Nokea
A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse should ensure that which medication is available if the client develops a significant bleeding problem?
- A. Retaplase
- B. Phytonadione
- C. Protamine sulfate
- D. Fresh frozen plasma
Correct Answer: C
Rationale: Protamine sulfate is the antidote for heparin sodium. Fresh frozen plasma may be used for bleeding related to warfarin therapy. Retaplase is a thrombolytic agent used to dissolve blood clots. Phytonadione is the antidote for warfarin.
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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.
A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.
- A. Assess the client's visual acuity.
- B. Observe the client's gait and posture.
- C. Evaluate the client's muscle strength.
- D. Look for any hazards in the home care environment.
- E. Ask a family member to move in with the client until recovery is complete.
- F. Request that the client transfer to an assisted living environment for at least 1 month.
Correct Answer: A,B,C,D
Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.
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.
The nurse is planning care for a client admitted with suicidal ideations. To best assure client safety the nurse will implement additional precautions during which time period?
- A. During the day shift
- B. On weekday evenings
- C. Between 8 am and 10 am
- D. During the unit shift change
Correct Answer: D
Rationale: At shift change, there is often less availability of staff. The psychiatric nurse and staff should increase precautions for suicidal clients at that time. The night shift also presents a high-risk time, as do weekends, not weekdays.
The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.
- A. Are you planning to become an organ donor?
- B. Do you feel the need to discuss your end-of-life decisions with your family?
- C. Did you have the discussion with your son about being your health care surrogate?
- D. Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?
- E. Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?
Correct Answer: B,D,E
Rationale: A living will lists the treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. The client may want to discuss her or his decisions with the family. Although both the living will and durable powers of attorney for health care are based on values of informed consent, autonomy over end-of-life decisions, and control over the dying process, living wills do not involve health care surrogates or the decision to donate organs.