The Point: Safety - 1137

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding? -The order is correct and valid. -The order should specify the precise time to give the drug. -The ordered route is inappropriate for administration of this drug. -The nurse should clarify the order with the physician.

-The nurse should clarify the order with the physician.

A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The health care provider (HCP) has prescribed 2 units of packed red blood cells (RBCs). What should the nurse determine prior to initiating the blood transfusion? Select all that apply. -The vital signs have been taken and documented in accordance with facility policy and procedure. -There is a signed informed consent for transfusion therapy. -There is an IV access with the appropriate tubing and normal saline as the priming solution. -The client has an identification bracelet. -Blood typing and cross-matching are documented in the medical record. -There is the second unit of blood in the medication room.

-The vital signs have been taken and documented in accordance with facility policy and procedure. -There is a signed informed consent for transfusion therapy. -There is an IV access with the appropriate tubing and normal saline as the priming solution. -The client has an identification bracelet. -Blood typing and cross-matching are documented in the medical record.

The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN? -a 65-year-old client diagnosed with endometrial cancer who underwent an abdominal hysterectomy 3 days ago -a 52-year-old client with lung cancer admitted for acute dyspnea -a 28-year-old client being evaluated for a bone marrow transplant -a 45-year-old client receiving tube feedings

-a 52-year-old client with lung cancer admitted for acute dyspnea

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. -make the client more comfortable. -allow proper visualization of the small intestine.

-allow proper visualization of the large intestine.

A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should: -avoid touching the suture line. -give a pacifier to help soothe the infant. -place the infant in the prone position. -place the infant's arms in soft elbow restraints.

-place the infant's arms in soft elbow restraints.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? -wearing gloves during all client contact -assessing the client's temperature every 8 hours -monitoring the client's fluid intake and output -placing the client in respiratory isolation

-placing the client in respiratory isolation

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? -calcium -white blood cell (WBC) count -platelet count -potassium

-potassium

Immediately following endoscopy of the upper gastrointestinal tract, it is most important for the nurse to assess for: -return of the gag reflex. -peripheral pulses. -bowel sounds. -intake and output.

-return of the gag reflex.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: -severe abdominal pain. -constipation. -an elevated pulse. -confusion.

-severe abdominal pain.

Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches? -combing the hair -flexing and extending the wrists -pushing the hands into the mattress while raising the body in bed -squeezing a rubber ball

-squeezing a rubber ball

A client is taking large doses of aspirin daily to treat rheumatoid arthritis. The nurse should instruct the client to tell the health care provider (HCP) when having: -tinnitus. -low blood pressure. -rash. -abdominal cramps.

-tinnitus.

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 -disposal of used scalpel blades in a puncture-resistant container -use of protective goggles during a caesarean birth -placement of bloody sheets in a container designated for contaminated linens

-wearing of sterile gloves to bathe a neonate at 2 hours of age

A cardiologist prescribes digoxin 125 mcg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablet(s) would the nurse administer in each dose?

0.5

During a private conversation, a client with borderline personality disorder asks a nurse to "keep this secret," then displays multiple, self-inflicted, superficial lacerations of the forearms. What is the nurse's best response? -"I'm going to tell your physician. Do you want to tell me why you did that?" -"That's it! You're on suicide precautions." -"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." -"Tell me what type of instrument you used. I'm concerned about infection."

-"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

The client with recurrent depression and suicidal ideation tells the nurse, "I can't afford this medicine anymore. I know I'll be okay without it." What should the nurse do next? -Ask the social worker to find financial assistance for the client. -Inform the health care provider (HCP) of the client's statement. -Ask the client whether a family member could help. -Schedule a follow-up appointment in 48 hours.

-Ask the social worker to find financial assistance for the client.

Several large boxes of supplies need to be relocated to another room on a client care area. Which action should be taken to prevent the staff from experiencing back injuries when moving these supplies? -Stack the boxes so more can be moved at one time. -Break the boxes into smaller and lighter loads. -Push the boxes across the floor with the legs to the new location. -Pull the boxes across the floor to the new location.

-Break the boxes into smaller and lighter loads.

During a home health visit, a nurse assesses a client's medication and notes that the client has two prescriptions for fluid retention. One prescription reads, "Lasix, 40 milligrams one tablet daily." The next prescription reads, "Furosemide, 40 milligrams one tablet daily." Which instruction should be given to the client? -Use Lasix one day and furosemide the next day. -Take both medications as ordered. -Throw away one of the drugs to avoid confusing the client. -Call the health care provider for verification.

-Call the health care provider for verification.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? -Client's vital signs and breath sounds -Client's level of consciousness -Client's risk for falls -Client's nutritional status

-Client's level of consciousness

A nurse is reviewing a client's medical record and notes that the health care provider has prescribed furosemide 400 mg orally twice a day. What will be the best action by the nurse? -Ask the client about the usual prescribed medication dose and reason for the prescription. -Recheck the medication formulary for the usual drug dosage. -Notify the nurse manager of the erroneous prescription and complete an incident report. -Notify the health care provider about the concern for the prescribed dose.

-Notify the health care provider about the concern for the prescribed dose.

A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse? -Recommend the client remain in bed until strength returns. -Obtain an assistive device to help with the transfer. -Apply a back belt before beginning the transfer. -Break the transfer down into smaller steps.

-Obtain an assistive device to help with the transfer.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? -Assist the client to the bathroom. -Offer the client sips of clear liquids. -Assess cognitive status. -Remove restraints and assess skin and circulation.

-Remove restraints and assess skin and circulation.

The registered nurse (RN) must assign an unlicensed assistive personnel (UAP) to help care for an oncology client who is on neutropenic precautions. Which factor is most important in making this assignment? -The UAP has had cold symptoms for the last 2 days. -The UAP is in the 1st trimester of pregnancy. -The UAP has a fear of isolation clients. -The UAP has no experience with the neutropenic client.

-The UAP has had cold symptoms for the last 2 days.

A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? -respiration 26 breaths/minute -pulse rate of 84 beats/minute -blood pressure 84/52 mm Hg -temperature of 100.2° F (37.9° C)

-blood pressure 84/52 mm Hg

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination? -changing gloves immediately after use -speaking minimally when in the room -wearing protective coverings -standing 2 feet (61 cm) from the client

-changing gloves immediately after use

A client with heart failure is taking furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. What other sign should the nurse assess next? -fluid deficit. -hyperkalemia. -pulmonary edema. -digoxin toxicity.

-digoxin toxicity.

After administering an I.M. injection, a nurse should -recap the needle and discard the needle and syringe in any medical waste container. -discard the uncapped needle and syringe in a puncture-proof container. -break the needle using the facility-approved device and discard the needle and syringe in any medical waste container. -recap the needle and discard the needle and syringe in a puncture-proof container.

-discard the uncapped needle and syringe in a puncture-proof container.

The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply. t-elephone number of client -dose -frequency -healthcare provider signature -pharmacy name

-dose -frequency -healthcare provider signature

A client is taking spironolactone to control hypertension. The client's serum potassium level is [6 mEq/L (56mmol/L)]. For this client, the nurse's priority should be to assess their -electrocardiogram (ECG) results. -respiratory rate. -bowel sounds. -neuromuscular function.

-electrocardiogram (ECG) results.

When caring for a client receiving haloperidol, the nurse should assess for which problem? -oversedation -extrapyramidal symptoms -orthostasis -hypersalivation

-extrapyramidal symptoms

The nurses teaches the parents of an infant how to perform back slaps to dislodge a foreign body. What should the nurse tell the parents to use to deliver the blows? -heel of the hand -palm of the hand -entire hand -fingertips

-heel of the hand

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? -signs and symptoms of pregnancy -tests to evaluate for high-risk pregnancy -danger signs during pregnancy -labor techniques

-danger signs during pregnancy

A client is brought to the hospital's emergency department by a friend, who states, "I guess he had some heroin today." The nurse should assess the client further for which manifestations? -increased heart rate, dilated pupils, and fever -tremulousness, impaired coordination, increased blood pressure, and ruddy complexion -decreased respirations, constricted pupils, and pallor -eye irritation, tinnitus, and irritation of nasal and oral mucosa

-decreased respirations, constricted pupils, and pallor

After discussing preconception needs with a nulliparous client who eats a primarily Asian diet, which client statement indicates the need for further instruction? -"Eating soy products can increase my protein levels once I am pregnant." -"I should take folic acid supplements before I get pregnant." -"If I become pregnant, I can continue to eat sushi twice a week." -"I should continue to steam my vegetables rather than cooking them for a long time."

-"If I become pregnant, I can continue to eat sushi twice a week."

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? -"I'll show your partner how to disconnect the transducer so you can walk to the bathroom." -"Please press the call button. I'll disconnect you from the monitor so you can get out of bed." -"I'll insert a urinary catheter; then you won't need to get out of bed." -"Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan."

-"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."

After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which statement by the parents indicates effective teaching? -"We'll keep the restraints in place continuously until our health care provider says it's okay to remove them." -"We can take off the restraints while our child is playing, but we'll make sure to put them back on at night." -"We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on." -"The restraints should be taped directly to our child's arms so that they'll stay in one place."

-"We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on."

An unconscious client is brought to the emergency department following an opioid overdose. Physical assessment reveals pinpoint pupils, decreased muscle tone, pale skin, and shallow respirations with a rate of 8 breaths per minute. What is the nurse's best action? -Administer methadone. -Administer protamine sulfate. -Administer atropine sulfate. -Administer naloxone.

-Administer naloxone.

Which physiologic change during labor makes it necessary for the nurse to assess blood pressure frequently? -Blood pressure decreases as a sign of maternal pain. -Decreased blood pressure is the first sign of preeclampsia. -Blood pressure decreases at the peak of each contraction. -Alterations in cardiovascular function affect the fetus.

-Alterations in cardiovascular function affect the fetus.

The nurse is meeting weekly with an adolescent recently diagnosed with depression to monitor progress with therapy and antidepressant medication. The nurse should be most concerned when the client reports what information? -An acquaintance hanged herself two days ago. -She received a low score on her last history test. -Her younger brother has been starting fights with her for the last week. -She is experiencing intermittent headaches as a side effect of taking the antidepressant.

-An acquaintance hanged herself two days ago.

A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? -Arrange for typing and crossmatching of the client's blood. -Compare the client's identification wristband with the tag on the unit of blood. -Measure the client's vital signs. -Start an I.V. infusion of normal saline solution.

-Arrange for typing and crossmatching of the client's blood.

The nurse phones a client after 8 weeks postpartum to conduct a postpartum depression screen. The client states that she isn't enjoying the baby. She resents the baby due to the attention the infant receives from her partner. She has been unable to sleep and is overwhelmed with caring for her baby. What is the most appropriate immediate action from the nurse? -Call the physician about the client's symptoms. -Call the client's partner and say you are concerned about her. -Ask the client whether she has any thoughts of hurting herself or her baby. -Refer the client to a local postpartum support service as soon as possible.

-Ask the client whether she has any thoughts of hurting herself or her baby.

An 18-year-old client is seen in the emergency department following a fall from a horse. After vigorously cleaning a large, dirty laceration on the leg, a nurse dresses the wound. The client has received the full tetanus-toxoid immunization regimen at 11 years old. How should the nurse proceed with this client's care? -Request the practitioner to order a serum tetanus titer. -Collaborate with the practitioner for administering a dose of tetanus vaccine. -Teach the client that the client has life-long immunity to tetanus. -Advise the client to get a tetanus shot within the next 3 years.

-Collaborate with the practitioner for administering a dose of tetanus vaccine.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? -Ask the pharmacist for a list of preoperative medications for the client. -Transcribe the preoperative medication orders the surgeon has ordered. -Contact the surgeon for clarification because this is not a complete order. -Obtain new orders for the client from the physician on call.

-Contact the surgeon for clarification because this is not a complete order.

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. What intervention should the nurse perform immediately after the procedure? -Administer pain medication as needed to relieve mediastinal discomfort. -Monitor the client for signs of pneumothorax. -Advise the client not to talk until the gag reflex returns. -Encourage the client to gargle with oral lidocaine to decrease throat irritation.

-Monitor the client for signs of pneumothorax.

The health care provider (HCP) prescribes IV cefazolin 1 g for a client. In preparing to administer the cefazolin, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take? -Notify the HCP of the client's allergy to penicillin. -Continue to prepare to administer the cefazolin as prescribed. -Administer the cefazolin, staying at the client's bedside during the infusion. -Call the pharmacist to verify that the cefazolin should be administered as prescribed.

-Notify the HCP of the client's allergy to penicillin.

A pregnant client calls the nurse at 22 weeks gestation to report that she is experiencing some edema of her face and hands, with puffiness in her eyelids in the morning. What is the priority action by the nurse? -Suggest that the client recline in a lateral recumbent position. -Explain that this is a normal finding for pregnancy. -Tell the client to monitor her symptoms for 24 hours. -Refer the client to her physician.

-Refer the client to her physician.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? -Remove the dressing, clean the site, and apply a new dressing. -Remove the catheter, check for catheter integrity, and send the tip for culture. -Notify the physician. -Draw a circle around the moist spot and note the date and time.

-Remove the dressing, clean the site, and apply a new dressing.

A nurse is about to administer a medication and notices that the medication and dosage are unrelated to the client's diagnosis. Which interventions should the nurse take? Select all that apply. -Prepare to administer the medication. -Request a current medical drug reference to research the dose. -Double check the physician's order. -Refuse to administer the medication until the order can be clarified. -Ask if the client has ever taken the medication before.

-Request a current medical drug reference to research the dose. -Double check the physician's order. -Refuse to administer the medication until the order can be clarified.

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? -Risk for deficient fluid volume related to vomiting -Acute pain related to vertigo -Imbalanced nutrition: Less than body requirements related to nausea and vomiting -Risk for injury related to vertigo

-Risk for injury related to vertigo

A client presents to the nurses' station with symptoms of a panic attack, including shortness of breath, dizziness, trembling, and nausea. Which is the nurse's first intervention? -Teach the client relaxation techniques. -Administer PRN antianxiety medication. -Help the client identify triggers for anxiety. -Stay with the client, and offer support.

-Stay with the client, and offer support.

A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I'm pregnant. She's willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? -Symptom management will be difficult in early pregnancy without medications. -The mother is not likely to provide enough help for what the client needs. -The client will have difficulty financially supporting the baby. -The client did not say that the father of the baby was excited about this.

-Symptom management will be difficult in early pregnancy without medications.

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 is reddened, and the abdomen is distended. -The inguinal swelling can be reduced, and the infant has stool in their diaper. -The infant is irritable, and a thickened spermatic cord is palpable.

-The inguinal swelling is reddened, and the abdomen is distended.

The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question? -dextrose 5% in half-normal saline -solution D5.45 -lactated Ringer's solution -normal saline solution 0.9 -dextrose 5% in water (D5W)

-dextrose 5% in water (D5W)

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? -dizziness -diarrhea -hypertension -urinary frequency

-dizziness