When preparing to enter Irene's room to admit her, which of the following actions should Craig perform?
answer
Perform hand hygiene with an antimicrobial agent.
question
Identify at least four environmental safety measures that were implemented by the nurse when seeing Irene for the first time.
answer
1. Use two identifiers to ensure correct identification of client.
2. Elevate HOB 30 degrees to provide for comfort and promote lung expansion.
3. Place the upper rails in a raised position to prevent the client from rolling out of bed, and assist the client with positioning.
4. Bed is low position and locked.
5. Client is wearing an ID band.
6. Call light was within reach of the client.
question
Craig reviewed Irene's laboratory results and provider prescriptions. Which of the following is a priority action by Craig at this time?
answer
Administer potassium 40 mEq IV over 4 hr.
question
Craig is preparing to teach Irene about metronidazole (Flagyl). Which of the following should Craig include in the teaching?
answer
Do not drink alcohol while taking metronidazole.
question
The provider prescribes metronidazole 250 mg IV piggyback three times a day. The therapeutic dose is 7.5 mg/kg per day. Irene weighs 220lb. How many mg should she receive daily?
answer
750
question
The client began to cry as Craig was leaving the room. Which of the following is the most therapeutic response by Craig?
answer
"You appear upset; can we talk about what you are feeling?"
question
When caring for Irene, the most important means of disrupting the chain of infection is hand hygiene. Which of the following nursing actions also disrupts the transmission of Clostridium difficile?
answer
Keep personal care equipment used for client in room.
question
Irene asks for help to get to the commode. Which of the following techniques should Craig use to transfer Irene?
answer
Hoyer lift
question
Craig assesses Irene after she reports feeling dizzy. Based upon the assessment, which of the following is Craig's priority action at this time?
answer
Administer 500 mL of 0.9% sodium chloride over 30 minutes.
question
Craig discovers that Irene's IV site is infiltrated. Which of the following images illustrates infiltration of the IV site?
answer
C
question
Craig identifies that Irene's IV is infiltrated. Which of the following actions should he take at this time?
answer
Stop the IV infusion
question
Craig restart's Irene's IV because the first IV was infiltrated. Identify two measures that Craig implemented when restarting the IV to prevent infiltration.
answer
The IV should be inserted away from the joints. Inserting an IV near an area of flexion increases the potential of dislodging the catheter. Add extension tubing to decrease tension and pressure to the IV catheter. Secure extension and IV tubing to decrease movement of the IV catheter in the vein and decrease the possibility of dislodging the IV catheter.
question
Craig is preparing to assess Irene's abdomen. Place the steps of an abdominal assessment in the order in which they should be performed.
answer
Inspection, auscultation, percussion, palpation
question
Craig is preparing to listen to Irene's bowel sounds. Select the audio clip that best represents the bowel sounds that Craig should anticipate hearing when auscultating Irene's abdomen.
answer
b
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