Nokea
The nurse observes that a postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to prevent escalating the agitation?
- A. Gently hold the client's hand while speaking.
- B. Wait to approach until the client's agitation has subsided.
- C. Speak in a calm tone while moving slowly toward the client.
- D. Communicate with the client from the entrance to the room.
Correct Answer: C
Rationale: Speaking and moving slowly toward the client will prevent the client from becoming further agitated because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.
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The nurse is caring for a pregnant client with preeclampsia who is receiving a prescribed intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse should ensure that which priority item is available?
- A. Tongue blade
- B. Percussion hammer
- C. Calcium gluconate injection
- D. Potassium chloride injection
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle. Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate and should be available. An airway rather than a tongue blade is also an appropriate item. A percussion hammer may be important to assess reflexes but is not the priority item. Potassium chloride is not related to the administration of magnesium sulfate.
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.
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.
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.
A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. Which nursing interventions should be implemented to protect the client from infection? Select all that apply.
- A. Restrict all visitors.
- B. Admit the client to a private room.
- C. Place a mask on the client if the client leaves the room.
- D. Use strict aseptic technique for all invasive procedures.
- E. Place a 'See the Nurse Before Entering' sign on the door to the room.
- F. Remove a vase with fresh flowers in the room that was left by a previous client.
Correct Answer: B,C,D,E,F
Rationale: The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a private room on the nursing unit. The use of strict aseptic technique is necessary with all invasive procedures to prevent infection. A sign indicating 'See the Nurse Before Entering' should be placed on the door to the client's room, so the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. Not all visitors must be restricted; however, visitors need to be restricted to healthy adults and must perform strict hand-washing procedures and don a mask before entering the client's room.