Nokea
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
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The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure should the nurse implement?
- A. Obtain a sputum culture.
- B. Obtain folic acid as an antidote.
- C. Place the solution on a controlled infusion pump.
- D. Ensure that liver enzyme levels have been drawn as a baseline.
Correct Answer: C
Rationale: Foscarnet sodium is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. A sputum culture is not necessary. Folic acid is not an antidote. Foscarnet sodium is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy, not liver enzymes.
Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain the specimen early in the morning.
- C. Have the client brush his teeth before expectoration.
- D. Instruct the client to take deep breaths before coughing.
- E. Place the lid of the culture container face down on the bedside table.
Correct Answer: A,B,C,D
Rationale: The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings.
The nurse manager is developing an educational session for nursing staff on the components of informed consent and the information to be shared with a client to obtain informed consent. Which information should the nurse manager include in the session? Select all that apply.
- A. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused.
- B. The client cannot refuse a test, procedure, or treatment once the test, procedure, or treatment is started.
- C. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form.
- D. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.
- E. The nurse is responsible for obtaining the client's signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.
Correct Answer: A,C,D
Rationale: Informed consent is a person's agreement to allow something to happen based on full disclosure of risks, benefits, alternatives, and consequences of refusal. The primary health care provider (HCP) is responsible for conveying information and obtaining the informed consent. The nurse may be the person who actually ensures that the client signs the informed consent form; however, the nurse does this only after the HCP has instructed the client, and it has been determined that the client has understood the information. The following factors are required for informed consent: a brief, complete explanation of the test, procedure, or treatment; names and qualifications of persons performing and assisting in the test, procedure, or treatment; a description of the complications and risks, as well as anticipated pain or discomfort; an explanation of alternative therapies to the proposed test, procedure, or treatment, as well as the risks of doing nothing; and the client's right to refuse the test, procedure, or treatment even after it has been started.
A client receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed?
- A. Vitamin \mathrm{K
- B. Vitamin B_{12
- C. Methylene blue
- D. Protamine sulfate
Correct Answer: D
Rationale: Heparin is an anticoagulant. Therapeutic values of the aPTT for clients on heparin range between 60 and 70 seconds, depending on the control value. A value of 100 seconds indicates that the client has received too much heparin and is at risk for bleeding. The antidote for heparin overdosage is protamine sulfate and may be prescribed. Vitamin \mathrm{K is the antidote for warfarin sodium overdosage. Methylene blue is an antidote for cyanide poisoning. Vitamin \mathrm{B}_{12 is used to treat clients with pernicious anemia.
A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client?
- A. You will not be able to breast-feed the baby until 6 months after delivery.
- B. Breast-feeding is not advised, and you should seriously consider bottlefeeding the baby.
- C. Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.
- D. Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.
Correct Answer: D
Rationale: The pregnant client who tests positive for hepatitis B virus should be reassured that breast-feeding is not contraindicated if the infant receives prophylaxis at birth and remains on the schedule for immunizations. Therefore, options 1, 2, and 3 are incorrect.