Nokea
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity should the nurse plan time for after the arterial blood is drawn?
- A. Holding a warm compress over the puncture site for 5 minutes
- B. Encouraging the client to open and close the hand rapidly for 2 minutes
- C. Applying pressure to the puncture site by applying a 2 x 2 gauze for 5 minutes
- D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Correct Answer: C
Rationale: Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.
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Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.
- A. Use strict aseptic technique.
- B. Place the drainage bag lower than the bladder level.
- C. Inflate the balloon with 4 to 5 mL beyond its capacity.
- D. Swab the urinary catheter with sterile water before inserting.
- E. Advance the catheter 1 to 2 inches after urine appears in the tubing.
Correct Answer: A,B,E
Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.
A hospitalized client wants to leave the hospital before being discharged by the primary health care provider (PHCP). Which action should be the next intervention for the nurse to implement?
- A. Notify the nursing supervisor of the client's plans to leave.
- B. Ask the client about transportation plans from the hospital.
- C. Arrange medication prescriptions at the client's preferred pharmacy.
- D. Discuss the potential consequences of the plans for leaving with the client.
Correct Answer: A
Rationale: The nurse notifies the nursing supervisor of the client's plan to leave without the primary PHCP's approval to ensure client safety and to help the nurse manage the situation. This will help the nurse manage the situation in a thoughtful, comprehensive manner and complete nursing interventions that include asking about transportation, arranging medication prescriptions, and discussing the risks and benefits of leaving or remaining in the hospital. The PHCP should be contacted and the client encouraged to remain until the PHCP arrives. The nurse avoids coercion, restraint, or security measures meant to prohibit the client's exit to prevent claims of false imprisonment.
The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation should help the nurse determine if the client's crutches are fitted correctly?
- A. The top of the crutch is even with the axilla.
- B. The elbow is straight when the hand is on the handgrip.
- C. The client's axilla is resting on the crutch pad during ambulation.
- D. The elbow is at a 30-degree angle when the hand is on the handgrip.
Correct Answer: D
Rationale: When using crutches, for optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla. Therefore, options 1, 2, and 3 are incorrect.
The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?
- A. Administer rescue breathing during the defibrillation.
- B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.
- C. Charge the machine and immediately push the 'discharge' buttons on the console.
- D. Order any personnel away from the client, charge the machine, and defibrillate through the console.
Correct Answer: D
Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the 'discharge' buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as 'hands-off' defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.
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.