Preliminary Examination In Competency Appraisal

The nurse is required to administer 12.5 mg of promethazine intramuscularly. The medication is supplied in an ampule of 50 mg/mL. To calculate the amount of medication to be administered, we can use the formula: dose (mg) = volume (mL) × concentration (mg/mL). Rearranging the formula, we get volume (mL) = dose (mg) / concentration (mg/mL). Plugging in the values, we have volume (mL) = 12.5 mg / 50 mg/mL = 0.25 mL. Therefore, the nurse should administer 0.25 mL of promethazine to the client.

The nurse should instruct the parents to cover the baby's eyes with eye shields to prevent retinal damage during phototherapy. Phototherapy involves exposing the baby's skin to special lights that help break down bilirubin, a substance that can build up and cause jaundice. However, the lights used in phototherapy can be harmful to the baby's eyes, so it is important to protect them with eye shields. This will help prevent any potential damage to the baby's retinas and ensure the safety and well-being of the newborn during treatment.

The application of moist heat to an infiltrated intravenous infusion site will increase blood flow and improve capillary permeability. Moist heat helps to dilate blood vessels, which increases blood flow to the area. This increased blood flow can help to remove any accumulated fluid or medications that may be causing the infiltration. Additionally, improved capillary permeability allows for better exchange of oxygen, nutrients, and waste products between the blood vessels and the surrounding tissues, promoting healing and reducing inflammation.

The correct answer is the infectious waste receptacle. A suction canister used to collect drainage from a client's nasogastric tube would be considered infectious waste. This type of waste contains potentially harmful microorganisms and should be disposed of in a designated receptacle to prevent the spread of infection. The other options, such as the injurious waste receptacle, hazardous waste receptacle, or wastebasket in the client's bathroom, are not appropriate for disposing of infectious waste.

Before beginning a blood transfusion, it is important for the nurse to assess the patient's vital signs. This includes monitoring the patient's heart rate, blood pressure, respiratory rate, and temperature. Assessing vital signs can help the nurse determine if the patient is stable enough to receive the blood transfusion and can also help identify any potential complications or adverse reactions during the transfusion process. Therefore, assessing vital signs is a priority item before starting the transfusion.

To ensure that the client's daily weight is accurate, it is important to calibrate and "zero" the scale before obtaining a weight. This means that the scale should be adjusted to ensure that it is measuring accurately and that it starts at zero before the client steps on it. This helps to eliminate any potential errors or discrepancies in the weight measurement. Asking the client to wear supportive shoes, weighing the client by moving the sliding indicator, or weighing the client at different times of the day do not directly address the accuracy of the scale itself.

The nurse continues to advance the catheter if blood return shows in the backflash chamber of the catheter. This indicates that the catheter is properly inserted into the vein and blood is flowing through it. It is a positive sign that the catheter is in the correct position and can be secured in place.

The nurse determines that the client is no longer constipated based on the statement that the client has had a soft, formed bowel movement without straining every other day for the past 2 weeks. This indicates that the client's bowel movements are regular and normal, which is a sign of resolved constipation.

The client's symptoms of left leg pain, right-sided chest pain, and sudden onset of shortness of breath suggest a potential pulmonary embolism, which is a blockage in the pulmonary artery. Auscultating the client's lung sounds can help the nurse assess for any abnormal breath sounds, such as decreased or absent breath sounds on one side, which could indicate a pulmonary embolism. This action is crucial in identifying and addressing the client's condition promptly.

The most appropriate time to apply the hose before standing to get out of bed in the morning is the correct answer because it ensures that the client has the stockings on before any potential risk of thromboembolic disease occurs. Applying the stockings in the morning helps to prevent blood clots from forming while the client is inactive during sleep and prepares them for any activity throughout the day.

The client's symptoms, including headache, dyspnea, chills, apprehension, and increased pulse rate, are indicative of a potential adverse reaction to the IV infusion. Slowing down the infusion rate can help alleviate these symptoms and prevent further complications. Calling the physician may be necessary, but addressing the immediate symptoms should be the first action. Sitting the client up in bed and removing the IV catheter are not appropriate actions for this situation.

The expiration date is important to check regarding the age of blood cells before the transfusion is begun because blood cells start to deteriorate after a certain period of time. If the blood cells have expired, they may not be as effective or safe for transfusion.

The nurse asks the initial question, "Have you ever had a transfusion before?" to assess the client's previous experience with transfusions. This information is important to determine if the client has any known allergies or adverse reactions to blood products. It also helps the nurse to anticipate any potential complications or risks based on the client's previous transfusion history. By obtaining this information, the nurse can provide appropriate education and support to the client before the procedure.

The client may be experiencing septicemia as a complication of the blood transfusion. Septicemia is a severe infection that occurs when bacteria or other infectious organisms enter the bloodstream. The client's symptoms of vomiting, decreased blood pressure, and elevated temperature suggest an infection. These symptoms are consistent with septicemia rather than the other options listed.

Bubbling oxygen through a humidifier prevents drying of the nasal passages. Oxygen therapy can cause dryness and irritation in the nasal passages, which can lead to discomfort for the client. By passing the oxygen through a humidifier, moisture is added to the oxygen, ensuring that the nasal passages stay hydrated and preventing dryness. This helps to improve the client's comfort and overall well-being during oxygen therapy.

The client's temperature of 99.7°F (37.6°C) is only mildly elevated and may be due to normal diurnal deviations, as temperatures are highest during certain times of the day. Therefore, there is no need to cancel the discharge or administer aspirin. Instructing the client to use the incentive spirometer and drink plenty of fluids can help promote lung expansion and prevent complications such as atelectasis. Rechecking the temperature in 2 hours will provide a better assessment of the client's condition and help determine if they are stable for discharge.

After stopping the transfusion, the next immediate action should be to run normal saline at a keep-vein-open rate. This is done to maintain the patency of the IV line and ensure that the client continues to receive fluid and medication. Running normal saline at a keep-vein-open rate helps to prevent blood clotting in the IV line and maintains the client's hydration status. It is important to address the transfusion reaction, but ensuring that the client's IV line remains open and functional is a priority to prevent further complications.

The nurse should use the technique of loosening the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal. This technique ensures that the denture is loosened properly and can be safely removed without causing any discomfort or injury to the client. Using a foam swab or leaving the dentures in the client's mouth while brushing is not the correct technique for performing oral hygiene in this case. Donning sterile gloves before removing the dentures is not necessary for this procedure.

The nurse should hold items 6 inches above the field and drop them onto the sterile field inside the 1-inch border along the edge of the drape. This technique helps to prevent contamination of the sterile field by minimizing the risk of contact between non-sterile items and the sterile field. By holding items above the field, the nurse ensures that they do not come into direct contact with the potentially contaminated surface. Dropping them inside the 1-inch border along the edge of the drape further reduces the risk of contamination by keeping the items within the sterile area.

The nurse needs to stay with the client for approximately 15 minutes to ensure that a transfusion reaction is not occurring. This is because most transfusion reactions occur within the first 15 minutes of starting the transfusion. By closely monitoring the client during this time, the nurse can quickly identify any signs or symptoms of a reaction and take appropriate action.

The client's statement that the needles are safe to dispose of with household trash indicates a lack of understanding about proper disposal of insulin syringes and needles. Needles should never be disposed of in regular household trash because they can pose a risk of injury to others. Proper disposal methods include using a needle destruction device, placing the used needles and syringes in a puncture-proof container, or taking them to a clinic for proper disposal.

Each rescue breath should be given over 1 second and should produce a visible chest rise. This guideline for adult CPR is correct because it ensures that the rescue breath is given with enough time and force to properly inflate the lungs and create a visible rise in the chest. This is important for effective oxygenation during CPR. Giving one breath for every five compressions or two breaths for every 15 compressions may not provide adequate ventilation, and initially giving two quick breaths as rapidly as possible may not allow for proper inflation of the lungs.

When moving and repositioning a client who is unable to change position independently, it is important to raise the bed to the level of the caregiver's waist. This helps to maintain proper body mechanics and prevents strain or injury to the caregiver's back. After completing the move, the bed should be returned to the lowest level to ensure the client's safety and comfort. This technique promotes proper body alignment and reduces the risk of falls or pressure ulcers.

Resting and elevating the limb as much as possible is the appropriate intervention for the first 24 hours after a first-degree sprain of the ankle. This helps to reduce swelling and pain by promoting blood flow away from the injured area. Applying ice directly to the ankle can also help reduce swelling and pain, but it should not be done continuously as it can cause tissue damage. Soaking the foot in warm water is not recommended as it can increase swelling.

The physician has ordered to discontinue the IV line, which means that the IV catheter will be removed from the patient's site. After removing the catheter, the nurse needs to apply pressure to the site to prevent bleeding and promote clotting. Sterile 2x2 gauze is the most appropriate supply for this purpose as it can be used to apply direct pressure to the site and absorb any blood or fluids. Elastic wrap, Betadine swab, and adhesive bandage are not suitable for applying pressure and are not necessary for this procedure.

The appropriate action by the nurse is to obtain new IV tubing. This is because when the exposed tubing drops and hits the top of the medication cart, it can become contaminated. To ensure patient safety and prevent the risk of infection, it is necessary to replace the IV tubing with a new, uncontaminated one.

The nurse concludes that infiltration has occurred. Infiltration refers to the unintentional leakage of IV fluid into the surrounding tissue. The cool, pale, and swollen IV site indicates that the fluid is not properly infusing into the vein and is instead accumulating in the tissue. This can be caused by dislodgement of the IV catheter or improper placement, leading to fluid accumulation in the tissue. Infiltration can cause discomfort, tissue damage, and compromise the effectiveness of the IV therapy. Prompt intervention, such as discontinuing the IV and applying warm compresses, is necessary to prevent further complications.

The best description of a stage III pressure ulcer is full-thickness skin loss involving damage to subcutaneous tissue. This means that the ulcer has progressed beyond the epidermis and dermis, and has reached the layer of tissue beneath the skin. The presence of damage to the subcutaneous tissue indicates that the ulcer is at a more advanced stage and requires appropriate treatment and care.

The statement "I store the hearing aids in the protective box" demonstrates that the client is successfully adapting to the hearing aids because it shows that the client understands the importance of properly storing the hearing aids when they are not in use. Storing the hearing aids in a protective box helps to prevent damage and prolong their lifespan. This indicates that the client is taking responsibility for the care and maintenance of their hearing aids, which is an important part of successfully adapting to them.

Fresh-frozen plasma is prescribed and transfused to promote rapid volume expansion in a client who has experienced blood loss due to an arterial laceration. This is because fresh-frozen plasma contains various clotting factors, proteins, and electrolytes that help increase the volume of circulating blood and restore the body's fluid balance. By rapidly expanding the volume, fresh-frozen plasma helps to stabilize the client's blood pressure and prevent further complications associated with hypovolemia.

The client is benefiting most from the platelet transfusion if they exhibit a decreased oozing of blood from puncture sites and gums. Platelets are responsible for clotting and preventing excessive bleeding. Therefore, a decrease in oozing of blood indicates that the platelet transfusion has been effective in improving the client's clotting function. Increased hematocrit and hemoglobin levels may indicate improved red blood cell function, but they are not directly related to the benefits of platelet therapy. The decline of an elevated temperature to normal is not specifically related to platelet transfusion.

The nurse notes that the client's peripheral IV catheter site is showing signs of inflammation, including redness, warmth, pain, and slight swelling proximal to the insertion point. These symptoms are indicative of phlebitis, which is the inflammation of a vein. Phlebitis can occur as a result of mechanical irritation from the catheter or chemical irritation from the IV solution. The nurse's documentation of phlebitis suggests that the client's symptoms are likely due to inflammation of the vein rather than other possibilities such as infiltration, hypersensitivity to the IV solution, or an allergic reaction to the catheter material.

The nurse selects tubing with an in-line filter because it is specifically designed for blood products. An in-line filter helps to remove any potential contaminants or particles from the blood before it reaches the client. This ensures the safety and integrity of the transfusion, preventing any harm or adverse reactions to the client. The other options, such as an air vent, microdrip chamber, or tinted tubing, do not serve the same purpose of filtering the blood and ensuring its purity.

The experienced nurse should interrupt to state that the child's ear should be pulled down and back. This is because the new nurse is instructing the mother to pull the child's ear up and back, which is incorrect. Pulling the child's ear down and back helps to straighten the ear canal, allowing for easier administration of the ear drops. The experienced nurse should correct this mistake to ensure that the mother is taught the correct technique for administering ear drops to her child.

The experienced nurse needs to intervene in this situation because verifying the client's identity is crucial before administering medications. This step ensures that the right medication is given to the right client, preventing any potential medication errors or adverse reactions. It is a standard safety practice to check the client's room number and name on the name band before administering any medication.

The appropriate nursing action in this situation is to delay hanging the blood and notify the physician. A temperature of 100.6 F orally indicates a potential infection or fever, which can be a contraindication for blood transfusion. It is important to notify the physician to assess the client's condition and determine if it is safe to proceed with the transfusion.

The client is concerned about gas coming from the stoma after undergoing surgery for colon cancer. To address this concern, the nurse should ask the client to describe their usual dietary intake, including types of foods, as certain foods can contribute to gas production. The nurse should also advise the client to limit intake of gas-producing beverages such as carbonated sodas, as this can further contribute to gas formation. Additionally, the nurse should suggest that the client goes to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp. Pricking the colostomy stoma pouch with a pin is not a recommended method to address this issue.

The correct answer is feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter. This action ensures that the medication is correctly administered because it indicates that the suppository has been inserted far enough into the rectum for the medication to be absorbed. The sensation of the suppository pulling away suggests that it has passed the internal anal sphincter, which is the muscle that separates the rectum from the anus.

The correct technique for using a walker with partial weight-bearing involves keeping the elbows bent at a 30-degree angle. This position allows for better stability and support while walking.

The nurse needs to intervene when the nursing student applies the patch by rubbing it against the skin. Transdermal patches should not be rubbed or manipulated as it can alter the drug delivery rate and effectiveness. The patch should be applied gently and pressed firmly against the skin to ensure proper adhesion.

The nurse should assess the results of the white blood cell count to assess the effectiveness of the granulocyte transfusion. Granulocytes are a type of white blood cells that play a crucial role in fighting off infections. By monitoring the white blood cell count, the nurse can determine if the transfusion has successfully increased the number of granulocytes in the client's bloodstream, indicating an improved ability to fight infections. Assessing the hemoglobin level, hematocrit level, or erythrocyte count would not provide relevant information in this case, as they primarily measure red blood cell function and oxygen-carrying capacity.

Taking afternoon oral medications with a carbonated soft drink should be most concerning to the nurse because carbonated soft drinks can increase the absorption rate of medications. The carbonation in the drink can increase the acidity in the stomach, which can enhance the absorption of certain medications. This can lead to higher levels of the medication in the bloodstream, potentially causing adverse effects or interactions with other medications.

The statement "I can give the injection while your child is sleeping; then the injection won't be noticed" would be inappropriate because it implies that the nurse is planning to administer medication without the child's knowledge or consent. It is important to involve the child in their own healthcare decisions and respect their autonomy. Additionally, administering medication without the child's awareness may cause confusion or anxiety when they wake up and realize they have been given an injection without their knowledge.

If a febrile client is using a hypothermia blanket, the purpose is to lower the body temperature. Hypothermia is a condition where the body temperature drops below normal. Drowsiness can be a sign of hypothermia as the body's metabolic rate decreases. Decreased heart rate (HR) and decreased blood pressure (BP) are also signs of hypothermia as the body tries to conserve energy and maintain core temperature. Increased urine output, increased BP, and increased HR are not typically associated with hypothermia.

The nurse should obtain 0.9% sodium chloride from the IV storage area to hang with the blood product at the client's bedside. This solution is commonly used to administer blood products because it is isotonic, meaning it has the same concentration of solutes as blood. This helps to prevent hemolysis or damage to the red blood cells. Lactated Ringer's is not typically used for blood transfusions. 5% dextrose in 0.9% sodium chloride and 5% dextrose in 0.45% sodium chloride are not appropriate solutions for administering packed red blood cells.

The jaw thrust maneuver is used to open the airway in a victim who may have a potential neck or spinal injury. It involves placing the fingers behind the angle of the jaw and lifting it forward, without tilting the head back. This maneuver helps to maintain the alignment of the neck and spine while ensuring the airway remains open. In this scenario, the nurse witnesses a fall from the roof, indicating the possibility of a neck or spinal injury, making the jaw thrust maneuver the appropriate method to open the airway.

After injecting the potassium chloride into the port of the IV bag, the nurse should plan to rotate the bag gently. This is important to ensure proper mixing of the potassium chloride with the IV solution. By rotating the bag gently, the nurse can help distribute the potassium chloride evenly throughout the IV solution, which will help prevent concentration variations and ensure that the client receives the correct dosage of medication.

The assessment finding that would require immediate intervention by the nurse is a round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage. Serosanguineous drainage is a mixture of bloody and serous fluid, which is expected after surgery. However, a round JP drain should not have any drainage, as it indicates a possible dislodgement or malfunction of the drain. The nurse should assess the drain site, ensure proper placement, and notify the healthcare provider for further intervention if needed.

When entering the client's room, the nurse should don disposable medical examination gloves. This is because the client has a wound infection and is on contact precautions, indicating that there is a potential for the transmission of infectious material. By wearing gloves upon entering the room, the nurse can minimize the risk of contamination and protect both themselves and the client from the spread of infection.

The client adamantly refusing to take an oral dose of cephalexin despite measures to treat nausea indicates that the client is experiencing a strong aversion to the medication. Crushing the medication and mixing it with applesauce may not address the client's refusal and could potentially lead to non-compliance. Administering the medication after repeating the dose of antiemetic may not be effective in alleviating the client's aversion. Having the client suck on ice chips before taking the medication may provide temporary relief but does not address the underlying issue. Therefore, the best action for the nurse is to report the information to the client's physician and request a different medication order.