Mixed Content Review
In which situations should the nurse notify the primary healthcare provider of a medication incident? Select all that apply 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.
2. & 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client, and an incident report needs to be completed in this situation. 1. Incorrect: The primary healthcare provider should be notified if harm is brought to the client but not for all events with medications. An incident report should be completed so the hospital can track incident patterns for quality improvement. 3. Incorrect: Near misses do not need to be reported to the primary healthcare provider. Following the rights of medication administration every time ensures medication error prevention. 5. Incorrect: The nurse should answer questions regarding medication color. Depending on the manufacturer, the shape and color of the medication can vary.
Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning sudden infant death syndrome (SIDS)? 1. Place the infant in the prone position when placing the infant in the bed. 2. The child should sleep in a separate room from the parents. 3. The child should not have a pacifier in place when sleeping. 4. The child should be placed in the supine position when sleeping.
4. Correct: The child should be placed in the supine position when being put to bed for naps or for the night. This position has helped to reduce the incidence of SIDS by as much as 50% since the 1990s. 1. Incorrect: The child should not be placed in the prone position when being put to bed for sleep. If the child is awake and supervised, the prone position encourages muscular development. 2. Incorrect: The American Academy of Pediatrics recommends that the infant sleep in the same room with the parents, but not in the same bed. 3. Incorrect: The American Academy of Pediatrics recommends that a pacifier be used for the first 6 months because of the benefit in regard to pain management and prevention of sudden infant death syndrome, but recommends the child be weaned from the pacifier during the second 6 months of life.
Which assessment finding by the nurse is most indicative of fluid volume overload? 1. Client has pitting edema in lower extremities. 2. Client's blood pressure is 120/80. 3. Client's CVP measurement is 6 mmHg. 4. Weight gain of 1.5 pounds (0.68 kg) in one day.
1. Correct. A client in fluid volume overload may experience pitting edema in lower extremities, a bounding pulse, increased blood pressure, and shortness of breath. 2. Incorrect. This blood pressure reading is considered normal and is not a characteristic of fluid volume overload. 3. Incorrect. This CVP is within the normal range therefore not indicative of a fluid volume excess. In a fluid volume excess, the CVP would be elevated. 4. Incorrect. A weight gain in excess of 2 pounds (0.9 kg) is of concern for fluid volume excess. Any weight gain overnight is reason for concern; however, the stem asked which finding was most indicative.
An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes
1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! You should worry about which electrolyte when providing tube feeding? Sodium. The sodium level will go up when the client is dehydrated. Tube feedings will make the client dehydrated if the client is not receiving water. High sodium can lead to seizures. So the answer that relates to this complication is option 1: seizure precautions. If the client is already having neurological signs, a grand-mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. 2. Incorrect: When hypernatremia is present, the brain cells shrink because when the body is dehydrated, water is drawn from the cells into the vascular space. 3. Incorrect: Until serum sodium is corrected, the client will be unable to process information regarding time, place, and person. The brain does not like it when the sodium is messed up. 4. Incorrect: While you're taking vital signs, your client is having a seizure! Don't delay care!
Which statement made by a client diagnosed with Addison's disease indicates to the nurse that the client needs further teaching about fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "My medication dose will change based on my daily weight." 4. "I may need more medication if I feel weak or dizzy."
1. Correct: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 2. Incorrect: This is a correct statement of understanding by the client. Medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. 3. Incorrect: Another correct statement. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. 4. Incorrect: This statement indicates that the client understands therapy. Signs of being undermedicated include weakness, fatigue, dizziness and the client will need to report these symptoms, so more medication can be given to the client.
A child who is 12 hours status post tonsillectomy and adenoidectomy reports feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in an emesis basin. Which action should a nurse take first? 1. Notify the primary healthcare provider 2. Place ice collar on child's neck 3. Administer an antiemetic as prescribed 4. Apply bilateral pressure to the child's neck
1. 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. 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 appropriate action because the child's nausea is being caused by blood pooling in the stomach. 4. Incorrect: The application of pressure to the child's neck is contraindicated because this action would not resolve bleeding in the oropharynx and might block the carotid arteries causing harm to the child.
The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? Select all that apply 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.
1., 2., 3. & 5. Correct: Consistent use of latex condoms protects against STIs. Although chlamydia may have no symptoms, burning and discharge should be reported for further evaluation. If a person younger than 25 years old and is sexually, or an older person with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection, then testing for chlamydia should be done every year. Gay, bisexual, and men who have sex with men; as well as pregnant women should also be tested. Medication should be taken as prescribed, and rescreening should occur in 3 months to make sure that there is no more disease present. 4. Incorrect: Chlamydia does not always produce visible symptoms, and, if left untreated, can lead to pelvic inflammatory disease (PID). Even when chlamydia causes no symptoms, it can damage the reproductive system. False security may lead to unsafe sex practices.
A nurse is planning to provide information to a group of adults considering smoking cessation. What information should the nurse include? Select all that apply 1. Nicotine is the drug in tobacco products that produces dependence. 2. Withdrawal symptoms may include irritability, difficulty concentrating, and increased appetite. 3. Stopping smoking reduces the risk of coronary heart disease. 4. All smokers need to have a prescription for bupropion SR in order to quit. 5. Refer to smoking quit-lines that offer free support, advice, and counseling from experienced coaches.
1., 2., 3., 5. Correct: These are correct statements. Nicotine is the drug in tobacco products that produces dependence. Other withdrawal symptoms include anxiety and cravings for a cigarette. There are many health benefits to smoking cessation including reducing the risk of coronary heart disease, stroke, peripheral vascular disease, COPD and reduced risk for infertility in women. Clients should be referred to educational programs and support groups. 4. Incorrect: The majority of cigarette smokers quit without using this prescription; however, treatments can help the smoker quit, so they should discuss possible medications with their primary healthcare provider. Other medications such as the nicotine patch or varenicline (chantix) may also be used to assist with smoking cessation.
When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign.
1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. Pillows under the knees help with pressure on the lower back. However, if pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot.
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? Select all that apply 1. Feed when baby wakes up. 2. Let the baby cry so you know the baby is hungry. 3. Report to the primary healthcare provide 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. 6. Use a special cardiac nipple with a small opening.
1., 3., & 5. Correct. Feeding when baby awakens and when well rested will decrease workload of the heart. If baby starts to sweat, then baby is having to work too hard for feeding. 2. Incorrect: Would increase the workload of the heart. You want to minimize crying, feed before crying. 4. Incorrect: Small frequent feedings are best to increase caloric intake without overstimulating the baby. 6. 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 your baby to suck and he or she may swallow air, which may result in vomiting.
The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.
2. Correct: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, or cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution. 1. Incorrect: Normal saline is an appropriate solution and is used to clean pressure ulcers. This does not kill or damage cells. 3. Incorrect: Normal saline is an appropriate solution and pressure ulcers may be packed with sterile gauze. This helps remove necrotic tissue. 4. Incorrect: The wound should be covered with an appropriate dressing after cleaning. Hydrocolloid dressings support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrocolloid dressings are occlusive, so they provide a moist healing environment, autolytic debridement, and insulation.
The nurse is caring for a client who has the diagnosis of schizophrenia. The nurse enters the room to administer the morning dose of the prescribed antipsychotic medication. The client is drooling and has extreme muscular rigidity. After assessing the client for adequate respiratory effort, what is the nurse's priority? 1. Elevate HOB and give the medication as prescribed. 2. Hold the medication and call the primary healthcare provider. 3. Report the behaviors to the on-coming shift. 4. Hold the medication, and check the vital signs.
2. Correct: The nurse should hold the medication, and report the symptoms to the primary healthcare provider. The client may be experiencing neuroleptic malignant syndrome. 1. Incorrect: The client is experiencing symptoms of possible neuroleptic malignant syndrome. The nurse should not give another dose of the medication without consulting with the primary healthcare provider. 4. Incorrect: The client may be experiencing neuroleptic malignant syndrome. It is important to notify the primary healthcare provider immediately. 3. Incorrect: The symptoms that the client displays are very serious and should be reported to the primary healthcare provider immediately.
The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spouse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."
2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe. 1. Incorrect: This is a response by a person who is not codependent. This person is not afraid to show feelings and does not deny that there is a problem. 3. Incorrect: By not drinking with the client, the spouse shows that this behavior is not condoned. 4. Incorrect: Again, the spouse does not deny a problem and wants to help the client quit rather than making excuses.
The homecare nurse is visiting a client who recently had a miscarriage at 22 weeks. When is the most appropriate time for the nurse to discuss the topic of another pregnancy? 1. The topic should wait until the nurse builds rapport with the client. 2. Another pregnancy should not be discussed for at least six months. 3. Wait until the client initiates the topic of future pregnancies. 4. Discussion should begin immediately upon the first home visit.
3. CORRECT: A mother who has had a miscarriage will experience all, or some, of the Kübler-Ross's stages of death and dying, and therefore, each individual will have a unique response to the loss of a fetus. The best course of action by the nurse is to utilize therapeutic communication techniques and approach the client with open-ended statements. This allows the client to initiate the topic at whatever point is most appropriate for her own situation. 1.INCORRECT: Building rapport with a new client is an important aspect of establishing therapeutic communication. While each nurse/client relationship is unique, it is expected that rapport will begin to be established during the first visit. However, even after establishing rapport, the nurse must follow the client's lead when discussing the topic of another pregnancy. 2. INCORRECT: When dealing with a client who has suffered loss, there are no hard and fast rules for discussing the topic. Deciding that the topic should not be discussed for a specific length of time, like six months, is inappropriate. Whether the client can safely get pregnant should be discussed with the primary healthcare provider. However, the nurse should take cues from the client about the topic of another pregnancy. 4. INCORRECT: The client has just experienced the loss of a pregnancy and will need the time to come to terms with that situation. Each client grieves in a unique time frame when dealing with such a loss. Unlike teaching that is initiated upon admission, the discussion of another pregnancy is not appropriate at the first visit, unless the client broaches the subject.
A client with a new colostomy is learning to perform a colostomy irrigation. The nurse knows the teaching was successful when the client makes what statement? 1. "My spouse can verbalize all the steps in order." 2. "I have attended all the sessions on ostomy care." 3. "I can do the irrigation if I refer to the instructions." 4. "I don't need to irrigate if the ostomy is making stool."
3. CORRECT: The true test of learning is for the client to be able to actually complete a self-care task independently. There is nothing wrong with the client referring to written instructions to complete the task. 1. INCORRECT: While it is beneficial for another family member to be familiar with the process of ostomy irrigation, having the spouse recite the steps does not ensure the client has learned successfully. 2. INCORRECT: Though the client has attended all the teaching sessions presented on performing self-ostomy care, that fact does not guarantee the client could actually successfully complete the task. 4. INCORRECT: A surgeon generally will order daily irrigation of a new ostomy to help establish a consistent bowel pattern. Only the surgeon can determine when the client may discontinue ostomy irrigation.
A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.
3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant. 1. Incorrect: This infant is showing normal adaptation to extrauterine life. The rate of 50, even with short periods of apnea, is within expected limits for a newborn. No need for oxygen at this time. 2. Incorrect:There is no indication that this infant is experiencing respiratory distress which would require intubation. Shallow respirations at the rate of 30 to 50 times per minute are expected, even with short apneic periods of 5 seconds. 4. Incorrect: There is no need to contact the primary healthcare provider. The respiratory status of this infant, even with short periods of apnea, is normal for a full term infant 12 hours after birth. Continued monitoring is all that is needed at this time.
A housekeeper has been called to the medical-surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family waiting room. 4. Repair a malfunctioning curtain around a client's bed.
3. Correct: When considering multiple safety issues, the priority is the situation which puts the greatest number of individuals at risk. Liquid on a floor is a fall hazard to anyone in that vicinity. A family waiting room has dozens of visitors a day, including adults, children, clergy, other staff and possibly other clients. The floor needs to be clean and dry to prevent injury. 1. Incorrect: The only individuals affected in this situation would be those staff personnel authorized to be in the medication room. In addition to the housekeeper, nursing staff can also change sharps containers. Therefore, even a nurse could replace the filled containers if need be. This action is not the first priority. 2. Incorrect: Cleaning an isolation room is a time-consuming process. Waiting until more important tasks are completed will not put anyone at risk since the room cannot be used until cleaned. Another task has first priority. 4. Incorrect: The curtains that hang around a client's bed are for the purpose of privacy. Even a malfunctioning curtain, which could be anything from torn fabric to broken hooks, does not pose a hazard. Although the client may not have complete privacy, this problem would not affect other clients. There is another issue that affects many individuals.
A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.
3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the second step so that further injuries are not encountered. 2. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented. 4. Incorrect: This would be the third step.
What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? Select all that apply 1. Monitor central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities
3., 4. & 5. Correct: These are independent nursing actions that will increase venous return and decrease edema. Also the nurse should assess for crackles, changes in respiratory pattern, shortness of breath (SOB), orthopnea. 1. Incorrect: This is a collaborative intervention. Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. 2. Incorrect: This is a dependent intervention. Dependent nursing interventions are those that require an order from other health care professionals.
The nurse is presenting a seminar to expectant teen parents regarding infant car seat safety. What statement from a teen parent indicates to the nurse that teaching was successful? 1. "It's okay to place the car seat up front as long as it faces backwards." 2. "The baby has to stay rear facing until at least 40 pounds or 40 inches." 3. "Regular seat belts can be used if the child does not like the booster seat." 4. "An infant must stay in the backseat, facing backward, till at least a year old."
4. CORRECT: The nurse is looking for a statement that indicates the teen parents understand the proper use of infant car seats. Although there are some variations from state to state, the National Safety Council advises that infants should be in a rear-facing car seat in the back seat of a vehicle until at least age one year. This comment indicates the parents understand the teaching clearly. 1. INCORRECT: An infant or child car seat can never be placed in the front seat at any time, regardless of what direction it may face. Further teaching is definitely indicated. 2. INCORRECT: A child of 40 pounds or forty inches is of pre-school age, usually around 3 to 4 years old. This is too old for a rear-facing car seat. The issue of height and weight is more useful when determining whether a child can safely move from a car seat to a booster seat. The parents did not understand the instruction. 3. INCORRECT: The choice of booster seat versus regular car seat belts is not based on whether the child likes, or is comfortable, in using either type of restraints. The most accepted guideline for child safety is that children under the age of 8 years old should be in either a child's car seat or booster seat. Further teaching is needed.