Nursing Education Capstone (C947)

Correct Answer

B. Delay hanging the blood and notify the physician

Explanation

A fever of 100.6°F indicates that the client has a potential infection or inflammatory process. The nurse should delay the transfusion and notify the physician to assess the underlying cause of the fever. Blood transfusions should not be started when the client has a fever, as it could increase the risk of transfusion reactions or mask a reaction.

Why other options are wrong

A. Begin the transfusion as prescribed

Starting a blood transfusion while the client has a fever may increase the risk of complications, including transfusion reactions. It is important to first address the underlying cause of the fever before proceeding with the transfusion.

C. Administer an antihistamine and begin the transfusion

Administering an antihistamine does not address the underlying cause of the fever, and starting the transfusion with a fever may lead to complications. The fever should be evaluated by the physician before any further actions are taken.

D. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

Administering acetaminophen may lower the fever but does not address the root cause of the fever. It is important to delay the transfusion and notify the physician to determine whether the fever is due to an underlying condition that needs further treatment.

Correct Answer

B.) "This medication will make me feel very ill if alcohol is ingested within 12 hours of taking this medication."

Explanation

Disulfiram (Antabuse) works by causing an adverse reaction when alcohol is consumed, leading to symptoms like nausea, vomiting, and flushing. The patient must understand that they should avoid alcohol in all forms, including in food and medications, for at least 12 hours after taking disulfiram to avoid these unpleasant effects.

Why other options are wrong

A.) "This medication will decrease my craving for alcohol and help with alcohol detoxification."

Disulfiram does not help with alcohol cravings or detoxification. It works by creating a physical deterrent to alcohol consumption, causing severe reactions if alcohol is ingested, but it does not directly affect cravings.

C.) "I will be sure to avoid drinking alcohol but may still consume foods that contain alcohol."

This is incorrect because the patient should avoid all sources of alcohol, including foods that contain alcohol, to prevent a reaction with disulfiram.

D.) "If I forget to take a dose of this medication, I will double the next dose."

Doubling the dose if a dose is missed could lead to dangerous side effects. The proper action is to take the next dose as scheduled and not to double up. The patient should be instructed on how to handle missed doses.

Correct Answer

A. Start chest compressions

Explanation

When a patient is found unresponsive without respirations or a pulse, the nurse should immediately begin chest compressions as the first step in cardiopulmonary resuscitation (CPR). According to the American Heart Association guidelines, starting high-quality chest compressions promptly is the priority in cardiac arrest situations because it helps maintain circulation to vital organs. Delays in initiating compressions can result in poor outcomes and decreased chances of survival.

Why other options are wrong

B. Give breaths with a manual resuscitator bag

Although providing ventilations is important during CPR, it is not the first priority. Chest compressions should be started immediately, and breaths are added after the initiation of compressions or once a secure airway is established. Focusing on breaths first delays circulation and reduces the effectiveness of early resuscitation efforts.

C. Establish an airway

Establishing an airway is a critical component of CPR, but it follows the initiation of chest compressions. The current guidelines emphasize starting with compressions to maintain perfusion. Airway management is important but should not precede the first round of chest compressions when a patient has no pulse or respirations.

D. Administer oxygen

Administering oxygen is not the first step in a cardiac arrest situation. Oxygen delivery is useful after CPR is initiated and the airway is managed. Without circulation, oxygen cannot be effectively transported to tissues, so chest compressions must come first to restore perfusion.

Correct Answer

b. Wearing of corrective shoes and foot braces

Explanation

After the initial correction phase, wearing corrective shoes and foot braces is crucial to maintaining the results achieved and preventing the recurrence of the clubfoot deformity. This step is part of the long-term management and helps to ensure that the foot continues to grow in the correct alignment. Parents are educated about the importance of adherence to this treatment plan to avoid complications.

Why other options are wrong

a. Continuous use of the Ponseti method

The Ponseti method is typically used during the initial correction phase, not as part of long-term maintenance. After the correction phase, the emphasis shifts to the use of corrective shoes and foot braces, rather than ongoing use of the Ponseti method.

c. Lifetime physical therapy

While physical therapy may be helpful for some children, it is not a routine requirement for children with clubfoot after the initial treatment. The focus is primarily on using braces and corrective shoes to maintain the foot's alignment.

d. Routine surgical intervention every few years

Routine surgical intervention is generally not required for children with properly managed clubfoot after the initial correction phase. Surgery is typically only necessary if the deformity recurs despite the use of braces and shoes. The goal is to avoid unnecessary surgeries through proper follow-up care and brace use.

Correct Answer:

B) Level of consciousness

Explanation:

The Glasgow Coma Scale (GCS) is specifically designed to assess a patient's level of consciousness by evaluating three key aspects: eye opening, verbal response, and motor response. It helps to determine the severity of brain injury and monitor changes in the patient's neurological status. The GCS is a widely used tool in assessing a patient's level of consciousness, which can provide crucial information about the patient's neurological function.

Why other options are wrong:

A) Reflex activity: The GCS does not assess reflex activity. Reflexes may be assessed separately through other neurological exams, such as checking deep tendon reflexes.

C) Cognitive ability: While GCS scores may give some indirect information about cognitive function, it is primarily a measure of consciousness rather than cognitive abilities, such as memory or problem-solving.

D) Sensory involvement: Sensory involvement, such as touch, temperature, or pain perception, is not specifically assessed through the GCS. Sensory tests are usually done through a separate neurological assessment.

Correct Answer:

B) End-stage renal disease

Explanation:

Polycystic kidney disease (PKD) is a progressive condition in which cysts develop in the kidneys, leading to kidney dysfunction over time. The most serious complication of PKD is the progression to end-stage renal disease (ESRD), which occurs when the kidneys lose their ability to filter waste and maintain fluid balance. This often requires dialysis or a kidney transplant for survival. Other complications like diabetes insipidus, chronic urinary tract infections (UTIs), and syndrome of inappropriate antidiuretic hormone (SIADH) can occur, but ESRD is the most severe and life-threatening consequence of PKD.

Why other options are wrong:

A) Diabetes insipidus: While diabetes insipidus may occur in some patients with PKD due to kidney dysfunction, it is not the most serious complication. Diabetes insipidus leads to excessive urination and thirst, but it does not typically lead to kidney failure like ESRD does.

C) Chronic UTI: Chronic UTIs are common in individuals with PKD due to cysts in the kidneys that can obstruct urinary flow. While UTIs require attention, they are not as life-threatening as the progression to end-stage renal disease.

D) Syndrome of inappropriate antidiuretic hormone secretion: SIADH is another potential complication in PKD due to kidney dysfunction, but it is less common and less severe than the progression to ESRD. It causes fluid retention and electrolyte imbalances, but it is not the most serious complication of PKD.

Correct Answer

B. 0.9% sodium chloride

Explanation

Packed red blood cells should be infused with normal saline (0.9% sodium chloride), as it is the only solution that is compatible with blood products. Using any other solution, such as dextrose or Lactated Ringer’s, can cause hemolysis or clot formation. Normal saline ensures that the red blood cells are properly transported without causing damage.

Why other options are wrong

A. Lactated Ringer's

Lactated Ringer’s solution is not compatible with packed red blood cells. It contains calcium, which can cause clotting when mixed with blood products, so it should not be used for blood transfusions.

C. 5% dextrose in 0.9% sodium chloride

While this solution contains normal saline, the addition of dextrose makes it inappropriate for use with packed red blood cells. Dextrose can cause hemolysis of red blood cells and damage the blood product.

D. 5% dextrose in 0.45% sodium chloride

This solution is also inappropriate for blood transfusions due to the presence of dextrose, which can cause hemolysis of red blood cells. It is crucial to use only normal saline for blood infusions.

Correct Answer:

C) Obtaining vital signs every 15-30 minutes

Explanation:

UAPs can be delegated to tasks that are routine and non-complex, such as obtaining vital signs. Monitoring vital signs is an essential part of assessing the patient's overall health status, and frequent checks can help the nurse detect changes in the patient's condition. However, more complex tasks such as administering medications or conducting assessments for the Glasgow Coma Scale are within the nurse’s scope of practice and should not be delegated to UAPs.

Why other options are wrong:

A) Routine patient assessment: A routine patient assessment requires the nurse’s clinical judgment and expertise to evaluate the patient's condition thoroughly. It involves evaluating not just vital signs, but also physical and cognitive status, which requires professional knowledge.

B) Administering pain medication: Administering medication, including pain medications, is within the scope of practice for licensed nurses, not UAPs. This task requires proper assessment, dosage calculation, and knowledge of potential side effects.

D) Gathering assessment information for the GCS: The Glasgow Coma Scale assessment involves evaluating specific neurological responses, which requires clinical knowledge and expertise. It should be performed by the nurse or another licensed healthcare provider, not a UAP.

Correct Answer

B. Elevate the head of the bed to 30 degrees

Explanation

Elevating the head of the bed to 30 degrees is the recommended position for a patient with increased intracranial pressure (ICP) because it promotes venous drainage from the brain without compromising cerebral perfusion. This positioning helps to decrease ICP and improve oxygenation by enhancing respiratory mechanics. It is a standard intervention in the management of increased ICP.

Why other options are wrong

A. Keep the head of the bed flat

Keeping the bed flat can impair venous outflow from the brain, potentially worsening ICP by allowing cerebral blood to pool. This position is not typically recommended for patients with increased ICP unless otherwise indicated due to specific conditions like hypotension.

C. Left side lying with the head supported on a pillow

While side-lying can be a safe position in general, it does not optimize venous drainage and can increase ICP if the neck is not properly aligned. It is not the preferred position for reducing ICP.

D. Trendelenburg

The Trendelenburg position increases venous return to the brain, potentially worsening ICP. This position is contraindicated in patients with elevated ICP as it can lead to cerebral edema and further complications.