Nokea
The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate to include at this age? Select all that apply.
- A. Lock up all poisons.
- B. Cover electrical outlets.
- C. Never shake the infant's head.
- D. Place the infant on the back to sleep.
- E. Remove hazardous objects from low places.
Correct Answer: C,D
Rationale: The age-appropriate instructions that are most important are to instruct the mother not to shake or vigorously jiggle the baby's head and to place the infant on his or her back to sleep. Options 1, 2, and 5 are important instructions to provide to the mother as the child reaches the age of 6 months and begins to explore the environment.
You may also like to solve these questions
A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which measure should the nurse anticipate will most likely be prescribed that will provide appropriate care of the client's body?
- A. Closing the eyes with paper tape
- B. Maintaining the client in a supine position
- C. Placing gauze pads wet with saline covered by a small ice pack on the eyes
- D. Placing the client in a lateral recumbent position rotating right and left sides
Correct Answer: C
Rationale: When a corneal donor dies, the eyes are closed and usually the primary health care provider prescribes placing gauze pads wet with saline over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated, and the corneas are usually transplanted within 24 to 48 hours. The head of the bed should be elevated. With the head of the bed elevated, the eyes will likely remain closed.
A hospitalized client wants to leave the hospital before being discharged by the primary health care provider (PHCP). Which action should be the next intervention for the nurse to implement?
- A. Notify the nursing supervisor of the client's plans to leave.
- B. Ask the client about transportation plans from the hospital.
- C. Arrange medication prescriptions at the client's preferred pharmacy.
- D. Discuss the potential consequences of the plans for leaving with the client.
Correct Answer: A
Rationale: The nurse notifies the nursing supervisor of the client's plan to leave without the primary PHCP's approval to ensure client safety and to help the nurse manage the situation. This will help the nurse manage the situation in a thoughtful, comprehensive manner and complete nursing interventions that include asking about transportation, arranging medication prescriptions, and discussing the risks and benefits of leaving or remaining in the hospital. The PHCP should be contacted and the client encouraged to remain until the PHCP arrives. The nurse avoids coercion, restraint, or security measures meant to prohibit the client's exit to prevent claims of false imprisonment.
The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse should ensure that which specific safety consideration is in place for the client before administering the medication?
- A. Oxygen therapy
- B. Oxygen saturation monitor
- C. Continuous cardiac monitoring
- D. Noninvasive blood pressure cuff
Correct Answer: C
Rationale: Amiodarone is an antidysrhythmic medication that affects cardiac rhythm. Continuous cardiac monitoring is essential to detect any adverse effects such as arrhythmias, which can be life-threatening. This ensures a safe environment for the client during administration. Oxygen therapy and oxygen saturation monitoring are not specific requirements for amiodarone administration unless indicated by the client's condition. A noninvasive blood pressure cuff is useful but not the primary safety consideration compared to cardiac monitoring.
Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.
- A. Use strict aseptic technique.
- B. Place the drainage bag lower than the bladder level.
- C. Inflate the balloon with 4 to 5 mL beyond its capacity.
- D. Swab the urinary catheter with sterile water before inserting.
- E. Advance the catheter 1 to 2 inches after urine appears in the tubing.
Correct Answer: A,B,E
Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.
The post-myocardial infarction client is scheduled for a technetium-99 m ventriculography (multigated acquisition [MUGA] scan). The nurse should ensure that which item is in place before the procedure?
- A. A Foley catheter
- B. Signed informed consent
- C. A central venous pressure (CVP) line
- D. Notation of allergies to iodine or shellfish
Correct Answer: B
Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergy to iodine and shellfish is not a concern.