The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include?
Empty the child's mouth of any poisonous substance still present.
Rationale: Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with and absorption of the substance. The parent should call the Poison Control Center before giving any treatment. Never induce vomiting unless instructed to do so by the Poison Control Center or a health care provider. The same applies for giving the child milk to drink because not all poisons are neutralized that way.
The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first?
Immediately wash hands vigorously with soap and warm water.
Rationale: The immediate action of vigorously washing the hands will help reduce the risk of potential exposure to bloodborne pathogens. The nurse should then follow the facility's policy and procedure for employee needlestick injury.
The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take? [Select all that apply.]
-Mark the entry as "mistaken entry-wrong patient."
-Enter the time the error was discovered.
Rationale: The entry should be identified as being a mistake. Records should not be deleted. It is not necessary to notify the health care provider, complete an incident report or notify the nurse manager as long as the nurse follows the appropriate policy for correcting documentation errors. The nurse needs to enter the time the error was discovered in order to have a record of the change.
The client is diagnosed with active tuberculosis [TB] and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is:
To trace and screen recent contacts the client had
Rationale: Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary or most important reason for required reporting.
The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents?
Wash hands thoroughly with soap and warm water after contact with the child.
Rationale: The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and they can safely return to daycare or school one week after symptoms begin. In children under 6-years-old, who represent approximately 1/3 of all cases of hepatitis A, the disease may be asymptomatic and jaundice is rarely evident.
The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse? [Select all that apply.]
-The client is talking on the telephone and
laughing
-The client is crossing his legs
-The client is drinking a cup of black tea
-The air is released rapidly while auscultating for Korotkoff sounds
Rationale: Systolic and diastolic blood pressure increase when talking. If the artery is below heart level, you may get a false-high reading. Caffeine can increase blood pressure if ingested up to 30 minutes prior to taking the reading. The client should not be crossing his legs during BP measurement as that can artificially increase the blood pressure.The air should be released gradually/slowly while auscultating for sound. The cuff positioned at 2 to 3 cm above the antecubital fossa is correct.
The automated external defibrillator [AED] has been applied to a client receiving cardiopulmonary resuscitation [CPR]. Indicate how the nurse will proceed by placing the following actions in the correct order. [Instructions: Drag and drop the steps into the correct
order.]
-123456Press the analyze button when the AED prompts the nurse to do so.
-Immediately resume CPR.
-Call out "stand clear" when the AED prompts the nurse to administer a shock.
-Allow time for the AED to administer a shock.
-Press the shock button on the AED.
-Wait for the AED to analyze the client's heart rhythm.
1. -Wait for the AED to analyze the client's heart rhythm.
2.-Call out "stand clear" when the AED prompts the nurse to
administer a shock.
3.-Press the shock button on the AED.
4.-Allow time for the AED to administer a shock.
5.-Immediately resume CPR.
An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce?
Urine and saliva will be radioactive for 24 hours after ingestion.
Rationale: The client's urine and saliva will be radioactive for 24 hours after ingestion. The nurse should teach or reinforce teaching to double flush the commode after use, use disposable utensils and avoid close contact with children and pregnant women for seven days after therapy. Because the treatment may cause nausea, it is best that the client does not eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water.
The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? [Select all that apply.]
-"Please tell me your full name and date of birth."
-"Do you have any questions about the colonoscopy?"
-"Describe what the health care provider told you about a colonoscopy."
Rationale: The nurse first verifies the identity of the client using two identifiers to ensure the correct client is consenting to the procedure. The health care provider is responsible for providing the information necessary for the client to make an informed decision regarding the procedure, including the alternatives. The role of the nurse in the informed consent process includes ensuring the person is understands the procedure and is capable consenting to the procedure. Impediments to informed consent include language barriers, temporary or permanent disorientation, confusion and anxiety. Having the client describe the procedure allows the nurse to determine if the client understands the information they received from the health care provider. The nurse should also watch the client sign the form to ensure it is signed by the client and not by another person.
A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? [Select all that apply.]
-The client's status is documented every 15 minutes.
-The appropriate client advocate or relative has been notified.
-The radial and pedal pulses are palpable and strong.
Rationale: To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Using profanity and cursing is not cause for physical restraints. To justify physical restraints, the client must be an imminent threat to themselves or others. Strong radial and pedal pulses indicate that the restraints are not occluding circulation. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client.