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An older client had an open reduction with internal fixation (ORIF) for a hip fracture 4 days ago. Which measure should the nurse implement to provide safe care?
- A. Provide ice chips instead of drinking water.
- B. Instruct the client to call for help before getting up.
- C. Minimize opioid administration to prevent dizziness.
- D. Tell the client to roll to the affected side first before getting up.
Correct Answer: B
Rationale: The nurse instructs the client to call for help before getting up because the client has multiple risk factors for falls, is of older age, has postoperative status, and may also be receiving opioid analgesia. Restricting fluid intake with ice chips is not indicated; besides, adequate hydration is important for maintaining cardiac output and renal function, for keeping respiratory secretions thin, and in preventing constipation. The nurse administers opioid analgesics as indicated and fulfills the nurse's duty owed to the client by acting to resolve pain. The nurse instructs the client to roll to the unaffected side to get up to prevent excessive stress on the fragile surgical wound.
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The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?
- A. Inflate the balloon with water.
- B. Secure the catheter to the client.
- C. Measure the initial urine output.
- D. Advance the catheter 2.5 to 5cm .
Correct Answer: D
Rationale: The balloon of a urinary catheter is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5cm further after urine begins to flow so as to provide sufficient space to inflate the balloon. The balloon is not inflated as soon as urine appears because the balloon could be located in the urethra. After the insertion procedure and inflation of the balloon, the nurse secures the catheter to the client's leg and then measures the initial urine output.
The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?
- A. Reassign the coworker to the care of clients not receiving opioids.
- B. Notify the primary health care provider that the client needs an increase in opioid dosage.
- C. Review the client's medication administration record immediately and discuss the observations with the nursing supervisor.
- D. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally.
Correct Answer: C
Rationale: In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.
The nurse is caring for a pregnant client with preeclampsia who is receiving a prescribed intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse should ensure that which priority item is available?
- A. Tongue blade
- B. Percussion hammer
- C. Calcium gluconate injection
- D. Potassium chloride injection
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle. Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate and should be available. An airway rather than a tongue blade is also an appropriate item. A percussion hammer may be important to assess reflexes but is not the priority item. Potassium chloride is not related to the administration of magnesium sulfate.
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions should the nurse implement in the postprocedure period? Select all that apply.
- A. Restricting visitors
- B. Checking the client's groin for bleeding
- C. Encouraging the client to increase fluid intake
- D. Placing the client's bed in the high-Fowler's position
- E. Instructing the client to move the toes when checking circulation, motion, and sensation
Correct Answer: B,C,E
Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the primary health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions should be implemented to protect the client from infection? Select all that apply.
- A. Restrict all visitors.
- B. Admit the client to a private room.
- C. Place a mask on the client if the client leaves the room.
- D. Use strict aseptic technique for all invasive procedures.
- E. Place a 'See the Nurse Before Entering' sign on the door to the room.
- F. Remove a vase with fresh flowers in the room that was left by a previous client.
Correct Answer: B,C,D,E,F
Rationale: The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a private room on the nursing unit. The use of strict aseptic technique is necessary with all invasive procedures to prevent infection. A sign indicating 'See the Nurse Before Entering' should be placed on the door to the client's room, so the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. Not all visitors must be restricted; however, visitors need to be restricted to healthy adults and must perform strict hand-washing procedures and don a mask before entering the client's room.