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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.
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A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
- A. Stir the needle to 15° before administration.
- B. Aspire the syringe prior to administration.
- C. Administer the medication to the abdomen.
- D. Massage the site following the injection.
Correct Answer: C
Rationale: Correct Answer: C - Administer the medication to the abdomen.
Rationale: Heparin is typically administered subcutaneously. The abdomen has a larger subcutaneous tissue area compared to other sites, allowing for better absorption and reducing the risk of tissue damage. Administering heparin in the abdomen also minimizes the risk of hitting blood vessels and nerves. It is important to rotate injection sites to prevent tissue damage and ensure consistent absorption.
Summary of other choices:
A: Stirring the needle to a specific angle is unnecessary and can increase the risk of needle breakage or improper administration.
B: Aspiration is not required for subcutaneous injections as it may cause unnecessary tissue trauma.
D: Massaging the site after injection can lead to bruising and discomfort.
E, F, G: Choices left blank as they are not relevant to the administration of heparin.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45-degree angle.
- B. Place the client's arm in a dependent position.
- C. Shave excess hair from the insertion site.
- D. Initiate IV therapy in the veins of the hand.
Correct Answer: A
Rationale: The correct answer is A: Insert the catheter at a 45-degree angle. When inserting a peripheral IV catheter for an older adult client, the nurse should aim to insert the catheter at a 45-degree angle to reduce the risk of complications such as infiltration. Inserting at this angle helps to ensure proper placement in the vein and reduces the likelihood of the catheter slipping out or causing discomfort to the client. Placing the client's arm in a dependent position (B) is not necessary and could potentially cause unnecessary discomfort. Shaving excess hair from the insertion site (C) is not recommended as it can irritate the skin and increase the risk of infection. Initiating IV therapy in the veins of the hand (D) may not be the best choice for an older adult client due to potential fragility of hand veins and difficulty with vein accessibility.
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 using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
- A. Combine client care tasks when caring for multiple clients.
- B. Wait until the end of the shift to document client care.
- C. Use the planning step of the nursing process to prioritize client care delivery.
- D. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: C
Rationale: Correct Answer: C - Use the planning step of the nursing process to prioritize client care delivery.
Rationale:
1. The planning step involves setting goals, outcomes, and interventions, helping the nurse organize and prioritize care efficiently.
2. Prioritizing care based on client needs ensures critical tasks are addressed first, promoting client safety and well-being.
3. It allows the nurse to allocate time effectively, focusing on urgent and important tasks first.
4. By following the nursing process, the nurse can provide individualized care tailored to each client's specific needs.
Incorrect Choices:
A: Combining tasks can lead to overlooking important details for each client.
B: Waiting to document care can result in errors, omissions, and delays in communication.
D: Allowing interruptions can disrupt workflow and hinder efficient time management.