Saunders Q&A H 7 67-150

Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique would the nurse use to transfer the client from the stretcher to the bed?

A transfer board and the assistance of four people

A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?

"I need to be sure to place my cup of coffee on the counter."

A client is admitted to the labor and delivery unit for a labor induction to help manage severe gestational hypertension. The primary health care provider has prescribed oxytocin to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many mL/hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000 mL of 0.225% normal saline?

12

The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse would check to see that the oxygen flow rate is prescribed at which rate?

2-4L

A primary health care provider prescribes 1000 mL of 0.45% normal saline solution to run over 8 hours. The drop factor is 15 drops/mL. The nurse adjusts the flow rate to how many drops per minute to safely administer this intravenous (IV) solution? Fill in the blank and round answer to the nearest whole number.

31

The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an assistive personnel (AP). Which clients would the nurse assign to the LPN because of client needs that cannot be met by AP? Select all that apply.

A client requiring frequent suctioning A client requiring a dressing change to the foot A client requiring reinforcement of teaching about a diabetic diet

A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)?

A suction unit and oxygen

Which statements describe characteristics of case management? Select all that apply.

A case manager collaborates with other staff members and actively coordinate client discharge planning. The evaluation process involves continuous monitoring and analysis of the needs of the client and services provided. A case manager coordinates a hospitalized client's acute care and follows up with the client after discharge to home. A case manager usually does not provide direct care.

A client is being admitted to the hospital following insertion of a radiation implant after being diagnosed with cervical cancer. Which priority action would the nurse implement in the care of this client?

Admit the client to a private room.

A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions would be implemented to protect the client from infection? Select all that apply.

Admit the client to a private room. Place a mask on the client if the client leaves the room. Use strict aseptic technique for all invasive procedures. Place a "See the Nurse Before Entering" sign on the door to the room. Remove a vase with fresh flowers in the room that was left by a previous client.

The nurse inserts an indwelling urinary catheter into a client being prepared for surgery to remove a kidney stone. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action would the nurse implement next?

Advance the catheter 2.5 to 5 cm.

To ensure that the client self-administers medications safely in the home, which action would the nurse implement?

Ask the client to explain and demonstrate self-administration procedures.

Which actions are most appropriate for the nurse to take in the event of an accidental poisoning in a child? Select all that apply.

Assess for airway patency, breathing, and circulation. Determine the type and amount of substance ingested. Remove any visible materials from the nose and mouth. Save vomitus for laboratory analysis.

The nurse assists a postoperative appendectomy client from a lying to a sitting position to prepare for ambulation. Which nursing action is most appropriate initially to maintain the safety of the client?

Assess the client for signs of dizziness and hypotension.

After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. Which rationale is the basis for these instructions?

Avoid maternal or infant injury caused by the potential for syncope or overexertion.

A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response would the nurse communicate to the client?

Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations."

An adult client who has a severe neurocognitive impairment is scheduled for gallbladder surgery. With regard to the informed consent, which would the nurse implement first to facilitate the scheduled surgery?

Check for the identity of the client's legal guardian. **A mentally or emotionally incompetent client is an individual who has been declared incompetent, is unconscious, is under the influence of chemical agents such as alcohol or drugs, or has chronic dementia or another mental deficiency that impairs thought processes and the ability to make decisions.

The nurse, after administering an injection to a client, accidentally drops the syringe on the floor. Which nursing action is most appropriate in this situation?

Carefully pick up the syringe from the floor and dispose of it in a sharps container.

A client remains in diagnosed atrial fibrillation with rapid ventricular response despite prescribed pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. Which action would the nurse plan to take to ensure safety and prevent complications of this procedure?

Check that the defibrillator is set on the synchronous mode.

The nurse would implement which safety measures to prevent an electrical shock when using electrical equipment? Select all that apply.

Check the electrical cord for fraying. Keep the electrical cord away from the sink. Disconnect the electrical cord from the wall socket when cleaning the equipment.

The nurse prepares a client for discharge who is prescribed intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line for a foot infection. Which instruction would the nurse include in client teaching about necessary daily infusion care in the home?

Check the insertion site for redness and swelling.

A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions would the nurse implement in the postprocedure period? Select all that apply.

Checking the client's groin for bleeding Encouraging the client to increase fluid intake Instructing the client to move the toes when checking circulation, motion, and sensation

The nurse is assigned to care for a client who is in traction. Which intervention by the nurse would ensure a safe environment for the client?

Checking the weights to be sure that they are off the floor

A client suspected of having developed tuberculosis is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment would the nurse plan to have available at the bedside?

Chest tube and drainage system

The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame

Continuously **Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken

The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager would note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?

Covers the connection site with a bath blanket to enhance extremity warmth

The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction?

Cuts need to be avoided.

A registered nurse (RN) in charge of the client care unit is preparing the assignments for the day. The RN assigns assistive personnel (AP) to make beds and bathe one of the clients on the unit and assigns additional AP to fill the water pitchers and serve juice to all of the clients. Another RN is assigned to administer all medications. Based on the assignments designed by the RN in charge, which nursing care delivery model is being implemented?

Functional **The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members

A client diagnosed with terminal liver cancer asks the home care nurse to witness the client's signature on a living will with the client's attorney in attendance. Which action is most appropriate for the nurse to implement?

Decline to witness the signature on the living will. **Living wills are written documents and need to be signed by the client. The client's signature must be either witnessed by nonagency individuals or notarized; thus, the nurse should decline to sign the will to avoid a conflict of interest.

When the nurse manager encourages staff to provide input in the decision-making process, which leadership style is being demonstrated?

Democratic

The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client would indicate to the nurse that the client understands how to manage urine as a biohazard?

Disinfect the toilet with household bleach after voiding for 6 hours after a treatment.

The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.

Do you feel the need to discuss your end-of-life decisions with your family "Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?" "Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?"

A registered nurse is a preceptor for a new nurse and is observing the new nurse organize the client assignments and prioritize daily tasks. The registered nurse would intervene if the new nurse implements which action?

Documents task completions at the end of the day

The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action would the nurse implement at this time?

Draw a line through the incorrect information and initial the change.

The nurse is preparing the client's morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action would the nurse take?

Draw the dose from a new vial.

A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse would develop a plan of care for the client and include which intervention?

Eliminating sources of caffeine from meal trays

A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance?

Encourage the nurses to verbalize feelings regarding the change.

The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers would the nurse include in this review? Select all that apply.

Ensure that crib sides are up. Use large, soft toys without small parts. Ensure that an infant or toddler is never left unattended while lying on a changing table.

The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include?

Moving slowly from a sitting to a standing position

After receiving detailed information about a colonoscopy from the primary health care provider (PHCP), the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?

Have two nurses witness the client sign with an X.

The nurse is going to suction an adult client with a tracheostomy who has respiratory secretions. Which intervention would the nurse implement to perform this procedure safely?

Hyperoxygenating the client by asking the client to take four to five deep breaths

A primary health care provider has written a prescription to administer methylergonovine maleate to a postpartum client. The nurse would contact the primary health care provider to verify the prescription if which condition is present in the mother?

Hypertension **Methylergonovine maleate is an ergot alkaloid used to treat uterine atony.

A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety?

I have a car seat that I will put in the front seat to keep my baby safe."

The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement would the nurse communicate in response?

I have a legal obligation to report this type of abuse."

The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which would be the initial step in the process of change for the nurse manager?

Identify the inefficiency that needs improvement or correction.

The registered nurse (RN) is reviewing a plan of care developed by a new nurse for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the new nurse needs further teaching and should revise the plan of care if which incorrect intervention is documented?

Immobilize the child if a seizure occurs.

A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse would include which action in the plan of care to ensure a safe environment for the child?

Initiating seizure precautions

Which interventions would the emergency department nurse implement during the management of a client suspected of exposure to anthrax? Select all that apply.

Instruct the client to shower thoroughly using soap and water. Consult with the primary health care provider regarding postexposure prophylaxis with oral fluoroquinolones for the client. Handle clothing minimally. Instruct the client to remove contaminated clothing.

An emergency department nurse is a member of an all-hazards disaster preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions would initially be included in the plan? Select all that apply.

Isolate the client. Don protective equipment immediately. Notify infectious disease specialists, public health officials, and the police. Identify all client contacts, including transport services to the emergency department and clients in the waiting room.

A client receiving chemotherapy to treat lung cancer has an extremely low white blood cell count and is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client now allowed to consume? Select all that apply.

Italian bread Baked chicken Well cooked cheese burger

The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position would the nurse assist the client into to maintain safety during the procedure?

Left side-lying with the head of the bed elevated 45 degrees

The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate to include at this age? Select all that apply.

Never shake the infant's head. Place the infant on the back to sleep.

A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which is the most appropriate initial nursing action?

Notify the primary health care provider (PHCP) of the client's request.

A postoperative client begins to drain small amounts of bright red blood from the tracheostomy tube 24 hours after a laryngectomy. Which priority action would the nurse implement?

Notify the surgeon

The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent?

Obtain a new set of contact lenses for use after the infection clears

The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission

Offer revaccination to the client.

The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions would the nurse take to properly secure and handle legal evidence? Select all that apply.

Place paper bags on the hands and feet. Cut clothing along the seams, avoiding bullet holes. Collect all personal items, including items from clothing pockets. Do not allow family members, significant others, or friends to be alone with the client.

The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure would the nurse implement?

Place the solution on a controlled infusion pump.

The nurse assesses a client 24 hours following an above-the-knee amputation. Which action would the nurse take to ensure that the client's residual limb is placed in the most appropriate position?

Position the residual limb flat on the bed. **after the first 24 hours, the residual limb is usually placed flat on the bed (as prescribed) to reduce hip contracture

A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse would ensure that which medication is available if the client develops a significant bleeding problem?

Protamine sulfate **Protamine sulfate is the antidote for heparin sodium

The nurse is assigned to care for a hospitalized toddler. Which measure would the nurse plan to implement as the highest priority of care?

Protect the toddler from injury

A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem-solve situations, and does not prioritize nursing care. Which strategy is most appropriate for the charge nurse to employ?

Provide support and identify the underlying cause of the staff nurse's problem.

The nurse is observing a client using a walker after experiencing a stroke. Which observation by the nurse would determine that the client is using the walker correctly?

Puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it

The nurse manager is reviewing the principles of surgical asepsis with the nursing staff. In which situations would the nurse manager communicate to the staff that it is necessary to use the principles of surgical asepsis? Select all that apply.

Reapplying sterile dressings Inserting an intravenous (IV) line Inserting a urinary (Foley) catheter Suctioning the tracheobronchial airway

When teaching a competent postoperative client about a patient-controlled analgesia (PCA) pump, the nurse would include which instructions to the client? Select all that apply.

Report the inability to void. Report any nausea and vomiting. Push the button before the pain becomes too great. Inform the nurse about the pain levels being experienced.

The nurse in the day care center is told that a child with a diagnosis of autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. Which priority consideration would the nurse incorporate in planning activities for this child?

Safety

The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated acquisition [MUGA] scan). The nurse would ensure that which item is in place before the procedure?

Signed informed consent **MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary.

The nurse observes that a postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to prevent escalating the agitation?

Speak in a calm tone while moving slowly toward the client.

A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The assistive personnel (AP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the AP that which intervention is needed for infection control?

Standard precautions are sufficient because the disease is transmitted sexually.

To ensure that the client diagnosed with cancer has adequate and safe pain control, which plan would the nurse implement?

Start with low doses of medication and gradually increase to a safe dose that relieves pain.

The nurse prepares for the admission of the child with a diagnosis of tonic-clonic seizures and plans to place which items at the bedside?

Suction apparatus and oxygen

A delivery room nurse is preparing a client for a cesarean delivery to facilitate the birth of triplets. Which position will promote maximum uteroplacental perfusion during this surgery?

Supine position with a wedged right hip

The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation would help the nurse determine if the client's crutches are fitted correctly?

The elbow is at a 30-degree angle when the hand is on the handgrip.

Which scenarios demonstrate a participative style of leadership? Select all that apply.

The nurse manager arranges unit meetings for all shifts to deal with an identified problem The nurse manager proposes several methods of dealing with a problem and invites team input. The nurse manager considers staff input related to a problem but makes the final decision on implementation of the solution. **Participative leadership demonstrates an "in-between" style, neither authoritarian nor democratic.

Which situation represents the primary nursing care delivery model?

The registered nurse (RN) performs all tasks needed by the individual client to optimize health.

When assessing the client with a wrist restraint at the beginning of the day shift, which observation by the charge nurse would indicate that the nurse who placed the restraint on the client failed to follow safety guidelines?

The wrist restraint was applied snugly.

The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse would ensure that which specific priority item is at the client's bedside?

Tracheotomy set

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough suspected of having pneumonia. Which intervention would the nurse implement to obtain the specimen?

Use a sterile plastic container for obtaining the specimen.

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which action is most appropriate for the nurse to implement in order to decrease the risk of infection?

Use aseptic technique in handling the TPN solution.

A client who has experienced a stroke has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is not sufficient to provide support. The nurse determines that the client could benefit from the greater support, stability, and safety provided by which devices? Select all that apply.

Walker Tripod cane Quadripod cane

The nurse places a hospitalized client with a diagnosis of active tuberculosis in a private, well-ventilated isolation room. In addition, which action would the nurse take before entering the client's room?

Wash the hands and place a high-efficiency particulate air (HEPA) respirator over the nose and mouth.

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the client asks if it is safe for her toddler to receive the vaccine. Which response by the nurse is most appropriate

Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine."