Nokea
A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Which priority nursing intervention based on these objective data should the nurse implement?
- A. Provide safety for the client and other clients on the unit.
- B. Bring the client to a less stimulated area to regain control.
- C. Provide the clients on the unit with a sense of comfort and safety.
- D. Assist the staff in caring for the client in a controlled environment.
Correct Answer: A
Rationale: If a client is exhibiting signs that indicate loss of control, the nurse's immediate priority is to ensure safety for all clients. Option 1 is the only option that addresses the client's and other clients' safety needs. Option 2 addresses the client's needs. Option 3 addresses other clients' needs. Option 4 is not client centered.
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A primary health care provider prescribes 1000 mL of 0.45% normal saline solution to run over 8 hours. The drop factor is 15 drops/mL. The nurse plans to adjust the flow rate to how many drops per minute to safely administer this intravenous (IV) solution? Fill in the blank and round answer to the nearest whole number.
Correct Answer: 31
Rationale: The prescribed 1000 mL is to be infused over 8 hours. Follow the formula for calculating IV flow rates and multiply 1000 mL by 15 (drop factor). Then divide the result by 480 minutes (8 hours × 60 minutes). The infusion is to run at 31.2 or 31 drops/min.
An emergency department nurse is a member of an all-hazards disaster preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions should initially be included in the plan? Select all that apply.
- A. Isolate the client.
- B. Don protective equipment immediately.
- C. Notify infectious disease specialists, public health officials, and the police.
- D. Lock down the emergency department and the entire hospital immediately.
- E. Identify all client contacts, including transport services to the emergency department and clients in the waiting room.
- F. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room immediately.
Correct Answer: A,B,C,E
Rationale: An all-hazards disaster preparedness group is a multifaceted internal and external disaster preparedness group that establishes action plans for every type of disaster or combination of disaster events. In the event of emergency department exposure to a communicable disease such as smallpox, the client would be isolated immediately and the staff would immediately don protective equipment. The emergency department would be locked down immediately. Locking down the entire hospital may not be necessary and infectious disease specialists and public health officials will determine whether it is necessary to take this action. Infectious disease specialists, public health officials, and the police are notified. All client contacts (name, addresses, telephone numbers), including transport services to the emergency department and clients in the waiting room, would be identified so that the public health department can follow through on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days after exposure will help prevent the disease or make it less severe, it is unreasonable and unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room.
The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan?
- A. Turn the head slowly when spoken to.
- B. Remove throw rugs and clutter in the home.
- C. Drive at times when the client does not feel dizzy.
- D. Walk to the bedroom and lie down when vertigo is experienced.
Correct Answer: B
Rationale: The client should maintain the home in a clutter-free state and have thrown rugs removed because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. If vertigo does occur, the client should immediately sit down or lie down (rather than walking to the bedroom) or grasp the nearest piece of furniture.
The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse should ensure that which specific priority item is at the client's bedside?
- A. Cardiac monitor
- B. Tracheotomy set
- C. Intermittent gastric suction
- D. Underwater seal chest drainage system
Correct Answer: B
Rationale: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure.
The nurse employed in a home health agency is religiously opposed to homosexuality and cannot care for a client diagnosed with human immunodeficiency virus (HIV). The nurse then leaves the client's home. Which statement accurately identifies the nurse's rights and actions? Select all that apply.
- A. The nurse has the moral right to leave the client's home at any time.
- B. The nurse has a legal right to inform the client of any barriers to providing care.
- C. The nurse has a duty to protect self from client care situations that are morally repellent.
- D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.
- E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.
Correct Answer: D,E
Rationale: The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection, to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse's personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).