Nokea
Which findings documented in the history of an older client should require the nurse to implement an accident prevention protocol? Select all that apply.
- A. Range of motion is limited.
- B. Peripheral vision is decreased.
- C. Transmission of hot impulses is delayed.
- D. The client reports incidences of nocturia.
- E. High-frequency hearing tones are perceptible.
- F. Voluntary and autonomic reflexes are slowed.
Correct Answer: A,B,C,D,F
Rationale: The physiological changes that occur during the aging process increase the client's risk for accidents. Musculoskeletal changes include a decrease in muscle strength and function, lessened joint mobility, and limited range of motion. Sensory changes include a decrease in peripheral vision and lens accommodation, delayed transmission of hot and cold impulses, and impaired hearing as high-frequency tones become less perceptible. Nervous system changes include slowed voluntary and autonomic reflexes. Genitourinary changes may include nocturia.
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A primary health care provider prescribes 1000 mL of 0.45% normal saline solution to run over 8 hours. The drop factor is 15 drops/mL. The nurse plans to adjust the flow rate to how many drops per minute to safely administer this intravenous (IV) solution? Fill in the blank and round answer to the nearest whole number.
Correct Answer: 31
Rationale: The prescribed 1000 mL is to be infused over 8 hours. Follow the formula for calculating IV flow rates and multiply 1000 mL by 15 (drop factor). Then divide the result by 480 minutes (8 hours × 60 minutes). The infusion is to run at 31.2 or 31 drops/min.
The nurse employed in a home health agency is religiously opposed to homosexuality and cannot care for a client diagnosed with human immunodeficiency virus (HIV). The nurse then leaves the client's home. Which statement accurately identifies the nurse's rights and actions? Select all that apply.
- A. The nurse has the moral right to leave the client's home at any time.
- B. The nurse has a legal right to inform the client of any barriers to providing care.
- C. The nurse has a duty to protect self from client care situations that are morally repellent.
- D. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.
- E. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.
Correct Answer: D,E
Rationale: The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client's safety at risk and the refusal is primarily associated with religious objections, not personal objection, to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse's personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).
The nurse is preparing to administer a first dose of prescribed pentamidine isethionate intravenously to a client. Before administering the dose, which safety measure should the nurse consider for this client?
- A. Assign to a private room.
- B. Establish a supine position.
- C. Place on respiratory precautions.
- D. Assist to a semi-Fowler's position.
Correct Answer: B
Rationale: Pentamidine isethionate is an antiinfective medication and can cause severe and sudden hypotension, even with administration of a single dose. The client should be lying down during administration of this medication. The blood pressure is monitored frequently during administration. Assigning to a private room, instituting respiratory precautions, or assisting to a semi-Fowler position are all unnecessary interventions.
An emergency department nurse is a member of an all-hazards disaster preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions should initially be included in the plan? Select all that apply.
- A. Isolate the client.
- B. Don protective equipment immediately.
- C. Notify infectious disease specialists, public health officials, and the police.
- D. Lock down the emergency department and the entire hospital immediately.
- E. Identify all client contacts, including transport services to the emergency department and clients in the waiting room.
- F. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room immediately.
Correct Answer: A,B,C,E
Rationale: An all-hazards disaster preparedness group is a multifaceted internal and external disaster preparedness group that establishes action plans for every type of disaster or combination of disaster events. In the event of emergency department exposure to a communicable disease such as smallpox, the client would be isolated immediately and the staff would immediately don protective equipment. The emergency department would be locked down immediately. Locking down the entire hospital may not be necessary and infectious disease specialists and public health officials will determine whether it is necessary to take this action. Infectious disease specialists, public health officials, and the police are notified. All client contacts (name, addresses, telephone numbers), including transport services to the emergency department and clients in the waiting room, would be identified so that the public health department can follow through on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days after exposure will help prevent the disease or make it less severe, it is unreasonable and unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room.
The nurse is assigned to care for a client who is in traction. Which intervention by the nurse should ensure a safe environment for the client?
- A. Making sure that the knots are at the pulleys sites
- B. Checking the weights to be sure that they are off the floor
- C. Making sure that the head of the bed is kept at a 90-degree angle
- D. Monitoring the weights to be sure that they are resting on a firm surface
Correct Answer: B
Rationale: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. The head of the bed is usually kept low to provide countertraction. Weights are not to be kept resting on a firm surface.