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The nurse identifies a medication error involving a client with a colostomy. Which action should the nurse take first?
- A. Administer the correct medication.
- B. Notify the physician and complete an incident report.
- C. Monitor the client for adverse effects.
- D. Educate the client about the error.
Correct Answer: B
Rationale: Notifying the physician and completing an incident report is the first action after a medication error to ensure proper follow-up and documentation. Administering medication, monitoring, or educating the client are secondary steps after reporting. CN: Safety and infection control; CL: Synthesize
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After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon.
- C. Empty drainage.
- D. Record the amount in the unit as output on the client's chart.
Correct Answer: C
Rationale: A full portable wound suction unit (e.g., Jackson-Pratt) should be emptied to maintain suction and prevent complications. The drainage is then measured and recorded.
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
- A. Apply heat to the extremity
- B. Elevate the legs above the heart
- C. Stop smoking
- D. Begin a jogging program
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
The nurse should expect single-donor platelets to be ordered for which of the following clients?
- A. A client who is receiving multiple platelet transfusions.
- B. A client who is deficient in coagulation factors.
- C. A client whose platelet count is greater than 50,000/mm³.
- D. A client who is refractory to random-donor platelets.
Correct Answer: D
Rationale: Single-donor platelets are used for clients refractory to random-donor platelets to reduce the risk of alloimmunization and improve transfusion efficacy.
A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.