Nokea
The nurse is planning care for a client admitted with suicidal ideations. To best assure client safety the nurse will implement additional precautions during which time period?
- A. During the day shift
- B. On weekday evenings
- C. Between 8 am and 10 am
- D. During the unit shift change
Correct Answer: D
Rationale: At shift change, there is often less availability of staff. The psychiatric nurse and staff should increase precautions for suicidal clients at that time. The night shift also presents a high-risk time, as do weekends, not weekdays.
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The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action should the nurse implement at this time?
- A. Obliterate the incorrect information with a black marker.
- B. Use correction fluid to cover up the incorrect information.
- C. Erase the error completely and write in the correct information.
- D. Draw a line through the incorrect information and initial the change.
Correct Answer: D
Rationale: To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.
The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission?
- A. Offer revaccination to the client.
- B. Document the previous immunization on the client record.
- C. Instruct the client that this vaccine provides lifelong immunity.
- D. Explain to the client that he can be revaccinated only during the fall months.
Correct Answer: A
Rationale: During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client?
- A. The client's history of falls
- B. Assistive devices used by the client
- C. The client's postural (orthostatic) vital signs
- D. The degree of intention tremors exhibited by the client
Correct Answer: C
Rationale: Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.