SIM #1 REVIEW
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. - Obtain the fire extinguisher. - Extinguish the fire. - Activate the fire alarm. - Close the door to the patient's room. - Remove the patient from the room.
- Remove the patient from the room. - Activate the fire alarm. - Close the door to the patient's room. - Obtain the fire extinguisher. - Extinguish the fire. Remember RACE: Rescue the client; activate the alarm; contain the fire in the client's room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire.
Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? Select all that apply. 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 4. 7 year old in Buck's traction for a femur fracture. 5. 10 year old transferred from ICU yesterday with a head injury.
1. & 4. Correct: These clients have conditions that the LPN/VN can care for with little assistance from the RN. Bowel training is a health promotion, self care activity that is within the scope of practice for the LPN/VN. Buck's traction is a type of skin traction that is also within the scope of practice for the LPN/VN. 2. Incorrect: This client will probably have IV fluids prescribed that the RN will need to administer. Assessment of lung status would be important since the client is a new admit with asthma. This is a potentially unstable client and would not be appropriate for the LPN/VN. 3. Incorrect: This client, admitted with septicemia, is potentially unstable and will probably require IV antibiotics and very close monitoring due to being very young with a major infection. 5. Incorrect: This client will need close observation and the higher skill level of an RN since there is a head injury and the client spent time in the ICU only one day before.
The nurse manager is teaching the principle of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from least restrictive to most restrictive? Place in correct order from least restrictive to most restrictive. - Take the patient to the quiet room for a time out. - Verbally tell the patient to stop the unaccepting behavior and escort the patient to another part of the day room. - Walk the patient out to the courtyard. - Place the patient in the isolation room with staff observation. - Restrain patient's arms with wrist restraints. - Use four point soft cloth restraints.
- Verbally tell the patient to stop the unaccepting behavior and escort the patient to another part of the day room. - Walk the patient out to the courtyard. - Take the patient to the quiet room for a time out. - Place the patient in the isolation room with staff observation. - Restrain patient's arms with wrist restraints. - Use four point soft cloth restraints. First, verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client's arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive.
The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? Select all that apply. 1. A bruit is heard with a stethoscope. 2. A thrill is felt on palpation. 3. There is a blood return on the venous side of the shunt. 4. Urine output greater than 30 mL/hr. 5. There is a strong radial pulse in the arm with the AV shunt.
1, & 2. Correct: AV shunts should have the presence of a bruit and a thrill which indicates patency. 3. Incorrect: IV sticks should not be performed on the shunt or the extremity where the shunt is placed except for initiating dialysis. 4. Incorrect: This is not related to patency of AV shunt. This would be related to assessing the patency of an indwelling catheter. 5. Incorrect: Radial pulse does not determine patency of AV shunt. Only the confirmation of a bruit and a thrill ensure patency.
The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? Select all that apply. 1. Lowers the blood glucose 2. Provides more energy 3. Increases insulin need 4. Reverses complications of diabetes 5. Increases the workload of the liver
1. & 2. Correct: In the presence of adequate insulin, exercise lowers the blood glucose. Exercise releases endorphins, providing the client with increased energy and feelings of well-being. 3. Incorrect: Exercise does not require the need; for the increased production of insulin. 4. Incorrect: Exercise does not reverse complications. Exercise helps prevent microvascular and macrovascular changes/complications. 5. Incorrect: Exercise does not increase the workload of the liver.
A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed."
1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question.
A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking
1. Correct: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development.
A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? 1. Blood cultures times two 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr
1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed. 2. Incorrect: The ceftriaxone is administered after the appropriate IV has been initiated. This would be the last intervention to be initiated. 3. Incorrect: The IV can be started at any point, but should be done after the cultures so the blood sample would not be affected in anyway. 4. Incorrect: Fluids will be started after the cultures are obtained and after the IV is started so as not to alter the results of the blood work and ensure correct treatment.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? 1. Suggest client eat several small meals a day, with the largest at breakfast. 2. Recommend eating meals in a semi-recumbent position. 3. Administer metoclopramide 1 hour after meals. 4. Avoid fruit juices and carbonated beverages.
1. Correct: Large meals are difficult to manage when the client is anorexic and has loss of appetite, as is usually the case with Hepatitis B. Anorexia may also worsen during the day, making intake of food difficult later in the day. 2. Incorrect: Recommend eating in upright position to reduce sensation of abdominal fullness and therefore enhance intake. 3. Incorrect: Antiemetics, such as metoclopramide, should be given ½ hour before meals, to reduce nausea, and increase food tolerance. 4. Incorrect: Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day to supply client with extra calories. These may be easier to digest/tolerate than other foods.
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.
1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1.
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)
1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test
Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? 1. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.
1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? 1. Use simple words. 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong.
1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed. Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance needed. This is not the time for open ended questions and would increase the client's anxiety.
The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? Select all that apply. 1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 4. Obtain a yearly chest x-ray. 5. Proper disposal of tissues.
1., 2., 3. & 5. Correct: In an effort to prevent transmission of TB to others, the nurse should carefully instruct about the importance of hygiene measures, including mouth care, covering the mouth when coughing and sneezing, proper disposal of tissues, and hand hygiene. A TB skin test is especially important when living in tight quarters such as an assisted living center. 4. Incorrect: Chest x-rays are not needed yearly, especially without signs and symptoms of TB.
A client has just delivered a newborn. Based on the primary healthcare provider's notation, what prescriptions does the nurse anticipate administering to the mother? Select all that apply. EXHIBIT: Healthy male (21 inches long, 7 pounds) delivered to 22 y/o female Para 1 Gravida 1. Client is Rh negative and the newborn is Rh positive. Rubella titer less than 1:8. Hepatitis B status negative. Tetanus toxoid 2 years ago. 1. Measles, mumps and rubella (MMR) vaccine 2. Hepatitis A vaccine 3. Hepatitis B immune globulin 4. RH0(D) immune globulin 5. Tetanus toxoid
1., & 4. Correct: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother. 2. Incorrect: The mother is negative for hepatitis but current guidelines recommend that the newborn be given the hepatitis B vaccine. Hepatitis A vaccine is not given. 3. Incorrect: The mother is negative for hepatitis. If the newborn had been born to a mom who has hepatitis B, the newborn would receive the hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth. 5. Incorrect: Mom is up to date on tetanus toxoid vaccine.
A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? Select all that apply. 1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. 4. Position upright with head tilted slightly backwards. 5. Dissolve the cholinesterase inhibitor medication in water.
1., 2., & 3. Correct: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing. 4. Incorrect: Tilt head slightly forward (chin tuck, head turn). 5. Incorrect: The cholinesterase inhibitor should not be dissolved in water due to the client's difficulty swallowing. Liquids should be thickened.
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? Select all that apply. 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety. 3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse. 5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect.
Which intervention should the nurse initiate for a client post liver biopsy? Select all that apply. 1. Apply direct pressure to site immediately after needle is removed. 2. Assess puncture site every 15 minutes for 1 hour. 3. Position client on left side. 4. Keep client NPO for 24 hours. 5. Advise client that pain may occur in right shoulder as the anesthetic wears off.
1., 2., & 5. Correct: Anyone who has a liver problem is at risk for bleeding. The clotting factor produced in the liver is prothrombin. Anytime a needle is inserted into the body and removed, bleeding can occur. Whenever there is risk for bleeding, the preventive measure is to apply pressure. The puncture site should be monitored frequently. The client may experience some discomfort once the anesthetic wears off. 3. Incorrect: Lying on the left side does not put pressure on the puncture site. The liver is on the right side, as is the puncture site. 4. Incorrect: The client will be prescribed NPO for 2 hours. The client's usual diet as tolerated will be resumed after the 2 hours.
Three hours after delivery of a client's newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client's bladder is distended? Select all that apply. 1. Fundus 3 cm above umbilicus 2. Excessive lochia 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 5. Tenderness above symphysis pubis
1., 2., & 5. Correct: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also sign of distended bladder. 3. Incorrect: Voiding every 2-3 hours should be encouraged to prevent possible displacement of the uterus and the development of atony. The clients ability to do this would prevent bladder distention. 4. Incorrect: Fundus in abdominal midline is what we want and is not a sign of bladder distention. We do not want it displaced over to the side from midline.
Which nurse is providing cost effective care to a client? Select all that apply. 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves.
1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client.
A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? Select all that apply. 1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. 4. Positioning you with your affected lung down. 5. Palpating around the incision site for air under the skin.
1., 2., 3., & 5. Correct: Anytime fluid is being removed from a client, there is a risk they could develop a fluid volume deficit, or worse, shock. Checking vital signs frequently is important. Examining the dressing for bleeding is appropriate. Listening to lung sounds is appropriate. The nurse percusses the lungs as part of the respiratory assessment. (Hyperresonance indicates air in the pleural space. Dull percussions indicate fluid in the pleural space) Subcutaneous emphysema could indicate a pneumothorax. There is air leaking into the tissue. 4. Incorrect: Turn the client on the unaffected side for at least one hour to allow the pleural puncture site to heal and promote lung expansion of the affected lung.
Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen.
1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client has difficulty swallowing and is at risk for choking making the client unstable. Therefore, the nurse should not allow the UAP to feed this client.
In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? Select all that apply. 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 6. Obtain assistance from other nurses or nurse assistants as needed.
1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Select all that apply. 1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off.
1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. 6. Incorrect: Quality improvement looks at improving processes and does not use intimidation and punishment to improve quality care.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? Select all that apply. 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain
1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection. 5. Incorrect: Bleeding is not a sign of infection. It may occur along with an infection but will not be caused by it.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? Select all that apply. 1. Firm, nodular liver 2. Ascites 3. Increased serum albumin levels 4. Increased ALT and AST levels 5. Lowered ammonia levels 6. Bleeding from the GI tract
1., 2., 4., & 6. Correct: With cirrhosis, the liver can become very large in size and feels very firm and nodular upon palpation. Third spacing of fluids out of the vascular space (ascites) occurs due to lowered albumin levels. The client is often in a nutritional deficit which contributes to the lowered albumin level. Also, the liver is sick and unable to synthesize albumin. The liver enzymes ALT and AST will be elevated with liver problems such as cirrhosis. Increased pressure in the liver (portal hypertension) causes a backward pressure throughout the GI tract. Esophageal varices may form as a result of this pressure. If variceal rupture occurs, GI bleeding will be noted. In addition, liver diseases, such as cirrhosis, are the common causes of blood clotting problems because the liver is unable to produce the needed clotting factors. 3. Incorrect: Serum albumin levels are low in clients with cirrhosis. When the liver becomes damaged, it stops making certain proteins, including the blood protein albumin. 5. Incorrect: Ammonia levels rise in clients with cirrhosis because the liver is unable to convert the ammonia to urea to be excreted by the kidneys.
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply. 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5. Correct: These are written correctly with complete, concise and objective information for each statement pertaining to the client. 2. Incorrect: "Appears" is a subjective word. Remember to use objective words. Pain should be assessed in an objective manner, such as by using a pain scale that is appropriate for the client's age and communication abilities. If the client were unable to respond to a pain scale assessment, the nurse would need to describe objectively the behavior of concern; for instance, the nurse could document "client moaning, guarding abdominal area with both hands, and knees pulled towards chest". 4. Incorrect: Do not use trailing zeros after a decimal point to prevent incorrect dosage. Likewise, always lead a decimal point with a zero (0.5).
What should the nurse include when educating a client about the use of nitroglycerin sublingual. Select all that apply. 1. Do not swallow nitroglycerin. 2. Keep the medication is a moist, warm place. 3. The medication may burn when taken. 4. Sit or lie down when taking this medication. 5. The most common side effect is vomiting.
1., 3., & 4. Correct: Nitroglycerin is to be taken sublingually. Do not swallow because this will decrease the effectiveness of the medication. The medication may or may not burn or fizz when placed under the tongue. Because hypotension occurs due to vasodilation, the client should sit or lie down when taking to prevent injuries from falls. 2. Incorrect: Keep nitroglycerin in a dark, glass bottle and a dry and cool place to maintain the effectiveness of the medication. 5. Incorrect: The most common side effect is a headache and should be taught to the client as an expected side effect that does not have to be reported to the primary healthcare provider.
When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? Select all that apply. 1. Nervousness 2. Weight gain 3. Exophthalmos 4. Loss of appetite 5. Constipation 6. Hot and sweating
1., 3., & 6. Correct: With hyperthyroidism, the client has too much energy. They report being nervous and feeling hot. Exophthalmos is an irreversible eye condition where the eyes bulge. This condition is associated with hyperthyroidism that has not been treated early enough to prevent this from occurring. Due to the hypermetabolic state, the client will often report feeling hot and will be sweating. 2. Incorrect: The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 4. Incorrect: Loss of appetite is seen in the client with hypothyroidism. The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 5. Incorrect: Constipation is a sign of hypothyroidism due to slowed GI motility. In hyperthyroidism, the nurse would expect increased GI motility.
Which task would be appropriate for the charge nurse to assign to a LPN/VN? Select all that apply. 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
1., 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication. 2. Incorrect: Administering morphine IVP is out of the scope of practice for the LPN/VN since it is a complex, high risk IV push medication and has the potential to depress the client's respiratory rate.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Select all that apply. 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? 1. Prolonged bleeding time 2. Elevated reticulocyte count 3. Decreased platelet count 4. Elevated bands
2. Correct: Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase. 1. Incorrect: Prolonged bleeding times occur with liver problems. 3. Incorrect: A decreased platelet count will cause bleeding but will not tell the nurse if there is chronic bleeding. 4. Incorrect: Elevated bands are a part of the WBC differential and are increased with acute infection.
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container
2. Correct: Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities. 1. Incorrect: Hazardous, drug-contaminated sharps should not be placed in red biohazard containers that are used for infectious wastes, since these are often autoclaved or microwaved. 3. Incorrect: Biohazard waste containers are not designed for sharps and can cause injuries. 4. Incorrect: Chemical containers are not designed for sharps and can cause injuries.
A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? 1. "I will try to keep my legs together as close as possible." 2. "I will not elevate the head of the bed." 3. "I know that I cannot ever swim again." 4. "I can resume my exercises at the gym within one month."
2. Correct: Flexion of the hip should be avoided after hip surgery. Elevating the HOB would cause flexion, which could cause hip dislocation. 1. Incorrect: The legs should be kept in an abducted (legs apart) position following surgery to keep the head of the femur in the acetabulum (hip in the socket). An abductor pillow is often used to accomplish this and prevent the legs being close together or crossing. 3. Incorrect: Swimming is a non-weight bearing exercise that is encouraged during rehabilitation for post hip replacement clients. Walking is another good exercise for these clients. 4. Incorrect: Stressors on the hip joint should be kept to a minimum for the first 3 to 6 months. Some exercises in the gym could put too much strain on the new hip joint and cause dislocation.
The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? 1. Dilated pupils after 1 minute of CPR 2. Presence of a carotid pulse with each compression 3. Cardiac rhythm on the monitor 4. Rise and fall of client's chest with ventilations
2. Correct: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression. 1. Incorrect: Dilated pupils are a neurological sign. Pupils should constrict if CPR is effective and is not the priority assessment for determining effective CPR. 3. Incorrect: The cardiac rhythm reflects the electrical activity of the heart. It does not indicate effective cardiac compressions with CPR. 4. Incorrect: Responsiveness is a neurological check. It determines if the client responds to stimuli. Responsiveness is documented as alert, responds to verbal stimuli, and responds to painful stimuli, or unresponsive.
The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? 1. Apply gauze padding beneath the tubing. 2. Use petroleum jelly on the nares and cheeks. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears.
2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The charge nurse would not need to intervene if the new nurse applied gauze padding beneath the tubing to protect the client's skin. This is acceptable. 3. Incorrect: The charge nurse would not need to intervene if the new nurse provided mouth and nose care every four hours as needed to protect the client's skin and mucous membranes. This is acceptable. 4. Incorrect: The charge nurse would not need to intervene if the new nurse placed the oxygen mask straps well above the client's ears to protect the client's skin. This is acceptable.
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver
4. Correct: This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine. 1. Incorrect: The endotracheal (ET) tube is a device for maintaining an open airway, not for opening it. 2. Incorrect: This is a trauma client who may have a C-spine injury. The head tilt-chin lift maneuver would manipulate the client's C-spine therefore is not used with this client to open the client's airway. 3. Incorrect: The oral airway is a device for maintaining an open airway, not for opening it.
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1. Send the client to the waiting room. 2. Place the client in a negative pressure room. 3. Put a surgical mask on the client. 4. Initiate contact precautions.
2. Correct: The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure. 1. Incorrect: Sending this client to the waiting room will expose others to smallpox. Even if you don't recognize these specific disease symptoms, fever and rash should cue you to thinking of this as a potential infectious disease. 3. Incorrect: Having the client wear a surgical mask is not sufficient in this case. All healthcare providers should wear a N95 respirator when in contact with the client. After the client is sequestered, the nurse should notify the ED primary healthcare provider for further treatment instructions. 4. Incorrect: Airborne precautions are necessary because that is the primary transmission mode for smallpox.
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? 1. Maintain continuous cardiac monitoring. 2. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. 3. Provide alprazolam 0.25 mg PO PRN. 4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.
2. Correct: The respiratory status of the client takes priority. The administration of naloxone will block the opioid, initiating a reversal of the central nervous system (CNS) and respiratory depression. 1. Incorrect: Continuous cardiac monitoring is appropriate, however, airway takes priority. 3. Incorrect: Alprazolam will worsen respiratory depression. Alprazolam is a benzodiazepine. The action of this drug may depress the CNS. 4. Incorrect: IV fluids will be initiated, but airway takes priority.
The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? 1. Confusion and disorientation. 2. Scared and lonely and grabs the nurse's hand for comfort. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse.
2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question.
The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick.
2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow. 1. Incorrect: The finger should be dependent to enhance blood flow to the site, so it needs to be below the level of the heart to be effective. 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick.
The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? Select all that apply. 1. Document the medication with times and doses to be given, then administer the medication as ordered. 2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. 5. Call the pharmacy to see if the medication needs to be changed.
2., 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety. 1. Incorrect: No, this medication could cause harm to the client. The client is allergic to this medication. 5. Incorrect: No, the primary healthcare provider, not the pharmacy, should be notified for medication changes. The primary healthcare provider is responsible for prescribing the medication.
What symptoms does the nurse expect to see in a client with bulimia nervosa? Select all that apply. 1. Amenorrhea 2. Feelings of self-worth unduly influenced by weight 3. Recurrent episodes of binge eating 4. Recurrent inappropriate compensatory behavior to prevent weight gain 5. Lack of exercise
2., 3. & 4. Correct: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa. 1. Incorrect: Amenorrhea is found in anorexia nervosa. 5. Incorrect: Excessive exercise is found in bulimia nervosa as a means to compensate for the binge eating.
What should the nurse include when teaching a client in renal failure about peritoneal dialysis? Select all that apply. 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately.
Which client should the nurse, working the Emergency Department (ED), see first? 1. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. 2. Client who is a diabetic and has an infected sore on the foot. 3. Client with adrenal insufficiency who feels weak. 4. Client with a fracture of the forearm that has been placed in a splint.
3. Correct: Adrenal insufficiency with weakness think SHOCK first. This is a client that does not have enough of all their steroids, including glucocorticoids, mineralocorticoids or sex hormones. The most pertinent of these is aldosterone, which causes loss of sodium and water, and leads to shock (fluid volume deficit). Since the client is feeling weak, this is a clear sign of fluid volume deficit (FVD) and potentially for shock. 1. Incorrect: Symptoms of Chronic Obstructive Pulmonary Disease (COPD), include a non-productive cough, because of the chronic inflammation and mucous in the lungs. 2. Incorrect: The presenting problem is the infected sore on the foot, not the client's diabetes. This is not an emergency situation. Therefore, this client would not be the priority. 4. Incorrect: Since the arm is splinted, the client is stable until further assessments and treatments can be completed, such as x-rays, medications, and casting. The client would not be seen first in this situation.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.
3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse.
A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? 1. Administer the medication as prescribed. 2. Obtain pre-filled syringes from the pharmacy. 3. Discuss client rights with the primary healthcare provider. 4. Tell the client what has been prescribed.
3. Correct: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is that deception is involved. Deceit is harmful to both clients and healthcare professionals. 1. This is causing an ethical dilemma for the nurse. The nurse is now lying to the client by giving the placebo which is clearly wrong. The client is not aware that the solution administered is sterile saline. 2. Obtaining pre-filled syringes does not correct the ethical dilemma faced by the nurse and does nothing to fix the problem. 4. Telling the client will cause mistrust. It is best to discuss the issue with the primary healthcare provider. A discussion with the primary healthcare provider concerning the saline order should occur prior to any discussion with the client.
A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"
3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby.
What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain? Select all that apply. 1. Decreased sensation to touch. 2. Impaired vision. 3. Impaired speech. 4. Decreased concentration. 5. Decreased hearing.
3., & 4. Correct: The frontal lobe is responsible for motor control, ability to speak words, concentration, memory, and judgment. 1. Incorrect: This is the function of the parietal lobe. 2. Incorrect: This is the function of the occipital lobe. 5. Incorrect: This is the function of the temporal lobe.
A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? 1. Instruct the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client. 3. Advise the spouse to consider an extended care facility for the client. 4. Determine why the spouse is not encouraging self-care by the client.
4. Correct: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems. 1. Incorrect: Simply instructing the spouse to require the client to perform self-care activities may result in affirmative verbal response from the spouse without actual follow-through after the home health nurse leaves. 2. Incorrect: Hiring others to perform care activities that the client can do independently does not contribute to the self-care model. 3. Incorrect: There are no indications provided in the stem that the client needs an extended care facility.
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client with twins at 28 weeks gestation.
4. Correct: Both clients are presenting with the possibility of preterm deliveries. The room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure. 1. Incorrect: The client will require frequent postpartum assessments and nursing care. The client will likely have a great deal of activity in her room and this would be potentially harmful to the newly admitted client. 2. Incorrect: This client will have a increase of activities in her room as the preterm labor progresses. There is also the potential of an emergency delivery. 3. Incorrect: The client is admitted with placenta previa. Emergency deliveries may occur if the client becomes hypovolemic or there are signs of fetal compromise.
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? 1. TPN has been hanging for 12 hours 2. Central venous catheter's dressing is clean and dry 3. TPN fluid is room temperature when beginning administration 4. TPN appears oily in consistency
4. Correct: Do not use TPN if it looks curdled, oily, or has particles in it. This is an indication that something is wrong with the solution and could harm the client if given. 1. Incorrect: This TPN does not need to be replaced at 12 hours. It can infuse for 24 hours. 2. Incorrect: This is a description of an occlusive clean dressing at the insertion site. This description would not require intervention. 3. Incorrect: TPN should be at room temperature when beginning administration. Solutions that is too cold could cause vasoconstriction and undue harm to the client.
What instruction is most important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously? 1. Alternate the injection sites from one body area to another with each dose. 2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe. 3. Massage the injection site after the medication is injected. 4. Insulin syringes should be stored at room temperature.
4. Correct: Insulin syringes and needles should be stored at room temperature. The potential benefits or risks of refrigerating the syringe are unknown. 1. Incorrect: Insulin injection sites are rotated, but within a chosen site e.g., the abdomen. Once all the sites in that area are used, then another area of the body is selected e.g., the arm. 2. Incorrect: As a rule, remember clear before cloudy; that is, draw up the regular (clear) insulin first, and then draw up the long acting insulin, isophane suspension (cloudy). 3. Incorrect: Gently blot any blood with a gauze pad. Do not massage the site. Massaging or rubbing the site will alter the rate of absorption of the medication.
During shift change the night charge nurse reports to the day charge nurse that the client admitted with an ingestion of unknown drugs, was physically restrained last night at 10:00 pm. The client was incoherent, combative, and attempting to leave the facility. No family members were present. The night charge nurse noted that there was no primary healthcare provider prescription for the restraints. On last assessment 30 minutes ago, the client was still combative. What is the best action by the day shift charge nurse? 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain a prescription from the primary healthcare provider on rounds this shift.
4. Correct: Since the restraints are still needed and 24 hours have not passed, it would be acceptable to wait until the primary healthcare provider makes rounds. A prescription for physical restraints must be written within a 24 hour period. Generally, restraints are not used past a 24 hour period. The prescription for the restraint should include why the client requires physical restraints and a time period for using them and no more than 24 hours. 1. Incorrect: Do not assume. The oncoming nurse needs to assess the client in order to determine if restraints are still needed for the safety of this client. 2. Incorrect: If the client is indeed still incoherent and combative, restraints are still warranted to prevent the client from harming self or others. 3. Incorrect: Periodical checks will not keep the client from harming self or others and "periodically" is not an acceptable time frame for this action.
After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? 1. Leave the client lying with the unaffected ear facing up. 2. Place a cotton ball firmly into the affected ear for 15 minutes. 3. Pull the pinna of the ear down and back. 4. Gently massage the tragus of the ear.
4. Correct: This is a correct nursing measure that will facilitate the flow of medication in the auditory canal. 1. Incorrect: The client can remain on the side for 5 to 10 minutes with the affected ear up to help distribute the medication and prevent the medication from escaping the ear canal. 2. Incorrect: The cotton ball is placed loosely at the opening of the auditory canal for 15 minutes to prevent the medication from escaping the canal when the client changes positions. 3. Incorrect: The pinna is pulled up and back on an adult client when instilling the ear drops to straighten the ear canal.
