Nokea
The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.
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A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 100 mL/hr
- B. 150 mL/hr
- C. 75 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.
A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
- A. Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae
- B. Use a mechanical lift
- C. Twist at the waist while holding the client
- D. Ask for assistance from another staff member
Correct Answer: A
Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client's hands on the nurse's shoulders and the nurse's hands under the client's axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.
When 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 side-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 action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?
- A. I will need to change the colostomy bag every day.
- B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
- C. I need to empty the colostomy bag when it is one-third to one-half full.
- D. I will need to take care of the skin around the stoma to prevent irritation.
Correct Answer: A
Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.
What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct Answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.