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A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: Participate with the compressions or breathing. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to leave the room for equipment. The client's advanced directives should have been filed on admission and his choices known prior to the initiation of CPR.
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The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs (NSAIDs)
- B. Cough medicines with guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct Answer: A
Rationale: Non-steroidal anti-inflammatory drugs (NSAIDs). Medications with NSAIDs may increase the response to Coumadin (warfarin) and increase the risk of bleeding.
The HCP is about to examine the client on contact precautions for MRSA without donning PPE. Which is the best action by the nurse?
- A. Hand the provider a gown and gloves
- B. Not say anything; it is the HCP's decision
- C. Notify the charge nurse and unit manager
- D. Monitor for increased infections on the unit
Correct Answer: A
Rationale: A: Providing PPE ensures immediate compliance with contact precautions. B: Ignoring the breach risks transmission. C, D: These actions delay intervention.
A clinic nurse is teaching parents with young children. About which most common sources of infectious disease transmission should the nurse teach the parents?
- A. Stool and oral and respiratory secretions
- B. Sharing dirty toys and used utensils
- C. Contact with blood from scrapes and sores
- D. Touching others after rubbing a runny nose
Correct Answer: A
Rationale: A: Young children commonly transmit infections via stool and respiratory secretions due to poor hygiene. B, C, D: These are less common sources in this age group.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?
- A. A 79 year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. An incontinent client who has had 3 diarrhea stools
- D. An 80 year-old ambulatory diabetic client
Correct Answer: A
Rationale: A 79 year-old malnourished client on bed rest. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake.
The nurse is using contact precautions when caring for the client. When changing the client's IV solution bag, the nurse inadvertently touches the end of the exposed spike of the tubing. Which is the most appropriate action by the nurse?
- A. Insert the spike into the new IV solution bag
- B. Remove the gloves and obtain another pair
- C. Discard the tubing and obtain another sterile tubing
- D. Use alcohol to cleanse the spike of the tubing
Correct Answer: C
Rationale: C: The contaminated spike requires new sterile tubing to prevent infection. A: Using contaminated tubing risks infection. B: Changing gloves doesn't address tubing contamination. D: Alcohol cannot sterilize the spike.