Nokea
To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement?
- A. Perform a pill count of each prescription bottle at every home visit.
- B. Instruct the client to double up on a medication when a dose is missed.
- C. Provide information on the purpose of all the prescribed medications.
- D. Ask the client to explain and demonstrate self-administration procedures.
Correct Answer: D
Rationale: To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually it is not acceptable to double up on missed medication and conducting a pill count on each visit is unrealistic and disrespectful.
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Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique should the nurse use to transfer the client from the stretcher to the bed?
- A. A bath blanket and the assistance of four people
- B. A bath blanket and the assistance of three people
- C. A transfer board and the assistance of two people
- D. A transfer board and the assistance of four people
Correct Answer: D
Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer board and the assistance of four people. This permits optimal stabilization and support of the spine, while allowing the client to be moved smoothly and gently. Therefore, the remaining options are incorrect and unsafe.
The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?
- A. Administer rescue breathing during the defibrillation.
- B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.
- C. Charge the machine and immediately push the 'discharge' buttons on the console.
- D. Order any personnel away from the client, charge the machine, and defibrillate through the console.
Correct Answer: D
Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the 'discharge' buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as 'hands-off' defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.
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 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.
Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.
- A. Use strict aseptic technique.
- B. Place the drainage bag lower than the bladder level.
- C. Inflate the balloon with 4 to 5 mL beyond its capacity.
- D. Swab the urinary catheter with sterile water before inserting.
- E. Advance the catheter 1 to 2 inches after urine appears in the tubing.
Correct Answer: A,B,E
Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.