RATIONALE: Normal saline solution is the only I.V. solution that is compatible with any blood product. Lactated Ringer's and dextrose solutions are incompatible with blood products.
RATIONALE: When a client is getting the wrong I.V. solution, the nurse should maintain the access and start the proper solution. She doesn't have to remove the catheter. Doing so would subject the client to unnecessary needle sticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. After starting the correct solution, the nurse should complete an incident report describing the specific error.
"RATIONALE: To determine the number of milliliters of morphine the client should receive, the nurse should use the fraction method in the following equation:
3 mg/X ml = 4 mg/1 ml
To solve for X, cross-multiply:
3 mg × 1 ml = X ml × 4 mg
3 = 4X
3/4 = X
0.75 ml = X"
RATIONALE: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
RATIONALE: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client how long the transfusion will take and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess the client's vital signs at least hourly during the transfusion, not just at the conclusion of the transfusion.
RATIONALE: A nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. She should give the injection in the ventrogluteal area only in a child who has been walking for about 1 year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.
RATIONALE: The client must drink 6 to 8 glasses of fluid daily to prevent renal problems, such as crystalluria and stone formation. If the drug is effective, symptoms should improve within a few days. Sore throat and sore mouth are adverse effects; the client should report them to a physician right away. The drug causes photosensitivity, but the client should use a PABA-free sunscreen; PABA can interfere with the drug's action.
RATIONALE: A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic.
RATIONALE: A nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps-disposal container isn't readily available. A sharps-disposal container is available in most instances. Nurses shouldn't recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps-disposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries.
RATIONALE: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the heart's workload by decreasing the heart rate. Opioids reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).
RATIONALE: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth, then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the client places the tablet between the gum and the cheek.
