Nokea
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.
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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.
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate?
- A. 2 to 3 liters per minute
- B. 4 to 5 liters per minute
- C. 6 to 8 liters per minute
- D. 8 to 10 liters per minute
Correct Answer: A
Rationale: In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client may lose the respiratory drive, and respiratory failure results. Thus, the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute, unless a specific health care provider prescription indicates a different flow of the oxygen.
The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention should the nurse perform to provide a safe environment for the client at this time?
- A. Place pads on the side rails.
- B. Connect the client to a bedside ECG.
- C. Remove all food or fluids within the client's reach.
- D. Place a water-seal chest drainage set at the bedside.
Correct Answer: C
Rationale: After this procedure, the client remains NPO until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse should monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.
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.
The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?
- A. It limits movement of a limb during a painful procedure.
- B. It prevents the violent client from injuring self and others.
- C. At night it keeps the client in bed instead of wandering about.
- D. It is useful in preventing the client from pulling out intravenous lines.
Correct Answer: C
Rationale: Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A primary health care provider's prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.