NU 270 Safety & Security Preparedness

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? Limit visits by family members. Maintain accurate fluid intake and output records. Use the smallest needle possible for injections. Encourage the client to use a wheelchair.

Use the smallest needle possible for injections. Explanation: Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

Which of the following is a true statement regarding safety during a home visit? The nurse should park his or her car away from the home. The nurse should take reactive measures. The nurse should never walk into a patient's home uninvited. The nurse should schedule visits according to the patient's lifestyle.

The nurse should never walk into a patient's home uninvited. Explanation: The nurse should never walk into a patient's home uninvited. A plan of action should always be established in case of emergencies. The nurse should park his or her car close to the home. The scheduled visits should be only in the daylight hours.

A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include? Floss before going to bed. Use a soft toothbrush and allow it to air dry before storing. Treat cavities immediately. Gargle after each meal.

Using a logrolling motion to change positions Explanation: After a laminectomy, logrolling is used to change the client's position. When in bed, a pillow is placed under the client's head and the knee rest is elevated slightly to relax the back muscles. When lying on his or her side, extreme knee flexion is avoided. Sitting is discouraged except for defecation.

A nurse is assisting in developing a teaching plan for a client who is about to enter the third trimester of pregnancy. The teaching plan should note that which symptom should be reported immediately? dyspnea on exertion increased vaginal mucus hemorrhoids blurred vision

blurred vision Explanation: During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they do not require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? renal failure esophageal atresia bronchopulmonary dysplasia hydrocephalus

bronchopulmonary dysplasia Explanation: Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation.

A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate drug dependence. hypoglycemia. hepatitis. sepsis.

drug dependence. Explanation: Hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness are classic symptoms of drug dependency that usually appear within the first 24 hours after birth. Sepsis is indicated by temperature instability and tachycardia. Hepatitis will manifest as jaundice. Hypothermia, muscle twitching, diaphoresis, and respiratory distress may be signs of hypoglycemia.

The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? elevating the neonate's head and giving nothing by mouth elevating the neonate's head for 1 hour after feedings avoiding suctioning unless cyanosis occurs giving the neonate only glucose water for the first 24 hours

elevating the neonate's head and giving nothing by mouth Explanation: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status.

A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown above), into which position would the nurse assist the client?

left lateral Explanation: The fetal heart rate monitoring strip shows late decelerations, which indicate uteroplacental circulatory insufficiency and can lead to fetal hypoxia and acidosis if the underlying cause is not corrected. The client would be turned onto her left side to increase placental perfusion and decrease contraction frequency. In addition, the intravenous fluid rate may be increased and oxygen administered. The right lateral, supine, and prone positions do not increase placental perfusion.

Which venous access device can be used for less than 6 weeks in clients requiring parenteral nutrition? implanted ports nontunneled catheters tunneled catheters peripherally inserted central catheters

nontunneled catheters Explanation: The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, and it allows the client freedom of movement. It also provides easy access to the dressing site. Peripherally inserted central catheter (PICC) lines may be used for intermediate terms (3 to 12 months). Tunneled central catheters are for long-term use and may remain in place for many years. Implanted ports are devices used for long-term home IV therapy (e.g., Port-A-Cath, Mediport, Hickman Port, P.A.S. Port). Reference:

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m. (1400), the client has a capillary glucose level of 250 mg/dl for which the client receives 8 units of regular insulin. The nurse should expect the dose's onset to be at 2:15 p.m. (1415) and its peak to be at 3 p.m.(1500). onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600). onset to be at 4 p.m. (1600) and its peak to be at 6 p.m.(1800). onset to be at 2 p.m. (1400) and its peak to be at 3 p.m.(1500).

onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600). Explanation: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m. (1400), the expected onset would be from 2:15 (1425) to 2:30 p.m. (1430) and the peak from 4 (1600) to 6 p.m. (1800).