The nurse is preparing to administer metoprolol (Lopressor) to a new client. Which of the following actions by the nurse are correct? Select all that apply.
Rationale:
B: Checking the client's blood pressure and apical pulse is essential prior to administering metoprolol, as it helps gauge the client’s cardiovascular status and ensures safe medication administration.
C: Verifying allergies before medication administration protects the client from potential adverse reactions, ensuring that the nurse is aware of any contraindications related to the medication prescribed.
D: Using two patient identifiers is a crucial safety measure that ensures the correct patient receives the medication, minimizing the risk of errors in medication administration.
A: Holding for a heart rate greater than 80 bpm does not align with standard practice for metoprolol, which typically requires monitoring for rates significantly lower than this threshold.
E: Advising against grapefruit juice is relevant for some medications, but metoprolol does not have significant interactions with grapefruit, making this advice unnecessary in this specific context.
The nurse has given a client an injection and then notes that the sharps container is full. Which is the correct action by the nurse?
Rationale:
The nurse should exchange the full container for a new one. This action ensures that all sharps are disposed of safely and that the risk of injury or contamination is minimized, maintaining a safe environment for both staff and patients.
B: place the syringe on top of the container so it will not roll off. This practice poses significant safety risks, as it can lead to accidental needle-stick injuries or spills.
C: force the syringe into the top of the container as well as it will fit. Attempting to cram additional sharps can compromise the container's integrity, increasing the risk of exposure to hazardous materials.
D: put the syringe into her pocket and dispose of it in another room. Storing a syringe in the pocket is highly unsafe, exposing both the nurse and others to potential harm from needle-stick injuries.
A nurse is preparing to administer IV Rocephin for infection to a client. The client has a central venous line infusing blood but no other IV access. The blood still has 30 minutes left to infuse. The Rocephin is due now. How should the nurse proceed?
Rationale:
C: Stop the blood, flush the line with 0.9% NS, administer the Rocephin, and then flush the line with the NS before restarting blood. This procedure ensures the Rocephin is effectively delivered while maintaining the integrity of the central venous line, preventing potential interactions between the blood product and the antibiotic, thus ensuring patient safety and medication efficacy.
A: Hold the Rocephin since it will be too late to give it after the blood completes infusing. Delaying the Rocephin administration does not consider the urgency of treating the infection effectively and appropriately.
B: Draw up the Rocephin in a syringe after reconstitution and inject it into the blood bag so it can infuse with the blood. This method risks contamination and alters the blood product’s composition, compromising patient safety.
D: Allow the blood to finish infusing before giving Rocephin; the Rocephin will be administered during an acceptable time frame for 'on time' administration. Waiting neglects the immediate need for antibiotic therapy, which could worsen the patient's infection.
After administering the annual Mantoux tuberculin skin test to employees, the nurse instructs the staff to return within how many hours after administration to have the results determined?
Rationale:
Employees must return within 48 to 72 hours after the Mantoux tuberculin skin test for result interpretation. This timeframe allows sufficient time for potential reactions to manifest on the skin.
A: 12 to 24 hours. This duration is insufficient for an accurate assessment, as the skin response typically requires longer to develop following the test administration.
B: 24 to 48 hours. While closer to the accurate timeframe, this option still falls short, as full reaction evaluation necessitates waiting until the 48-hour mark for reliable results.
D: 72 to 84 hours. This period exceeds the recommended timeframe, potentially leading to unnecessary delays in determining the test outcome, which should be assessed by the 72-hour limit.
The nurse is talking with a client about primary and secondary prevention of cancer. Which statements are examples of primary prevention? Select all that apply.
Rationale:
Limiting alcohol to no more than 1 ounce per day, getting vaccinated against human papilloma virus (HPV), and eating a low-fat diet high in fiber, including fruits and vegetables are examples of primary prevention. These actions directly reduce the risk of developing cancer through lifestyle choices and vaccinations aimed at preventing disease before it occurs.
A: removing colon polyps to prevent colon cancer Involves intervention after polyps are discovered, categorizing it as secondary prevention rather than a proactive measure to avoid cancer altogether.
C: colonoscopy at age 50 years and then every 10 years Functions as a screening procedure to detect cancer early, classifying it under secondary prevention rather than a method to avert the disease.
D: yearly mammogram for all women older than 40 years Serves as a diagnostic tool for early cancer detection, positioning it within secondary prevention strategies rather than preventing cancer before it develops.
The nurse is caring for a client with influenza. Which precautions would the nurse expect to be in place for this client?
Rationale:
Droplet precautions would be expected for a client with influenza. These precautions are necessary because influenza is transmitted through respiratory droplets when an infected person coughs, sneezes, or talks, thus protecting others from exposure.
A: contact Precautions for contact transmission are not suitable for influenza, as the virus primarily spreads through droplets rather than direct contact with contaminated surfaces or materials.
C: airborne Influenza does not require airborne precautions, as its transmission does not occur via aerosolized particles that remain suspended in the air over long distances.
D: protective environment A protective environment is unnecessary for influenza, which does not involve immunocompromised patients needing protection from environmental pathogens, as influenza is primarily a contagious respiratory illness.
The nurse is caring for a client with Guillain-Barre syndrome. Due to paralysis, the client is unable to press the call button with his finger. The nurse must make accommodations for this client to be able to call for help. Which action by the nurse is correct?
Rationale:
Utilize a call light adapter that will allow the client to call for help by turning his head to activate a special button. This solution directly addresses the client's paralysis, providing an effective means of communication without requiring finger movement. It ensures the client can summon assistance independently, enhancing safety and dignity in their care.
A: Leave the client's door open and instruct him to yell loudly for help. This option does not consider the client's physical limitations and fails to provide a reliable method for emergency communication.
B: Ask a family member to stay around the clock so she can call for the client. Relying on family members for constant supervision is impractical, burdensome, and does not ensure timely assistance when needed.
C: Round on the client as often as possible since there are no alternatives. Frequent rounds may not be feasible or sufficient for urgent situations, leaving the client vulnerable without an effective way to call for help.
The nurse is reviewing the facility's emergency preparedness plan. Which statement is true regarding emergency preparedness?
Rationale:
Without stress management and intervention during and after an event, staff members are at risk of developing post-traumatic stress disorder (PTSD). Addressing mental health proactively is essential to safeguard the well-being of healthcare providers following traumatic incidents. This highlights the critical importance of supporting staff emotionally to prevent long-term psychological effects after emergencies.
A: Nurses play supporting roles during and after a disaster or emergency. While nurses do provide crucial support, the statement lacks emphasis on the need for mental health interventions to prevent PTSD.
B: The critical incident stress debriefing team analyzes what went wrong and what went right with the plan. This statement misrepresents the team's primary focus, which is more about emotional support than analyzing procedural effectiveness.
C: The administrative review meets with team members shortly after the event to promote effective coping strategies to staff. This implies a focus on strategy rather than the immediate need for stress management to prevent PTSD among staff.
The nurse is teaching a family about safety from poisons. The nurse would include which statements in her teaching? Select all that apply.
Rationale:
If someone accidentally ingests poison, try to induce vomiting unless the person is unconscious. This guidance is critical as inducing vomiting can prevent further absorption of the toxin, promoting safety in emergencies.
A: If someone accidentally ingests poison, try to induce vomiting unless the person is unconscious. Inducing vomiting can lead to severe complications if the individual is unconscious or at risk of aspiration.
B: If the person vomits, save the vomitus in case it is requested by the Poison Control Center or emergency department. While saving vomitus may seem helpful, it can complicate treatment decisions and is not always necessary.
C: Post the phone number of the Poison Control Center near the phone if you have small children. While important, this action alone does not address immediate responses needed in case of poison exposure.
D: If the Poison Control Center recommends going to the hospital, drive as fast as you can safely do so. Speeding to the hospital can increase risk; careful driving ensures safety for all, especially in emergencies.
The nurse is caring for a client who just returned from a supratentorial craniotomy, during which a large tumor was removed. Which of the following interventions by the nurse are appropriate for this client? Select all that apply.
Rationale:
Elevating the head of the bed 30 degrees, monitoring neurological status every 2 hours, and checking for signs of increased intracranial pressure are essential post-operative interventions to promote cerebral perfusion and prevent complications.
B: elevate the head of the bed 90 degrees. Positioning the head at 90 degrees can compromise venous drainage and potentially increase intracranial pressure, which is detrimental after craniotomy.
E: apply antiembolism stockings to the client once he is alert. Immediate post-operative care prioritizes neurological assessments and positioning, making the application of antiembolism stockings less critical until the patient is more stable.
F: turn the client every 2 hours from the operative side to the nonoperative side. Turning immediately from the operative side can disrupt healing and increase the risk of complications, requiring more cautious movement.
The nurse is supervising the unlicensed assistive personnel (UAP) while providing care for a client with an internal radioactive implant. Which action by the UAP requires immediate intervention by the nurse?
Rationale:
The UAP assists the client in setting up the meal tray. Assisting with meal trays can lead to unnecessary exposure to radiation for the UAP, violating safety protocols for clients with internal radioactive implants.
B: The UAP wears a dosimeter badge while performing client care. Wearing a dosimeter badge ensures monitoring of radiation exposure, which is essential for safety in this context.
C: The UAP closes the door to the room upon entering and exiting. Closing the door minimizes radiation exposure to others, demonstrating adherence to safety protocols and protecting bystanders.
D: The UAP places soiled linen in a laundry cart and takes it to the soiled utility area. Handling soiled linen without proper precautions poses a contamination risk, yet this action does not immediately compromise safety.
The nurse sees a small fire in a trash can at the nurses' station. She retrieves the fire extinguisher. Which is the correct method to put out the fire?
Rationale:
Pull the pin, aim the hose at the fire's base, squeeze the handles, and sweep from side to side slowly to ensure even coverage and extinguish flames.
This method effectively targets the base where the fire originates, maximizing the extinguisher's impact. Sweeping from side to side ensures thorough application of the extinguishing agent, promoting complete fire suppression and preventing re-ignition.
A: pull the pin, squeeze the handles, aim at the top of the fire, and sweep downward to contain the flames. Aiming at the top is ineffective, as it misses the fire's source.
B: squeeze the handles firmly, aim hose at the top of the fire, and then spray downward in a sweeping motion until flames are extinguished. Targeting the top may allow flames to spread rather than addressing the core issue.
C: pull the pin, aim hose at the outside of the trash can, and coat it thoroughly to contain the fire before spraying flames inside trash can. Coating the outside fails to directly combat the flames, risking the fire's escalation.
The nurse is performing discharge teaching to a client who gave birth to her first child. Which statement by the client indicates a need for further teaching?
Rationale:
I will put my baby to sleep on her tummy. This statement indicates a need for further teaching, as placing infants on their stomachs for sleep increases the risk of Sudden Infant Death Syndrome (SIDS), which is a critical safety concern for newborns.
B: My baby's first visit to the doctor should be 3 to 5 days after birth. This is a standard recommendation, ensuring early monitoring of the baby's health and addressing any concerns promptly.
C: I should keep my baby in an approved car seat while riding in the car. Proper car seat usage is vital for infant safety during travel, highlighting responsible parenting practices.
D: I will keep the numbers of my pediatrician and the poison control center handy. Having these numbers accessible is prudent, facilitating quick access to professional guidance in emergencies related to the baby’s health.
The nurse is educating a client on meningitis. Which statements would the nurse include in the teaching? Select all that apply.
Rationale:
Immunocompromised clients and older adults are at increased risk of meningitis. This statement is accurate as these populations have weakened immune systems or age-related vulnerabilities, making them more susceptible to infections such as meningitis.
A: The CDC recommends an initial vaccine at age 6 or upon entering first grade. This statement misrepresents the timing of vaccination, as the recommendation typically occurs earlier in childhood, not at age 6.
D: Young preschool-age children have the highest rates of infection from life-threatening meningococcal infection. While children are at risk, the highest rates are seen in infants and adolescents, not specifically preschool-age children.
E: A booster vaccine is given at age 11 or 12 to children living in crowded spaces, such as group homes or summer camps. This statement inaccurately limits the booster recommendation, which applies broadly to all children at that age, regardless of living conditions.
The nurse is teaching a group of parents with infants and toddlers about poisoning. Which information would the nurse include in her teaching? Select all that apply.
Rationale:
Place all chemicals on a high shelf out of reach, do not induce vomiting if the child is unconscious, call the Poison Control Center before inducing vomiting, and keep the number of the Poison Control Center near the phone.
This set of guidelines ensures maximum safety for infants and toddlers by preventing access to harmful substances and promoting appropriate responses during poisoning emergencies, emphasizing prevention and immediate action.
E: if the child ingests household cleaners or grease, induce vomiting. Inducing vomiting can exacerbate the situation, as certain substances may cause further harm when expelled from the stomach.
The nurse is preparing to administer Protonix 40 mg PO to a client. The medication dispenser system is out of the tablets, but the nurse realizes that he can override and pull out IV Protonix instead. The client has a patent IV, and the nurse decides this will save time instead of calling the pharmacy for the missing medication. Which of the six rights of medication administration has the nurse violated?
Rationale:
The nurse has violated the right route.
Administering IV Protonix instead of the prescribed oral form constitutes a breach of the right route, which mandates that medications must be given via the correct method as ordered by the physician.
A: right dose The dosage of 40 mg remains the same; thus, the amount being administered is not in question.
B: right time The timing of administration is not indicated as an issue, so there is no violation regarding when the medication is given.
D: right patient There is no evidence to suggest the nurse is administering the medication to the wrong client, ensuring the right patient remains a priority.
E: right medication The medication being given is Protonix; however, the route of administration is the focus of the violation, not the medication itself.
F: right documentation The scenario does not mention any omission in documenting the medication administered, leaving this aspect unaffected by the nurse's actions.
A client is diagnosed with Meniere's disease. Which nursing diagnosis would take priority for this client?
Rationale:
Risk for injury takes priority due to the unpredictable nature of Meniere's disease, which can cause vertigo and balance disturbances, increasing the likelihood of falls and accidents for the client.
B: Disturbed body image focuses on psychological aspects, which, while relevant, are secondary to immediate physical safety concerns arising from the instability associated with Meniere's disease.
C: Low self-esteem may develop as a result of the condition, yet it does not address the urgent physical risks posed by the symptoms like vertigo and disorientation.
D: Impaired skin integrity pertains to skin health, which is not a primary concern in the context of Meniere's disease, where balance and safety are paramount.