safety NCLEX
The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client?
1. Prepare a private room at the end of the hallway.
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
2. On the nonoperative side with the legs abducted Rationale: Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided to prevent displacement of the prosthesis.
The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure?
3. Rinsing with a large volume of fluid Rationale: The client who is unconscious is at great risk of aspiration. The nurse assesses the client for the presence of a gag reflex. The nurse turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or padded tongue blade is used to open the mouth; use of the nurse's gloved fingers is avoided to prevent injury to the nurse. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration.
The nurse is instructing a client to perform a two-point gait for crutch walking. The nurse should tell the client to perform which action?
Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.
At a local school, a community health nurse is providing an educational session on childhood poisoning. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse should include taking which action first if an accidental poisoning occurs?
Call the Poison Control Center.
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take
Hold the feeding and reinstill the residual amount.
The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question?
Hydrochlorothiazide orally twice daily
The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions should the nurse take? Arrange the actions in the order that they should be performed. All options must be used.
Protect the client from injury. Activate the fire alarm. Close the doors to the other clients' rooms. Pull the pin on the fire extinguisher. Extinguish the fire. Rationale: In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency workers to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then obtains the fire extinguisher, pulls the pin, and extinguishes the fire.
A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased, and the client is still shivering. What should the nurse do next?
Remove the hypothermia blanket and notify the client's health care provider
The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing? 1. Basic level 2. Primary level 3. Secondary level 4. Tertiary level
Tertiary level Rationale: The tertiary level is focused on rehabilitation skills. Therefore, teaching a client who had a stroke how to use a walker is a tertiary level of prevention. The primary level is focused on prevention. The secondary level is a screening level that entails such procedures as vision screening, mammography, or similar screening tests. There is no basic level of prevention.
The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration?
3. Upright in a chair Rationale: It is best to assist the client who is at risk for aspiration and is dysphagic to sit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents. Options 1, 2, and 4 are not the best positions to prevent aspiration of food and fluids.
The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Click on the image to indicate your answer.
Rationale: Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position (option 4) or Trendelenburg's position (option 2) would increase intracranial pressure. A reverse Trendelenburg's position (option 3) would not be helpful and may be uncomfortable for the client.
A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?
Within 20 to 30 minutes of application
The nurse creates a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan?
Place a lead shield at the bedside.
The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?
2. Contact the electrical maintenance department for assistance Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.
The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly? Click on the Question Video button to view a video showing preparation procedures.
Makes sure that two fingers can be inserted under the restraint Rationale: Click on the Rationale Video button. When applying a restraint, the nurse applies the restraint snugly and makes sure that two fingers can be inserted under the restraint. This ensures that the restraint is not applied too tightly, causing constriction and injury to the client. The sheepskin or soft part of the restraint needs to be against the client's skin. Although a quick-release tie is used, the restraint is never attached to the side rail because of possible injury to the client if the side rail is lowered. Rather, it is secured to the bed frame.
The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider?
Aspiration is a concern with an NG tube feeding. Rationale: NG tube feedings are beneficial for some clients but present several significant possible complications such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. Another serious complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. NG tubes may be left in place from weeks to months depending on the type of tube inserted. The rate of the feedings should not be increased unless prescribed. A rate that is too rapid also may cause diarrhea, fluid overload, or aspiration.
The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client?
"I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side." 2. "I should sleep on my right side." 3. "I should sleep with my head flat." 4. "I should not wear my glasses at any time."
1. "I should sleep on my left side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.
The nurse is assessing an older adult who was just admitted to the emergency department with a possible hip fracture. What typical complaints of types and/or locations of pain might the nurse expect? Select all that apply 1. No pain 2. Groin pain 3. Sciatic pain 4. Pain referred to the lower leg 5. Pain referred to the lower back 6. Pain referred to the back of the knee
1. No pain 2. Groin pain 5. Pain referred to the lower back 6. Pain referred to the back of the knee Rationale: Clients with a fractured hip may have no pain, groin pain, pain referred to the lower back, or pain referred to the back of the knee. Sciatic pain and pain referred to the lower leg are not examples of complaints of pain related to hip fracture.
The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure that no one smokes in my home." 2. "I need to be sure that I stay at least 10 feet away from any burning candles." 3. "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time." 4. "I need to be sure that there is space between the oxygen concentrator and the wall in the room.
3. "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time." Rationale: The use of small electric items, tools, or other equipment could emit sparks and should be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the client. The client also should be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. The oxygen concentrator is kept away from walls and corners to permit adequate airflow.
The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation?
4. Carefully pick up the syringe from the floor and dispose of it in a sharps container. Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid injury to anyone. A syringe should not be swept up because this action poses an additional risk of needle stick. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should not be recapped because of the risk of getting pricked with a contaminated needle.
A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure?
3. Keep traveled paths in the home free of clutter. Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can promote safety by encouraging the family to keep pathways free of clutter to prevent falls. Speaking to the client in a loud voice may help compensate for a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively. Lowering the temperature of the hot water heater would be useful if the client had peripheral nerve damage.
The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times?
A pair of scissors
A cold, moist compress is prescribed to be applied to the client's right knee. Which should the nurse plan for?
Ensure that the temperature of the compress is 15°C (59°F). Rationale: The procedure for applying cold, moist compresses is the same as that for warm compresses. The cold compress is applied for 20 minutes at a temperature of 15°C (59°F) to relieve inflammation and swelling. Clean or sterile compresses can be used, although sterile may be prescribed for open wounds. When using cold compresses, the nurse needs to observe for adverse reactions such as burning or numbness, mottling of the skin, redness, extreme paleness, and a bluish skin discoloration. If these adverse reactions occur, the compress is immediately removed.
The nurse is transcribing a health care provider's prescription and notes that the client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse documents which military time in the medication record for administration of the medication? Click on the image to indicate your answer.
Rationale: Many health care agencies use military time, which is a 24-hour system that avoids misinterpretation of a.m. and p.m. times. Instead of two 12-hour cycles in standard time, the military clock uses one 24-hour time cycle in which 1:00 p.m. is 1300 military time.
The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition?
"Do you live in a house that is more than 25 years old?
A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client?
1. Walker Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1. Prepare the triage rooms. 2. Activate the emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist in treating the casualties.
2. Activate the emergency response plan. Rationale: In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the ED for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.
A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication?
2. Massaging the area after removing the needle Rationale: An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb should form under the skin with injection. After withdrawal of the needle, the area may be patted dry with a 2 × 2 sterile gauze. The area should not be rubbed, to prevent the spread of the medication beyond the area of injection. All equipment is then disposed of, and the area of injection is outlined (circled) for later reference.
The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action?
2. Pulls the pinna of the ear back and down. Rationale: Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child should lie on the unaffected side with the ear to receive the drop facing upward.
The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. 1. Confusion because of homelessness 2. Risk for unsafe conditions because of homelessness 3. Anxiety when consciousness is regained because of the unfamiliar surroundings 4. Lack of knowledge regarding hygiene because of the client's unkempt condition 5. Risk for infection because of his unkempt condition, various scratches, and homelessness
2. Risk for unsafe conditions because of homelessness 3. Anxiety when consciousness is regained because of the unfamiliar surroundings 5. Risk for infection because of his unkempt condition, various scratches, and homelessness Rationale: Infection is a priority because of the client's poor hygiene, altered skin integrity, and homelessness. Injury is also a concern because of the client's situation (homelessness). Waking up in an unfamiliar place can lead to anxiety. No data in the question indicate that the client has confusion or lacks knowledge.
The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation1. Wait until the client's agitation has subsided before approaching the client. 2. Speak and move slowly toward the client while assessing the client's needs. 3. Speak to the client at the entrance of the room to avoid any episodes of agitation. 4. Walk up behind the client and gently put a hand on the client's shoulder while speaking.
2. Speak and move slowly toward the client while assessing the client's needs. Rationale: Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option. Walking up behind the client may cause the client to become startled and react violently.
A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel to clean up the blood spill is incorrect? 1. Uses tongs to collect any broken glass 2. Wears gloves for the cleaning procedure 3. Blots up the spill with a face cloth or cloth towel 4. Disinfects the area of the blood spill with a dilute bleach solution
3. Blots up the spill with a face cloth or cloth towel Rationale: The unlicensed assistive personnel (UAP) should blot the spill with an absorbent disposable material, such as paper towels or terry wipes but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.
The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question? 1. How to use the "stop-go" button 2. About reporting discomfort in the knee to the nurse 3. How to reset the degrees of flexion or extension according to comfort 4. Whether the knee should stay aligned with the hinged joint on the machine
3. How to reset the degrees of flexion or extension according to comfort Rationale: The client should not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and about the need to notify the nurse if the client experiences knee discomfort. The client also should be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse reporting laws 2. Notifying the case worker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member
3. Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusive situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority.
The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action?
3. Using a gloved finger to open the client's mouth Rationale: The client who is unconscious is at great risk for aspiration. The UAP turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.
A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method?
3. Ventrogluteal muscle using Z-track technique Rationale: The correct technique for administering intramuscular iron is deep in the ventrogluteal muscle using Z-track technique. This method minimizes the possibility that the injection will stain the skin a dark color. The medication is not given in the thighs, arms, or abdomen or by the subcutaneous route.
The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the safe nursing action in this situation? 1. Obtain a dust pan and mop to sweep up the syringe. 2. Call the housekeeping department to pick up the syringe. 3. Carefully pick up the syringe from the floor and gently recap the needle. 4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
4. Carefully pick up the syringe from the floor and dispose of it in a sharps container. Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid injury to anyone. A syringe should not be swept up because this action poses an additional risk of needle stick. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should not be recapped because of the risk of getting pricked with a contaminated needle.
A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family? 1. Applying a premolded splint 2. Active range of motion to the affected leg 3. Passive range of motion to the affected leg 4. Encouraging the client to stand unassisted on the leg
4. Encouraging the client to stand unassisted on the leg Rationale: Depending on the client's functional ability, either passive or active range of motion is indicated to keep the joint moving freely. Application of a premolded splint also would keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.
When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1. Limiting the time with the client to 1 hour per shift 2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care 5. Removing the dosimeter film badge when entering the client's room 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client
2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care Rationale: The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.
The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?
3. Properly glazed pottery Rationale: Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.
The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? 1. Encourage early ambulation. 2. Discuss the resumption of home care and other activities with the client. 3. Review hand washing techniques and pericare procedures with the client. 4. Instruct the client in proper positioning of the newborn to facilitate breast-feeding.
3. Review hand washing techniques and pericare procedures with the client. Rationale: Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication.
The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients? 1. Every 1 hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours
1. Every 1 hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV site may be checked even more frequently, depending on agency policy and whether medication also is being infused. Options 2, 3, and 4 are incorrect
The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client? 1. Prepare a private room at the end of the hallway. 2. Assign one primary nurse to care for the client during the hospital stay. 3. Place a sign on the door that indicates that visitors are limited to 60-minute visits. 4. Place a linen bag outside of the client's room for discarding linens after morning care.
1. Prepare a private room at the end of the hallway. Rationale: The client with an internal cervical radiation implant should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. Nurses assigned to this client should be rotated so that one nurse is not consistently caring for the client and being exposed to excess amounts of radiation. The client's room should be marked with appropriate signs (per agency policy) that indicate the presence of radiation. Visitors should be limited to 30-minute visits. All linens should be kept in the client's room until the implant is removed, in case the implant has dislodged and needs to be located.
The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions? 1. Refers to medication as "candy for when you are sick" 2. Says he or she will store medications in child-proof containers 3. Keeps the Poison Control Center telephone number readily available 4. States the intention to label all toxic substances and place them in a locked area
1. Refers to medication as "candy for when you are sick" Rationale: Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. The Poison Control Center telephone number should be visible near all telephones. Toxic substances should be labeled with poison stickers and placed in a locked area out of reach of children.
The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 1. Keep leads on the child at all times. 2. Place the monitor inside the child's crib. 3. Adjust the monitor to eliminate false alarms. 4. Sleep in the same bed as the monitored infant. 5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone.
5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone. Rationale: An apnea monitor should not be adjusted to eliminate false alarms; adjustments could compromise the monitor's effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The caregiver should not sleep in the same bed as a monitored infant. Pets and children should be kept away from the monitor and infant. Emergency rescue numbers should be kept near phones in the home. Leads should be removed when the infant is not attached to the monitor.
The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? 1. Stop the IV infusion. 2. Obtain a prescription for a chest x-ray. 3. Notify the health care provider. 4. Apply cold compresses to the insertion site.
1. Stop the IV infusion. Rationale: The assessment indicates that infiltration of the IV solution has occurred, and the infusion must be stopped immediately to prevent further infiltration of the chemotherapy fluid. The nurse next notifies the health care provider (HCP) of the occurrence. The HCP needs to prescribe the treatment for the insertion site. There is no useful reason for doing a chest x-ray.
A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit?
3. Approaching the client from the unaffected side Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases a client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment so as to become aware of the affected half of the body. The nurse approaches the client from the affected side to increase awareness further.
A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home? 1. Conduct pill counts on each home visit. 2. Demonstrate the proper procedure to take prescribed medications. 3. Instruct the client to double up on medications if a dose has been missed. 4. Have the client verbalize and demonstrate the correct administration procedures
4. Have the client verbalize and demonstrate the correct administration procedures Rationale: To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.
The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do? Avoid the use of commercially prepared ice bags. 2. Keep the ice pack on the eye continuously for 24 hours. 3. Place the ice pack directly on the eye and cover with gauze. 4. Cover the ice pack with a pillowcase and place it on the eye.
Cover the ice pack with a pillowcase and place it on the eye. Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes and may be reapplied after a short time. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.
