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The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.
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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.
A registered nurse (RN) delegates the changing of a client's colostomy bag to a licensed practical nurse (LPN) who has never performed the procedure on a client. Which is the most appropriate action for the RN to implement?
- A. Perform the procedure with the LPN.
- B. Request that the LPN observe another LPN perform the procedure.
- C. Ask the LPN to review the materials from the in-service before performing the procedure.
- D. Instruct the LPN to review the procedure in the hospital manual and use the written procedure as a reference.
Correct Answer: A
Rationale: The RN must remember that, even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Because colostomy bag change is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions after the procedure. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Although it is appropriate to review the in-service materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.
The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?
- A. Uses sterile technique for needle insertion
- B. Wears full protective clothing such as goggles, mask, gown, and gloves
- C. Covers the connection site with a bath blanket to enhance extremity warmth
- D. Puts on a mask and gives one to the client to wear during connection to the machine
Correct Answer: C
Rationale: While the client is receiving hemodialysis, the connection site should not be covered, and it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the procedure. Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both the nurse and client are extremely important. It is also imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and a gown.
The nurse is working in the emergency department of a small local hospital when a client with multiple stab wounds arrives by ambulance. Which action by the nurse is contraindicated when handling potential legal evidence?
- A. Initiating a chain of custody log.
- B. Giving clothing and wallet to the family.
- C. Cutting clothing along seams, avoiding stab holes.
- D. Placing personal belongings in a labeled, sealed paper bag.
Correct Answer: B
Rationale: Potential evidence is never released to the family to take home. Basic rules for handling evidence include initiating a chain of custody log to track handling and movement of evidence, limiting the number of people with access to the evidence, and carefully removing clothing and placing personal belongings in a labeled, sealed paper bag to avoid destroying evidence. This also usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears.
The nurse hangs a 1000-\mathrm{mL intravenous (IV) solution of \mathrm{D}_5W ( 5\% dextrose in water) at 9 am and sets the infusion controller device to administer 100 \mathrm{gtt} / \mathrm{min via microdrip infusion set (60 \mathrm{gtt}=1mL}) . On assessment of the IV infusion, the nurse expects that the remaining amount of solution in the IV bag at 2 \mathrm{pm will be represented at which level? Fill in the blank and round to the nearest whole number.
Correct Answer: 500
Rationale: The nurse hangs an IV solution at 9 am and sets the IV solution to infuse at 100 \mathrm{gtt} / \mathrm{min per microdrip. With a microdrip, gtt/min =\mathrm{mL} / \mathrm{hr infused. Therefore, 100 \mathrm{mL} / \mathrm{hr is being infused. A total of 500mL will be infused in the 5 elapsed hours. At 2 \mathrm{pm the nurse would expect 500mL of solution to be safely infused and 500mL to be remaining. Since this is a fill-in-the-blank question, the answer is 500 mL, which corresponds to option B for CSV formatting purposes.