Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection?
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3. Places the top of the diaper just above the umbilicus.
4. Wraps sterile petroleum gauze around umbilical cord.
5. Submerges newborn in warm water up to the chest for first bath.
1., & 2. Correct: Cleaning from front to back will decrease the risk of infection by reducing the number of microorganisms at the urethral meatus. Keeping the umbilical cord clean and dry will decrease the risk of infection and will allow it to fall off.
3. Incorrect: The top of the diaper should be placed just below the umbilicus to prevent exposure to body waste and moisture. Placing the diaper above the umbilical cord will cause the diaper to rub the umbilicus, which will increase the risk of infection.
4. Incorrect: This would keep the umbilical cord moist and could lead to infection. Also a sterile dressing is not warranted. The umbilical cord needs to be kept dry so it will fall off.
5. Incorrect: The newborn should not be placed in water until after the umbilical cord falls off. Water submersion keeps the cord moist and at risk for infection. The umbilical cord should be kept dry so that it will fall off.
Question:
A client tells the nurse, “I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing.” What action should the nurse take first to assure that the client’s request is respected?
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2. Report client wishes during the end-of-shift report.
3. Have the client sign an advanced directive.
4. Ask the client who holds the durable power of attorney for health care decisions.
1. Correct: The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client’s end- of-life wishes have been communicated and will honor the client’s wishes.
2. Incorrect: It is appropriate to report the client’s end-of-life wishes to other care givers, but not before ensuring a DNR order is in place.
3. Incorrect: If the client has advance directives, a copy should be placed in the medical record. However, a DNR prescription must also be in place to ensure the client is not resuscitated.
4. Incorrect: The client's request can be initiated by notifying the primary healthcare provider. It would be helpful for the client to have a durable power of attorney.
Question:
A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal?
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1. "I should wrap the needle in a paper towel and place in the trash."
2. "I should use a hospital issued biohazard container for all needles."
4. "I should take my needles to the nearest hospital for disposal. "
3. Correct: At home, an FDA approved sharps container is not needed, however, needles, syringes, and sharps may be disposed of in a hard plastic container. Clients should follow their community guidelines for sharps container disposal. This protects the sanitation engineers from injury by the sharps.
1. Incorrect: Syringes must be placed in a safe container in order to protect others from becoming injured by sharps. Wrapping the needle in a paper towel and placing in the trash increases the possibility of injury to someone.
2. Incorrect: The hospital is not involved in sharps disposal in the home. A hard plastic container with a screw on cap is an acceptable container to dispose of needles.
4. Incorrect: The hospital is not involved in sharps disposal in the home. The client can dispose of needles safely at home in a hard plastic container with a screw on cap. The needle should not be brought to the hospital for disposal.
Question:
A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating “Diabetic”, and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take?
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1. Obtain consent from the social worker on duty in the emergency department.
3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment.
4. Withhold treatment until a parent arrives to the emergency department.
2. Correct: In emergencies, if it is impossible to obtain consent from the client or an authorized person, a health care provider may perform a procedure required to benefit the client or save a life without liability for failure to obtain consent. In such cases the law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis (DKA).
1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation.
3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent.
4. Incorrect: Consent for a minor is not needed in the event of an emergency. This is an emergency, so begin treatment for DKA.
Question:
The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of
D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number.
You answered this question CorrectlyEnter the answer for the question below.
Question:
The nurse is caring for a client in an outpatient clinic. The client is being treated with warfarin for prevention of a stroke due to atrial fibrillation. The international normalized ratio (INR) was noted to be 4.6. What should the nurse do?
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2. Instruct the client to continue medication as ordered.
4. Inform the client to return to the clinic per routine monitoring schedule.
5. Take no action as this value is within target range.
1. & 3. Correct: The primary healthcare provider should be notified. The value of 4 is above the usual target range of 2-3. The client has a potential for decreased clotting and bleeding. The client should be told to watch for signs of bleeding.
2. Incorrect: The medication dosage is likely to be reduced.
4. Incorrect: The client should not leave the clinic until the primary healthcare provider has been notified. Further action is indicated and may include changing the usual warfarin dosage.
5. Incorrect: The normal range for a INR is 2-3. When a client is prescribed warfarin, the INR should increase to a therapeutic target range. The value of 4.6 is greater than the usual target range.
Question:
Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)?
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1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating.
3. Collects a urine specimen from an indwelling catheter tubing.
5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP).
6. Perform perineal care of a client who has urinary incontinence.
• Rationale
• Strategies
2. , 4., & 6. Correct: These are all tasks that can be performed by the UAP. The UAP has received training for completing these tasks.
1. Incorrect: The UAP cannot provide teaching; that is planned and implemented by the RN.
3. Incorrect: This is out of the scope of practice for the UAP as it is requires entering a sterile system using sterile technique.
5. Incorrect: The UAP does not have the knowledge and skill to irrigate catheters of any kind. This is a skilled procedure.
Question:
A client was prescribed thioridazine hcl five days ago and presents to the emergency department with a shuffling gait, tremors of the fingers, drooling, and muscle rigidity. Which adverse reaction to this medication does the nurse suspect?
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1. Akinesia
2. Neuroleptic malignant syndrome
4. Oculogyric crisis
3. Correct: Pseudoparkinsonism may appear 1 to 5 days following initiation of antipsychotic medications: occurs most often in women, the elderly, and dehydrated clients. Symptoms include tremor, shuffling gait, drooling, and rigidity.
1. Incorrect: Akinesia is defined as muscle weakness. This client is not presenting with this symptom.
2. Incorrect: Neuroleptic malignant syndrome is a rare, but fatal complication of neuroleptic drugs. Symptoms include hyperpyrexia up to 107 degrees, tachycardia, tachypnea, fluctuations in BP, diaphoresis, coma.
4. Incorrect: Oculogyric crisis is uncontrolled rolling back of the eyes and may appear as part of dystonia (involuntary muscular movements of face, arms, legs, and neck). Oculogyric crisis is not a side effect of thioridazine.
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