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The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?
- A. Elevate the foot of the bed.
- B. Put the bed in reverse Trendelenburg.
- C. Position the residual limb flat on the bed.
- D. Keep the residual limb slightly elevated with the client lying on the operative side.
Correct Answer: D
Rationale: Following an above-the-knee amputation, the residual limb is typically elevated for the first 24 hours to reduce swelling and promote venous return, which helps prevent complications such as edema. Positioning the client on the operative side with the residual limb slightly elevated (e.g., on a pillow) is the safest initial action to achieve this. Elevating the foot of the bed (option 1) may not specifically target the residual limb and could cause discomfort. Reverse Trendelenburg (option 2) elevates the head, which is not relevant to limb positioning. Keeping the limb flat (option 3) does not address swelling reduction.
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The nurse is preparing the client's morning prescribed NPH insulin dose and notices a clumpy precipitate inside the insulin vial. Which action should the nurse implement?
- A. Draw the dose from a new vial.
- B. Draw up and administer the dose.
- C. Shake the vial in an attempt to disperse the clumps.
- D. Warm the bottle under running water to dissolve the clump.
Correct Answer: A
Rationale: The nurse should always inspect the vial of insulin before use for solution changes that may signify loss of potency. NPH insulin is normally uniformly cloudy. Clumping, frosting, and precipitates are signs of insulin damage. In this situation, because potency is questionable, it is safer to discard the vial and draw up the dose from a new vial.
The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position should the nurse assist the client into to maintain safety during the procedure?
- A. Right side-lying with the head of the bed flat
- B. Prone with the head turned toward the affected side
- C. Sims' position with the head of the bed elevated 45 degrees
- D. Left side-lying with the head of the bed elevated 45 degrees
Correct Answer: D
Rationale: A thoracentesis is a procedure in which fluid or air is removed from the pleural space via a transthoracic aspiration. Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.
The nurse, after administering an injection to a client, accidentally drops the syringe on the floor. Which nursing action is most appropriate in this situation?
- A. Obtain a dust pan and mop to sweep up the syringe.
- B. Call the housekeeping department to pick up the syringe.
- C. Carefully pick up the syringe from the floor and gently recap the needle.
- D. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
Correct Answer: D
Rationale: Used syringes should always be placed in a sharps container immediately after use to avoid individuals from becoming injured. A syringe should not be swept up because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe. Syringes should never be recapped under any circumstances because of the risk of getting pricked with a contaminated needle.
The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client's feeling about the procedure?
- A. Getting a cup of coffee and join in on the conversation
- B. Determining whether or not the client should be drinking coffee
- C. Complementing the staff nurse on the development of a good therapeutic relation
- D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area
Correct Answer: D
Rationale: The nurse manager should ask the second nurse to stop eating and drinking in the client area. A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions; appropriate hand-washing and sterilization procedures; and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. None of the remaining options relate to management of this potential complication.
A client has a prescription for valproic acid 250 mg once daily. To maximize the client's safety, which time is best for the nurse to schedule administration of the medication?
- A. With lunch
- B. With breakfast
- C. Before breakfast
- D. At bedtime with a snack
Correct Answer: D
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset.