Nokea
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care?
- A. Providing a consistent caregiver
- B. Protecting the toddler from injury
- C. Adapting the toddler to the hospital routine
- D. Allowing the toddler to participate in play and diversional activities
Correct Answer: B
Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.
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The nurse manager is developing an educational session for nursing staff on the components of informed consent and the information to be shared with a client to obtain informed consent. Which information should the nurse manager include in the session? Select all that apply.
- A. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused.
- B. The client cannot refuse a test, procedure, or treatment once the test, procedure, or treatment is started.
- C. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form.
- D. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.
- E. The nurse is responsible for obtaining the client's signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.
Correct Answer: A,C,D
Rationale: Informed consent is a person's agreement to allow something to happen based on full disclosure of risks, benefits, alternatives, and consequences of refusal. The primary health care provider (HCP) is responsible for conveying information and obtaining the informed consent. The nurse may be the person who actually ensures that the client signs the informed consent form; however, the nurse does this only after the HCP has instructed the client, and it has been determined that the client has understood the information. The following factors are required for informed consent: a brief, complete explanation of the test, procedure, or treatment; names and qualifications of persons performing and assisting in the test, procedure, or treatment; a description of the complications and risks, as well as anticipated pain or discomfort; an explanation of alternative therapies to the proposed test, procedure, or treatment, as well as the risks of doing nothing; and the client's right to refuse the test, procedure, or treatment even after it has been started.
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.
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.
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.
After receiving detailed information about a colonoscopy from the primary health care provider (HCP), the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?
- A. Contact the provider to obtain informed consent.
- B. Obtain a verbal informed consent from the client.
- C. Have two nurses witness the client sign with an X.
- D. Clarify information to the client with another nurse.
Correct Answer: C
Rationale: Nurses are responsible to ensure that the signed informed consent form is in the client's medical record before a procedure and for clarifying facts that have already been presented by the HCP. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the HCP. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.