Nokea
The nurse notes that a client's lithium level is 3.9 \mathrm{mEq} / \mathrm{L}(3.9 \mathrm{mmol} / \mathrm{L}) . Based on this data, which priority intervention should the nurse implement?
- A. Determining visual acuity
- B. Assisting with ambulation
- C. Monitoring intake and output
- D. Instituting seizure precautions
Correct Answer: D
Rationale: The lithium level must be monitored closely in a client taking lithium. A therapeutic regimen is designed to attain a serum lithium level of 0.8 to 1.2 \mathrm{mEq} / \mathrm{L}(0.8 to 1.2 \mathrm{mmol} / \mathrm{L}) for maintenance treatment. A level of 3.9 \mathrm{mEq} / \mathrm{L (3.9 \mathrm{mmol} / \mathrm{L}) is in the toxic range, and seizures may occur at levels of 3.5 \mathrm{mEq} / \mathrm{L (3.5 \mathrm{mmol} / \mathrm{L}) and higher. While the remaining options are appropriate interventions, they are not the priority because they are not related to the possibility of toxicity.
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The nurse is planning care for a client with a prescription for anticoagulant agents. Which should the nurse identify as a potential concern for this client?
- A. Fatigue
- B. Bruising
- C. Infection
- D. Dehydration
Correct Answer: B
Rationale: Anticoagulant therapy predisposes the client to injury because of the agent's inhibitory effects on the body's normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 1, 3, and 4 are unrelated to this form of therapy.
A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the UAP that which intervention is needed for infection control?
- A. Enteric precautions should be instituted for the client.
- B. Gloves and mask should be used when in the client's room.
- C. Contact isolation should be initiated because the disease is highly contagious.
- D. Standard precautions are sufficient because the disease is transmitted sexually.
Correct Answer: D
Rationale: Chlamydia is a sexually transmitted infection. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used. Recognizing the necessary precautions will help you in identifying the remaining options as incorrect.
A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions should the nurse implement in the postprocedure period? Select all that apply.
- A. Restricting visitors
- B. Checking the client's groin for bleeding
- C. Encouraging the client to increase fluid intake
- D. Placing the client's bed in the high-Fowler's position
- E. Instructing the client to move the toes when checking circulation, motion, and sensation
Correct Answer: B,C,E
Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the primary health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler's position (flexion) increases the risk of occlusion or hemorrhage.
A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance?
- A. Cancel the implementation of the change.
- B. Implement the change first on a trial basis.
- C. Delay implementing the change for a few weeks.
- D. Encourage the nurses to verbalize feelings regarding the change.
Correct Answer: D
Rationale: Face-to-face meetings to address the issue at hand will allow verbalization of feelings, identification of problems and issues, and the development of strategies to solve the problem. Option 1 will not address the problem. Option 2 is not the initial intervention. Option 3 may provide a temporary solution to the resistance but will not specifically address the concern.
A registered nurse (RN) is orienting an unlicensed assistive personnel (UAP) to the clinical nursing unit. The RN determines that the UAP needs further teaching if which action is performed by the UAP during a routine hand-washing procedure?
- A. Keeps hands lower than elbows
- B. Dries from forearm down to fingers
- C. Washes continuously for 10 to 15 seconds
- D. Uses 3 to 5mL of soap from the dispenser
Correct Answer: C
Rationale: The UAP needs further teaching if they wash continuously for only 10 to 15 seconds, as proper hand-washing requires at least 15 to 20 seconds of continuous scrubbing to effectively remove pathogens. Keeping hands lower than elbows is correct to allow water to flow from the cleaner area (forearms) to the dirtier area (hands). Drying from forearm to fingers is appropriate to prevent recontamination of hands. Using 3 to 5 mL of soap is adequate for effective cleaning.