Nokea
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.
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The nurse notes that a client's lithium level is 3.9 \mathrm{mEq} / \mathrm{L}(3.9 \mathrm{mmol} / \mathrm{L}) . Based on this data, which priority intervention should the nurse implement?
- A. Determining visual acuity
- B. Assisting with ambulation
- C. Monitoring intake and output
- D. Instituting seizure precautions
Correct Answer: D
Rationale: The lithium level must be monitored closely in a client taking lithium. A therapeutic regimen is designed to attain a serum lithium level of 0.8 to 1.2 \mathrm{mEq} / \mathrm{L}(0.8 to 1.2 \mathrm{mmol} / \mathrm{L}) for maintenance treatment. A level of 3.9 \mathrm{mEq} / \mathrm{L (3.9 \mathrm{mmol} / \mathrm{L}) is in the toxic range, and seizures may occur at levels of 3.5 \mathrm{mEq} / \mathrm{L (3.5 \mathrm{mmol} / \mathrm{L}) and higher. While the remaining options are appropriate interventions, they are not the priority because they are not related to the possibility of toxicity.
A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions should be implemented to protect the client from infection? Select all that apply.
- A. Restrict all visitors.
- B. Admit the client to a private room.
- C. Place a mask on the client if the client leaves the room.
- D. Use strict aseptic technique for all invasive procedures.
- E. Place a 'See the Nurse Before Entering' sign on the door to the room.
- F. Remove a vase with fresh flowers in the room that was left by a previous client.
Correct Answer: B,C,D,E,F
Rationale: The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a private room on the nursing unit. The use of strict aseptic technique is necessary with all invasive procedures to prevent infection. A sign indicating 'See the Nurse Before Entering' should be placed on the door to the client's room, so the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. Not all visitors must be restricted; however, visitors need to be restricted to healthy adults and must perform strict hand-washing procedures and don a mask before entering the client's room.
The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?
- A. Inflate the balloon with water.
- B. Secure the catheter to the client.
- C. Measure the initial urine output.
- D. Advance the catheter 2.5 to 5cm .
Correct Answer: D
Rationale: The balloon of a urinary catheter is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5cm further after urine begins to flow so as to provide sufficient space to inflate the balloon. The balloon is not inflated as soon as urine appears because the balloon could be located in the urethra. After the insertion procedure and inflation of the balloon, the nurse secures the catheter to the client's leg and then measures the initial urine output.
A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the UAP that which intervention is needed for infection control?
- A. Enteric precautions should be instituted for the client.
- B. Gloves and mask should be used when in the client's room.
- C. Contact isolation should be initiated because the disease is highly contagious.
- D. Standard precautions are sufficient because the disease is transmitted sexually.
Correct Answer: D
Rationale: Chlamydia is a sexually transmitted infection. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used. Recognizing the necessary precautions will help you in identifying the remaining options as incorrect.
A registered nurse is delegating activities to the nursing staff. Which activities can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.
- A. Collecting a urine specimen from a client
- B. Obtaining frequent oral temperatures on a client
- C. Assessing a client who returned from the recovery room 6 hours ago
- D. Assisting a post-cardiac catheterization client who needs to lie flat to eat lunch
- E. Accompanying a client being discharged to meet his spouse at the hospital exit door
Correct Answer: A,B,D,E
Rationale: Unlicensed assistive personnel (UAP) are trained to perform noninvasive tasks and those that meet basic client needs, such as collecting specimens, taking vital signs, assisting with activities of daily living, and escorting clients. Therefore, collecting a urine specimen, obtaining frequent oral temperatures, assisting a post-cardiac catheterization client to eat lunch while lying flat, and accompanying a client to the hospital exit are appropriate tasks for the UAP. Assessing a client who returned from the recovery room requires clinical judgment and is a task for a licensed nurse, as it involves evaluating the client's condition and identifying potential complications.