Nokea
A client is being admitted to the hospital after receiving a radiation implant after being diagnosed with cervical cancer. Which priority action should the nurse implement in the care of this client?
- A. Encourage the family to visit.
- B. Admit the client to a private room.
- C. Place the client on protective isolation.
- D. Encourage the client to take frequent rest periods.
Correct Answer: B
Rationale: The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Protective isolation is unnecessary; rather, individuals other than the client need to be protected. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation.
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A client receiving chemotherapy has an extremely low white blood cell count and is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client now allowed to consume? Select all that apply.
- A. Raw celery
- B. Fresh apple
- C. Italian bread
- D. Tossed salad
- E. Baked chicken
- F. Well-cooked cheeseburger
Correct Answer: C,E,F
Rationale: An extremely low white blood cell count places the client at risk for infection. In the immunocompromised client, a low-bacteria diet is implemented. Italian bread, baked chicken, and a well-done cheeseburger are acceptable to consume because all products are thoroughly cooked. The client avoids eating fresh fruits and vegetables. Fresh fruits and vegetables harbor organisms and place the client at risk for infection.
The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply.
- A. Restraints should be secured with a quick-release tie.
- B. A primary health care provider's prescription is required.
- C. Restraints are secured to side rails so that they can be easily removed as necessary.
- D. Restraints are used when other measures have failed to prevent selfinjury or injury to others.
- E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms.
- F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.
Correct Answer: A,B,D
Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A primary health care provider's prescription is required for the use of restraints. Restraints should be secured with a quickrelease tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints, not a usual part of treatment plans, may be indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.
The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action should the nurse instruct the unlicensed assistive personnel (UAP) to implement in the care of the client?
- A. Ambulate the client frequently.
- B. Encourage a diet that is high in protein.
- C. Monitor the temperature every 2 hours.
- D. Remove the water pitcher from the bedside.
Correct Answer: D
Rationale: A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest because a direct correlation exists among proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse should ensure that which specific safety consideration is in place for the client before administering the medication?
- A. Oxygen therapy
- B. Oxygen saturation monitor
- C. Continuous cardiac monitoring
- D. Noninvasive blood pressure cuff
Correct Answer: C
Rationale: Amiodarone is an antidysrhythmic medication that affects cardiac rhythm. Continuous cardiac monitoring is essential to detect any adverse effects such as arrhythmias, which can be life-threatening. This ensures a safe environment for the client during administration. Oxygen therapy and oxygen saturation monitoring are not specific requirements for amiodarone administration unless indicated by the client's condition. A noninvasive blood pressure cuff is useful but not the primary safety consideration compared to cardiac monitoring.
The nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should implement immediate care for a client with which injury?
- A. Fractured tibia
- B. Penetrating abdominal injury
- C. Bright red bleeding from a neck wound
- D. Open massive head injury, resulting in deep coma
Correct Answer: C
Rationale: The client with bright red (arterial) bleeding from a neck wound is in 'immediate' need of treatment to save the client's life. This client is classified as an emergent (life-threatening) client and would wear a color tag of red from the triage process. A green or 'minimal' (nonurgent) designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. The client with a penetrating abdominal injury would be tagged yellow and classified as 'urgent,' requiring intervention within 60 to 120 minutes. A designation of 'expectant' would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded 'black' in the triage process. The client who is color-coded 'black' is given supportive care and pain management but is given definitive treatment last.