Nokea
The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan?
- A. Turn the head slowly when spoken to.
- B. Remove throw rugs and clutter in the home.
- C. Drive at times when the client does not feel dizzy.
- D. Walk to the bedroom and lie down when vertigo is experienced.
Correct Answer: B
Rationale: The client should maintain the home in a clutter-free state and have thrown rugs removed because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. If vertigo does occur, the client should immediately sit down or lie down (rather than walking to the bedroom) or grasp the nearest piece of furniture.
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The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse should ensure that which specific priority item is at the client's bedside?
- A. Cardiac monitor
- B. Tracheotomy set
- C. Intermittent gastric suction
- D. Underwater seal chest drainage system
Correct Answer: B
Rationale: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure.
A client is admitted to the psychiatric unit after a suicide attempt. The nurse should plan which intervention as the most important to maintain client safety?
- A. Assigning a staff member to remain with the client at all times.
- B. Requesting that the client promise to alert staff of suicidal thoughts.
- C. Removing the client's personal clothing and replacing them with a hospital gown.
- D. Placing the client in a seclusion room where all dangerous articles are removed.
Correct Answer: A
Rationale: Hanging is a serious suicide attempt. The plan of care must reflect the action that will promote the client's safety. Constant observation by a staff member is necessary. It is not advisable to rely on the client to report suicidal thoughts at this point in the treatment. Removing one's clothing does not maximize all possible safety strategies. Placing the client in seclusion further isolates the client.
A new nurse is learning the functions of the unit's nurse manager. Which functions are included? Select all that apply.
- A. Recruiting new employees
- B. Conducting regular staff meetings
- C. Assisting staff in meeting annual goals
- D. Monitoring professional standards of practice on the nursing unit
- E. Delegating problem-solving of client or family complaints to all nursing staff
- F. Writing prescriptions for primary health care providers (HCPs) when conducting rounds
Correct Answer: A,B,C,D
Rationale: Responsibilities of the nurse manager (middle manager) include recruiting new employees (interviewing and hiring), conducting regular staff meetings, assisting staff in meeting annual goals for the unit and systems needed to accomplish goals, monitoring professional standards of practice on the nursing unit, developing an ongoing staff development plan, conducting routine staff evaluations, acting as a role model, submitting staff schedules for the unit, conducting regular client rounds and problem-solving client and family complaints, establishing and implementing a unit quality improvement plan, and conducting rounds with primary HCPs. The nurse is not responsible for writing prescriptions for HCPs when conducting rounds; the HCP is responsible for writing prescriptions.
The nurse employed in a home health agency is religiously opposed to homosexuality and cannot care for a client diagnosed with human immunodeficiency virus (HIV). The nurse then leaves the client's home. Which statement accurately identifies the nurse's rights and actions? Select all that apply.
- A. The nurse has the moral right to leave the client's home at any time.
- B. The nurse has a legal right to inform the client of any barriers to providing care.
- C. The nurse has a duty to protect self from client care situations that are morally repellent.
- D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.
- E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.
Correct Answer: D,E
Rationale: The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection, to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse's personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).
A primary health care provider has written a prescription to administer methylergonovine maleate to a postpartum client. The nurse should contact the primary health care provider to verify the prescription if which condition is present in the mother?
- A. Hypertension
- B. Excessive lochia
- C. Difficulty locating the uterine fundus
- D. Excessive bleeding and saturation of more than one peripad per hour
Correct Answer: A
Rationale: Methylergonovine maleate is an ergot alkaloid used to treat uterine atony. It is contraindicated for the hypertensive woman, individuals with severe hepatic or renal disease, and during the third stage of labor. Excessive lochia, a uterine fundus that is difficult to locate, and excessive bleeding are clinical manifestations of uterine atony indicating the need for methylergonovine.