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The nurse is planning care for a client with a prescription for anticoagulant agents. Which should the nurse identify as a potential concern for this client?
- A. Fatigue
- B. Bruising
- C. Infection
- D. Dehydration
Correct Answer: B
Rationale: Anticoagulant therapy predisposes the client to injury because of the agent's inhibitory effects on the body's normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 1, 3, and 4 are unrelated to this form of therapy.
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A registered nurse (RN) is orienting an unlicensed assistive personnel (UAP) to the clinical nursing unit. The RN determines that the UAP needs further teaching if which action is performed by the UAP during a routine hand-washing procedure?
- A. Keeps hands lower than elbows
- B. Dries from forearm down to fingers
- C. Washes continuously for 10 to 15 seconds
- D. Uses 3 to 5mL of soap from the dispenser
Correct Answer: C
Rationale: The UAP needs further teaching if they wash continuously for only 10 to 15 seconds, as proper hand-washing requires at least 15 to 20 seconds of continuous scrubbing to effectively remove pathogens. Keeping hands lower than elbows is correct to allow water to flow from the cleaner area (forearms) to the dirtier area (hands). Drying from forearm to fingers is appropriate to prevent recontamination of hands. Using 3 to 5 mL of soap is adequate for effective cleaning.
The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?
- A. Reassign the coworker to the care of clients not receiving opioids.
- B. Notify the primary health care provider that the client needs an increase in opioid dosage.
- C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor.
- D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.
Correct Answer: C
Rationale: In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.
In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action should the nurse implement to best assure client safety?
- A. Quickly finish the bath before answering the call.
- B. Immediately leave the client's room and answer the call.
- C. Cover the client, place the call light within reach, and then leave to answer the call.
- D. Leave the door open and ask staff to monitor the client, and then leave to answer the call.
Correct Answer: C
Rationale: Because the telephone call is an emergency, the nurse may need to answer it. To maintain privacy and safety, the nurse covers the client and places the call light within the client's reach. Additionally, the client's door should be closed or the room curtains pulled around the bathing area. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. None of the other options effectively meet the client's safety needs.
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions should the nurse implement in the postprocedure period? Select all that apply.
- A. Restricting visitors
- B. Checking the client's groin for bleeding
- C. Encouraging the client to increase fluid intake
- D. Placing the client's bed in the high-Fowler's position
- E. Instructing the client to move the toes when checking circulation, motion, and sensation
Correct Answer: B,C,E
Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the primary health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions should the nurse implement for this client?
- A. Enteric precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: C
Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.