Nokea
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.
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A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? Select all that apply.
- A. The client fell out of bed.
- B. No bruises or injuries are noted on the client.
- C. The client apparently climbed over the side rails when the nurse was out of the room.
- D. The health care provider was notified that the client was found lying on the floor next to the bed.
- E. The client is alert and oriented and stated that he needed to 'go to the bathroom and didn't want to bother the nurse.'
- F. Vital signs are temperature: 98.6°F (37°C); pulse 78 beats per minute and regular; respirations 16 breaths per minute and regular; blood pressure 188/78 mm Hg.
Correct Answer: B,D,E,F
Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report should always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.
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.
A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?
- A. Initiating seizure precautions
- B. Using a wheelchair for out-of-bed activities
- C. Assisting the child with ambulation at all times
- D. Minimizing contact with other children on the nursing unit
Correct Answer: A
Rationale: Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. Options 2 and 3 are not required unless functional deficits exist. Based on the child's diagnosis, option 4 is not necessary.
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
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.