Nokea
A client is admitted to the labor and delivery unit for a labor induction. The primary health care provider has prescribed oxytocin to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many \mathrm{mL} / \mathrm{hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000mL of 0.225\% normal saline? Fill in the blank and round to the nearest whole number.
Correct Answer: 12
Rationale: Use the medication calculation formula to calculate the correct dose. Formula: 10 units of oxytocin in 1000mL of 0.225\% normal saline = 10,000 milliunits per 1000mL or 10 milliunits per 1mL . Solve by the ratio proportion method. 10 milliunits : 1mL :: 2 milliunits : xmL} / \mathrm{min . 10x = 2 , x = 2 \text{ divided by } 10 , x = 0.2mL} / \mathrm{min . Multiply by 60 minutes to get the amount infused per hour: 0.2 \times 60 = 12mL} / \mathrm{hr . Since this is a fill-in-the-blank question, the answer is 12 mL/hr, which corresponds to option C for CSV formatting purposes.
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The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
- A. Sedating the client
- B. Applying wrist restraints
- C. Contacting the client's primary health care provider
- D. Considering all possible alternative measures
Correct Answer: D
Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
- A. Initiating seizure precautions
- B. Using a wheelchair for out-of-bed activities
- C. Assisting the child with ambulation at all times
- D. Minimizing contact with other children on the nursing unit
Correct Answer: A
Rationale: Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. Options 2 and 3 are not required unless functional deficits exist. Based on the child's diagnosis, option 4 is not necessary.
A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? Select all that apply.
- A. The client fell out of bed.
- B. No bruises or injuries are noted on the client.
- C. The client apparently climbed over the side rails when the nurse was out of the room.
- D. The health care provider was notified that the client was found lying on the floor next to the bed.
- E. The client is alert and oriented and stated that he needed to 'go to the bathroom and didn't want to bother the nurse.'
- F. Vital signs are temperature: 98.6°F (37°C); pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular; blood pressure 188/78 mm Hg.
Correct Answer: B,D,E,F
Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.