Nokea
Which is an example of a sentinel event?
- A. The terminally ill client is referred to hospice and dies 3 months later.
- B. A client receives an unordered mammogram which reveals a small cyst.
- C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
- D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.
Correct Answer: D
Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
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Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?
- A. Alpha tocopherol (vitamin E)
- B. Ascorbic acid (vitamin C)
- C. Calcitriol (vitamin D)
- D. Pyridoxine (vitamin B6)
Correct Answer: D
Rationale: Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.
After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?
- A. Go to the client to assess for signs and symptoms of decreased cardiac output.
- B. Call the physician to inform them of the VF episode for medication adjustments.
- C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
- D. Document the incident on the code report form and follow up regularly.
Correct Answer: A
Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.
The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.
A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in a right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.