Nokea
A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
- A. Contact the healthcare provider and complete a medication variance form.
- B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
- C. Notify the charge nurse and complete an incident report to explain the missed dose.
- D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct Answer: D
Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.
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The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct Answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- A. Do not massage any reddened areas.
- B. Encourage passive range of motion exercises on extremities.
- C. Position the client laterally, supine, and prone in sequence.
- D. Gently lift the client when moving into a desired position.
Correct Answer: D
Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.
A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?
- A. Take measures to promote as much comfort as possible.
- B. Report any signs of drug addiction to the nurse immediately.
- C. Wait until the client's pain is gone before assisting with personal care.
- D. This client's pain will be difficult to manage, as the cause is unknown.
Correct Answer: A
Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.
The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?
- A. Hand washing before preparing the injection.
- B. Technique for drawing medication from a vial.
- C. Selection and rotation of injection sites.
- D. Proper disposal of injection equipment.
Correct Answer: B
Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.