A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
Rationale:
The client remains free of signs and symptoms of phlebitis. This outcome reflects successful management of the I.V. therapy by preventing inflammation of the vein, which is a common complication. Maintaining vein integrity and patient comfort without redness, swelling, or pain indicates effective nursing care and proper I.V. site maintenance, ensuring safe infusion and minimizing risks.
A: Monitor fluid intake and output every 4 hours involves assessment, not an expected outcome, focusing on data collection rather than a direct result of I.V. therapy.
C: Edema and warmth are noted at I.V. insertion site indicate inflammation or infection, representing a complication, not a desired or expected outcome.
D: There is a risk for infection related to I.V. insertion identifies a potential problem, not an actual outcome, thus it cannot be considered an appropriate expected result.
What medication should be given immediately to a client with acute asthma and decreased forced expiratory volume?
Rationale:
Bronchodilators should be given immediately to a client with acute asthma and decreased forced expiratory volume.
Bronchodilators rapidly relax airway smooth muscles, improving airflow and relieving bronchospasm during acute asthma exacerbations. This immediate effect increases forced expiratory volume, alleviating respiratory distress. They serve as the first-line treatment for acute symptoms, providing prompt relief, unlike steroids, which have slower onset and different therapeutic roles in asthma management.
A: Beta-adrenergic blockers cause bronchoconstriction and worsen asthma symptoms, thus contraindicated during acute exacerbations.
C: Inhaled steroids reduce inflammation but act slowly, making them unsuitable for immediate relief in acute asthma attacks.
D: Oral steroids have a delayed onset and cannot provide the rapid bronchodilation needed during an acute asthma episode.
How should the first flap of an envelop-wrapped sterile package be opened?
Rationale:
The first flap of an envelope-wrapped sterile package should be opened away from the body. Opening away prevents contamination from the person handling the package by minimizing the risk of the sterile field touching clothing or skin. This practice helps maintain sterility and ensures that the contents remain uncontaminated, which is critical for patient safety and infection control in medical settings.
B: To the left of the body lacks guidance on contamination control and does not address the importance of distancing the sterile field from the person’s body, which increases contamination risk.
C: To the right of the body focuses on direction but ignores sterility principles, failing to prevent the sterile surface from contacting the handler’s body or clothing.
D: Toward the body directs the flap toward the person, increasing exposure to potential contaminants from clothing, skin, or breath, which compromises the sterile integrity of the package.
A nurse recognizes that a helping relationship is established with a patient if the communication.
Rationale:
A helping relationship is established with a patient if the communication encourages the patient to express his thoughts and feelings. This option highlights the critical aspect of therapeutic communication, where the nurse facilitates patient self-expression, fostering trust and understanding. It emphasizes patient-centered dialogue essential for effective support, emotional relief, and collaborative care, which are foundational in nursing relationships.
A: Occurs spontaneously throughout the nurse-client relationship assumes unplanned communication naturally builds rapport but lacks intentional therapeutic focus required for helping relationships.
B: Has no time limits suggests unlimited duration, which is impractical and disregards boundaries necessary for professional and effective nurse-patient interactions.
C: Is equally reciprocal between the nurse and the patient implies balanced exchange, yet helping relationships prioritize patient expression over equal sharing to promote healing and support.
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, 'Will I be able to talk normally after surgery?' What is the most accurate response by the nurse?
Rationale:
You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration. This answer accurately reflects that total laryngectomy results in a permanent stoma and loss of natural voice, requiring specialized rehabilitation for alternative communication methods such as esophageal speech, electrolarynx, or tracheoesophageal puncture voice prosthesis to regain speech ability.
A: You will breathe through a permanent opening in your neck, but you will not be able to communicate orally. This statement ignores available voice rehabilitation options and inaccurately implies permanent loss of all oral communication ability.
B: You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed. Speech does not return simply after tube removal; voice restoration requires specific therapy and devices.
D: You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally. Artificial devices assist speech but rarely restore completely normal voice; this overstates the typical outcome after total laryngectomy.
Sitz bath is an example of:
Rationale:
A sitz bath is an example of a therapeutic bath. Therapeutic baths are designed to relieve discomfort, promote healing, and provide specific health benefits, often targeting particular body parts, such as the perineal area. Sitz baths use warm water to soothe pain, reduce inflammation, and enhance circulation, distinguishing them from routine or cleansing baths that primarily focus on general cleanliness or hygiene.
A: Routine bed bath Routine bed baths focus on overall patient hygiene, typically involving washing the entire body in bed, lacking the targeted medicinal or soothing properties inherent in sitz baths.
B: Cleansing bath Cleansing baths primarily aim to remove dirt and sweat from the skin, emphasizing cleanliness rather than therapeutic effects like pain relief or healing stimulation provided by sitz baths.
D: Partial bath Partial baths involve washing only selected body parts for hygiene purposes, without the specialized therapeutic intention or localized healing benefits characteristic of a sitz bath.
A patient, unsure of the need for surgery, asks the nurse, 'What should I do?' What answer by the nurse is based on advocacy?
Rationale:
The nurse’s response, "Tell me more about what makes you think you don't want surgery," exemplifies advocacy by encouraging the patient to express concerns and supporting informed decision-making. This approach respects patient autonomy, fosters open communication, and helps the nurse understand the patient’s perspective to provide appropriate guidance or assistance tailored to their needs and values.
A: If I were you, I sure would not have this surgical procedure. This option imposes the nurse’s personal opinion, undermining patient autonomy and disregarding individual concerns, which contradicts the principle of advocacy.
B: Gosh, I don't know what I would do if I were you. This response displays uncertainty and fails to support or empower the patient, lacking the proactive engagement necessary for advocacy.
D: Let me talk to your doctor and I will get back to you as soon as I can. Though helpful, this defers responsibility instead of directly addressing the patient’s concerns through active listening and support.
A physician's order reads Potassium chloride (KCl) 30mEq to be added to 1L ml normal saline and to be given over 10-hour period. The available potassium chloride is 40mEq per 20ml. Nurse Corazon should prepare how many milliliters of Potassium Chloride to administer the correct dose of medication?
Rationale:
Nurse Corazon should prepare 15ml of Potassium Chloride to administer the correct dose. The order requires 30mEq, and since 40mEq is contained in 20ml, the proportion calculation (30mEq × 20ml ÷ 40mEq) yields 15ml. This ensures the accurate dosage is administered safely over the prescribed 10-hour period in normal saline.
B: 10ml does not provide enough potassium chloride because it only delivers 20mEq, which is less than the ordered 30mEq, risking underdosing the patient.
C: 50ml exceeds the prescribed dose significantly, delivering 100mEq, which could cause hyperkalemia and serious adverse effects.
D: 20ml corresponds to 40mEq, which is higher than the needed 30mEq, risking overdose and potential toxicity.
While caring for a client who's immobile, the nurse documents the following information in the client's chart: Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." This nursing diagnosis accurately reflects the potential of:"
Rationale:
Risk for impaired skin integrity related to immobility.
This diagnosis fits because the documentation highlights preventive measures like repositioning every two hours and monitoring skin condition with no current damage, indicating a risk rather than actual skin impairment. The client’s improved skin turgor and mobility interventions support the focus on preventing potential skin breakdown due to immobility.
B: Impaired skin integrity related to immobility represents actual skin damage, but the notes specify intact skin with no redness, so no current impairment exists.
C: Constipation related to immobility involves bowel issues, yet the documentation focuses exclusively on skin care and repositioning, without any mention of bowel function.
D: Disturbed body image related to immobility concerns psychological perception, which is not addressed in the physical care and skin condition details provided.
The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order should the nurse question?
Rationale:
Exercise to the point of discomfort should be questioned for a patient with peripheral artery disease taking clopidogrel. This approach may exacerbate symptoms and increase the risk of tissue damage due to compromised blood flow. Clopidogrel prevents clotting, so careful management of activity levels is essential to avoid complications from overexertion or ischemia during exercise.
A: Cilostazol drug therapy enhances blood flow and reduces symptoms by dilating arteries and inhibiting platelet aggregation, complementing clopidogrel’s antiplatelet effects, making it appropriate for peripheral artery disease management.
B: Omeprazole drug therapy prevents gastrointestinal irritation and bleeding risks associated with clopidogrel, protecting the stomach lining without interfering with peripheral artery disease treatment.
C: Use of treadmill for exercise promotes circulation and improves walking distance safely in peripheral artery disease patients, supporting vascular health without risking injury from excessive exertion.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?
Rationale:
Muscle twitching can be an early sign of hyponatremia, so the nurse instructs the client to notify the clinic if this symptom occurs. Hyponatremia causes neurological disturbances due to low sodium levels affecting nerve function, making muscle twitching a critical symptom for timely medical evaluation and intervention to prevent further complications like seizures or altered mental status.
A: "Have your spouse watch you for irritability and anxiety." While irritability and anxiety may occur, this advice lacks specificity and does not emphasize urgent symptoms requiring immediate medical attention.
C: "Call your primary health care provider for diarrhea." Diarrhea can cause electrolyte imbalance but is not a direct symptom of hyponatremia itself and does not address early warning signs.
D: "Bake or grill your meat rather than frying it." Cooking methods do not impact hyponatremia risk or symptoms, making this advice irrelevant for sodium level management.
Amy Jones, a high school senior, wants to become a geriatric nurse practitioner. What nursing degree will she need to attain this goal?
Rationale:
Amy Jones will need to earn a master's degree to become a geriatric nurse practitioner.
A master's degree is required for nurse practitioners because it provides advanced clinical training, specialized knowledge, and the authority to diagnose and treat patients independently, which is essential for geriatric care. This level of education prepares nurses for the complexities of aging populations and advanced practice roles.
A: licensed practical nurse lacks the advanced education and clinical training required for nurse practitioner roles and cannot independently diagnose or treat patients.
B: associate degree prepares nurses for basic nursing roles but does not provide the graduate-level education needed for advanced practice specialties like geriatric nurse practitioner.
C: baccalaureate degree offers foundational nursing education but does not fulfill the advanced clinical and theoretical requirements necessary for nurse practitioner certification.
Elise is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?
Rationale:
The nurse anticipates a prescription to decrease the PN rate to 50 mL/hour.
Decreasing the PN rate to 50 mL/hour allows gradual weaning, ensuring the body adjusts to enteral nutrition while maintaining necessary nutrient and fluid support. This controlled reduction helps prevent metabolic imbalances and supports gastrointestinal adaptation as solid foods are introduced, promoting a safe transition from parenteral to oral intake.
A: Discontinue the PN. Abruptly stopping PN risks nutritional deficits and metabolic instability before the patient fully tolerates solid foods, potentially causing adverse effects during the transition phase.
C: Start 0.9% normal saline at 25 mL/hour. Introducing saline alone does not provide essential calories or nutrients needed during PN weaning and does not address the gradual reduction of parenteral support.
D: Continue current infusion rate prescriptions for PN. Maintaining the existing infusion rate ignores the need for gradual tapering, which is crucial to safely adjust the patient’s metabolism to enteral feeding.
A competent adult patient is scheduled for surgery. Who signs the informed consent form to allow the surgery?
Rationale:
The patient signs the informed consent form to allow the surgery. This is because informed consent is a legal and ethical requirement ensuring that the competent adult patient voluntarily agrees to the procedure after understanding the risks, benefits, and alternatives. Only the patient’s signature validates that they have given permission for surgery, reflecting autonomy and decision-making capacity.
A: a relative Only a competent adult patient can legally authorize surgery; relatives may provide support but lack the authority to sign consent unless designated as a legal proxy or in emergencies.
B: the physician Physicians obtain consent but do not sign on behalf of the patient; their role is to inform, not to authorize surgery through signature.
C: a nurse Nurses assist in care but are not empowered to sign consent forms; their responsibility is to witness or facilitate, not to grant permission.
The student nurse has earned <As= in all of her prerequisite courses. For the first exam in a nursing course, she earns a <D= and now feels that she may not be smart enough to become a nurse. What type of <loss= is the student experiencing?
Rationale:
The student is experiencing a perceived loss.
Perceived loss refers to a loss that is felt by the individual but cannot be verified by others. The student feels inadequate due to her exam grade, which affects her self-esteem and confidence, even though no actual or tangible loss has occurred. This emotional response defines perceived loss.
A: Actual loss involves tangible, observable loss, which is not present here as the student has not lost any physical item or position.
C: Physical loss pertains to losing a body part or physical function, which does not apply to this emotional and academic situation.
D: Situational loss relates to changes caused by external circumstances, not the internal emotional perception of failure the student experiences.
There is great variation among individual responses to the same stressor. In addition to age, nutritional status, and genetic inheritance, which additional factor influences the expression of stress response and reflects the complex psychological processing involved?
Rationale:
The individual's appraisal of the stressor influences the expression of the stress response and reflects complex psychological processing. This factor involves how a person interprets and evaluates the stressor, affecting emotional and physiological reactions uniquely. It integrates cognitive assessment with emotional judgment, which varies greatly among individuals, thereby shaping personalized stress responses beyond biological or external event characteristics.
A: The type of stressor affects stress but does not encompass the individual's mental evaluation or processing, which is crucial for psychological interpretation and personalized stress responses.
B: The amount of stress relates to intensity but lacks the interpretive cognitive dimension that shapes how stress is experienced and manifested psychologically.
C: The context of the stressful event provides background but does not fully account for the internal psychological appraisal that determines individual response differences.
As a science, nursing relies on:
Rationale:
Nursing relies on scientifically tested knowledge. Scientifically tested knowledge ensures nursing practices are evidence-based, reliable, and validated through rigorous methods, enabling safe, effective patient care. This foundation supports clinical decision-making, improves health outcomes, and advances the profession by integrating research findings systematically, distinguishing nursing as a science rather than relying solely on tradition or unverified information.
A: Experimental research focuses on controlled trials but nursing also incorporates observational and qualitative studies; it’s a subset rather than the entire basis.
B: Non-experimental research lacks manipulation of variables, limiting causality; nursing science encompasses diverse methodologies beyond this single approach.
C: Physician-generated research excludes nursing-specific investigations; nursing science depends on specialized, interdisciplinary research contributions for its knowledge base.
When palpating a client's body to detect warmth, the nurse should use which part of the hand?
Rationale:
The nurse should use the back (dorsal surface) of the hand to detect warmth when palpating a client's body. This area has thinner skin and less sensory nerve endings, making it more sensitive to temperature changes. Using the dorsal surface allows the nurse to accurately assess skin temperature without interference from the more sensitive fingertips or finger pads.
A: Fingertips possess high tactile sensitivity ideal for texture and fine sensation but are less suitable for temperature detection due to their dense nerve endings, which may distort warmth perception.
B: Finger pads are primarily designed for detailed tactile assessment, such as texture or swelling, but their rich nerve supply makes them less effective for accurately sensing temperature variations.
D: Ulnar surface (ventral surface) is better suited for vibration detection rather than temperature assessment, as it lacks the sensitivity needed to perceive subtle warmth changes on the skin.
After having an argument with a spouse, which defense mechanism is the patient exhibiting when becoming verbally abusive toward the nurse?
Rationale:
The patient is exhibiting displacement.
Displacement occurs when emotional impulses, like anger from an argument with a spouse, are redirected from the original source to a safer or more accessible target, such as a nurse. This defense mechanism protects the individual from confronting the true cause of distress by shifting feelings to someone less threatening, explaining the verbal abuse toward the nurse.
A: Denial involves refusing to accept reality or facts, which does not match the patient's aggressive verbal behavior redirected toward the nurse.
B: Projection transfers one’s own unacceptable feelings onto others, but the patient is not attributing their anger to the nurse, just redirecting it.
C: Sublimation channels unacceptable impulses into socially acceptable activities, which contrasts with the patient’s openly hostile and verbally abusive conduct.
The nurse understands that the transdermal route is:
Rationale:
The transdermal route is absorbed through the skin. This method allows medication to pass through the epidermal layers directly into the bloodstream, providing a controlled and sustained release of the drug over time. It bypasses the digestive system, reducing gastrointestinal side effects and avoiding first-pass metabolism by the liver, enhancing drug efficacy and patient compliance.
A: Dissolved inside the cheek refers to the buccal route, not transdermal. It involves absorption through oral mucosa, which is distinct from skin absorption pathways.
C: Inserted into the vaginal cavity describes the vaginal route, which involves mucosal absorption, differing anatomically and pharmacokinetically from transdermal skin absorption.
D: Inhaled into the respiratory tract pertains to the pulmonary route, where drugs enter via lungs, contrasting with transdermal systemic delivery through the skin.
A nurse conducts a smoking-cessation program for patients of a neighborhood clinic. This is an example of which of the following aims of nursing?
Rationale:
A nurse conducting a smoking-cessation program exemplifies preventing illness. Preventing illness focuses on measures that reduce risk factors and stop disease development before it occurs. Smoking cessation directly targets behaviors leading to chronic diseases, thus halting the onset of health problems, which aligns precisely with the preventive aim of nursing by promoting healthier lifestyle choices and reducing future medical complications.
A: promoting health Emphasizes enhancing well-being and encouraging positive lifestyle changes but focuses more broadly on overall health improvement rather than specifically targeting disease prevention through risk factor reduction.
C: restoring health Centers on helping patients recover from illness or injury, involving treatment and rehabilitation, which differs from proactive efforts aimed at stopping diseases before they start.
D: facilitating coping with disability or death Concentrates on supporting patients and families facing chronic conditions or end-of-life issues, not on interventions designed to prevent illness in healthy individuals.
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction?
Rationale:
Using a heating pad on the feet at night to increase circulation is unsafe for patients with chronic peripheral artery disease (PAD). Heat application can cause burns due to impaired sensation and does not effectively improve arterial blood flow, potentially leading to tissue damage and worsening complications in PAD.
A: Buying loose clothes that do not bind the legs or waist helps prevent restricted blood flow and reduces the risk of worsening PAD symptoms, supporting proper circulation.
C: Walking to the point of pain, resting, and repeating promotes collateral circulation and improves walking distance, making it a recommended exercise regimen for PAD patients.
D: Changing position frequently and avoiding crossing legs prevents venous stasis and arterial compression, which helps maintain adequate blood flow in patients with PAD.
What part of the eye examination should occur first?
Rationale:
Visual acuity should occur first in the eye examination. Measuring visual acuity establishes a baseline for the patient's vision and helps determine if further testing is necessary. It is a straightforward, non-invasive procedure that provides essential information about the patient’s central vision before assessing more complex aspects like eye movements or internal structures.
A: Extraocular movements assess muscle function but do not provide initial vision clarity, making them less immediate than visual acuity for baseline assessment.
B: Internal structures examination follows initial vision tests because it requires specialized equipment and patient cooperation, unsuitable as the first step.
D: Visual fields testing evaluates peripheral vision but is complex; starting with central visual clarity (acuity) is more practical and informative.
Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client?
Rationale:
Nurse Hazel should prioritize knowing the client's Hgb and Hct levels before administering a unit of whole blood. Monitoring hemoglobin and hematocrit values is essential to assess the severity of anemia and determine the need for transfusion. These indicators provide critical information about oxygen-carrying capacity and blood volume, guiding safe and effective transfusion therapy while preventing complications.
A: Blood pressure and pulse rate provide vital signs but do not directly assess the need for blood transfusion or guide dosage adjustments. They are more relevant for monitoring during transfusion rather than pre-transfusion assessment.
B: Height and weight are important for medication dosing but do not offer specific information on blood oxygen-carrying capacity or anemia severity, which are crucial for determining the necessity of transfusion.
C: Calcium and potassium levels affect cardiac function but are not primary indicators for transfusion decisions. They are monitored to prevent electrolyte imbalances during transfusion, not to assess transfusion need.
You are currently monitoring a client who is undergoing blood transfusion when suddenly he experienced chills, urticaria, hypotension, and respiratory distress. Which action should be taken?
Rationale:
The correct action is to run normal saline at a keep-vein-open rate. This helps maintain venous access, dilutes the blood, and prevents hypotension while the transfusion reaction is managed. Normal saline is isotonic and compatible with blood products, making it the safest fluid to administer during a transfusion reaction to stabilize the patient.
A: Remove the intravenous (IV) line Removing the IV line immediately may cause loss of venous access, complicating further management and medication administration. Maintaining IV access is critical during a transfusion reaction for rapid intervention.
B: Run a solution of 5% dextrose in water Administering 5% dextrose can cause hemolysis and is not compatible with blood transfusions. It risks exacerbating the reaction and is unsuitable for managing transfusion complications.
D: Obtain a culture of the tip of the catheter device removed from the client Culturing the catheter tip is irrelevant at the moment of acute transfusion reaction and delays urgent treatment; it does not address immediate patient stabilization needs.
Nurse Labs is assigned to the following clients. The client that the nurse would see first after endorsement?
Rationale:
The nurse would see the 44 year-old myocardial infarction (MI) client who is complaining of nausea first. This client exhibits potential signs of a life-threatening cardiac complication, such as worsening ischemia or arrhythmia, requiring immediate assessment and intervention to prevent deterioration. Prioritizing this client aligns with emergency nursing principles focused on airway, breathing, circulation, and urgent symptom management.
B: A 34 year-old post operative appendectomy client of five hours who is complaining of pain requires pain management but does not indicate an immediate life-threatening condition demanding urgent attention over cardiac concerns.
C: A 26 year-old client admitted for dehydration whose intravenous (IV) has infiltrated needs IV site assessment and fluid replacement but is less critical compared to acute cardiac symptoms suggesting ischemic complications.
D: A 63 year-old post operative abdominal hysterectomy client of three days whose incisional dressing is saturated with serosanguinous fluid requires wound evaluation but this is not as immediately urgent as potential cardiac instability.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Rationale:
Helping the patient to splint the chest when coughing promotes airway clearance. This technique supports the chest wall, reduces pain during coughing, and enables more effective expectoration of thick sputum, which is essential in bacterial pneumonia for clearing secretions and improving ventilation.
A: Restricting oral fluids worsens sputum viscosity and impedes mucus clearance, counterproductive for airway management.
B: Pursed-lip breathing mainly aids in controlling dyspnea, not in mobilizing thick secretions or clearing airways in pneumonia.
D: Wearing nasal O2 cannula provides oxygenation but does not directly facilitate sputum clearance or enhance effective coughing.
Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent?
Rationale:
Two tablets per dose should be administered to provide the prescribed 1 g of sulfisoxazole.
Each tablet contains 500 mg, so two tablets equal the required 1,000 mg (1 g) dose. This ensures the adolescent receives the exact amount prescribed safely, preventing underdosing or overdosing. The nurse’s calculation matches the medication label, confirming accurate and appropriate administration for the urinary tract infection treatment.
A: ½ tablet would deliver only 250 mg, which significantly underdoses the prescribed 1 g, risking ineffective treatment and persistent infection.
B: 1 tablet provides just 500 mg per dose, half the prescribed amount, potentially leading to inadequate therapeutic effects and treatment failure.
D: 3 tablets equal 1,500 mg, exceeding the prescribed dose, risking toxicity and adverse effects in the adolescent patient.
Dr. G writes the following order for the client who has been recently admitted 'Digoxin .125 mg P.O. once daily.' To prevent a dosage error, how should the nurse document this order onto the medication administration record?
Rationale:
Digoxin .125 mg P.O. once daily accurately reflects the prescribed dose without unnecessary zeros or misspellings. This format prevents misinterpretation and dosage errors by clearly indicating the intended medication strength and administration route in a standard, safe manner.
B: xigoxin .125 mg P.O. once daily contains a typographical error in the drug name, which could cause confusion or incorrect medication administration.
C: Digoxin .1250 mg P.O. once daily inaccurately increases the dosage by adding an extra zero, risking a tenfold overdose and jeopardizing patient safety.
D: Digoxin 0.1250 mg P.O. once daily includes a leading zero that is acceptable, but the trailing zero might be misread, increasing the chance of dosage misinterpretation.
After securing the catheter to the client, the nurse should also secure the catheter to the bed linens and hang the urine drainage bag:
Rationale:
The nurse should hang the urine drainage bag below the level of the bladder.
This positioning prevents urine from flowing back into the bladder, reducing the risk of infection and ensuring proper drainage. Hanging the bag below bladder level uses gravity to facilitate continuous urine flow, minimizing urinary tract infections and complications associated with urine reflux, which can occur if the bag is placed higher than the bladder.
A: Above the level of the bladder allows urine to flow backward, increasing infection risk due to urine reflux into the bladder.
B: At the level of the bladder does not utilize gravity effectively, potentially causing urine stagnation and increasing infection likelihood.
D: At any level the nurse prefers disregards safety protocols and may compromise drainage efficiency or increase infection chances.