Nokea
The nurse performing an admission assessment notes that a client has been prescribed metoclopramide for a prolonged period. The nurse should immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
- A. Dry mouth
- B. Anxiety or irritability
- C. Excessive drowsiness
- D. Uncontrolled rhythmic movements of the face or limbs
Correct Answer: D
Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses should be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.
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The nurse should plan to wear this protective device when caring for hospitalized clients with which diagnosed disorders? (Refer to the figure.) Select all that apply.
- A. Scabies
- B. Tuberculosis
- C. Hepatitis A virus
- D. Pharyngeal diphtheria
- E. Streptococcal pharyngitis
- F. Meningococcal pneumonia
Correct Answer: D,E,F
Rationale: A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client's infection. Droplet precautions refer to precautions used for organisms that can spread through the air but are unable to remain in the air farther than 3 feet. Many respiratory viral infections such as respiratory viral influenza require the use of a standard surgical mask when caring for the client. Some other disorders requiring the use of a standard surgical mask include pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and the pneumonic plague. Scabies and hepatitis A are transmitted by direct contact with an infected person and require the use of contact precautions for protection. Tuberculosis requires the use of airborne precautions and the use of an individually fitted particulate filter mask. A standard surgical mask would not protect the nurse from Mycobacterium tuberculosis.
A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment should the nurse plan to have available at the bedside?
- A. Intubation tray
- B. Morphine sulfate injection
- C. Portable chest x -ray machine
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client should be premedicated before the procedure, or a local anesthetic is used. A portable chest x -ray machine would be called for to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.
A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
- A. Sedating the client
- B. Applying wrist restraints
- C. Contacting the client's primary health care provider
- D. Considering all possible alternative measures
Correct Answer: D
Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
- A. Suggest the nurse manager as a witness.
- B. Agree to sign the document as a witness.
- C. Notify the provider of the client's request.
- D. Help the client find an unrelated third party.
Correct Answer: D
Rationale: An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client's signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the provider unless the absence of the advance directive interferes with client care.
A client is admitted to the labor and delivery unit for a labor induction. The primary health care provider has prescribed oxytocin to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many \mathrm{mL} / \mathrm{hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000mL of 0.225\% normal saline? Fill in the blank and round to the nearest whole number.
Correct Answer: 12
Rationale: Use the medication calculation formula to calculate the correct dose. Formula: 10 units of oxytocin in 1000mL of 0.225\% normal saline = 10,000 milliunits per 1000mL or 10 milliunits per 1mL . Solve by the ratio proportion method. 10 milliunits : 1mL :: 2 milliunits : xmL} / \mathrm{min . 10x = 2 , x = 2 \text{ divided by } 10 , x = 0.2mL} / \mathrm{min . Multiply by 60 minutes to get the amount infused per hour: 0.2 \times 60 = 12mL} / \mathrm{hr . Since this is a fill-in-the-blank question, the answer is 12 mL/hr, which corresponds to option C for CSV formatting purposes.