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A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse should develop a plan of care for the client and include which intervention?
- A. Limiting oral and intravenous fluids
- B. Measuring the client's pulse once each shift
- C. Providing the client with short, frequent walks
- D. Eliminating sources of caffeine from meal trays
Correct Answer: D
Rationale: Sinus tachycardia is an elevated heart rate that can be exacerbated by stimulants such as caffeine. Eliminating sources of caffeine from meal trays helps manage the client's heart rate, which is critical in the context of an acute respiratory infection where cardiac demand may already be increased. Limiting fluids is not indicated unless specific fluid overload conditions are present, which is not mentioned. Measuring the pulse once per shift is insufficient for monitoring tachycardia, as more frequent assessments are needed. Short, frequent walks may be beneficial for respiratory function but do not directly address tachycardia management.
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The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent?
- A. Avoid using all eye makeup to prevent possible reinfection.
- B. Apply hot compresses to decrease pain and lessen irritation.
- C. Obtain a new set of contact lenses for use after the infection clears.
- D. Isolate for 3 days after beginning antibiotic eye drops to avoid the spread of infection.
Correct Answer: C
Rationale: Conjunctivitis is inflammation of the conjunctiva. A new set of contact lenses should be obtained. If the client has conjunctivitis, eye makeup should be replaced but can still be worn. Cool compresses decrease pain and irritation. Isolation for 24 hours after antibiotics are initiated is necessary.
The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.
- A. Obtaining an informed consent for a surgical procedure
- B. Providing information necessary for a client to make informed decisions
- C. Providing assistance in asserting the client's human and legal rights if the need arises
- D. Including the client's religious or cultural beliefs when assisting the client in making an informed decision
- E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being
Correct Answer: B,C,D,E
Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would include the client's religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients' rights in a general by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Informed consent is part of the primary health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.
The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action should the nurse implement at this time?
- A. Obliterate the incorrect information with a black marker.
- B. Use correction fluid to cover up the incorrect information.
- C. Erase the error completely and write in the correct information.
- D. Draw a line through the incorrect information and initial the change.
Correct Answer: D
Rationale: To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.
The nurse hangs a 1000-\mathrm{mL intravenous (IV) solution of \mathrm{D}_5W ( 5\% dextrose in water) at 9 am and sets the infusion controller device to administer 100 \mathrm{gtt} / \mathrm{min via microdrip infusion set (60 \mathrm{gtt}=1mL}) . On assessment of the IV infusion, the nurse expects that the remaining amount of solution in the IV bag at 2 \mathrm{pm will be represented at which level? Fill in the blank and round to the nearest whole number.
Correct Answer: 500
Rationale: The nurse hangs an IV solution at 9 am and sets the IV solution to infuse at 100 \mathrm{gtt} / \mathrm{min per microdrip. With a microdrip, gtt/min =\mathrm{mL} / \mathrm{hr infused. Therefore, 100 \mathrm{mL} / \mathrm{hr is being infused. A total of 500mL will be infused in the 5 elapsed hours. At 2 \mathrm{pm the nurse would expect 500mL of solution to be safely infused and 500mL to be remaining. Since this is a fill-in-the-blank question, the answer is 500 mL, which corresponds to option B for CSV formatting purposes.
The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.