Nokea
Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
- A. The client is increasingly agitated.
- B. The client's left hand is pale and cold.
- C. The client's skin under the restraint is red.
- D. The client verbalizes the reason for the restraints.
- E. The client is unable to reach the gastrostomy tube with his or her hands.
- F. The client demonstrates behavior that includes biting the attending staff.
Correct Answer: A,B,C,F
Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.
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A client who had expressed suicidal ideations upon admission is being discharged home with family. Which statement by a family member might constitute criteria for delaying discharge?
- A. The client's wife asks, 'Does he know that I've already moved out and filed for a divorce?'
- B. The client's daughter states, 'I've decided to postpone my wedding until Dad's feeling better.'
- C. The client's son states, 'One of his friends visited last week to tell us Dad's union is out on strike.'
- D. The client's brother asks, 'Will my brother be able to continue as executor of our parent's trust?'
Correct Answer: A
Rationale: Single, divorced, and widowed clients have suicide rates that are greater than those who are married. Although the client might feel responsible for his daughter's postponement of the wedding, if presented as an action to include him, the client will feel loved and cared for. Although the situation of the strike is stressful, the client will probably receive a portion of his wages and can derive hope and a sense of belonging from being a member of the union. Although being suicidal may reduce the ability to concentrate, if the client perceives the executorship positively, taking the role away reinforces the client's low self-esteem and self-worth. This statement by the client's brother also indicates a need for the client's brother to be educated about depressive illness.
A client is admitted to the labor and delivery unit for a labor induction. The primary health care provider has prescribed oxytocin to be initiated by piggyback at an initial rate of 2 milliunits/min and increased by a rate of 2 milliunits/min every 30 minutes until contractions are 2 to 3 minutes apart, lasting 80 to 90 seconds. How many \mathrm{mL} / \mathrm{hr will the nurse initially set the infusion pump if the dilution of the oxytocin is 10 units of oxytocin in 1000mL of 0.225\% normal saline? Fill in the blank and round to the nearest whole number.
Correct Answer: 12
Rationale: Use the medication calculation formula to calculate the correct dose. Formula: 10 units of oxytocin in 1000mL of 0.225\% normal saline = 10,000 milliunits per 1000mL or 10 milliunits per 1mL . Solve by the ratio proportion method. 10 milliunits : 1mL :: 2 milliunits : xmL} / \mathrm{min . 10x = 2 , x = 2 \text{ divided by } 10 , x = 0.2mL} / \mathrm{min . Multiply by 60 minutes to get the amount infused per hour: 0.2 \times 60 = 12mL} / \mathrm{hr . Since this is a fill-in-the-blank question, the answer is 12 mL/hr, which corresponds to option C for CSV formatting purposes.
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan?
- A. Assisting the client to deal with long-term care placement
- B. Including the client's significant others in the teaching session
- C. Following up on laboratory and diagnostic tests that were prescribed
- D. Including information the primary health care provider has indicated
Correct Answer: B
Rationale: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.
An adult client who has a severe neurocognitive impairment is scheduled for gallbladder surgery. With regard to the informed consent, which should the nurse implement first to facilitate the scheduled surgery?
- A. Check for the identity of the client's legal guardian.
- B. Inform the legal guardian about advance directives.
- C. Arrange for the surgeon to provide informed consent.
- D. Ensure that the legal guardian signed the informed consent.
Correct Answer: A
Rationale: A mentally impaired client is not competent to sign an informed consent, so the nurse should first verify the identity of the client's legal guardian. This action fulfills part of the nurse's duty in informed consent, helps avoid improperly signed documents, and directs the surgeon to the legal representatives of the client's interests. The client and/or legal guardian is asked about the existence of an advance directive at the time of admission, so this should have already been done, making option 2 incorrect. The surgeon is responsible for obtaining the informed consent, but based on the options provided, option 3 is not the first nursing action. Likewise, option 4 is not the first action; the nurse checks identity of the legal guardian first.