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The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action should the nurse take next?
- A. Check the client's pupillary responses.
- B. Hang the dose of medication immediately.
- C. Give a dose of droperidol with the tobramycin.
- D. Hold the dose and call the primary health care provider (HCP).
Correct Answer: D
Rationale: Tobramycin is an antibiotic (aminoglycoside). Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. The nurse should hold the dose and notify the HCP. Ototoxicity is a toxic effect of therapy with aminoglycosides and could result in permanent hearing loss. There is no need to check the pupillary response. Administering the dose would be an unsafe response.
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A registered nurse (RN) delegates the changing of a client's colostomy bag to a licensed practical nurse (LPN) who has never performed the procedure on a client. Which is the most appropriate action for the RN to implement?
- A. Perform the procedure with the LPN.
- B. Request that the LPN observe another LPN perform the procedure.
- C. Ask the LPN to review the materials from the in-service before performing the procedure.
- D. Instruct the LPN to review the procedure in the hospital manual and use the written procedure as a reference.
Correct Answer: A
Rationale: The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions after the procedure. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.
The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.
- A. Obtaining an informed consent for a surgical procedure
- B. Providing information necessary for a client to make informed decisions
- C. Providing assistance in asserting the client's human and legal rights if the need arises
- D. Including the client's religious or cultural beliefs when assisting the client in making an informed decision
- E. Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being
Correct Answer: B,C,D,E
Rationale: In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would include the client's religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients' rights in a general by speaking out against policies or actions that might endanger the client's well-being or conflict with his or her rights. Informed consent is part of the primary health care provider-client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.
The nurse is discussing accident prevention with the family of a client who is being discharged from the hospital after having hip surgery. Which physical factors place the client at risk for injury in the home? Select all that apply.
- A. A night-light in the bathroom
- B. Elevated toilet seat with armrests
- C. Cooking equipment such as a stove
- D. Smoke and carbon monoxide detectors
- E. Objects such as a doormat and scatter rugs
- F. A low thermostat setting on the water heater
Correct Answer: C,E
Rationale: Physical hazards in the environment place the client at risk for accidental injury and death. Injuries in the home frequently result from tripping over or coming into contact with common household objects such as a doormat, small rugs on the floor or stairs, or clutter around the house. Adequate lighting such as night-lights in dark hallways and bathrooms reduces the physical hazard by illuminating areas in which a person moves about. An elevated toilet seat with armrests and nonslip strips on the floor in front of the toilet are useful in reducing falls in the bathroom. Cooking equipment and appliances, particularly stoves, can be a main source for in-home fires and fire injuries. Smoke and carbon monoxide detectors should be placed throughout the home to alert members of the household of a potential danger. A low thermostat setting on the water heater reduces the risk of burns during water use such as bathing or showering.
Regular insulin by continuous intravenous (IV) infusion is prescribed for a client with diabetes mellitus who has a blood glucose level of 700 mg/dL (40 mmol/L). How should the nurse administer this medication safely?
- A. Mix the solution in 5% dextrose.
- B. Change the solution every 6 hours.
- C. Infuse the medication via an electronic infusion pump.
- D. Titrate the infusion according to the client's urine glucose levels.
Correct Answer: C
Rationale: Insulin is administered via an infusion pump to prevent inadvertent overdose and subsequent hypoglycemia. Dextrose is added to the IV infusion once the serum glucose level reaches 250 mg/dL (14.2 mmol/L) to prevent the occurrence of hypoglycemia. Administering dextrose to a client with a serum glucose level of 700 mg/dL would counteract the beneficial effects of insulin in reducing the glucose level. There is no reason to change the solution every 6 hours. Glycosuria is not a reliable indicator of the actual serum glucose levels because many factors affect the renal threshold for glucose loss in the urine.
The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?
- A. Uses sterile technique for needle insertion
- B. Wears full protective clothing such as goggles, mask, gown, and gloves
- C. Covers the connection site with a bath blanket to enhance extremity warmth
- D. Puts on a mask and gives one to the client to wear during connection to the machine
Correct Answer: C
Rationale: While the client is receiving hemodialysis, the connection site should not be covered, and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the procedure. Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and a gown.