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When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?
- A. The presence and location of any pressure ulcers.
- B. Measures already taken to maintain client safety.
- C. Any special mattresses on the client's bed.
- D. Current vital signs and oxygen saturation.
Correct Answer: B
Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.
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While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
- A. Remove the cap and apply direct gentle pressure with the syringe
- B. Contact the healthcare provider regarding the need for a chest x-ray
- C. Cover the cap with tape and label the port as being obstructed
- D. Remove the catheter while applying gentle pressure at the insertion site
Correct Answer: B
Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.
An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?
- A. Invite him to participate in the evening group activity
- B. Schedule frequent private phone calls to his parents
- C. Provide access to a variety of video games in his room
- D. Encourage him to learn his way around the hospital
Correct Answer: A
Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment.
Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.
The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?
- A. Aspirates the newborn's nares using a syringe
- B. Applies a dressing to the cord after the newborn's bath
- C. Breastfeeds the infant every hour during the night
- D. Positions the infant supine in the crib to sleep
Correct Answer: D
Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn's nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.
A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer's at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 900 mL in the last 24 hours
- B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
- C. Increased blood urea nitrogen (BUN)
- D. 24-hour intake at the current infusion rate
Correct Answer: B
Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.
When preparing the client for a thoracentesis, which action is essential for the nurse to take?
- A. Encourage the client to cough during the procedure
- B. Ask the client to void prior to the procedure
- C. Have the client lie in the prone position
- D. Determine if chest x-rays have been completed
Correct Answer: B
Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.