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A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
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A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
- A. Encourage isometric exercises
- B. Suction Q8 hr
- C. Give low-dose heparin
- D. Promote incentive spirometer use
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice A) does not specifically target airway patency. Suctioning every 8 hours (choice B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice C) is used to prevent blood clots, not to maintain airway patency.
A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all.
- A. Take frequent sips of water
- B. Wear sunglasses when exposed to sunlight
- C. Use a soft toothbrush when brushing teeth
- D. Take the medication with an antacid
- E. Urinate prior to taking the medication
Correct Answer: A, B, E
Rationale: The correct choices for managing anticholinergic effects of oxybutynin are A, B, and E. A: Taking frequent sips of water helps combat dry mouth, a common anticholinergic effect. B: Wearing sunglasses when exposed to sunlight helps with sensitivity to light, another anticholinergic effect. E: Urinating prior to taking the medication helps reduce urinary retention, a potential side effect.
Incorrect choices: C: Using a soft toothbrush is not directly related to managing anticholinergic effects. D: Taking the medication with an antacid may interfere with its absorption and is not recommended.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect?
- A. Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds.
- B. Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver.
- C. Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity.
- D. Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. The 1st-pass effect refers to the metabolism of a drug in the liver before it reaches systemic circulation.
2. Medications administered orally undergo first-pass metabolism in the liver, leading to potential inactivation.
3. Administering such meds through nonenteral routes (e.g., intravenous) bypasses the liver, avoiding inactivation.
4. Choice A discusses receptor activity, not related to the first-pass effect.
5. Choice C refers to drug elimination rate, not specific to the first-pass effect.
6. Choice D discusses safety margin and monitoring, not directly related to drug metabolism.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to assistive personnel (AP)?
- A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia
- B. Reinforcing teaching w/a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely delegated to assistive personnel (AP). This task involves a straightforward procedure that does not require advanced nursing skills or critical thinking. The nurse can provide clear instructions and oversee the AP's performance.
Choice A is incorrect because feeding a client with aspiration pneumonia requires close monitoring by a nurse due to the risk of complications. Choice B is incorrect as reinforcing teaching for a client learning to walk with a quad cane involves assessing the client's understanding and progress, which is within the nurse's scope. Choice D is incorrect because applying a sterile dressing to a pressure ulcer requires sterile technique and assessment of wound healing, which should be done by a nurse.