Elevate Module 6
A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room assignment is appropriate for the nurse to make for this client? 1. Rooming with an 8 year old in sickle cell crisis. 2. Rooming with a 2 year old admitted with bacteremia. 3. Rooming with a 3 year old with pneumonia. 4. Rooming with a 4 year old with gastroenteritis.
1 Rationale 1. Correct: Sickle cell disease and a child in a sickle cell crisis is not considered contagious. This is the only option that does not have an infectious process, so this would be the best room assignment for the child with the fracture. In addition, the children are close in age with the same development tasks, so activities for the children may be similar. 2. Incorrect: Bacteremia is an infectious process in which there is viable bacteria in the blood stream. The source of the infection is not noted. The child with a fracture who will be having surgery should not be placed in a room with a child who has a known infection. 3. Incorrect: The child with pneumonia has an infectious process that may be viral or bacterial. The child with the fracture should not be assigned to this room due to the risk of air-borne exposure to the infectious agent. 4. Incorrect: Gastroenteritis is a diarrheal illness with inflammation in the stomach and small intestine. This is contagious, so if all possible, this child should be kept in a private room, so other children would be less likely to contract the gastroenteritis. It may be viral, bacterial, or parasitic in origin. The child with the fracture should not be assigned to the room with the child with gastroenteritis.
After receiving morning report, the nurse knows which client should be assessed first? 1. Has anxiety disorder reporting shortness of breath 2. Requesting a piece of writing paper due to aphasia 3. Admitted in alcohol withdrawal with a serum sodium of 130 mEq/L (130 mmol/L) 4. Diagnosed with depression and scheduled for discharge to an outpatient care program
1 Rationale 1. Correct: The nurse should first assess the client with shortness of breath because the client could be exhibiting signs of a life-threatening condition or could be having a panic attack secondary to severe anxiety. 2. Incorrect: The nurse should assess the client with aphasia third, providing the requested writing paper, in order to identify the client's need(s). 3. Incorrect: The nurse should assess the client who is experiencing alcohol withdrawal for signs of hyponatremia and other electrolyte imbalances second. A critical value for sodium is ˂ 120. During acute withdrawal following chronic alcohol abuse, urinary elimination of sodium, chloride, and water increases eliminating the fluid and electrolytes that were retained in excess during alcohol abuse. 4. Incorrect: The nurse should assess the client who is preparing for discharge last because this client is the most stable.
Which client should the clinic nurse assess first? 1. Client reporting sudden onset of scrotal pain and edema. 2. Client with a history of benign prostatic hypertrophy who is unable to void. 3. Client reporting purulent drainage from the penis. 4. Client who has had an erection for 2 hours.
1 Rationale 1. Correct:The client with sudden onset of scrotal pain and edema is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. If treated quickly, the testicle can usually be saved. 2. Incorrect: The client with a history of benign prostatic hypertrophy who is unable to void should be assessed next. The client has retention and may need to be catheterized for relief and to prevent renal damage. 3. Incorrect: The third client to be assessed should the one who has purulent drainage, which is a sign of infection. 4 Incorrect: The last client to be assessed would be the client who has a two hour erection. Priapism, a persistent, often painful erection that lasts for more than 4 hours should be treated.
A mother brings her 6 week old infant to the ED and reports that the baby isn't gaining weight, and has not wet a diaper in 12 hours. The baby vomits after every feeding. Which nursing interventions would help this infant? 1. Burp frequently during and after feeding. 2. Provide small frequent feedings. 3. Elevate head of bed 30 degrees for sleeping. 4. Administration of H2 blockers. 5. Give Pedialyte only until vomiting stops.
1, 2, 3, 4 Rationale 1., 2., 3., & 4. Correct: First, did you recognize that this infant has gastric reflux? These interventions will promote stomach emptying and prevent gastric reflux. Frequent burps during and after feeding can keep air from building up in your baby's stomach. Feed the baby slightly less than usual if bottle-feeding, or cut back a little on nursing time. The idea is to not overfill the stomach. The ideal position to improve stomach emptying and for sleeping with gastric reflux is HOB elevated 30 degrees and the prone position. 5. Incorrect: We definitely don't want to give this baby thin liquids. They need thickened feedings. This is really important to decrease the risk of aspiration.
A pediatric nurse plans care for a child diagnosed with nephrotic syndrome. Which assessment findings should the nurse anticipate? 1. Hypoalbuminemia 2. Proteinuria 3. Foamy urine 4. Hypocoagulability 5. Hypertension 6. Anasarca
1, 2, 3, 5, 6 Rationale 1., 2., 3., 5., & 6. Correct: The nurse should anticipate that the child will exhibit signs of proteinuria because of the increased glomerular membrane permeability found in nephrotic syndrome. This proteinuria results in hypoalbuminemia. The foamy urine is a result of fat bodies in the urine from the hyperlipidemia. Excess fluid leads to hypertension. Anasarca is total body edema. It is much greater than edema of the extremities. The entire body is edematous. This would be seen with nephrotic syndrome. 4. Incorrect: The severe loss of antithrombotic factors in the urine by affected kidneys and increased production of prothrombic factors by the liver makes the client hypercoagulable not hypocoagulable.
Which intervention would the nurse initiate in a 2 year old diagnosed with Sickle Cell Crisis? 1. Initiate IV therapy 2. Perform chest physiotherapy 3. High flow oxygen 4. Administer analgesics 5. Monitor intake and output 6. Initiate strict neutropenic precautions
1, 2, 4, 5 Rationale 1., 2., 4., & 5. Correct: The client with Sickle Cell Crisis may be dehydrated. Increasing hydration will improve ability of RBCs to flow through the vascular system. Patients with sickle cell disease are prone to pneumonia, which can be potentially fatal because of its hypoxic effect of increasing sickling. Mobilizes secretions and increases aeration of lung fields. Dehydration causes increase in sickling and occlusion of capillaries other than hypovolemia or decrease in blood volume. Decrease renal perfusion may indicate vascular occlusion. 3. Incorrect: Oxygen therapy is not usually indicated unless the client is hypoxic. Oxygen is not helpful in reducing pain or reducing sickling. High flow oxygen can suppress the formation of the needed new red blood cells. 6. Incorrect: Sickle cell clients aren't neutropenic from sickle cell disease. In order to pick an answer like this for a client, the nurse would need to know what the client's ANC (absolute neutrophil count) is. Y'all, what are neutrophils? They are part of the WBC count. So, if a client is on neutropenic precautions, their neutrophil count is low and we are worried about them getting an infection. The client in this scenario has sickle cell disease, so the problem is the RBCs. We would be looking for anemia, not neutropenia.
What developmental milestone does the nurse expect to see in a 2 year old toddler? 1. Builds towers of 4 or more blocks. 2. Says sentences with 2 to 4 words. 3. Does puzzles with 3 or 4 pieces. 4. Takes turns in games. 5. Walks up and down stairs holding on. 6. Stands on tiptoe.
1, 2, 5, 6 Rationale 1., 2., 5., & 6. Correct: When checking the developmental milestones of a 2 year old, the nurse should expect to see the toddler build a tower of at least 4 blocks, say short sentences of 2-4 words, walk up and down stairs while holding on, and stand on tiptoe. 3. Incorrect: The toddler should be able to complete a 3-4 piece puzzle by age 3. This would not be of concern if a 2 year old is unable to complete this task. 4. Incorrect: The toddler should be able to take turns during a game by age 3. This would not be of concern if a 2 year old does not take turns. A two year old plays mainly beside other children. Let's Talk How a child plays, learns, speaks, acts, and moves offers important clues about the child's development. Developmental milestones are things most children can do by a certain age. Look at what milestones should be reached by the toddler's second birthday. Socially and emotionally most toddlers can copy others, especially adults and older children. They get excited when with other children. The two year old shows more and more independence and shows defiant behavior (doing what he or she has been told not to). At this age, the toddler plays mainly beside other children, but is beginning to include other children, such as in chase games. Language and communication ability include pointing to things or pictures when they are named, pointing to things in a book, knowing names of familiar people and body parts, saying sentences with 2 to 4 words, and following simple instructions. The two year old also repeats words overheard in conversation. By two years of age cognitive ability should include finding things even when hidden under two or three covers, completing sentences and rhymes in familiar books, playing simple make-believe games, and building towers of 4 or more blocks. By this age the toddler begins to sort colors and shapes and can names items in a picture book such as a cat, bird, or dog. The two year old can follow two-step instructions such as "Pick up your shoes and put them in the closet." You might see the toddler use one hand more than the other. Movement and physical development by 2 years should include the ability to stand on tiptoes, kick a ball, begin to run, climb onto and down from furniture without help, walk up and down stairs holding on, throw a ball overhand, and makes or copy straight lines and circles. The nurse should be concerned if the 2 year old doesn't use 2-word phrases (for example, "drink milk"), doesn't know what to do with common things (brush, phone, fork, spoon), doesn't copy actions and words, doesn't follow simple instructions, doesn't walk steadily, or loses skills the toddler once had.
A client is admitted with a diagnosis of exacerbation of left-sided heart failure. Which intervention is appropriate for the nurse to initiate? 1. Monitor urinary output hourly 2. Start IV of normal saline (NS) at 75 mL/hr. 3. Obtain arterial blood gases (ABGs). 4. Initiate oxygen at 2 L/nasal cannula. 5. Elevate head of bed 65-70 degrees. 6. Give furosemide 40 mg IVP.
1, 3, 4, 5, 6 Rationale 1., 3., 4., 5., & 6. Correct: Priority nursing interventions for a client with an acute exacerbation of left-sided heart failure include monitoring intake and output hourly, ABGs, oxygen administration, high-fowler's position and diuretic therapy. 2. Incorrect: IV of NS could make the problem worse. NS is isotonic and would increase the vascular space even more.
What developmental milestones does the nurse expect to see in a 9 month old infant? 1. Looks for fallen object. 2. Follows 1-step verbal command without gestures. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something.
1, 3, 4, 5, 6 Rationale 1., 3., 4., 5., & 6. Correct: When looking for the developmental milestones of a 9 month old, the nurse should expect to see the infant look for an object that has been dropped or that the infant sees someone hide. The infant can play simple games like peek-a-boo or itsy-bitsy spider. The word "no" should be understood by this age. Picking up things like cereal o's between the thumb and index finger is the pincer grasp that is achieved at this age. By nine months the infant should be able to pull self to a stand and stand while holding on to something. 2. Incorrect: The infant begins to follow simple directions like "pick up the toy" around the age of 1 year.
What intervention should the nurse initiate when caring for a child following a tonsillectomy and adenoidectomy? 1. Encourage fluid intake of clear liquids. 2. Regular suctioning of the mouth and throat. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Provide ice cream as desired. 6. Position side lying
1, 3, 4, 6 Rationale 1., 3., 4., & 6. Correct: Following tonsillectomy and adenoidectomy, when the child is alert and swallows without difficulty, the nurse should encourage the oral intake of clear fluids. Avoid fluids with red or brown color to distinguish fresh or old blood in vomitus. Also, the nurse would administer pain medication around the clock, and apply an ice collar to the front of the neck if needed. Oral fluid intake prevents dehydration, weight loss, and local infection. Pain medication, such as acetaminophen with or without codeine, administered at regular intervals controls pain more effectively than PRN administration. An ice collar that is applied to the front of the neck decreases pain as well as the risk for hemorrhage. Placing the child prone or side lying promotes drainage of blood and unswallowed saliva from the mouth that can potentially be aspirated. 2. Incorrect: Oral suctioning puts stress on the tonsillectomy site and may cause bleeding. Suctioning is only done as needed and must be performed carefully to avoid trauma. 5. Incorrect: Dairy products may coat the throat causing the child to cough and clear the throat. Coughing should be discouraged as this puts stress on the tonsillectomy site and may cause bleeding.
The nurse is planning discharge teaching for the family of a 6 month old client with heart failure. Which instructions about feeding should the nurse include in discharge teaching? 1. Feed when baby wakes up. 2. Use a special cardiac nipple with a small opening. 3. Report to the primary healthcare provider if baby sweats during feedings. 4. Give 8 ounces thickened feeding every 2 hours to increase calorie intake. 5. Feed when baby is well rested.
1, 3, 5 Rationale 1., 3., & 5. Correct. Feeding when the baby awakens and when well rested will decrease the workload on the heart. If the baby starts to sweat, then the baby is having to work too hard for feeding. 2. Incorrect: Some babies with heart disease have difficulty feeding from a nipple with a small hole for an opening. A soft nipple with a larger hole in the nipple allows the formula to flow more easily. Small holes in the nipple make it harder for the baby to suck and he or she may swallow air, which may result in vomiting. 4. Incorrect: Small frequent feedings are best to increase caloric intake without overstimulating the baby. Thickened feedings may increase the effort of feeding.
When providing care to a client diagnosed with pheochromocytoma, which actions could the RN complete rather than delegating to the licensed practical nurse (LPN)? 1. Explain the purpose of the vanillylmandelic acid test. 2. Remove caffeinated beverages from the client's meal tray. 3. Remind client not to smoke. 4. Instruct the client on activity restrictions 5. Monitor hydration status.
1, 4 Rationale 1., & 4. Correct: The RN must retain the actions of assessment, evaluation, and teaching. These cannot be delegated to the LPN. 2. Incorrect: The LPN can remove items from a client's meal tray that are not on the prescribed meal plan. 3. Incorrect: Reminding a client to not smoke is reinforcing teaching and appropriate for the LPN scope of practice. 5 Incorrect: The LPN can monitor hydration status but would not be allowed to evaluate hydration status. The LPN can monitor, reinforce teaching, data collect and intervene as part of their role on the NCLEX.
The pediatric nurse is planning an educational seminar for new parents. The seminar will focus on tips for administering medication to children. Which points should the nurse include? 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.
1, 5 Rationale 1. & 5. Correct: Demonstration with return demonstration by the parent is an appropriate teaching strategy. Give clear examples and demonstrations and speak in layman's terms. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. 2. Incorrect: Do not place crushed drugs into the child's favorite food or snack. The medication can change the taste of the food, and the child may refuse, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. 3. Incorrect: Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, he or she will not receive the correct dose. 4. Incorrect: Don't refer to drugs as candy. Children may try to take more candy leading to overdose. Let's Talk When thinking about administering medication to children, keep in mind the importance of proper administration, and ensuring that the child get all of the medication prescribed. Safety is also a key factor, so remember these things as you look at the options. Option 1. This is true. Demonstration with return demonstration by the parent is an appropriate teaching strategy. Give clear examples and demonstrations and speak in layman's terms. For instance, with a dosing cup, you would want to explain that the parent should use the cup that came with the medication. Don't mix and match cups to different products or the wrong amount may be given. We don't want them to just fill it up. They should look carefully at the lines and letters on the cup to be sure that the correct amount has been poured. Be sure they understand that the cup needs to be level by putting it on a flat surface. Option 2. This is false. If you do this, then you might not get the child to eat that food again. The medication can change the taste of the food, and the child may refuse, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. Option 3. Wrong. Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, he or she will not receive the correct dose. Option 4. Don't refer to drugs as candy. Children may try to take more candy leading to overdose. Option 5. True. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. This is a safety issue!
A child who is 11 hours status post tonsillectomy and adenoidectomy reports frequent swallowing, feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in an emesis basin. Which action should the nurse take immediately? 1. Notify the primary healthcare provider 2. Place ice collar on child's neck 3. Administer an antiemetic as prescribed 4. Draw blood for hemoglobin and hematocrit 5. Position upright, leaning forward 6. Have client gargle with cold salt water
1, 5 Rationale 1. & 5. Correct: The nurse should notify the primary healthcare provider immediately because the appearance of moderate red-tinged vomitus could indicate hemorrhage in the surgical area. Raise the head of bed with client leaning forward to prevent aspiration until the primary healthcare provider arrives to take action to fix the problem. 2. Incorrect: The child should not have a moderate amount of red-tinged vomitus 12 hours post-op. The primary healthcare provider should be notified. Ice collar will not fix the problem. 3. Incorrect: Administering an antiemetic is not an immediate action because the child's nausea is being caused by blood pooling in the stomach. 4. Incorrect: The immediate concern is to stop the bleeding. This action will not stop the bleeding. 6. Incorrect: This will not correct the problem. The client likely has a bleeder and needs to have it corrected by the primary healthcare provider.
A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Exhibit: Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with adventitious sounds noted to left lung base. Grimaces with light abdominal palpation above the pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils equal, round, and react to light. Vital Signs: Blood pressure 90/40 mm Hg Heart rate 112 beats/min Respiratory rate 32 breaths/min Temperature 103o F (39.4 o C) axillary O2 saturation 94% 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature. 4. Urine description and output.
2 Rationale 2. Correct. Septic shock involves persistent hypotension. The low blood pressure indicates that systemic tissue perfusion will not be adequate. This decreased perfusion will result in dysfunction and sometimes failure of one or more organs, such as the kidneys, heart, brain, liver and lungs. The blood pressure needs to be improved rapidly. This will be accomplished using IV fluids and sometimes vasopressors. 1. Incorrect. The Oxygen sat is 94%, so the adventitious lung sounds do not need immediate intervention. The abnormal lung sounds are the result of the diffuse infiltrates that occur as a result of the inflammatory process and increased capillary permeability which allows fluid to escape into the lung tissues and alveoli. As this progresses, gas exchange can be severely compromised. However, at this point, this client is remaining above 90% with the O2 sat levels, so the problem of poor tissue perfusion from hypotension would be the priority. 3. Incorrect. The second priority is to treat the infection that is a likely cause of the temperature elevation and hypotension. Parenteral antibiotics are administered as soon as wound or blood cultures have been obtained. When sepsis is suspected, antibiotic therapy is essential and should be instituted as soon as possible. The early initiation of antibiotics can be a lifesaving measure. 4. Incorrect. This may be the cause of the sepsis, but the priority is to improve the tissue perfusion and ultimately raise the BP. The second priority is to treat the infection. As the tissue perfusion improves, and the infection is treated, the urinary output and appearance of the urine should improve unless permanent kidney damage resulted.
A nurse is caring for a 5-year-old child who has a history of spinal cord injury at the sixth thoracic vertebrae. Vital signs are heart rate 56 beats per minute and a blood pressure of 154/86 mm Hg. Which action should the nurse take first? 1. Complete a neurological assessment 2. Turn off the oscillating fan 3. Place the client in right lateral position 4. Activate the critical response team
2 Rationale 2. Correct: The child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord injury. Any number of things can stimulate the sympathetic nervous system, including a draft or wind from a fan. The nurse should turn the fan off. 1. Incorrect: Although a neurological assessment is an important priority of care, the nurse should first investigate the potential cause of the problem. 3. Incorrect: Head of bed elevation is essential in autonomic dysreflexia to decrease blood pressure. 4. Incorrect: The nurse should first assess the likely causes of the problem before notifying the critical response team.
The RN is reviewing client assignments with the LPN working on a medical floor. Which clinical assignment would be appropriate for the LPN? 1. The client with nausea, vomiting, and mild metabolic alkalosis 2. The client with chronic back pain admitted for pain management 3. The client waiting to go to surgery for a scheduled total knee replacement 4. The client with a stage 3 decubitus ulcer requiring a dressing change 5. The client newly diagnosed with Guillain Barre' syndrome
2, 3, 4 Rationale 2., 3., & 4. Correct: The LPN can manage pain and can prep someone for the OR. The LPN can also do wound care on a decubitus ulcer. Remember, look at the client where they are here and now. 1. Incorrect: The LPN cannot take care of an unstable client and that includes anyone with an acid base imbalance. 5. Incorrect: The LPN cannot take care of a complicated client. The client newly diagnosed with Guillain Barre' syndrome can have progressing paralysis leading to respiratory failure. This is a complicated and unstable client.
Which signs, if observed in a child, should a clinic nurse associate with Kawasaki disease? 1. Productive cough 2. Strawberry tongue 3. High and persistent fever 4. Enlarged cervical lymph nodes 5. Peeling of the skin on the hands 6. Extremely red sclera
2, 3, 4, 5, 6 Rationale 2., 3., 4., 5., & 6. Correct: The nurse should recognize strawberry tongue, high and persistent fever, enlarged cervical lymph nodes, extremely red eyes without a thick discharge and redness of the palms of the hands and soles of the feet as signs of Kawasaki disease. Kawasaki's disease is an autoimmune disease in which the medium-sized blood vessels throughout the body become inflamed. Many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes, are affected. The most prominent signs are a high and persistent fever that is not responsive to normal treatment with acetaminophen or ibuprofen, extreme irritability, and the presence of a "strawberry tongue" caused by necrotizing microvasculitis. Peeling of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets occurs in the second phase of the disease. 1. Incorrect: Coughing is not a typical sign of Kawasaki disease.
What developmental milestone does the nurse expect to see in a four month old baby? 1. Responds to own name. 2. Pushes up to elbows, when lying on stomach. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Watches the path of something as it falls. 6. Reaches for toy with one hand.
2, 3, 4, 6 Rationale 2., 3., 4., & 6. Correct: By the age of four months, the nurse would expect the baby to be able to push up to the elbows when lying prone. A baby may be able to roll over from abdomen to back by 4 months. At 4 months the baby should be able to push down on legs when feet are on a hard surface. Reaching for a toy with one hand is seen when the baby is 4 months of age. 1. Incorrect: A baby can respond to their own name by 6 months, not 4 months. 5. Incorrect: When checking the developmental milestones of a 9 month old, the nurse should expect to see the baby watch the path of something as it falls.
As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Developing a response plan for each individual potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Every hospital should prepare for all the same emergencies. 6. Conduct a risk assessment to identify potential emergencies.
2, 3, 4, 6 Rationale 2., 3., 4., & 6. Correct: Developing a single response plan rather than multiple plans, educating individuals to the specifics of the response plan, practicing the plan, and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principle of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. The first step when developing a emergency response plan is to conduct a risk assessment to identify potential emergencyemergencies. An understanding of what can happen will enable the team to determine resource requirements and to develop plans procedures to prepare. 1. Incorrect: One good response plan should be developed rather than multiple plans. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. 5. Incorrect: Consideration must be given to the proximity of chemical plants, nuclear facilities, schools, and areas where large groups gather.
The nurse is providing discharge teaching for a family of a 2 year old going home on digoxin. Which teaching should the nurse include? 1. Use a 5 mL syringe to draw up the medication so the numbers can be seen easily. 2. Give 1 hour before or 2 hours after feedings. 3. Add the medication to the sippy cup so it is easier to administer. 4. Check the apical pulse before giving medication. 5. Store the medication in the refrigerator.
2, 4 Rationale 2., & 4. Correct: Digoxin should be given on an empty stomach for better absorption. The apical pulse should be checked prior to administering digoxin. 1. Incorrect: Remember, rarely do we give more than 1mL to an infant, so it should be drawn up in the smallest available syringe (1mL syringe). This age child may require a slightly higher dose, but the 3 mL syringe could be used. Keep in mind that you are increasing the chance of a medication error using a larger syringe. 3. Incorrect: NEVER add medication to a bottle or sippy cup. If the child doesn't drink the entire amount in the cup, you have no idea how much medication was actually administered. 5. Incorrect: Digoxin should be stored at room temperature.
The nurse admits a client with a C-spine injury to the neuro intensive care unit. The admission assessment is completed. What is the nurse's priority intervention? Exhibit: Client reports blurred vision and a headache rated 9/10. BP 200/110, pulse 55. 1. Reduce air drafts in room 2. Loosen tight clothing 3. Elevate the head of the bed to high fowlers 4. Administer hydralazine
3 Rationale 3. Correct: This client is experiencing autonomic dysreflexia! This is a priority question, so what would I do first. Elevate the HOB to decrease the BP. 1. Incorrect: This is a correct answer, but not the priority response. Air drafts may be a stimulus of autonomic dysreflexia and would need to be removed, but if I don't elevate the bed or sit them up first, they could have a hypertensive stroke! 2. Incorrect: This is a correct answer, but not the priority response. If I don't elevate the bed or sit them up first, they could have a hypertensive stroke! 4. Incorrect: This is a correct answer, but not the priority response. Elevating the HOB may lower the BP. If that does not work, then hydralazine may be given.
The nurse is caring for a client with a history of Gastroesopeageal Reflux Disease (GERD). Based on the assessment, what is the priority intervention? Exhibit: Lung sounds diminished on the left side posteriorly with crackles noted bilaterally. Frequent, moist cough. Temp of 103º F (39.45ºC) 1. Administer esomeprazole 2. Establish IV access 3. Obtain oxygen saturation 4. Get chest x-ray
3 Rationale 3. Correct: Y'all, what do you think is wrong with this client? Did you say pneumonia? Yes, these are classic things we see with Pneumonia, so you better be checking oxygenation. Is a client with GERD at risk for pneumonia? Yes, because the acid that is refluxing can be aspirated into the lungs. 1. Incorrect: A client with GERD will often be treated with a proton pump inhibitor such as esomepraxole (Nexium), but the priority at this time is oxygenation. 2. Incorrect: The nurse needs to check oxygenation first. 4. Incorrect: Oxygenation takes priority.
Which client should the nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+ 2. Multigravida on po terbutaline with a pulse rate of 110/per minute 3. Primigravida on IV oxytocin with contractions every 3-4 minutes 4. Multigravida on po methyldopa with a blood pressure of 142/90.
4 Rationale 4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. 1. Incorrect: + DTRs are normal. Clinical signs of safe dosage of magnesium sulfate include normal deep tendon reflexes. Adverse effects include depressed reflexes. 2. Incorrect: Maternal tachycardia (up to 120 bpm) is expected when on this medication. Terbutaline is a beta adrenergic agonist could have significant cardiovascular effects. 3. Incorrect: The desired contraction pattern with oxytocin is 3 in 10 minutes. A contraction every 3-4 minutes would equal 3 contractions in 10 minutes. The dosage of the oxytocin is individualized until the desired contraction rate is achieved.
In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last. The Correct Order 1. Client with a respiratory rate of 28/min and end-expiratory wheezes on auscultation. 2. Client reporting continuing angina after taking three doses of nitroglycerin. 3. Client who has soaked a towel with blood from a thigh laceration. 4. Client with a BP of 92/52. Client with right sided hemiparesis and a BP of 150/88.
This is the Correct Order Rationale When triaging clients remember the following for prioritizing care in the emergency department: airway, breathing, circulation, bleeding, shock, disability. The first client to be sent into the ED for treatment is # 4, the client who is wheezing with a respiratory rate of 28/min is having a breathing problem. The second client to send into the ED should be # 2, the client with continuing angina after taking three doses of nitroglycerin. The client may be having an MI. The third client to be sent into the ED should be # 1, the client who is bleeding from a severe thigh laceration. The bleeding needs to be stopped ASAP to prevent shock. The fourth client to go into the ED should be # 5, the client with a BP of 92/52 - going into shock. The fifth client to go into ED should be # 3, the client who has developed hemiparesis and stable VS.
