Nokea
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize
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A client with an ileal conduit should report:
- A. Mucus in urine.
- B. Stoma bleeding.
- C. Yellow urine.
- D. No odor.
Correct Answer: B
Rationale: Stoma bleeding is abnormal and may indicate trauma or infection.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
- A. Assess breath sounds.
- B. Remove the catheter.
- C. Insert a peripheral I.V.
- D. Reposition the client.
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.