A home care nurse is providing instructions to the mother of...

A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?

A. I need to use the back burners for cooking.
B. I need to remain in the kitchen when I prepare meals.
C. I need to be sure to place my cup of coffee on the counter.
D. I need to turn pot handles inward and to the middle of the stove.

Correct Answer: C

Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.

The nurse administers digoxin 0.25 \mathrm{mg by mouth rather than the prescribed dose of 0.125 \mathrm{mg to the client. After assessing the client and notifying the health care provider, which action should the nurse implement first?

A. Write an incident report.
B. Administer digoxin immune Fab.
C. Tell the client about the medication error.
D. Tell the client about the adverse effects of digoxin.

Correct Answer: A

Rationale: According to agency policy, the nurse should file an incident report when a medication error occurs to accurately document the facts. The nurse should assess the client first and then contact the primary health care provider (HCP) because in this situation the client received too much medication. The client should be informed of the error and the adverse effects in a professional manner to avoid alarm and concern. However, in many situations, the HCP prefers to discuss this with the client. Digoxin immune Fab is reserved for extreme toxicity and requires a prescription and may be prescribed depending on the client's response and the serum digoxin level.

The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention should the nurse perform to provide a safe environment for the client at this time?

A. Place pads on the side rails.
B. Connect the client to a bedside ECG.
C. Remove all food or fluids within the client's reach.
D. Place a water-seal chest drainage set at the bedside.

Correct Answer: C

Rationale: After this procedure, the client remains NPO until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse should monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.

Which situation represents the primary nursing care delivery model?

A. The registered nurse (RN) performs all tasks needed by the individual client to optimize health.
B. The RN provides care to 4 clients, while the unlicensed assistive personnel (UAP) is assigned to care for 2 clients.
C. The RN develops a plan of care for each client and collaborates with other staff members assigned to the same group of clients.
D. The UAP is assigned to make beds and fill water pitchers. The RN is assigned to administer medications.

Correct Answer: A

Rationale: In primary nursing, option 1, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. Option 2 does not follow the guidelines for any specific type of nursing care delivery approach. Team nursing, option 3, is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members.

The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?

A. It limits movement of a limb during a painful procedure.
B. It prevents the violent client from injuring self and others.
C. At night it keeps the client in bed instead of wandering about.
D. It is useful in preventing the client from pulling out intravenous lines.

Correct Answer: C

Rationale: Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A primary health care provider's prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.

RN Infection Control and Patient Safety

RN Infection Control and Patient Safety Related

Correct Answer: C

You may also like to solve these questions

Correct Answer: A

Correct Answer: C

Correct Answer: A

Correct Answer: C

Correct Answer: A