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Monday, March 16, 2009

NSNA Review For Nclex-RN Bullets

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Flammable materials and metal devices or liquids (that are capable of carrying electricity) are removed from the client and bed before discharging the paddles of the defibrillator. The nitroglycerin patch has a metallic backing and should be removed.

Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias post countershock. The client typically receives a dose of an intravenous sedative or antianxiety agent. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level is typically set at 50 to 100 joules. During the procedure, any oxygen is removed temporarily, because oxygen supports combustion, and a fire could result from electrical arcing.

A depressed person is often withdrawn. Also, the person experiences difficulty concentrating, loss of interest or pleasure, low energy and fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide stimulation in a structured environment.

Safe nursing actions intended to prevent injury to the client include keeping the side rails up, the bed in low position, use of a nightlight, and providing a call bell that is within the client’s reach. Responding promptly to the client’s use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Communicating with the client via an intercom does not meet the client’s needs to prevent potential injury.

When a client is cardioverted, the defibrillator is charged to the energy level ordered by the physician. Cardioversion is usually started at 50 to 100 joules.

The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family, and an order needs to be obtained from the physician. The nurse should explain carefully to the client and family about the reasons why the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied the restraint on a client who was refusing such, the nurse could be charged with battery. Compromising with the client is unethical.

Electrical equipment should be grounded. The third longer prong in an electrical plug is the ground. Theoretically, the ground prong carries any stray electrical current back to the ground, hence its name

A nurse can be charged with false imprisonment if clients are made to wrongfully believe that they cannot leave the hospital. Most health care facilities have documents for clients to sign that relate to the clients’ responsibilities when they leave against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.

Defamation occurs when information is communicated to a third party that causes damage to someone else’s reputation either in writing (libel) or verbal (slander). Common examples are discussing information about a client in public areas or speaking negatively about coworkers. The situation identified in the question can cause emotional harm to the client, and the nurses could be charged with slander. This situation also violates the client’s right to confidentiality.

Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned task. When encountered with this situation, the nurse should set priorities and identify potential areas of harm to the client. All pertinent facts related to client care problems and safety issues should be documented. The nurse should perform only those tasks in which training has been received. It is the nurse’s responsibility to clearly describe these tasks.

The RN must remember that even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability, may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that the LPN observe another LPN perform the procedure does not ensure that the procedure will be done correctly. Because this is a new procedure for this LPN, the RN should accompany the LPN, provide guidance, and answer questions following the procedure. Although it is appropriate to review the inservice materials and the hospital procedure manual, it is best for the RN to accompany the LPN to perform the procedure.

Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate and should be available at the client’s bedside.

In accord with the agency’s policies, nurses are required to file incident reports when a situation arises that could or did cause a client harm. The nurse also contacts the physician. If a dose of 0.125 mg was prescribed, and a dose of 0.25 mg was administered, then the client received too much medication. Additional medication is not administered and in fact could be detrimental to the client. The client should be informed when an error has occurred, but in a professional manner so as not to cause fear and concern. In many situations, the physician will discuss this with the client.

Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations.

Therapeutic values of the aPTT for clients on heparin ranges between 60 and 70 seconds, depending on the control value. A value of 100 seconds indicates that the client has received too much heparin. The antidote for heparin overdosage is protamine sulfate. Vitamin K is the antidote for warfarin sodium (Coumadin) overdosage. Methylene blue is an antidote for cyanide poisoning. Vitamin B12 is used to treat clients with pernicious anemia.

Clients with Parkinson’s disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of Levadopa, which can also cause postural hypotension and increase the client’s risk for falls. Although knowledge of the client’s use of assistive devices and history of falls is helpful, it is not the most important piece of assessment data based on the wording of this question. Clients with Parkinson’s disease generally have resting, not intention, tremors.

Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client’s unaffected (strong) side. For example, if the client’s right leg is involved, and the client is sitting on the edge of the bed, position the wheelchair next to the client’s left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.

A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 years for kidney donation, 55 years for pancreas or liver donation, and 40 years for heart donation. The client should be free of communicable disease, such as human immunodeficiency virus, hepatitis, or syphilis, and the involved organ must not be diseased. Another contraindication is malignancy, with the exception of noninvolved skin and cornea.

Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. A urine output of 45 mL per hour indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues.

Basic rules for handling evidence include limiting the number of people with access to the evidence; initiating a chain of custody log to track handling and movement of evidence; and careful removal of clothing to avoid destroying evidence. This usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.

The client with arterial bleeding from a neck wound is in “immediate” need of treatment to save the client’s life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as “delayed,” requiring intervention within 30 to 60 minutes. A green or “minimal” designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of “expectant” would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded “black” in the triage process. The client who is color-coded “black” is given supportive care and pain management, but is given definitive treatment last.

Proper hand washing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using rubbing and circular motions. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

The client who is on neutropenic precautions is immunosuppressed and is admitted to a single (private) room on the nursing unit. A precaution sign should be placed on the door to the client’s room. Standing water and fresh flowers should be removed to decrease the microorganism count. The client should wear a mask whenever leaving the room to be protected from exposure to microorganisms.

In caring for the incontinent client, the nurse should wear gloves and a gown to protect the hands and uniform from contamination.

The corneal reflex is tested in selected situations, such as with the unconscious client. The client who is unconscious is at great risk for corneal abrasion. For this reason, the safest way to test the corneal reflex is by touching the cornea lightly with cotton. The lids of both eyes blink when the cornea is touched.

When using a hydraulic lift, the client is positioned in the center of the sling, which is then attached to chains or straps that attach the sling to the lift. The client’s hands and arms are crossed over the chest, and the client is raised from the bed into a sitting position. The client is also raised off the mattress with the lift and is lowered slowly once the sling is positioned over the chair.

If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or “wandering bracelet.” This allows the client to move about the residence freely while preventing the client from leaving the premises.

Nurses are advised not to document the filing of an incident report in the nurses’ notes for legal reasons. Incident reports inform the facility administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility insurance company to a potential claim and the need for further investigation.

Nurses are encouraged not to accept verbal orders from the physician because of the risks of error. The only exception to this may be in an emergency situation, and then the agency policy and procedure must be adhered to. Although the client will be informed of the change in the treatment plan, this is not the most appropriate action at this time. The physician needs to write the new order. It is inappropriate to ask another individual other than the physician to write the order.

Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is also a stimulant and should be limited in the client taking this medication. The client should be taught to limit caffeine intake as well.

Orthostatic hypotension is a concern for clients taking antihypertensive medications. Clients are advised to avoid standing in one position for lengthy amounts of time, to change positions slowly, and to avoid extreme warmth (showers, bath, weather). Clients are also taught to recognize the symptoms of orthostatic hypotension, including dizziness, lightheadedness, weakness, and syncope.

When walking with clients, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet.

Mercury is a hazardous material. Accidental breakage of a mercury-in-glass thermometer is a health hazard to the client, nurse, and other health care workers. Mercury droplets are not to be touched. If a breakage or spill occurs, the Environmental Services Department is called and a mercury spill kit is used to clean up the spill.

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