitting, the client should choose a chair with good support and a straight back. The client should sit with feet flat on the floor.
A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find:
irritability and poor sucking. Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in neonates with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies.
A client with a well-managed ileostomy reports the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. The nurse should:
notify the health care provider (HCP). Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the health care provider (HCP) examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the HCP has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.
Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m. (1400), the client has a capillary glucose level of 250 mg/dl for which he receives 8 units of regular insulin. The nurse should expect the dose's:
onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600). Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m. (1400), the expected onset would be from 2:15 (1425) to 2:30 p.m. (1430) and the peak from 4 (1600) to 6 p.m. (1800).
The nurse should instruct the client with a platelet count of less than 150,000/?L (150 × 109/L) to avoid which activity?
straining to have a bowel movement 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.
The nurse is discussing postoperative care with the parents and their 5-year-old child who is going to have a tonsillectomy and adenoidectomy. The nurse should emphasize which measures?
use of sips of clear liquids when awake and alert Once the child is alert, he may have sips of clear liquids. Once the child is able to tolerate clear liquids, he can progress to a full liquid diet that would include ice cream. Eating enhances the blood supply to the throat, which promotes rapid healing. Coughing is discouraged because it disrupts the suture line and may cause bleeding. Aspirin is contraindicated because it interferes with platelet aggregation and promotes bleeding.
A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?
"I will heat my infant's formula in the microwave." Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.
Which instruction about levothyroxine administration should a nurse teach a client?
"Take the drug on an empty stomach." The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).
A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which of the following is the most appropriate statement by the manager?
"You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care." By following standard precautions and using personal protective equipment when exposed to or handling blood or body fluids there should be no risk of exposure. The other options are either ineffective or not necessary when caring for a client who is HIV positive.
A client is to receive 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse run the infusion? Record your answer using a whole number.
21 One unit of packed red blood cells contains 250 mL, and this is to infuse over 2 hours (120 minutes). First, determine the number of mL/minute by dividing 250 mL by 120 minutes: 250 mL/120 min = 2.1 mL/min. Then multiply by the drop factor of 10 gtt/mL: 2.1 mL/min × 10 gtt/mL = 21 gtt/min.
The maximum transfusion time for a unit of packed red blood cells (RBCs) is:
4 hours. A unit of packed RBCs may be transfused over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. The nurse should discard any blood not given within this time, or return it to the blood bank, in accordance with facility policy.
Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently?
Alterations in cardiovascular function affect the fetus. During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease.
A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. What should the nurse do next?
Apply a sterile, moist dressing. Evisceration involves separation of all layers of the abdominal wall, resulting in protrusion of abdominal contents. The nurse's first priority should be to protect the client's abdominal contents. She should apply warm, sterile saline dressings over the protruding viscera. Next, the nurse should institute NPO status because the client will ultimately need surgery. The client is at risk for shock, so the nurse should monitor vital signs frequently after applying the sterile, moist dressing. The extensiveness of the protrusion is not important, it will need surgical repair regardless.
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 while providing care may cause 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 nurse is caring for several clients on an oncology unit. Which client should the nurse see first?
Client with a white blood cell count of 2000 µL A white blood cell count of 2000 µL puts the client at risk for infection. The nurse would want to see this client in order to reduce the transmission of bacteria and other organisms from working with other clients. The client on bed rest can wait and the other clients are stable.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?
Contact the physician and report the findings. The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?
Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. 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 client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?
Decreasing environmental stimulation This client is at increased risk for injuring himself or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. If this nursing intervention is ineffective, the nurse may administer a sedative, as ordered. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, involving him in unit activities is contraindicated.
The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate?
Eat a soft, bland diet. Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing.
The nurse is caring for a client with unsuccessful laboring who is anticipating a caesarian section. What is the final assessment the nurse should make in the birthing room immediately before the client is transported to the operating room?
Fetal heart tones The purpose of a cesarean section (C-section) is to preserve the life or health of the mother and her fetus and may be the best birth choice when there is evidence of maternal or fetal complications. The final assessment the nurse should make in the birthing room before transporting the client to the operating room is to assess fetal heart tones. This information should be communicated to the operating room staff so they are aware of the presence or absence of fetal distress. Abdominal palpations may be performed to assess uterine activity and fetal position. Vaginal exams are performed to assess cervical readiness and labor progression. At this time, the physician has already determined a need for a C-section; therefore, these assessments are not required. Maternal temperature is not an immediate assessment required prior to entering the operating room.
A nurse's ex-boyfriend enters the unit and states, "If I cannot have her, then no one will." Hospital security escorts him out of the building and warned him not to return. The unit manager holds a staff meeting to confirm that which workplace violence policies and procedures will be implemented? Select all that apply.
Give a quick overview of the hospital's workplace violence policies and procedures. Offer counseling for the nurse and any other staff threatened by the ex-boyfriend. Work with security and the nurse to initiate workplace precautions related to the ex-boyfriend. Ask security to help the nurse understand how to initiate a protective order against her ex-boyfriend. National guidelines exist for managing workplace violence. Unit staff, hospital administration, and hospital security personnel develop and enforce the resulting policies. These include training all staff about workplace violence, processes for reporting of such violence, and counseling for the staff victim. Protecting staff and clients may include posting the ex-boyfriend's picture at employee entrances and a protective order initiated by the nurse. With these policies and procedures in place, it is counterproductive to ask the nurse to take a leave of absence.
A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?
Hold the cane in the right hand. To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4 to 6 inches (10 to 15 cm) from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, and then move the uninvolved leg.
When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?
Hold the medication and report the information to the physician to ensure client safety. The nurse should report the information to the physician because the client's safety may be endangered. She shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving him another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.
A client has massive bleeding from esophageal varices. In what order from first to last should the nurse and care team provide care for this client? All options must be used.
Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety. The goal that has the highest priority when a client has a massive bleed from esophageal varices is to maintain a patent airway. The nurse should position the client to prevent aspiration and assess respirations and oxygen saturation. The nurse should then assist the health care provider (HCP) in controlling the hemorrhage by using esophageal balloon tamponade. Octreotide may be administered to reduce portal pressure. The third priority is to restore circulating blood volume with blood and IV fluids. Esophageal bleeding is an anxiety-provoking event for the client, and although life-saving measures are the priority, the nurse and health care team should explain procedures to the client and provide reassurance as needed.
The health care provider (HCP) prescribes IV cefazolin 1 g for a client. In preparing to administer the cefazolin, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take?
Notify the HCP of the client's allergy to penicillin. The nurse should notify the HCP that the client is allergic to penicillin before giving the cefazolin. Cephalosporins are contraindicated in clients who are allergic to penicillin. Clients who are allergic to penicillin may have a cross-allergy to cephalosporins.
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. Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.
A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?
Potassium level of 3.1 mEq/L (3.1 mmol/L) Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of digoxin toxicity.
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?
Pregnancy should be avoided for 4 weeks after the immunization. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus. The vaccine does not protect a future fetus from infection. Rather it protects the woman from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus. The vaccine will provide immunity to rubella, also known as German measles. The injection immunizes the client against the 3-day or German measles, not chickenpox.
A nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?
Runs of ventricular tachycardia on a cardiac monitor Physicians sometimes use lidocaine drips to treat clients whose arrhythmias haven't been controlled with oral medication and whose runs of ventricular tachycardia are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren't as significant as ventricular tachycardia in this situation.
A nurse is administering an IV antineoplastic agent when the client says, "My arm is burning by the IV site." What should the nurse do first?
Stop infusing the medication. Antineoplastic agents can cause severe tissue damage if they extravasate; therefore, the nurse immediately stops the infusion and then notifies the primary care provider. If extravasation has occurred, it may be appropriate to apply ice packs to the site. Ice packs cause desired vasoconstriction; warm, moist packs cause vasodilation. Ice packs should not remain in place for more than 15 to 20 min because rebound vasodilation can occur; the ice packs are removed for a short time and then reapplied as needed.
A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions?
The client will show no self-harm or harm to staff. The client is at increased risk for injury because of his/her hyperactivity, agitation, and disorientation. The goal for no self-harm or harm to staff best fits the priority for this situation. Although the client's anxiety and orientation is a concern and is important for the client's care, the client's safety always takes highest priority. The nurse should plan first and foremost to prevent injury and harm for which the client is at risk given his/her current condition.
The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse?
The feeding that is infusing has been hanging for 8 hours. Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.
A child has a seizure while a nurse is performing a bed bath. Which of the following are priority actions for the nurse to implement? Select all that apply.
Time the length of the seizure. Turn the child to a side-lying position. Observe the stages of the seizure. It is important to assess the characteristics of the seizure to help the physician diagnose the type of seizure. Turning the child to a side-lying position may prevent aspiration of secretions. Placing a tongue depressor in the mouth or restraining extremities can cause injury to the child and is contraindicated.
The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN?
a 52-year-old client with lung cancer admitted for acute dyspnea Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status. If the RN is the care provider, the RN will have greater interaction with the individual client. The RN is responsible for assessment of all the clients. The other clients would not be considered unstable, and maintaining a patent airway is always the priority in providing care. Care for the other clients could be assigned safely, according to the abilities of the LPN/VN and UAP.
A client with a history of post-traumatic stress is found in his room panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to:
allow privacy, but check on the client frequently. The nurse should acknowledge that the client is performing self-care for his anxiety symptoms. The most respectful action is to allow privacy but to check on the client frequently. The client is likely chanting or reciting a mantra. There is no indication that he is experiencing respiratory conflict. The client does not need a sitter or a psychiatric consult.
In preparation for total knee surgery, a 200-lb (90.7 kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications?
aquatic exercise When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.
A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to:
assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin. For a client taking warfarin following a valve replacement, the INR should be between 2 and 3.5. The nurse should notify the physician of an elevated INR level and communicate assessment data regarding possible bleeding. The nurse shouldn't administer medication such as warfarin or vitamin K without a physician's order. The nurse should notify the physician before holding a medication scheduled to be administered during another shift.
A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL (51.1 g/L), and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the health care provider (HCP) and family to next:
attempt to stabilize the client through the use of fluid replacement. The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respects the client's religious beliefs and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.
The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 ml/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:
discontinue the infusion. Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated IV sites should not be irrigated; doing so will only cause more swelling and pain.
A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate:
drug dependence. Hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness are classic symptoms of drug dependency that usually appear within the first 24 hours after birth. Sepsis is indicated by temperature instability and tachycardia. Hepatitis will manifest as jaundice. Hypothermia, muscle twitching, diaphoresis, and respiratory distress may be signs of hypoglycemia.
A 7-year-old child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray?
fork For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with the tines.
A primigravid client in active labor has just received an epidural block for pain. After administration of the epidural block, the nurse should assess the client for:
hypotension. One of the most common maternal side effects after epidural anesthesia is hypotension. Therefore, the blood pressure must be assessed frequently after administration of this type of anesthesia. Other side effects include bladder distention, a prolonged second stage of labor, pruritus, nausea and vomiting, and delayed respiratory depression. Spinal headache may be an adverse effect of spinal anesthesia, but it is much less common with an epidural anesthetic. Hyperreflexia is not an adverse effect of epidural anesthesia. Uterine relaxation is associated with general anesthesia not epidural anesthesia.
The plan of care for a client with hypertension taking propranolol hydrochloride should include:
instructing the client to notify the health care provider of irregular or slowed pulse rate. Propranolol hydrochloride is a ?-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other arrhythmias. The client needs to be instructed not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension. Propranolol dosage is not adjusted based on weekly blood pressure readings. Measurement of partial thromboplastin time values is not a factor in treatment of hypertension.
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 ml per hour and oxygen at 2 L/min. The nurse should first:
notify the health care provider (HCP). PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the HCP should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the HCP promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches?
squeezing a rubber ball A client being prepared for crutch walking should be taught to support weight with the hands when crutch walking. Supporting weight in the axillae is contraindicated owing to the risk of possible nerve damage and circulatory obstruction. The client should be taught to squeeze a ball vigorously to help strengthen the hands in preparation for weight bearing with the hands. Hair combing is not likely to strengthen the hands. Wrist flexion and extension may help with wrist joint mobility but will not strengthen the hands. Using the hands to push into the mattress will not be helpful because the mattress will not provide sufficient resistance to strengthen the hands.
The nurse irrigates a client's colostomy. If the client has abdominal cramping after receiving about 150 mL of solution during the colostomy irrigation, the nurse should:
stop the flow of the solution. Abdominal cramping that may occur during a colostomy irrigation results from colon stimulation by the irrigating solution. The best course of action is to temporarily stop the flow of solution until cramping subsides. Having the client sit up in bed or advancing the cone or tube will not help stop cramping. There is no need to remove the cone or tube because it will need to be reinserted when irrigation is continued.
The client with major depression and suicidal ideation has been taking bupropion 100 mg PO 3 times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which behavior?
suicide attempt The nurse must monitor the client for a suicide attempt at this time when the client is starting to feel better because the depressed client may now have enough energy to carry out an attempt. Bupropion inhibits dopamine reuptake; it is an activating antidepressant and could cause agitation. Although bupropion lowers the seizure threshold, especially at doses greater than 450 mg/day, and visual disturbances and increased libido are possible adverse effects, the nurse must closely monitor the client for a suicide attempt. As the client with major depression begins to feel better, the client may have enough energy to carry out an attempt.
A mother of a 4-year-old child asks the nurse how to talk with her daughter about strangers. The little girl is very friendly and her mother is concerned that her child could be abducted. The nurse should tell the mother:
to talk with her daughter about what she should do if a stranger talks to her. Preschoolers can begin to take a role in their own safety. They must be taught what a stranger is and what to do if a stranger approaches them. Living in a safe town doesn't eliminate the need to warn a child about talking to strangers. Although it's appropriate for the mother to talk with her daughter about strangers and have the daughter tell her if a stranger approaches her, the child needs to be aware of what to do at the time that the situation occurs, not only afterward. Contacting social services isn't appropriate because the nurse is capable of answering the mother's questions.
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?
umbilical cord 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.