The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
1.Taking a rectal temperature for a client who has undergone nasal surgery
2.Taking an oral temperature for a client with a cough and nasal congestion
3.Taking an axillary temperature for a client who has just consumed hot coffee
4.Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
2.Taking an oral temperature for a client with a cough and nasal congestion
Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect action as the answer. Recall that nasal congestion is a reason to avoid taking an oral temperature, as the nasal congestion will cause problems with breathing while the temperature is being taken.
The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply
1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Atorvastatin
1,2,3
Note the subject of the question, data provided by the client necessitating contacting the PHCP. Determining that ibuprofen is classified as an NSAID will help you determine that it should not be combined with anticoagulants. Also recalling that hypoglycemia can occur as an adverse effect if taken with antidiabetic agents will help you recall that these medications should not be combined. From the remaining options, it is necessary to remember that toxicity can result if NSAIDs are combined with calcium channel blockers. Also note that options 4 and 5 are comparable or alike and are antilipemic medications. This will assist in eliminating these options.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?
1.Document the findings.
2.Attempt to arouse the client.
3.Contact the primary health care provider (PHCP) immediately.
4.Check the medication administration history on the PCA pump.
2.Attempt to arouse the client.
Rationale:
The primary concern with opioid analgesics is respiratory
depression and hypotension. Based on the assessment findings, the
nurse should suspect opioid overdose. The nurse should first attempt
to arouse the client and then reassess the vital signs. The vital
signs may begin to normalize once the client is aroused, because sleep
can also cause decreased heart rate, blood pressure, respiratory rate,
and oxygen saturation. The nurse should also check to see how much
medication has been taken via the PCA pump and should continue to
monitor the client closely to determine whether further action is
needed. The nurse should contact the PHCP and document the findings
after all data are collected, after the client is stabilized, and if
an abnormality still exists after arousing the client.
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?
1.Modified left lateral recumbent position
2.Modified right lateral recumbent position
3.On the left side of the body, with the head of the bed elevated 45 degrees
4.On the right side of the body, with the head of the bed elevated 45 degrees
1.Modified left lateral recumbent position
Focus on the subject, positioning for enema administration. Use knowledge regarding the anatomy of the bowel to answer the question. The descending colon is located on the lower left side of the body. The head of the bed should be flat during enema administration.
A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?
1.Administer the eye drop first, followed by the eye ointment.
2.Administer the eye ointment first, followed by the eye drop.
3.Administer the eye drop, wait 15 minutes, and administer the eye ointment.
4.Administer the eye ointment, wait 15 minutes, and administer the eye drop.
1.Administer the eye drop first, followed by the eye ointment.
When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?
1."Take a deep breath when I tell you, and hold it while I remove the tube."
2."Take a deep breath when I tell you, and bear down while I remove the tube."
3."Take a deep breath when I tell you, and slowly exhale while I remove the tube."
4."Take a deep breath when I tell you, and breathe normally while I remove the tube."
1."Take a deep breath when I tell you, and hold it while I remove the tube."
Rationale:
The client should take a deep breath, because the client's
airway will be temporarily obstructed during tube removal. The client
is then told to hold the breath and the tube is withdrawn slowly and
evenly over the course of 3 to 6 seconds (coil the tube around the
hand while removing it) while the breath is held. Bearing down could
inhibit the removal of the tube. Exhaling is not possible during
removal because the airway is temporarily obstructed during removal.
Breathing normally could result in aspiration of gastric secretions
during inhalation.
The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?
1."The enema will be given while I am sitting on the toilet."
2."I should try and hold the fluid as long as possible after it is run in."
3."I know that there will be some cramping after the enema solution is run in."
4."I should tell the nurse if cramping occurs when the fluid is running in."
1."The enema will be given while I am sitting on the toilet."
Rationale:
The enema is never administered while on a toilet due to safety.
The enema is administered while the client is in a left side-lying
(Sims') position with the right knee flexed. This allows enema
solution to flow downward by gravity along the natural curve of the
sigmoid colon and rectum. It is important for the client to retain the
fluid for as long as possible to promote peristalsis and defecation.
If the client complains of fullness or pain, the flow is stopped for
30 seconds and restarted at a slower rate. The higher the solution
container is held above the rectum, the faster the flow and the
greater the force in the rectum; this could increase cramping.
Note the strategic words, need for further instruction. This indicates a negative event query, and the need to select the option that is incorrect. Eliminate options 3 and 4 first because they are comparable or alike. From the remaining options, focusing on the subject, safety, will direct you to the correct option.
The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?
1.Deflate the cuff on the tube.
2.Place the inner cannula into the tube.
3.Ensure that the client is able to speak.
4.Ensure that the client is able to swallow.
1.Deflate the cuff on the tube.
Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.
The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
1."I change my pouch every week."
2."I change the appliance in the morning."
3."I empty the urinary collection bag when it is two-thirds full."
4."When I'm in the shower, I direct the flow of water away from my stoma."
3."I empty the urinary collection bag when it is two-thirds full."
Rationale:
The urinary collection bag should be changed when it is
one-third full to prevent pulling of the appliance and leakage. The
remaining options identify correct statements about the care of a
urinary stoma.
The nurse is assisting a primary health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?
1.Stay very still.
2.Exhale very quickly.
3.Inhale and exhale quickly.
4.Perform the Valsalva maneuver.
4.Perform the Valsalva maneuver.
Rationale:
When the chest tube is removed, the client is asked to perform
the Valsalva maneuver (take a deep breath, exhale, and bear down).
After premedicating the client for pain 30 minutes prior to the
procedure if desired, the tube is quickly withdrawn, and an airtight
dressing is taped in place. An alternative instruction is to ask the
client to take a deep breath and hold the breath while the tube is removed.