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A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? Select all that apply.
- A. The client fell out of bed.
- B. No bruises or injuries are noted on the client.
- C. The client apparently climbed over the side rails when the nurse was out of the room.
- D. The health care provider was notified that the client was found lying on the floor next to the bed.
- E. The client is alert and oriented and stated that he needed to 'go to the bathroom and didn't want to bother the nurse.'
- F. Vital signs are temperature: 98.6°F (37°C); pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular; blood pressure 188/78 mm Hg.
Correct Answer: B,D,E,F
Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.
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A client who had expressed suicidal ideations upon admission is being discharged home with family. Which statement by a family member might constitute criteria for delaying discharge?
- A. The client's wife asks, 'Does he know that I've already moved out and filed for a divorce?'
- B. The client's daughter states, 'I've decided to postpone my wedding until Dad's feeling better.'
- C. The client's son states, 'One of his friends visited last week to tell us Dad's union is out on strike.'
- D. The client's brother asks, 'Will my brother be able to continue as executor of our parent's trust?'
Correct Answer: A
Rationale: Single, divorced, and widowed clients have suicide rates that are greater than those who are married. Although the client might feel responsible for his daughter's postponement of the wedding, if presented as an action to include him, the client will feel loved and cared for. Although the situation of the strike is stressful, the client will probably receive a portion of his wages and can derive hope and a sense of belonging from being a member of the union. Although being suicidal may reduce the ability to concentrate, if the client perceives the executorship positively, taking the role away reinforces the client's low self-esteem and self-worth. This statement by the client's brother also indicates a need for the client's brother to be educated about depressive illness.
A client is admitted to the labor and delivery unit for a labor induction. The primary health care provider has prescribed oxytocin to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many \mathrm{mL} / \mathrm{hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000mL of 0.225\% normal saline? Fill in the blank and round to the nearest whole number.
Correct Answer: 12
Rationale: Use the medication calculation formula to calculate the correct dose. Formula: 10 units of oxytocin in 1000mL of 0.225\% normal saline = 10,000 milliunits per 1000mL or 10 milliunits per 1mL . Solve by the ratio proportion method. 10 milliunits : 1mL :: 2 milliunits : xmL} / \mathrm{min . 10x = 2 , x = 2 \text{ divided by } 10 , x = 0.2mL} / \mathrm{min . Multiply by 60 minutes to get the amount infused per hour: 0.2 \times 60 = 12mL} / \mathrm{hr . Since this is a fill-in-the-blank question, the answer is 12 mL/hr, which corresponds to option C for CSV formatting purposes.
A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
- A. Initiating seizure precautions
- B. Using a wheelchair for out-of-bed activities
- C. Assisting the child with ambulation at all times
- D. Minimizing contact with other children on the nursing unit
Correct Answer: A
Rationale: Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. Options 2 and 3 are not required unless functional deficits exist. Based on the child's diagnosis, option 4 is not necessary.
A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment should the nurse plan to have available at the bedside?
- A. Intubation tray
- B. Morphine sulfate injection
- C. Portable chest x -ray machine
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client should be premedicated before the procedure, or a local anesthetic is used. A portable chest x -ray machine would be called for to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.
Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
- A. The client is increasingly agitated.
- B. The client's left hand is pale and cold.
- C. The client's skin under the restraint is red.
- D. The client verbalizes the reason for the restraints.
- E. The client is unable to reach the gastrostomy tube with his or her hands.
- F. The client demonstrates behavior that includes biting the attending staff.
Correct Answer: A,B,C,F
Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.