Nokea
The post-myocardial infarction client is scheduled for a technetium-99 m ventriculography (multigated acquisition [MUGA] scan). The nurse should ensure that which item is in place before the procedure?
- A. A Foley catheter
- B. Signed informed consent
- C. A central venous pressure (CVP) line
- D. Notation of allergies to iodine or shellfish
Correct Answer: B
Rationale: MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergy to iodine and shellfish is not a concern.
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The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.
- A. Place paper bags on the hands and feet.
- B. Give the clothing and wallet to the family.
- C. Cut clothing along the seams, avoiding bullet holes.
- D. Collect all personal items, including items from clothing pockets.
- E. Place wet clothing and personal belongings in a labeled, sealed plastic bag.
- F. Do not allow family members, significant others, or friends to be alone with the client.
Correct Answer: A,C,D,F
Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of kindizing any existing legal evidence.
The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame?
- A. Continuously
- B. Daily during hospitalization
- C. Every third day of hospitalization
- D. Every other day of hospitalization
Correct Answer: A
Rationale: Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options 2, 3, and 4 are incorrect.
The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate to include at this age? Select all that apply.
- A. Lock up all poisons.
- B. Cover electrical outlets.
- C. Never shake the infant's head.
- D. Place the infant on the back to sleep.
- E. Remove hazardous objects from low places.
Correct Answer: C,D
Rationale: The age-appropriate instructions that are most important are to instruct the mother not to shake or vigorously jiggle the baby's head and to place the infant on his or her back to sleep. Options 1, 2, and 5 are important instructions to provide to the mother as the child reaches the age of 6 months and begins to explore the environment.
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
- A. Urine output: 100mL} / \mathrm{hr
- B. \mathrm{pH of arterial blood: 7.32
- C. Capillary refill: 5 seconds
- D. Blood pressure: 90 / 48mmHg
Correct Answer: A
Rationale: Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .
Which clinical situation should the nurse identify as an example of slander?
- A. The primary health care provider tells a client that the nurse 'does not know anything.'
- B. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat.
- C. The nurse restrains a client at bedtime because the client gets up during the night and wanders around.
- D. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.
Correct Answer: A
Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.