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There has been an increase in medication errors and errors in ordering laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply.
- A. When a medication order or critical lab result is received with the current or critical lab result is received.
- B. When any verbal or phone order is received.
- C. Whenever a written order or printed critical test result is received.
- D. When the unit secretary takes a phone order.
- E. When the agency uses computerized health care records.
Correct Answer: A,B,D
Rationale: Read-back procedures are required for verbal, phone, or critical result communications to ensure accuracy, especially when relayed through staff like unit secretaries.
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Which of the following interventions will be most effective in improving transcultural communications with the client?
- A. Use touch to show concern and caring for the client.
- B. Focus attention on verbal communication skills only.
- C. Establish a rapport and listen to their concerns.
- D. Maintain eye contact at all times.
Correct Answer: C
Rationale: Establishing rapport and listening to concerns fosters trust and understanding, which are essential for effective transcultural communication.
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema. ROM exercises (A) and elevation (D) are helpful but secondary. Abdominal massage (B) is not indicated.
Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply.
- A. Avoid turning the toes or knee outward.
- B. Use an abduction pillow between the legs when in bed.
- C. Use an elevated toilet seat and shower chair.
- D. Do not extend the operative leg backwards.
- E. Restrict motion for 2 weeks after surgery.
Correct Answer: A,B,C,D
Rationale: These measures prevent dislocation and promote recovery. Motion is encouraged, not restricted, to aid rehabilitation.
A client is admitted to the unit with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and I.V. heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
- A. Administering aspirin as ordered
- B. Encouraging green leafy vegetables in the diet
- C. Monitoring the client's prothrombin time (PT)
- D. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR)
Correct Answer: D
Rationale: Heparin therapy for DVT requires monitoring aPTT to ensure therapeutic anticoagulation (1.5–2.5 times baseline). INR is less relevant for heparin but may be monitored if transitioning to warfarin. Aspirin is not typically used, and green leafy vegetables (high in vitamin K) may affect warfarin, not heparin.
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.