Safety

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? A. Ensure mouth breathing B. Apply pressure to the convex portion of the nose C. Provide a splint postoperatively D. Apply a warm pack postoperatively

A. Ensure mouth breathing For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A. Hypokalemia B. Hypernatremia C. Hyperkalemia D. Hypophosphatemia

A. Hypokalemia Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing intervention to help prevent fractures in the client? A. Promote safety. B. Provide adequate hydration. C. Encourage adequate nutrition. D. Increase mobility.

A. Promote safety. Safety is paramount because any injury, no matter how slight, can result in a fracture. Mobility, hydration, and nutrition are important, but will not prevent fractures.

A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas? A. Sclerae B. Nail beds C. Mucous membranes D. Ear lobes

A. Sclerae Jaundice, a yellowing of the skin, is directly related to elevations in serum bilirubin and is often first observed in the sclerae and mucous membranes. The term icterus is used to describe yellowing of the sclerae.

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. A. Time the length of the seizure. B. Place a tongue depressor in the child's mouth. C. Turn the child to a side-lying position. D. Restrain the twitching extremities. E. Observe the stages of the seizure.

A. Time the length of the seizure. C. Turn the child to a side-lying position. E. 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 nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client? A. alerting the healthcare provider of the third-degree heart block B. identifying a code-level status C. maintaining intravenous fluids D. assessing blood pressure and heart rate frequently

A. alerting the healthcare provider of the third-degree heart block The client may experience low cardiac output with third-degree AV block. The healthcare provider needs to intervene to preserve the client's cardiac output. Monitoring the blood pressure and heart rate are important, but not a priority. The identification of a code status during a heart block is not appropriate. IV fluids are not helpful if the heart is not perfusing.

The nurse would intervene when making which of the following observations in the surgical environment? A. A staff member is wearing scrub clothes in the semirestricted zone. B. A staff member dressed in street clothes enters the semirestricted zone. C. A staff member is wearing a surgical mask and shoe covers in the restricted zone. D. A staff member fails to wear a mask in the semirestricted zone.

B. A staff member dressed in street clothes enters the semirestricted zone. Street clothes are permitted in the unrestricted zone only.

A client received 2 units of packed red blood cells while in the hospital with rectal bleeding. Three days after discharge, the client experienced an allergic response and began to itch and break out with hives. What type of reaction does the nurse understand could be occurring? A. Anaphylactic reaction B. Delayed hypersensitivity response C. Sensitization D. An immediate hypersensitivity response

B. Delayed hypersensitivity response A delayed hypersensitivity response may develop over several hours or days, or it may reach maximum severity after repeated exposure. Examples of a delayed hypersensitivity response include a blood transfusion reaction that occurs days to weeks after blood administration, rejection of transplanted tissues, and reaction to a tuberculin skin test. Anaphylaxis is a rapid and profound type I hypersensitivity response. Sensitization is the process by which cellular and chemical events occur after a second or subsequent exposure to an allergen. An immediate hypersensitivity response is due to antibodies interacting with allergens and occurs rapidly.

A client who used heroin during her pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find A. a flattened nose, small eyes, and thin lips. B. lethargy 2 days after birth. C. irritability and poor sucking. D. congenital defects such as limb anomalies.

C. 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 cardiologist prescribes digoxin 125 mcg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablet(s) would the nurse administer in each dose? Record your answer using one decimal place. (For example: 6.2)

The nurse would begin by converting 125 mcg to milligrams: 125 mcg/1,000 = 0.125 mg Then the nurse would use the following formula to calculate the drug dosage: Dose on hand/Quantity on hand = Dose desired/X 0.25 mg/1 tablet = 0.125 mg/X 0.25X = 0.125 x 1 tablet X = 0.5 tablets 0.5