Nokea
After receiving detailed information about a colonoscopy from the primary health care provider (HCP), the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?
- A. Contact the provider to obtain informed consent.
- B. Obtain a verbal informed consent from the client.
- C. Have two nurses witness the client sign with an X.
- D. Clarify information to the client with another nurse.
Correct Answer: C
Rationale: Nurses are responsible to ensure that the signed informed consent form is in the client's medical record before a procedure and for clarifying facts that have already been presented by the HCP. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the HCP. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.
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The nurse is administering a dose of prescribed intravenous hydralazine to a client. To provide a safe environment, the nurse should ensure that which safety measure is in place before injecting the medication?
- A. Central line
- B. Thermometer
- C. Foley catheter
- D. Blood pressure cuff
Correct Answer: D
Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff is the item to have in place. Although intravenous access is needed, a central line is unnecessary. The other options are also unnecessary and are unrelated to the administration of this medication.
A client receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed?
- A. Vitamin \mathrm{K
- B. Vitamin B_{12
- C. Methylene blue
- D. Protamine sulfate
Correct Answer: D
Rationale: Heparin is an anticoagulant. Therapeutic values of the aPTT for clients on heparin range between 60 and 70 seconds, depending on the control value. A value of 100 seconds indicates that the client has received too much heparin and is at risk for bleeding. The antidote for heparin overdosage is protamine sulfate and may be prescribed. Vitamin \mathrm{K is the antidote for warfarin sodium overdosage. Methylene blue is an antidote for cyanide poisoning. Vitamin \mathrm{B}_{12 is used to treat clients with pernicious anemia.
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care?
- A. Providing a consistent caregiver
- B. Protecting the toddler from injury
- C. Adapting the toddler to the hospital routine
- D. Allowing the toddler to participate in play and diversional activities
Correct Answer: B
Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.
In which situation is the nurse manager utilizing an autocratic leadership style?
- A. The nurse manager provides the solution for a unit problem.
- B. The nurse manager allows the staff to solve their own unit problem.
- C. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal.
- D. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem.
Correct Answer: A
Rationale: The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals or solutions. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. Participatory leadership encourages input from the staff.