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The nurse working on an adult nursing unit is told to review the client census to determine which clients could be discharged if there are a large number of admissions from a newly declared disaster. The nurse determines that the clients with which medical situations would need to remain hospitalized? Select all that apply.
- A. Laparoscopic cholecystectomy
- B. Fractured hip, pinned 5 days ago
- C. Diabetes mellitus with blood glucose at 180 \mathrm{mg} / \mathrm{dL}(10.2 \mathrm{mmol} / \mathrm{L})
- D. Ongoing ventricular dysrhythmias while receiving procainamide
- E. Newly delivered postpartal client with a blood pressure of 146 / 94mmHg and 2+ proteinuria.
Correct Answer: D,E
Rationale: The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. The newly delivered postpartal client is showing classic signs for mild preeclampsia. This condition would need to be reversed before discharge. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services and support from the family at home.
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The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply.
- A. Elevate the left leg.
- B. Apply moist heat to the left leg.
- C. Administer acetaminophen as prescribed.
- D. Ambulate in the hall three times per shift.
- E. Administer anticoagulation as prescribed.
Correct Answer: A,B,C,E
Rationale: Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecular-weight anticoagulation; however, some primary health care providers may still prefer bed rest for the client.
The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client should indicate to the nurse that the client understands how to manage urine as a biohazard?
- A. Void into a bedpan and then empty the urine into the toilet.
- B. Purchase extra bottles of scented disinfectant for daily bathroom cleansing.
- C. Have one bathroom strictly set aside for the client's use for the next 8 weeks.
- D. Disinfect the toilet with household bleach after voiding for 6 hours after a treatment.
Correct Answer: D
Rationale: Intravesical instillation involves instilling a chemotherapeutic agent into the bladder via a urethral catheter. This method of treatment provides a concentrated topical treatment with minimal systemic absorption. The client retains the medication for approximately 2 hours. After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the toilet after voiding with household bleach for 6 hours after a treatment. There is no value in using a bedpan for voiding. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.
The clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy should the nurse initiate first in order to best meet the clients' needs?
- A. Assess the clients' functional abilities.
- B. Ensure that insurance will pay for participation in the program.
- C. Discuss the focus of the program with the multidisciplinary team.
- D. Include everyone who comes into the clinic in the teaching sessions.
Correct Answer: A
Rationale: Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the program. Options 2, 3, and 4 do not address the clients' needs related to the diagnosis.
Which actions are most appropriate for the nurse to take in the event of an accidental poisoning in a child? Select all that apply.
- A. Save vomitus for laboratory analysis.
- B. Place the child in a flat supine position.
- C. Induce vomiting if a household cleaner was ingested.
- D. Assess for airway patency, breathing, and circulation.
- E. Determine the type and amount of substance ingested.
- F. Remove any visible materials from the nose and mouth.
Correct Answer: A,D,E,F
Rationale: In the event of accidental poisoning, the poison control center is called before attempting any interventions. Additional interventions in an accidental poisoning include saving vomitus for laboratory analysis, which may assist with further treatment; assessing for airway patency, breathing, and circulation; determining the type and amount of substance ingested if possible to identify an antidote; removing any visible materials from the nose and mouth to terminate exposure; and positioning the victim with the head to the side to prevent aspiration of vomitus and assist in keeping the airway open. Vomiting is never induced in an unconscious person or one who is experiencing seizures because of the risk of aspiration. Additionally, vomiting is not induced if lye, household cleaners, hair care products, grease or petroleum products, or furniture polish was ingested because of the risk of internal burns.
The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention should the nurse incorporate into the nursing care plan to best assure client safety?
- A. Check the client's location every 15 minutes.
- B. Begin suicide precautions with 30-minute checks.
- C. Initiate one-to-one suicide precautions immediately.
- D. Ask the client to report suicidal thoughts immediately.
Correct Answer: C
Rationale: One-to-one suicide precautions are required for the client rescued from a suicide attempt. In this situation, additional significant information is that the client is delusional and hallucinating. Both of these factors increase the risk of unpredictable behavior, compromised judgment, and the risk of suicide. Options 1, 2, and 4 do not provide the constant supervision necessary for this client.