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The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN?
- A. Asking the client to take sips of water
- B. Asking the client to lie down on his right side
- C. Asking the client to look up at the ceiling for 30 seconds
- D. Instructing the client to void before taking the medication
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication.
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The nurse administers digoxin 0.25 \mathrm{mg by mouth rather than the prescribed dose of 0.125 \mathrm{mg to the client. After assessing the client and notifying the health care provider, which action should the nurse implement first?
- A. Write an incident report.
- B. Administer digoxin immune Fab.
- C. Tell the client about the medication error.
- D. Tell the client about the adverse effects of digoxin.
Correct Answer: A
Rationale: According to agency policy, the nurse should file an incident report when a medication error occurs to accurately document the facts. The nurse should assess the client first and then contact the primary health care provider (HCP) because in this situation the client received too much medication. The client should be informed of the error and the adverse effects in a professional manner to avoid alarm and concern. However, in many situations, the HCP prefers to discuss this with the client. Digoxin immune Fab is reserved for extreme toxicity and requires a prescription and may be prescribed depending on the client's response and the serum digoxin level.
The nurse assisting in the care of a client who is to be cardioverted should plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
- A. 50 to 100 joules
- B. 200 to 250 joules
- C. 250 to 300 joules
- D. 350 to 400 joules
Correct Answer: A
Rationale: Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. Cardioversion is usually started at 50 to 100 joules. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the primary health care provider, and the remaining options identify energy levels that are too high for cardioversion.
The nurse manager is reviewing the principles of surgical asepsis with the nursing staff. In which situations should the nurse manager communicate to the staff that it is necessary to use the principles of surgical asepsis? Select all that apply.
- A. Removing a dressing
- B. Reapplying sterile dressings
- C. Inserting an intravenous (IV) line
- D. Inserting a urinary (Foley) catheter
- E. Suctioning the tracheobronchial airway
- F. Caring for an immunosuppressed client
Correct Answer: B,C,D,E
Rationale: Surgical asepsis involves the use of sterile technique. Some examples of procedures in which surgical asepsis is necessary include reapplying sterile dressings, inserting an IV or urinary catheter, and suctioning the tracheobronchial airway. Medical asepsis, or clean technique, includes procedures to reduce and prevent the spread of microorganisms. Removing a dressing can be done by clean technique using clean gloves (although reapplying the dressing requires surgical asepsis). Caring for an immunosuppressed client requires medical asepsis techniques.
A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?
- A. I need to use the back burners for cooking.
- B. I need to remain in the kitchen when I prepare meals.
- C. I need to be sure to place my cup of coffee on the counter.
- D. I need to turn pot handles inward and to the middle of the stove.
Correct Answer: C
Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.
The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers should the nurse include in this review? Select all that apply.
- A. Ensure that crib sides are up.
- B. Place large, soft pillows in the crib.
- C. Use large, soft toys without small parts.
- D. Attach a pacifier to a stretchable piece of ribbon and pin to the infant's clothing.
- E. Allow a toddler who is toilet training privacy in the bathroom to promote autonomy.
- F. Ensure that an infant or toddler is never left unattended while lying on a changing table.
Correct Answer: A,C,F
Rationale: To promote safety for infants and toddlers, crib sides should never be left down because the child could roll and fall. Large, soft toys without small parts should be used because small parts can become dislodged and choking and aspiration may occur. For this same reason, an infant or toddler is never left unattended while lying on a changing table. Pillows, stuffed toys, comforters, or other objects should not be placed in the crib because the child can become entwined in these items and suffocate. Pacifiers should not be attached to string or ribbon because of the risk associated with choking. The child is never left alone in the bathroom, in the tub, or near any other water source because of the risk of drowning.