Nokea
The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions should the nurse implement to ensure client safety? Select all that apply.
- A. Check the client's level of consciousness.
- B. Check wheel locks of the operating room table.
- C. Complete the client transfer as quickly as possible.
- D. Tell the client to move self from the table to the stretcher.
- E. Raise side rails after the client is positioned on the stretcher per agency policy.
Correct Answer: A,B,E
Rationale: As part of the safe transfer of a client after a surgical procedure, the nurse should assess the client's level of consciousness and, if appropriate, let the client know that she or he will be transferred from the operating room table to the stretcher. The nurse checks the wheel locks of the table and the stretcher to prevent any movement during the transfer. In addition, the nurse raises the side rails per agency policy to prevent the client from falling off the stretcher. This is important because the client is likely to be sedated or disoriented and unable to protect herself or himself from falling. Personnel avoid hurried movements and rapid changes in position because hurried movements predispose the client to hypotension; moreover, secure, deliberate movement increases the security of the client. Because the client remains affected by anesthesia, the client should not move herself or himself.
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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.
The nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should implement immediate care for a client with which injury?
- A. Fractured tibia
- B. Penetrating abdominal injury
- C. Bright red bleeding from a neck wound
- D. Open massive head injury, resulting in deep coma
Correct Answer: C
Rationale: The client with bright red (arterial) bleeding from a neck wound is in 'immediate' need of treatment to save the client's life. This client is classified as an emergent (life-threatening) client and would wear a color tag of red from the triage process. A green or 'minimal' (nonurgent) designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. The client with a penetrating abdominal injury would be tagged yellow and classified as 'urgent,' requiring intervention within 60 to 120 minutes. A designation of 'expectant' would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded 'black' in the triage process. The client who is color-coded 'black' is given supportive care and pain management but is given definitive treatment last.
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.
The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?
- A. A client diagnosed with dementia
- B. A 1-day postoperative mastectomy client
- C. A client who requires some assistance with bathing
- D. A client who requires some assistance with ambulation
Correct Answer: B
Rationale: Assignment of tasks must be implemented based on the job description of the LPN and UAP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The UAP has the skills to care for a client requiring noninvasive care such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.
The nurse is planning the discharge instructions for an adult client who is a victim of family violence. The nurse should understand that it is most important that which information is included in the discharge plans?
- A. Instructions to call the police the next time the abuse occurs
- B. Exploration of the pros and cons of remaining with the abusive family member
- C. Specific information regarding 'safe havens' or shelters in the client's neighborhood
- D. Specific information about current opportunities to enroll in local selfdefense classes
Correct Answer: C
Rationale: For the victim of family violence, any of the options might be included in the discharge plan at some point if long-term therapy or a long-term relationship with the nurse is established. The question refers to an emergency department setting. It is most important to assist victims of abuse with identifying a plan for how to remove self from harmful situations should they arise again. An abused person is usually reluctant to call the police. It is not the best time for the nurse to explore the pros and cons of remaining with the abusive family member; additionally, this action does not ensure safety for the victim. Teaching the victim to fight back (as in the use of self-defense) is not the best action when dealing with a violent person.