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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
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The healthcare provider prescribes magnesium hydroxide 4,800 mg PO at bedtime for a patient with constipation. The bottle is labeled, 'Magnesium Hydroxide Saline Laxative, USP 400 mg per 5 mL'. How many ounces should the nurse instruct the patient to take with each dose? (Enter numerical value only.)
Correct Answer: 2
Rationale: 4,800 mg ÷ (400 mg/5 mL) = 60 mL = 2 oz.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?
- A. Modify the nursing interventions to achieve the client's goals.
- B. Determine if the expected outcomes were realistic.
- C. Obtain current client data to compare with expected outcomes.
- D. Review related professional standards of care.
Correct Answer: C
Rationale: Current data assesses goal achievement.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
History and Physical
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
Chart Reviewed: For each statement, click to indicate whether the statement is true or false.
- A. Hand washing only needs to be performed when exiting the client’s room.
- B. This client requires contact and droplet precautions.
- C. A gown and gloves should be worn any time there is potential for contact with secretions.
- D. A mask should always be worn when in the client’s room.
- E. This client would require a private room if admitted.
Correct Answer:
Rationale: Hand washing only needs to be performed when exiting the client’s room.
B . This client requires contact and droplet precautions.
C . A gown and gloves should be worn any time there is potential for contact with secretions.
D . A mask should always be worn when in the client’s room.
E . This client would require a private room if admitted.
Solution
Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.
Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it. Therefore, contact and droplet precautions are necessary.
Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.
Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.
Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.
The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?
- A. Print the electronic medical record (EMR) from a backup server.
- B. Identify information as a late entry in the record.
- C. Wait for notification that the system has been rebooted.
- D. Notify the information services department of the situation.
Correct Answer: D
Rationale: Notifying IT resolves system issues promptly.