EXAM STUDY MATERIALS July 29, 2024 12:59 PM Progression Exam: Safety Questions With Correct Answers A nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do? - answer✔✔Because a client who has attempted suicide could try again, the nurse should search his belongings and his room to rem ove any items that could be used in another suicide attempt. Expressing trust that the client won't cause harm to himself may increase the client's feelings of guilt and pain if he can't live up to that trust. The nurse should search the client's belonging s because the need to maintain a safe environment supersedes the client's right to privacy. Although frequent checks by staff members are helpful, they aren't enough. The client may attempt suicide between checks. Which practice should a nurse recommend to a client who has had a cesarean birth? - answer✔✔As for any postoperative client this client needs to be taught coughing and deep -
breathing exercises to keep the alveoli open and prevent infection. Frequent douching isn't recommended for any group of wome n and is contraindicated in women who have just given birth. Doing sit -ups at 2 weeks postpartum could damage the healing of the incision. Side -rolling exercises aren't an accepted medical practice. The nurse is caring for a multigravid client in active la bor when the nurse detects variable fetal heart rate decelerations on the electronic monitor. The nurse interprets this as the compression of which structure? - answer✔✔Variable decelerations are associated with compression of the umbilical cord. The nurse should alter the client's position and increase the IV fluid rate. Fetal head compression is associated with early decelerations. Severe compression of the fetal chest, such as during the process of vaginal birth, may result in transient bradycardia. Comp ression or damage to the placenta, typically from abruptio placentae, results in severe, late decelerations. The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication b ox, which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next: - answer✔✔The nurse should contact the pharmacy directly and request that a p roperly labeled medication be provided. The nurse should not administer any drug that is not properly labeled, even if the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at this point because the client nee ds to receive the antibiotic as soon as possible. A 68 -year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first: - answer✔✔Further assessment is needed in this situation. It is EXAM STUDY MATERIALS July 29, 2024 12:59 PM premature t o initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP. A client has a nasogastric (N G) tube. How should the nurse administer oral medication to this client? - answer✔✔To administer oral medication through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Making sure not to crush sustained -release tablets or empty capsules, she then inserts the liquid into the NG tube. Heating the tablets may destroy or alter the drug's action. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and clogging the tube. A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glyco pyrrolate, 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer? - answer✔✔Using the proportion method, the nurse solves for X and then adds the total number of milliliters together. When teaching parents of a neonate the proper position for the neonate's sleep, a nurse stresses the importance of placing the neonate on his back to reduce the risk of: - answer✔✔The su pine position is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with supine positioning. Although suffocation is less likely if the neonate is supine, the primary intervention for reducing suffocation risk i s removing blankets and pillows from the crib. The position for GER requires the head of the bed to be elevated. A client diagnosed with borderline personality disorder has self -inflicted cuts on her arms. The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first? - answer✔✔The client is at risk for suicide, and the nurse should determine how serious the client is, including if she has a plan and the means to implement the plan. While medication history may be imp ortant, the nurse should first attempt to determine suicide risk. Asking the client why she cut herself will likely cause the client to respond with insufficient information to determine suicide risk. A client receives an IV dose of gentamicin sulfate. How long after the completion of the dose should the peak serum concentration level be measured? - answer✔✔The peak serum dose of an antibiotic is drawn 30 minutes after the completion of the IV dose of the antibiotic. A pregnant woman states that she frequen tly ingests laundry starch. The nurse should assess the client for: - answer✔✔All pregnant clients should be screened for pica, or the ingestion of nonfood substances, such as clay, dirt, or laundry starch. Commonly, clients who practice pica are anemic. EXAM STUDY MATERIALS July 29, 2024 12:59 PM Muscle spasms are not associated with the ingestion of laundry starch. However, they may be related to seizure disorder or seizure activity or a calcium deficiency. Lactose intolerance is not associated with the ingestion of laundry starch. Lactose intolerance would occur when the client ingests milk or milk products. Diabetes mellitus is not associated with the ingestion of laundry starch. Diabetes mellitus is assoc iated with abnormal glucose levels, excessive thirst, and frequent voiding. The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instr uct the UAP to report to the nurse immediately if the client has: - answer✔✔A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency. An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately. Constipation will not require immediate intervention. A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most like ly to reflect an adverse effect of nitroglycerin? - answer✔✔Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should c heck the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above -normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration. A client who is disor iented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? - answer✔✔Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or
