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The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure should the nurse implement?
- A. Obtain a sputum culture.
- B. Obtain folic acid as an antidote.
- C. Place the solution on a controlled infusion pump.
- D. Ensure that liver enzyme levels have been drawn as a baseline.
Correct Answer: C
Rationale: Foscarnet sodium is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. A sputum culture is not necessary. Folic acid is not an antidote. Foscarnet sodium is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy, not liver enzymes.
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Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain the specimen early in the morning.
- C. Have the client brush his teeth before expectoration.
- D. Instruct the client to take deep breaths before coughing.
- E. Place the lid of the culture container face down on the bedside table.
Correct Answer: A,B,C,D
Rationale: The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings.
The nurse is observing a client using a walker. Which observation by the nurse should determine that the client is using the walker correctly?
- A. Puts weight on the hand pieces, slides the walker forward, and then walks into it
- B. Puts weight on the hand pieces, moves the walker forward, and then walks into it
- C. Puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it
- D. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor
Correct Answer: C
Rationale: To use a walker correctly, the client should place all four points of the walker flat on the floor to ensure stability, then put weight on the hand pieces to support their body, and finally walk into the walker. This sequence ensures the walker remains stable and provides maximum support. Option 1 is incorrect because sliding the walker can cause instability. Option 2 is incorrect because moving the walker forward without ensuring all points are flat may lead to tipping. Option 4 is incorrect because walking into the walker before placing it flat reverses the proper sequence and compromises safety.
The nurse is administering a dose of prescribed intravenous hydralazine to a client. To provide a safe environment, the nurse should ensure that which safety measure is in place before injecting the medication?
- A. Central line
- B. Thermometer
- C. Foley catheter
- D. Blood pressure cuff
Correct Answer: D
Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff is the item to have in place. Although intravenous access is needed, a central line is unnecessary. The other options are also unnecessary and are unrelated to the administration of this medication.
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
A client asks the home care nurse to witness the client's signature on a living will with the client's attorney in attendance. Which action is most appropriate for the nurse to implement?
- A. Decline to witness the signature on the living will.
- B. Sign the living will as a witness to the signature only.
- C. Notify the supervisor that a living will is being witnessed.
- D. Sign the living will with identifying credentials and employment agency.
Correct Answer: A
Rationale: Living wills are written documents and need to be signed by the client. The client's signature must be either witnessed by nonagency individuals or notarized; thus, the nurse should decline to sign the will to avoid a conflict of interest. There is no need to contact the supervisor or sign the living will with or without credentials because the nurse cannot sign this document as a witness. Therefore, options 2, 3, and 4 are incorrect.