Nokea
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
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A client receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed?
- A. Vitamin \mathrm{K
- B. Vitamin B_{12
- C. Methylene blue
- D. Protamine sulfate
Correct Answer: D
Rationale: Heparin is an anticoagulant. Therapeutic values of the aPTT for clients on heparin range between 60 and 70 seconds, depending on the control value. A value of 100 seconds indicates that the client has received too much heparin and is at risk for bleeding. The antidote for heparin overdosage is protamine sulfate and may be prescribed. Vitamin \mathrm{K is the antidote for warfarin sodium overdosage. Methylene blue is an antidote for cyanide poisoning. Vitamin \mathrm{B}_{12 is used to treat clients with pernicious anemia.
After receiving detailed information about a colonoscopy from the primary health care provider (HCP), the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?
- A. Contact the provider to obtain informed consent.
- B. Obtain a verbal informed consent from the client.
- C. Have two nurses witness the client sign with an X.
- D. Clarify information to the client with another nurse.
Correct Answer: C
Rationale: Nurses are responsible to ensure that the signed informed consent form is in the client's medical record before a procedure and for clarifying facts that have already been presented by the HCP. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the HCP. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care?
- A. Providing a consistent caregiver
- B. Protecting the toddler from injury
- C. Adapting the toddler to the hospital routine
- D. Allowing the toddler to participate in play and diversional activities
Correct Answer: B
Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.
The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure should the nurse implement?
- A. Obtain a sputum culture.
- B. Obtain folic acid as an antidote.
- C. Place the solution on a controlled infusion pump.
- D. Ensure that liver enzyme levels have been drawn as a baseline.
Correct Answer: C
Rationale: Foscarnet sodium is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. A sputum culture is not necessary. Folic acid is not an antidote. Foscarnet sodium is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy, not liver enzymes.
The nurse receives a telephone call from a client who states that he wants to kill himself and has a loaded gun on the table. Which intervention best assures the client's safety?
- A. Encouraging him to unload the gun and go to the hospital
- B. Telling the client that suicide is not the way to deal with his problem
- C. Using therapeutic communication techniques, especially the reflection of feelings
- D. Engaging the client while another staff member contacts the police for their assistance
Correct Answer: D
Rationale: In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A loaded gun in the home of the client who says that he wants to kill himself is a crisis. The client's safety is of prime concern. Keeping the client on the phone and getting help to the client is the best intervention. Option 1 lacks the authoritative action stance of securing the client's safety. Option 2 is not a helpful strategy and may block communication. Using therapeutic communication techniques is important, but overuse of reflection may sound uncaring or superficial and is lacking direction and a solution to the immediate problem of the client's safety.