Nokea
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.
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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.
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 receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed?
- A. Vitamin \mathrm{K
- B. Vitamin B_{12
- C. Methylene blue
- D. Protamine sulfate
Correct Answer: D
Rationale: Heparin is an anticoagulant. Therapeutic values of the aPTT for clients on heparin range between 60 and 70 seconds, depending on the control value. A value of 100 seconds indicates that the client has received too much heparin and is at risk for bleeding. The antidote for heparin overdosage is protamine sulfate and may be prescribed. Vitamin \mathrm{K is the antidote for warfarin sodium overdosage. Methylene blue is an antidote for cyanide poisoning. Vitamin \mathrm{B}_{12 is used to treat clients with pernicious anemia.
In which situation is the nurse manager utilizing an autocratic leadership style?
- A. The nurse manager provides the solution for a unit problem.
- B. The nurse manager allows the staff to solve their own unit problem.
- C. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal.
- D. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem.
Correct Answer: A
Rationale: The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals or solutions. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. Participatory leadership encourages input from the staff.
Which statements describe the characteristics of team nursing? Select all that apply.
- A. A registered nurse leads a team of staff members.
- B. Each nurse assumes responsibility for a specific task.
- C. Team members provide direct care to groups of clients.
- D. Unlicensed assistive personnel are given a client assignment.
- E. The registered nurse assumes responsibility for a caseload of clients over time.
- F. Team nursing maintains continuity of care across nursing shifts, days, and home care visits.
Correct Answer: A,C,D
Rationale: In team nursing, a registered nurse (RN) leads a team that is composed of other RNs, licensed practical or licensed vocational nurses, and unlicensed assistive personnel and technicians. The team members provide direct client care to groups of clients under the direct supervision of the RN team leader. In this model, unlicensed assistive personnel are given client assignments rather than being assigned particular nursing tasks. In functional nursing, tasks are divided, with one nurse assuming responsibility for specific tasks. Primary nursing is a model in which the RN assumes responsibility for a caseload of clients over time. In primary nursing, continuity of care across nursing shifts, days, and home care visits is maintained.