Nokea
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
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Regular insulin by continuous intravenous (IV) infusion is prescribed for a client with diabetes mellitus who has a blood glucose level of 700 mg/dL (40 mmol/L). How should the nurse administer this medication safely?
- A. Mix the solution in 5% dextrose.
- B. Change the solution every 6 hours.
- C. Infuse the medication via an electronic infusion pump.
- D. Titrate the infusion according to the client's urine glucose levels.
Correct Answer: C
Rationale: Insulin is administered via an infusion pump to prevent inadvertent overdose and subsequent hypoglycemia. Dextrose is added to the IV infusion once the serum glucose level reaches 250 mg/dL (14.2 mmol/L) to prevent the occurrence of hypoglycemia. Administering dextrose to a client with a serum glucose level of 700 mg/dL would counteract the beneficial effects of insulin in reducing the glucose level. There is no reason to change the solution every 6 hours. Glycosuria is not a reliable indicator of the actual serum glucose levels because many factors affect the renal threshold for glucose loss in the urine.
The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.
- A. Are you planning to become an organ donor?
- B. Do you feel the need to discuss your end-of-life decisions with your family?
- C. Did you have the discussion with your son about being your health care surrogate?
- D. Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?
- E. Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?
Correct Answer: B,D,E
Rationale: A living will lists the treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. The client may want to discuss her or his decisions with the family. Although both the living will and durable powers of attorney for health care are based on values of informed consent, autonomy over end-of-life decisions, and control over the dying process, living wills do not involve health care surrogates or the decision to donate organs.
The nurse is discussing accident prevention with the family of a client who is being discharged from the hospital after having hip surgery. Which physical factors place the client at risk for injury in the home? Select all that apply.
- A. A night-light in the bathroom
- B. Elevated toilet seat with armrests
- C. Cooking equipment such as a stove
- D. Smoke and carbon monoxide detectors
- E. Objects such as a doormat and scatter rugs
- F. A low thermostat setting on the water heater
Correct Answer: C,E
Rationale: Physical hazards in the environment place the client at risk for accidental injury and death. Injuries in the home frequently result from tripping over or coming into contact with common household objects such as a doormat, small rugs on the floor or stairs, or clutter around the house. Adequate lighting such as night-lights in dark hallways and bathrooms reduces the physical hazard by illuminating areas in which a person moves about. An elevated toilet seat with armrests and nonslip strips on the floor in front of the toilet are useful in reducing falls in the bathroom. Cooking equipment and appliances, particularly stoves, can be a main source for in-home fires and fire injuries. Smoke and carbon monoxide detectors should be placed throughout the home to alert members of the household of a potential danger. A low thermostat setting on the water heater reduces the risk of burns during water use such as bathing or showering.
The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.
- A. Is dead
- B. Has chest pain
- C. Has a leg sprain
- D. Has a chest wound
- E. Has multiple fractures
- F. Has full-thickness burns over 30% of the body
Correct Answer: B,D,F
Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).