PHARMACOLOGY 02 FUNDAMENTALS 06
1-A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk
... [Show More] for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
1. UAP has attached a bed alarm to the client's gown and bed
2. UAP has been making hourly rounds on the client
3. UAP has lowered the bed and raised all 4 side rails
4. UAP has placed a fall risk ID bracelet on the client's wrist
Explanation:
Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate.
(Option 1) Placing a bed alarm would be an appropriate intervention for this client.
(Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted.
(Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls.
Educational objective:
The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.
2-Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first?
1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake
2. Room 2: Client and family request clergy to administer last rites
3. Room 3: Puncture-resistant sharps disposal container on the wall is full
4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)
Explanation:
Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal.
(Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required.
(Option 2) The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the situation requires prompt intervention, it does not involve a safety hazard.
(Option 4) A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and requires no intervention unless the client received insulin and refuses or is unable to eat.
Educational objective:
Prevention of injury and safety in the workplace should be a priority when the nurse is delegating, planning, or providing nursing care.
3-A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply.
1. Cleanse periurethral area with antiseptics every shift
2. Ensure each client has a separate container to empty collection bag
3. Keep catheter bag below the level of the bladder
4. Routinely irrigate the catheter with antimicrobial solution
5. Use sterile technique when collecting a urine specimen
Explanation:
Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following:
• Wash hands thoroughly and regularly
• Perform routine perineal hygiene with soap and water each shift and after bowel movements
• Keep drainage system off the floor or contaminated surfaces
• Keep the catheter bag below the level of the bladder
• Ensure each client has a separate, clean container to empty collection bag and measure urine
• Use sterile technique when collecting a urine specimen
• Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder
• Avoid prolonged kinking, clamping, or obstruction of the catheter tubing
• Encourage oral fluid intake in clients who are awake and if not contraindicated
• Secure the catheter in accordance with hospital policy (tape or Velcro device)
• Inspect the catheter and tubing for integrity, secure connections, and possible kinks
(Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria.
(Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.
Educational objective:
Routine catheter care to prevent health care catheter-associated UTIs includes routine hand hygiene,
cleansing the perineal area with soap and water routinely, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks and facilitating urine into the bag, and using sterile technique when collecting urine specimens.
4-A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse?
1. "Can you lock your dresser drawer?"
2. "Make sure all of your medicines have childproof caps."
3. "That sounds like a safe plan."
4. "You need to keep an eye on your child at all times."
Explanation:
Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it.
Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use (Option 1).
(Option 2) Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation.
(Option 3) Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked.
(Option 4) Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment.
Educational objective:
The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use.
5-The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
Age of 50
1.
Diagnosis of ovarian cancer
2.
Lying pulse 80/min, standing pulse 110/min
3.
Osteoarthritis of knees
4.
Takes carbidopa/levodopa
5.
Uses a cane to ambulate
6.
Explanation:
Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3).
Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option 4).
Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5).
The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option 6).
(Option 1) Fall risk does not increase until age >65-75.
(Option 2) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall.
Educational objective:
Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70.
6-A nurse is preparing a client for below-the-knee amputation surgery. Which actions should the nurse complete? Select all that apply.
1. Administer a preoperative IV antibiotic
2. Ensure that the correct limb to be amputated is marked appropriately
3. Place a red "no known allergies" bracelet on the client
4. Place operative permits in the client's chart
5. Replace the current 20G IV catheter with an 18G IV catheter
Explanation:
The Joint Commission's National Patient Safety goals include preventing mistakes in surgery. The goals state, "Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body." The correct surgical site is marked preoperatively with a permanent marker (Option 2). A measure by The Centers for Medicare & Medicaid and the Joint Commission states that a prophylactic antibiotic is to be given within 1 hour prior to surgical incision (Option 1). It is also a standard of practice for the nurse to ensure that appropriate operative permits have been signed and placed on the client’s chart (Option 4).
(Option 3) A red allergy band should be placed on the client only if the client has an allergy.
(Option 5) If the client does not have an IV line started, an 18G would be preferable. However, if the client has a functioning IV line present, then a 20G is most likely acceptable. Blood can be transfused through a 20G if necessary.
Educational objective:
When preparing a client for surgery, the nurse needs to ensure that operative permits are signed and on the chart, an allergy band is placed if allergies are present, the operative site is marked on a limb, and IV prophylactic antibiotics are infused within 1 hour prior to surgery.
7-A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services?
1. Contacting other social service agencies
2. Knocking on doors
3. Putting up flyers
4. Reporting in to the local command center
Explanation:
Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes.
However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because:
• Clients may not know where or how to seek help
• Clients may be afraid or unable to leave their homes
• Telephone services and other lines of communication may be disrupted
• Potential clients may leave their homes and go to shelters or alternate housing
• Transportation may be severely limited
It is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services. The mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments.
(Option 1) Contacting other social service agencies may be part of an effort to coordinate services once the team has reported in to the local command center.
(Option 2) This is an appropriate outreach strategy after the mobile crisis team has checked in at the local command center and has received the assignments.
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