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The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?
- A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
- B. Ensure that the UAP has placed pillows effectively to protect the client
- C. Ask the UAP to use some pillows to prop the client in a side-lying position
- D. Assume responsibility for placing the pillows while the UAP completes another task
Correct Answer: A
Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.
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The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to the daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine currently followed.
Correct Answer: D
Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
- A. Encourage the client to use a nicotine patch.
- B. Reassure the client that it is almost time for another break.
- C. Have the client leave the unit with another staff member.
- D. Review the schedule of outdoor breaks with the client.
Correct Answer: D
Rationale: When a client becomes angry while waiting for a supervised break, it is essential to address their concerns effectively. Reviewing the schedule of outdoor breaks with the client provides concrete information, helps manage the client's expectations, and may alleviate their frustration. This intervention promotes transparency and empowers the client by clarifying the timing of their desired break, fostering a therapeutic and collaborative nurse-client relationship. Encouraging the client to use a nicotine patch (Choice A) does not address the client's immediate frustration with the break schedule. Reassuring the client about another break (Choice B) may temporarily placate them but does not address the underlying issue. Having the client leave the unit with another staff member (Choice C) may not be feasible or appropriate at that moment and does not address the client's concerns.
After insertion of the indwelling catheter, how should the nurse position the drainage container?
- A. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
- B. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
- C. At the head of the bed for easy and accurate measurement of urine.
- D. Beside the patient in their bed to avoid embarrassment.
Correct Answer: B
Rationale: The correct position for the drainage container after inserting an indwelling catheter is to have it placed lower than the bladder. This positioning helps maintain a constant downward flow of urine from the bladder, preventing backflow and ensuring proper drainage. Choice A is incorrect because having the drainage tubing taut does not promote proper urine flow and may cause kinking. Choice C is incorrect as placing the container at the head of the bed does not affect drainage and is not necessary for accurate measurement. Choice D is incorrect as the positioning of the drainage container should prioritize proper drainage and care over potential embarrassment.
How many drops per minute should a client weighing 182 pounds receive if a nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min? The drip factor is 60 gtt/ml.
- A. 31 gtt/min.
- B. 62 gtt/min.
- C. 93 gtt/min.
- D. 124 gtt/min.
Correct Answer: D
Rationale: To determine the drops per minute for the client, first convert the client's weight from pounds to kilograms: 182/2.2 = 82.73 kg. Calculate the dosage by multiplying 5 mcg by the client's weight in kg: 5 mcg/kg/min 82.73 kg = 413.65 mcg/min. Find the concentration of the solution in mcg/ml by dividing 250 ml by 50,000 mcg (50 mg): 250 ml/50,000 mcg = 200 mcg/ml. As the client needs 413.65 mcg/min and the solution is 200 mcg/ml, the client should receive 2.07 ml per minute. Finally, using the drip factor of 60 gtt/ml, multiply the ml per minute by the drip factor: 60 gtt/ml 2.07 ml/min = 124.28 gtt/min, which rounds to 124 gtt/min. Therefore, the client should receive 124 drops per minute. Choice D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate calculation based on the client's weight, dosage, concentration of the solution, and drip factor.
To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?
- A. Ventrogluteal
- B. Outer upper quadrant of the buttock
- C. Two inches below the acromion process
- D. Vastus lateralis
Correct Answer: A
Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.