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A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
- A. Make sure the client's room has at least six air exchanges per hour.
- B. Make sure the client wears a mask when outside her room if there is construction in the area.
- C. Place the client in a private room with negative-pressure airflow.
- D. Wear an N95 respirator when giving the client direct care.
Correct Answer: A
Rationale: The correct answer is A: Make sure the client's room has at least six air exchanges per hour. This is essential for a protective environment post-allogeneic stem cell transplant to reduce the risk of infection. Increasing air exchanges helps remove airborne pathogens and maintain a clean environment. Option B is incorrect as wearing a mask outside the room is not a part of a protective environment. Option C is incorrect as negative-pressure airflow is typically used for clients with airborne infections, not for stem cell transplant clients. Option D is incorrect as N95 respirators are not routinely required for providing direct care in a protective environment setting.
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A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E.
A: Wearing an N95 mask is crucial to prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain infectious particles.
E: Wearing a gown within 3 feet of the client prevents exposure to bodily fluids.
D: Removing the mask after exiting the room increases the risk of contamination.
False options would include not utilizing an N95 mask, not isolating soiled linens, not placing the client in a negative airflow room, and not wearing appropriate PPE when close to the client.
A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
- A. Stop the IV infusion.
- B. Place a pressure dressing over the IV site.
- C. Apply heat to the client's left hand.
- D. Start a new IV in a different site.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The IV site is showing signs of infiltration (edematous, blanched, cool skin, IV fluid not infusing). Stopping the infusion prevents further harm.
B: Place a pressure dressing over the IV site - A pressure dressing helps reduce swelling and prevent further infiltration.
C: Apply heat to the client's left hand - Applying heat can help improve blood flow and absorption of any infiltrated fluids, aiding in the resolution of the issue.
Summary:
D: Starting a new IV in a different site would be premature without addressing the current issue of infiltration.
E, F, G: No other actions are indicated based on the information provided.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 107
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time in hours (7 hr). This gives 107.14 mL/hr, rounded to 107 mL/hr. This ensures the correct administration of the solution over the specified time. Other choices are incorrect as they do not result from the correct calculation method, leading to incorrect infusion rates and potentially affecting patient outcomes.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.