safety
A school-age child has been diagnosed with Graves disease and is to start drug therapy. Which instruction should the nurse include in the teaching plan for the child's parent and teacher? Limit the amount of food that is offered to the child. Provide the child with a calm, nonstimulating environment. Understand that mood swings are rare with this disorder. Continue with the same amount of schoolwork and homework.
Provide the child with a calm, nonstimulating environment. Explanation: Because it takes approximately 2 weeks before the response to drug treatment occurs, much of the child's care focuses on managing the child's physical symptoms. Signs and symptoms of the disorder include an inability to sit still or concentrate, increased appetite with weight loss, emotional lability, and fatigue. Nursing care is directed toward ensuring that the parent and teacher know how to handle the child and suggesting a shortened school day, a nonstimulating environment, and decreased stress and workload. The child should be encouraged to eat a well-balanced diet.
The nurse is caring for a client with a panic attack. Which nursing intervention is most helpful for this client? Encourage the client to verbalize any fears, feelings, or concerns. Encourage the client to learn relaxation techniques. Encourage the client to identify what precipitated the attack. Stay with the client and remaining calm, confident, and reassuring.
Stay with the client and remaining calm, confident, and reassuring. Explanation: A panic-stricken client requires the assistance of a calm person who can provide support and direction. This approach is particularly important because the client already feels frightened and out of control. Having someone remain with the client helps prevent the client from feeling isolated and deserted. Encouraging the client to verbalize any fears, feelings, or concerns or encouraging the client to identify what precipitated the attack is futile because the client's level of anxiety prevents them from focusing on precipitating factors. Also, encouraging the client to learn relaxation techniques is not possible at this time as the client is unable to learn new information when the anxiety level is at the panic level. Staying with the client is the best action for the nurse.
The nurse assesses an aggressive client. Which behavior warrants the nurse's prompt reporting and use of safety precautions? starting a petition to delay bedtime declining attendance at a daily group therapy session naming another client as their adversary crying when talking about their recent divorce
naming another client as their adversary Explanation: The client exhibits aggression against a perceived adversary when they name another client as their adversary. The staff will need to watch the client carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate (not pathologic) behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action.
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? wearing of sterile gloves to bathe a neonate at 2 hours of age use of protective goggles during a caesarean birth placement of bloody sheets in a container designated for contaminated linens disposal of used scalpel blades in a puncture-resistant container
wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.
A client is to be discharged from an alcohol rehabilitation program. What should the nurse emphasize in the discharge plan as a priority? supportive friends a list of goals returning to work follow-up care
follow-up care Explanation: Follow-up care is essential to prevent relapse. Recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self-help group meetings, and other forms of aftercare. Supportive friends, a list of goals, and returning to work may be important and helpful to the client, but follow-up care is essential.
The graduate nurse is preparing to hang a secondary medication. The preceptor reminds the graduate nurse that two different medications will be running at the same time. What should the graduate nurse do? Select all that apply. Confer with the preceptor in deciding if compatibility is an issue and what should be done. Call the pharmacy and ask what should be done. Call the healthcare provider to ask if the medication is compatible with the I.V. fluid. Refer to a compatibility chart. Mix both medications and determine if there are color changes.
Confer with the preceptor in deciding if compatibility is an issue and what should be done. Refer to a compatibility chart. Explanation: The graduate nurse should refer to a compatibility chart and then confer with the preceptor determining compatibility and what should be done. The nurse should not mix the medications to determine change of color, this will prove nothing. The nurse should not call the pharmacy or the healthcare provider.
A client is receiving a transfusion of packed red blood cells. What should the nurse do to safely administer the blood? Do not infuse blood that has been hanging for more than 6 hours. Keep the blood refrigerated on the nursing unit until ready to administer. Administer the blood quickly to prevent wasting it if the client develops a fever. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction. Explanation: The nurse should stay with the client during the first 15 minutes of a blood transfusion because this is when reactions are most likely to occur. Blood products should never be refrigerated on the nursing unit. Blood that has not been infused after 4 hours should not be infused. The blood should be infused over the specific time prescribed by the health care provider (HCP). If a fever develops, the transfusion should be stopped immediately, and the blood reaction policy of the facility should be followed.
A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles?
The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. Explanation: The nurse should raise the bed for transfer, maintain a wide base of support during transfer, and lower the bed before leaving the room. Lowering the bed for a transfer places the nurse at risk for injury. Raising the bed before leaving the room places the client at risk for injury. The nurse should maintain a wide base of support for transfers and shouldn't encourage the client to grab or hold onto staff members during transfers. Although the nurse should explain the procedure to the client, the nurse shouldn't grab the client under the arms. This action could cause shoulder injury or nerve damage. The nurse shouldn't pull a client during transfers; doing so places the client at risk for skin-shear injuries.
A client has developed hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. Verify the medication prescription as written by the health care provider. (HCP). Return the cefazolin to the pharmacy. Request that cephalexin be sent promptly. Contact the pharmacy and speak to a pharmacist. Administer the cefazolin.
Verify the medication prescription as written by the health care provider. (HCP). Contact the pharmacy and speak to a pharmacist. Request that cephalexin be sent promptly. Return the cefazolin to the pharmacy. Explanation: One of the "five rights" of drug administration is "right medication." Cefazolin was not the medication prescribed. The pharmacist is a professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse.
A nurse is caring for a client who's in labor. The health care professional still isn't present. After the neonate's head is delivered, which nursing intervention would be appropriate? checking for the umbilical cord around the neonate's neck placing antibiotic ointment in the neonate's eyes assessing the neonate for respirations turning the neonate's head to the side to drain secretions
checking for the umbilical cord around the neonate's neck Explanation: After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment is administered to the neonate after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The neonate's head isn't turned during delivery. After birth, the neonate is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after birth.
A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority? offering the client a less-stimulating area in which to calm down ensuring the safety of this client and other clients on the unit removing the other clients from the area until this client settles down isolating the agitated client and offering sedation to calm the behavior
ensuring the safety of this client and other clients on the unit Explanation: Ensuring the safety of this client and other clients on the unit is the nurse's immediate priority. Moving the agitated client to a less-stimulating environment, isolating the client, or sedating the client address the client's needs but don't address those of the other clients. Removing other clients from the area until the agitated client calms down addresses the safety of the other clients without addressing the needs of the agitated client.
A client has accidentally received twice the normal dose of a medication that was administered on the previous shift. What should the nurse who discovers the error do first? Call the person who made the error, and request that an incident report be completed. Call the health care provider (HCP) to obtain a prescription for additional intravenous (IV) fluids to dilute the drug. Assess the client, and note any changes in condition. Administer a drug antidote per standing prescription.
Assess the client, and note any changes in condition. Explanation: In any situation that involves a medication error, the nurse first assesses the client immediately to determine any changes in condition and the need for urgent interventions. Calling the HCP or administering an antidote is not done until the client is assessed and the necessary data are gathered. The nurse finding the error can complete an incident report after the client's safety is established and any emergency treatments are completed.
A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? while walking, do weight bearing on the cast to increase balance. conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. keep the affected limb in extension and abduction at all times. sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches.
conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. Explanation: When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.
The nurse assesses an infant with a suspected inguinal hernia. Which finding would be most concerning? The infant's diaper is wet with urine, and the abdomen is nontender. The inguinal swelling can be reduced, and the infant has stool in their diaper. The inguinal swelling is reddened, and the abdomen is distended. The infant is irritable, and a thickened spermatic cord is palpable.
The inguinal swelling is reddened, and the abdomen is distended. Explanation: Abdominal distention and redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. A strangulated hernia necessitates immediate surgical intervention. The ability to reduce the hernia and normal stooling do not indicate it is incarcerated. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which problem? hygiene needs fatigue bleeding fainting
fainting Explanation: Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes their first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. The nurse determines a client's risk for bleeding before allowing them to shower. If the client was at high risk for bleeding, the shower should be delayed. Once in the shower, bleeding status would be difficult to determine.
A newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions? "Notify your healthcare provider if you experiences visual changes." "Limit foods high in potassium, such as bananas." "Report your morning and afternoon heart rates to your healthcare provider." "Increase your calorie intake if your appetite decreases."
"Notify your healthcare provider if you experiences visual changes." Explanation: Hypokalemia can exacerbate digoxin toxicity so potassium should not be limited. The client will be taught the signs and symptoms of digoxin toxicity and what needs to be reported to the healthcare provider. Visual changes and anorexia are signs of digoxin toxicity and should be reported. The heart rate will not need to be verified twice a day. Anorexia is a symptom of digoxin toxicity so if the client is anorexic that should be reported to the healthcare provider.
A 49-year-old client is admitted to the emergency department frightened and reporting hearing voices telling the client to do bad things. Which intervention should be the nurse's priority? Provide reassurance that the client is safe and the voices are not real. Assess the nature of the commands by asking what the voices are saying. Provide reassurance that the client is safe and promise the staff will protect the client. Administer a neuroleptic medication before speaking with the client.
Assess the nature of the commands by asking what the voices are saying. Explanation: Safety is the priority. The nurse should ask the client directly about the nature of the auditory commands to ensure the safety of the client and staff. The nurse should never make promises to the client that the nurse may not be able to fulfill. The provider may order a neuroleptic, but the nurse's priority is to address safety.
The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for an intravenous infusion. What should the nurse do next? Report the problem to the information technology team to have the barcode system recalibrated. Ask another nurse to verify the medication and the client so the medication can be given now. Contact the pharmacist immediately to check the prescription and the barcode label for accuracy. Administer the medication now, knowing the medication is labeled and the client is identified.
Contact the pharmacist immediately to check the prescription and the barcode label for accuracy. Explanation: The nurse should contact the pharmacist first to be sure the medication is labeled for administration to this client. The nurse should not administer the drug until all safety precautions have been observed; the nurse should also not ask another nurse to verify the medication or client. Later, if the problem cannot be resolved by relabeling the medication, the nurse or pharmacist can contact the information technology team to check the barcode system.
Which goal is most important when developing a long-term care plan for a child with hemophilia? Improve the child's self-esteem during bleeding episodes. Increase the parent's and child's knowledge about hemophilia. Prevent injury during each stage of development. Manage acute pain when there is bleeding into joints.
Prevent injury during each stage of development. Explanation: The priority for ongoing care for this child is to prevent injury while maintaining normal growth and interests. As with all chronic illnesses, there is a potential for self-esteem problems, but no data are presented to support this as a priority for care planning. The parents should have a good understanding of the disease process and realize the importance of obtaining regular health care for their child. The client may have episodes of acute pain, for the child who has bleeding into a joint, but this is a transient situation.
A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in their left chest. The client tells the nurse how excited they are because the client's planning to go rifle hunting with a grandson. How should the nurse respond?
"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." Explanation: The recoil from the rifle can damage the ICD, so the client should be warned against shooting a rifle with the left hand. Close proximity to a rifle won't cause the ICD to fire inadvertently. The client shouldn't take an extra dose of antiarrhythmic.
The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do? Raise the side rails to full upright position. Elevate the head of the bed. Loosen the bed restraints so the client can sit up. Assess the client to determine why she wants to sit up.
Assess the client to determine why she wants to sit up. Explanation: The nurse should first determine why the client wants to sit up and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising the side rails and elevating the head of the bed do not address the client's needs.
A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first?
Institute suicide precautions. Explanation: Delusions of grandeur are common symptoms of the manic phase of bipolar disorder. The priority nursing action is to maintain client safety and institute suicide precautions. Administering an antipsychotic and asking about the suicide plan are acceptable nursing actions, but first the nurse must ensure client safety. Asking a family member to sit with the client inappropriately delegates responsibility to someone else; the nurse must address the issue of client safety immediately.
A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: amphetamines. barbiturates. benzodiazepines. methadone.
methadone. Explanation: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as opiates such as heroin and morphine or stimulants such as cocaine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and using these drugs would make further detoxification treatment necessary.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? plastic spoon single-hole nipple paper straw rubber dropper
rubber dropper Explanation: An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.
The emergency department nurse is caring for a client having a STEMI. The health care provider has prescribed a weight-based heparin bolus of 40 units/kg, with a maximum dose of 4000 units. The client weighs 250 lb (113.64 kg). How many units of heparin will the nurse give?
4000 Explanation: To calculate a weight-based medication prescription, you must multiply the client's weight in kilograms by the prescribed dosage. 113.64 kg x 40 units/kg = 4545.6 units However, for this problem, the maximum heparin bolus allowed is 4000 units, so this client should be given 4000 units of heparin. More than the maximum dose should never be given. Heparin is a high-risk medication and giving too much could have serious consequences, such as uncontrolled hemorrhage.
A young adult client is brought to the emergency department with their fiancée after being involved in a serious motor vehicle crash. The client's Glasgow Coma Scale score is 7, and they demonstrate evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? The nurse will obtain a signed consent from the client's fiancée because the fiancée is of legal age and the couple is engaged to be married. Two nurses will receive verbal consent by telephone from the client's next of kin before inserting the catheter. The health care provider (HCP) will get a consultation from another HCP and proceed with the placement of the ICP catheter until the family arrives to sign the consent. The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent
The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. Explanation: In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which indicates a comatose state. The client cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The HCP should insert the catheter in this emergency. The client's fiancée cannot sign the consent because until the couple is married or the fiancée has designated power of attorney, the fiancée is not considered the client's next of kin. The HCP does not need to get a consultation from another HCP. When consent is needed for a situation that is not a true emergency, two nurses can receive verbal consent by telephone from the client's next of kin.
nurse should question an order for a heating pad for a client who has tight back muscles. a reddened abscess. active bleeding. purulent wound drainage.
active bleeding. Explanation: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.
A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to: remove all other clients from the day room. place the client in full leather restraints. call the physician and report the behavior. check the client's medical record for an order for an as-needed dose of medication for agitation.
remove all other clients from the day room. Explanation: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. Checking for an as-needed drug order and calling the physician are appropriate responses after ensuring the safety of other individuals. Because the client poses a danger to self and others, restraints may be used; however, less restrictive interventions should be attempted first.
A client is taking vancomycin. The nurse should report which possible side effect to the health care provider? tinnitus vertigo ataxia muscle stiffness
tinnitus Explanation: The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.
A client with a urinary tract infection is ordered co-trimoxazole. The nurse should provide which medication instruction? "Take the medication with food." "Don't be afraid to go out in the sun." "Avoid taking antacids during co-trimoxazole therapy." "Drink at least eight 8-oz (240 mL) glasses of fluid daily."
"Drink at least eight 8-oz (240 mL) glasses of fluid daily." Explanation: The nurse should instruct a client receiving a sulfonamide such as co-trimoxazole to drink at least eight 8-oz (240 mL) glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.
A short time after administering pain medication to a client, the nurse returns to the client's room and finds the client difficult to arouse. The nurse realizes that 25 ml of the liquid medication was administered instead of the ordered 25 mg, which is contained in 5 ml. How could the nurse have prevented this error? Have another nurse double check the medications before administration. Carefully review the order and medication label, then calculate the ordered dose. Attempt non-pharmacological pain control methods, and administer PRN pain medications as a last resort. Highlight dosage instructions on the medication bottles.
Carefully review the order and medication label, then calculate the ordered dose. Explanation: The nurse should always take the time to identify the client, carefully review the medication order, read the medication label, and calculate the ordered dose. Consistently following these steps helps prevent medication administration errors. The nurse should double check calculations with another nurse, not ask another nurse to double check all medications. The nurse can use non-pharmacological pain therapies, but as an adjunct to pain medications and not a last resort. Using non-pharmacological therapies only delays treatment and places the client at risk for intensified pain. Highlighting dosage instructions can lead to errors if done inconsistently. It is best to carefully review each order.
To give a Z-track injection, a nurse measures the correct medication dose and then changes the needle on the syringe. What is the rationale for this action? Changing the needle prevents the solution from entering a blood vessel. Changing the needle ensures that the client receives the entire dose. Changing the needle makes the injection less painful. Changing the needle prevents the drug from flowing back into the needle track.
Changing the needle makes the injection less painful. Explanation: Changing the needle decreases pain by eliminating any medication that may have been left on the needle and that could irritate the skin. Changing the needle has no bearing on whether the drug enters a blood vessel. Changing the needle isn't necessary to ensure that the client receives the entire dose and doesn't prevent the drug from flowing back into the needle track.
When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? Discontinue the I.V. infusion at that site and restart it in the other arm. Irrigate the I.V. tubing with 1 ml of normal saline solution. Check the tubing for kinks and reposition the client's wrist and elbow. Elevate the I.V. fluid bag.
Check the tubing for kinks and reposition the client's wrist and elbow. Explanation: The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge any clots that are present. Elevating the I.V. fluid bag may help if the nurse finds no kinks and if repositioning doesn't resolve the problem.
The nurse is preparing to administer a continuous enteral feeding. Which action is most important for the nurse to include in the plan of care? Inject air into the feeding tube to verify placement. Position the client on the left side. Elevate the head of the bed. Warm the formula before administering it.
Elevate the head of the bed. Explanation: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Injecting air into a feeding tube to verify placement is highly unreliable and should only be used to help confirm a test of the pH of the gastric aspirate.
A client is admitted to the emergency department after intentionally taking an overdose of amitriptyline hydrochloride. A nurse knows that giving the client activated charcoal will stimulate bowel motility so the client excretes the drug rapidly. bind with the ingested drug. neutralize the ingested drug. cause the client to vomit the ingested drug.
Explanation: Activated charcoal binds with the drug so that the body doesn't absorb it. Giving a client activated charcoal won't promote vomiting or stimulate bowel motility, and it doesn't neutralize the drug.
Which instruction should a nurse include in a home-safety teaching plan for a pregnant client?
Place a nonskid mat on the floor of the tub or shower. Explanation: Using a mat for the floor of the shower or tub will prevent slipping. The client shouldn't clean the cat's litter box because doing so puts her at risk for toxoplasmosis. Wearing high heels may make the client lose balance and fall. The client doesn't need to completely avoid having area rugs around the house. Nonslip rugs can be used to prevent tripping or falling.
When providing oral hygiene for an unconscious client, the nurse must perform which action? Place the client in semi-Fowler's position. Clean the client's tongue with gloved fingers. Place the client in a side-lying position. Swab the client's lips, teeth, and gums with lemon glycerin
Place the client in a side-lying position. Explanation: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.
A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first? Remove the client from the room. Use the fire extinguisher. Put a heavy blanket over the lamp. Call for help.
Remove the client from the room. Explanation: The acronym RACE promotes the safest sequence of response to fire. The letters stand for Remove the client from the scene, Activate the alarm, Contain the fire, and Extinguish the blaze.
An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? Verify that the site, side, and level are marked. Ask the parents if they have signed the operative permit. Ask the teen to point to the surgery site. Restate the surgery risks to the parents.
Verify that the site, side, and level are marked. Explanation: As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.
A client who is 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy? tachycardia sedative use dehydration hypertension
dehydration Explanation: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a sickle cell crisis
The nurse is teaching the client who has had laser surgery for retinal detachment. What should the nurse tell the client about activity while recovering from surgery? The activity level is: increased gradually; the client can resume usual activities in 5 to 6 weeks. restricted for about 2 months; the client should plan on being sedentary. not restricted; clients can resume usual activities. determined by the client's tolerance; clients can be as active as they wish.
increased gradually; the client can resume usual activities in 5 to 6 weeks. Explanation: After laser surgery, the retinal tear needs time to heal completely. This may take up to 2 months. Therefore, the resumption of activity should be gradual; typically, the client may resume usual activities in 5 to 6 weeks. Successful healing should allow the client to return to a previous level of functioning.
At what time should the blood be drawn in relation to the administration of the IV dose of gentamicin sulfate? 4 hours before the administration of the next IV dose just before the administration of the next IV dose 3 hours before the administration of the next IV dose 2 hours before the administration of the next IV dose
just before the administration of the next IV dose Explanation: To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next IV dose of gentamicin sulfate.
The client has just returned to the nursing unit following a gastrectomy. The nurse should place the client in which position? prone supine lateral recumbent low Fowler
low Fowler Explanation: A client who has had abdominal surgery is best placed in a low Fowler position postoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory and cardiovascular function. The prone, supine, or lateral recumbent position would not be tolerated by a client who has had abdominal surgery, nor do those positions support respiratory or cardiovascular functioning.
The nurse observes a visitor having a tonic-clonic seizure on the floor in the hallway of the acute care floor. What is the nurse's appropriate intervention when caring for the visitor? restraining the visitor to prevent harm placing an object between the teeth to prevent airway obstruction protecting the visitor's head with a pad to prevent injury laying the visitor on the back
protecting the visitor's head with a pad to prevent injury Explanation: Protect the head with a pad to prevent injury from striking hard surfaces during the seizure. After the visitor begins to have a seizure, nothing should be attempted to be inserted into the mouth. Broken teeth and injury to the mucosa may result. The visitor should be placed on the side if at all possible to facilitate drainage of saliva and mucus.
An older client reports episodes of severe anxiety resulting in shortness of breath, palpitations, chest pain, dizziness, and nausea. The physician prescribes lorazepam. What effect of this medication would be most important for the nurse to monitor on this client? sedation sleep disturbance paradoxical reactions hyponatremia
sedation Explanation: Lorazepam use, especially in older adults, has a pronounced sedative effect. This puts the client at risk for injury and falls. Hyponatremia, paradoxical reactions, and sleep disturbances are less common adverse effects of lorazepam and would not be as acutely dangerous to the elderly client as sedation.
A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to select special foods from a diet after client education by the nurse. change their own dressing with clean technique and be able to verbalize the steps. walk from their room to the end of the hall and back before discharge. walk with help in the hallway by the end of the evening shift.
walk from their room to the end of the hall and back before discharge. Explanation: Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change their own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.
A nurse is transferring a client to the operating room for a right leg amputation. What National Patient Safety goals will the operating room nurse follow? Select all that apply. Match the client identification number with the surgical permit. Have the right leg marked as the surgical site. Conduct a time out prior to the surgery. Read the client's identification arm band. Allow the client to sign the surgical consent form.
Conduct a time out prior to the surgery. Have the right leg marked as the surgical site. Read the client's identification arm band. Explanation: The nurse will follow the three National Patient Safety goals by conducting a time out prior to the surgery, marking the correct surgical site as the right leg, and using the client's arm band for client identification. Signing the consent form and matching the identification number with the surgical permit are not safety goals.
When teaching a client when to take glipizide to maximize the effectiveness of the drug, the nurse should instruct the client to perform which action? Take glipizide immediately after meals. Take glipizide as indicated by blood glucose values. Take glipizide four times a day at evenly spaced intervals. Take glipizide 30 minutes before breakfast.
Take glipizide 30 minutes before breakfast. Explanation: Glipizide is most effective when taken 30 minutes before breakfast. The duration of action is 10 to 24 hours.If the drug needs to be taken more than once a day, the dosage may be divided and taken twice a day before meals.It is not as effective to take the drug after meals.Although blood glucose levels will be monitored, the values do not dictate when the drug should be taken.
In preparation for total knee surgery, a 200-lb (90.7-kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications? weight lifting walking tai chi exercise aquatic exercise
aquatic exercise Explanation: When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.
A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation? asking the physician to make an incision and allowing the affected area to drain elevating the affected limb, applying cold compresses, and administering hyaluronidase as ordered elevating the affected limb, applying warm compresses, and administering phentolamine as ordered maintaining the limb in a dependent position and massaging it every 15 minutes
elevating the affected limb, applying warm compresses, and administering phentolamine as ordered Explanation: If extravasation occurs with dopamine administration, the nurse should elevate the affected limb, apply warm compresses, and administer phentolamine as ordered. The nurse shouldn't massage the limb or apply cold compresses. Physicians don't generally order hyaluronidase for dopamine extravasation. An incision isn't required or appropriate to drain the affected area.
The nurse gave the client the wrong medication. It is 2 hours later when the nurse realizes the error. What should the nurse do first? Assess the client's condition. Report the error to the unit manager. Notify the health care provider (HCP) of the error. Complete an incident report.
Assess the client's condition. Explanation: The nurse's first response to the error is to assess the client for any untoward reactions as a result of the error. Notifying the HCP and unit manager of the error as well as completing an incident report are all appropriate later actions, but the first action is to assess the client.
The nurse from the nursery is bringing a newborn to a client's room. The nurse took care of the client yesterday and knows the client and baby well. The nurse should implement which action to ensure the safest transition of the infant to the birth parent? Complete the hospital identification procedure with birth parent and infant. Ask the birth parent if there is anything else they need for the care of the baby. Assess whether the birth parent is able to ambulate to care for the infant. Check the crib to determine if there are enough diapers and formula.
Complete the hospital identification procedure with birth parent and infant. Explanation: The hospital identification procedures for clients and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the client and infant; this validation is a standard of care in an obstetric setting. Assessing the client's ability to ambulate, asking if there is anything else the client needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the client, but identification verification is a safety measure that must occur first.
When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands: results of treatment are rapid and dramatic but may not last. the client must take benztropine as ordered to prevent a return of symptoms. although uncomfortable, this reaction isn't serious. the client shouldn't buy drugs on the street.
the client must take benztropine as ordered to prevent a return of symptoms. Explanation: An oral anticholinergic agent such as benztropine is commonly ordered to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate.
A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which is the most appropriate response by the OHN? "Most nurses who have been splashed do not test positive if they wash immediately." "The test results will vary during the first year of testing for the disease." "We will test you in 4 weeks, and then we will have a definitive answer." "Accurate results will be obtained by testing at 3 months and again at 6 months."
"Accurate results will be obtained by testing at 3 months and again at 6 months." Explanation: Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.
A client is escorted to the psychiatric unit from the emergency department (ED) by staff and a security officer. The client's shoulder is bandaged, and their arm is in a sling because of a self-inflicted gunshot wound to the shoulder. Later, the client's spouse follows with a bag of the client's belongings. Which nursing action is most appropriate at this time? Ask the spouse whether the bag contains anything dangerous. Inspect the bag and its contents in the presence of the client and spouse. Instruct the spouse to unpack the bag and put the client's things in the dresser. Tell the spouse to take the items home because the client is suicidal.
Inspect the bag and its contents in the presence of the client and spouse. Explanation: The nurse inspects the bag and its contents in the presence of the client and the spouse so that they know what is allowed on the unit and what should be returned home and why. The nurse is responsible for the client's safety and that of the other clients and staff. Telling the spouse to take the client's things home because the client is suicidal diminishes the client's self-worth and is inaccurate. Instructing the spouse to unpack the bag and put the client's things away is inappropriate because it is the nurse's responsibility to manage safety issues pertaining to the client and the unit. Asking the spouse whether the bag contains anything dangerous would be poor judgment on the part of the nurse because the spouse would not be knowledgeable about the safety factors.
The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response? Inform the authorities, and begin evacuating clients and closing doors. Hang up the telephone immediately, and instruct a colleague to call 911 promptly. Hang up the telephone, and use the overhead paging system to call all staff to the nurses' station. Keep the individual on the line in order to gather more information about the details of the threat.
Keep the individual on the line in order to gather more information about the details of the threat. Explanation: If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.
A school-age child has been diagnosed with Graves disease and is to start drug therapy. Which instruction should the nurse include in the teaching plan for the child's parent and teacher? Provide the child with a calm, nonstimulating environment. Limit the amount of food that is offered to the child. Understand that mood swings are rare with this disorder. Continue with the same amount of schoolwork and homework.
Provide the child with a calm, nonstimulating environment. Explanation: Because it takes approximately 2 weeks before the response to drug treatment occurs, much of the child's care focuses on managing the child's physical symptoms. Signs and symptoms of the disorder include an inability to sit still or concentrate, increased appetite with weight loss, emotional lability, and fatigue. Nursing care is directed toward ensuring that the parent and teacher know how to handle the child and suggesting a shortened school day, a nonstimulating environment, and decreased stress and workload. The child should be encouraged to eat a well-balanced diet.
A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation? Adjust the medication administration record to reflect the correct dose only. Both nurses must acknowledge making the medication error. Tell the pharmacist that the wrong quantity of medication was sent to the unit. Only the nurse who transcribed the order should be accountable for the error.
Both nurses must acknowledge making the medication error. Explanation: The correct answer is that both nurses are responsible for this error. The first nurse transcribed the order incorrectly and did not recognize that the dose was too high when administering the medication. The second nurse should have known the dose was too high. Both nurses must admit to the error. The other options do not reflect a nurse's responsibility in admitting to an error and preventing injury to clients
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will decrease the bleeding. allow proper visualization of the large intestine. allow proper visualization of the small intestine. make the client more comfortable.
allow proper visualization of the large intestine. Explanation: For a colonoscopy, the nurse initially should position the client on the left side with knees bent to permit proper visualization of the large intestine. Visualization of the small intestine is not a goal of the procedure. This positioning of the client does not necessarily make the client more comfortable, and it does not affect the amount of any bleeding that may occur.
