Nokea
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.
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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 client is being admitted to the hospital after receiving a radiation implant after being diagnosed with cervical cancer. Which priority action should the nurse implement in the care of this client?
- A. Encourage the family to visit.
- B. Admit the client to a private room.
- C. Place the client on protective isolation.
- D. Encourage the client to take frequent rest periods.
Correct Answer: B
Rationale: The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Protective isolation is unnecessary; rather, individuals other than the client need to be protected. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation.
Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique should the nurse use to transfer the client from the stretcher to the bed?
- A. A bath blanket and the assistance of four people
- B. A bath blanket and the assistance of three people
- C. A transfer board and the assistance of two people
- D. A transfer board and the assistance of four people
Correct Answer: D
Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer board and the assistance of four people. This permits optimal stabilization and support of the spine, while allowing the client to be moved smoothly and gently. Therefore, the remaining options are incorrect and unsafe.
The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.
- A. Place paper bags on the hands and feet.
- B. Give the clothing and wallet to the family.
- C. Cut clothing along the seams, avoiding bullet holes.
- D. Collect all personal items, including items from clothing pockets.
- E. Place wet clothing and personal belongings in a labeled, sealed plastic bag.
- F. Do not allow family members, significant others, or friends to be alone with the client.
Correct Answer: A,C,D,F
Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of kindizing any existing legal evidence.
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.