Nokea
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.
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The nurse documents a written entry regarding client care in the client's medical record. When checking the entry, the nurse notices that some of the documented information was incorrect. Which action should the nurse implement at this time?
- A. Obliterate the incorrect information with a black marker.
- B. Use correction fluid to cover up the incorrect information.
- C. Erase the error completely and write in the correct information.
- D. Draw a line through the incorrect information and initial the change.
Correct Answer: D
Rationale: To correct a written error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.
The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission?
- A. Offer revaccination to the client.
- B. Document the previous immunization on the client record.
- C. Instruct the client that this vaccine provides lifelong immunity.
- D. Explain to the client that he can be revaccinated only during the fall months.
Correct Answer: A
Rationale: During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.
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.
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
Which clinical situation should justifiably be viewed as an assault?
- A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.
- B. The client requests a medical discharge, but the nurse physically forces the client to stay.
- C. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.
- D. The nurse overhears the primary health care provider making derogatory remarks to the client about the nurse's level of competency.
Correct Answer: A
Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.