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When teaching a competent postoperative client about a patient-controlled analgesia (PCA) pump, the nurse should include which instructions to the client? Select all that apply.
- A. Report the inability to void.
- B. Report any nausea and vomiting.
- C. Push the button before the pain becomes too great.
- D. Inform the nurse about the pain levels being experienced.
- E. Ask the family to assume management, when the client is sleeping.
Correct Answer: A,B,C,D
Rationale: PCA pumps have opioid medications infusing. Opioids can have an effect on the parasympathetic nervous system causing nausea, vomiting, and an inability to void and defecate; these occurrences need to be reported. The nurse must be kept informed about the pain relief achieved by the client and if there is any breakthrough pain. The client needs to be instructed to push the button before the pain becomes too great. Because the client is competent and there is a basal dose being administered, there is no need for the family to push the buttons for pain relief. In addition, no one other than the client should touch the pump unless instructed to do so.
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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.
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.
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 activities for a client diagnosed with depression who was just admitted to the hospital. Which therapeutic action should be implemented as part of the nurse's plan?
- A. Provide an activity that is quiet and solitary in nature.
- B. Plan nothing until the client asks to participate in the milieu.
- C. Offer the client a menu of activities and insist that the client participate in all of them.
- D. Provide a structured daily program of activities and encourage the client to participate.
Correct Answer: D
Rationale: A depressed person is often withdrawn. In addition, the person experiences difficulty concentrating, loss of interest or pleasure, low energy and fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide stimulation in a structured environment. Options 1 and 2 are restrictive and offer little or no structure and stimulation. The nurse should not insist that a client participate in all activities.
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
- A. Yes, a living will never expires.
- B. You need to speak with an attorney.
- C. I will call someone to answer your question.
- D. If it accurately reflects your situation and wishes.
Correct Answer: D
Rationale: The client should discuss the living will with the primary health care provider (HCP) on a regular basis to ensure that it contains the client's current wishes and desires based on the client's current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will should be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client's question on hold.