Nokea
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
- A. Urine output: 100mL} / \mathrm{hr
- B. \mathrm{pH of arterial blood: 7.32
- C. Capillary refill: 5 seconds
- D. Blood pressure: 90 / 48mmHg
Correct Answer: A
Rationale: Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .
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The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?
- A. Note the child's physical symptoms.
- B. Prepare the child for hydrostatic reduction.
- C. Prepare the child and parents for the possibility of surgery.
- D. Report the passage of a normal brown stool to the primary health care provider.
Correct Answer: D
Rationale: Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.
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.
The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame?
- A. Continuously
- B. Daily during hospitalization
- C. Every third day of hospitalization
- D. Every other day of hospitalization
Correct Answer: A
Rationale: Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options 2, 3, and 4 are incorrect.
The nurse is assigned to care for a client with a diagnosis of preeclampsia. The nurse should plan to implement which action to provide a safe environment?
- A. Maintain fluid and sodium restrictions.
- B. Take the client's vital signs every 4 hours.
- C. Turn off the room lights and draw the window shades.
- D. Encourage visits from family and friends for psychosocial support.
Correct Answer: C
Rationale: Clients with preeclampsia are at risk of developing eclampsia (seizures). Bright lights and sudden loud noises may initiate seizures in this client. A woman with preeclampsia should be placed in a dimly lighted, quiet, private room. Clients with preeclampsia have decreased plasma volume, and adequate fluid and sodium intake is necessary to maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present. Visitors should be limited to allow for rest and prevent overstimulation.
The nurse manager is providing an educational session to the nursing staff on the safe use of physical restraints. Which are examples of safety guidelines when using physical restraints? Select all that apply.
- A. Restraints should be secured with a quick-release tie.
- B. A primary health care provider's prescription is required.
- C. Restraints are secured to side rails so that they can be easily removed as necessary.
- D. Restraints are used when other measures have failed to prevent selfinjury or injury to others.
- E. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms.
- F. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them.
Correct Answer: A,B,D
Rationale: A physical restraint is a mechanical or physical device that is used to immobilize a client or extremity. It restricts the freedom of movement or normal access to a client's body. A primary health care provider's prescription is required for the use of restraints. Restraints should be secured with a quickrelease tie so that they can be easily removed in an emergency. Restraints are considered for use only when other measures have failed to prevent self-injury or injury to others. Restraints are secured to the bed frame, not the side rails, because the client may be injured if the side rail is lowered. Restraints, not a usual part of treatment plans, may be indicated by the person's condition or symptoms, and are not prescribed on a PRN basis.