NR446 CJE Readiness Open Check

The local clinic has seen an increase in treating children harmed by the use of OTC medications. The community nurse has been asked to present a talk for parents on safe use of OTC medications in the home. What information should the nurse include in the teaching?

• It is always safe to give your child an OTC drug as long as it is not expired.

• If no measuring device comes with the drug, then use a household teaspoon.

• Use the measuring device that comes with the drug and not another device.

• It is okay to estimate your child's weight if the OTC dose requires a weight.

Answer explanation

• → ❌ OTC medications are not always safe for children even if not expired. Some are contraindicated.

• → ❌ Household spoons are inaccurate and increase the risk of dosing errors.

• → ✅ Always use the manufacturer’s measuring device for accuracy.

• → ❌ Dosing based on weight should never be estimated—this can lead to overdosing or underdosing.

The nurse manager is conducting an in-service education session on catheter associated urinary tract infection (CAUTI). Which instruction will the nurse provide to the staff? Select all that apply.

• Use clean technique when inserting catheter

• Empty collection bag every 8 hours

• Collect urine specimen from catheter bag

• Clean meatus with 2% chlorhexidine gluconate wipes

• Change catheter once per week

Answer explanation

• (*) Clean meatus with 2% chlorhexidine gluconate wipes → ✅ Correct. Perineal hygiene with antiseptic wipes helps reduce bacterial colonization and risk of infection. (Some guidelines allow soap and water, but CHG is also accepted.)

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  (*) Clean technique → ❌ Incorrect. Catheter insertion requires strict sterile technique, not clean technique, to prevent CAUTI.

• (*) Empty collection bag every 8 hours → ❌ Incorrect. The bag should be emptied when 2/3 full or at regular intervals (often more frequent than every 8 hours) to prevent backflow and bacterial growth.

• (*) Collect urine specimen from catheter bag → ❌ Incorrect. Specimens should be collected from the sampling port after disinfecting, not from the drainage bag.

• (*) Change catheter once per week → ❌ Incorrect. Catheters are changed only when clinically indicated (blockage, leakage, contamination, or per policy), not routinely weekly.

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✨ Best practices to prevent CAUTI:

• _{Use sterile technique during insertion.}

• _{Keep drainage bag below bladder level.}

• _{Maintain closed drainage system.}

• _{Empty bag regularly (before overfilling).}

• _{Perform daily perineal hygiene.}

• _{Remove catheter as soon as no longer needed.}

The nurse administers an inhaled corticosteroid to a client with COPD. What is the most important intervention for the nurse to implement to prevent a common adverse effect of this drug?

• Provide client with cup of water to rinse the mouth (prevents thrush)

• Provide client with throat lozenges after each inhaled dose

• Instruct client to inhale drug steadily and slowly

• Have the client brush their teeth after each inhaled dose

Answer explanation

✅ Key teaching: Rinse mouth and spit after each inhaled corticosteroid use.

• Inhaled corticosteroids (e.g., fluticasone, budesonide) can cause oral candidiasis (thrush) due to local immunosuppressive effects.

• Rinsing the mouth with water after inhalation reduces drug residue and prevents fungal overgrowth.

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  Lozenges may soothe throat irritation but do not prevent thrush.

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  Inhale steadily and slowly → important for correct administration, but not directly related to preventing the adverse effect of thrush.

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  Brushing teeth is good for hygiene but less effective than rinsing at reducing drug deposits that cause oral candidiasis.

The nurse in the ED calls to report to the maternal-child unit for a client who is 34 weeks pregnant and being admitted with a diagnosis of placenta previa. As the nurse plans for the client's arrival on the unit, what is important to include in the plan of care?

• Preparation for the client to give birth via cesarean section.

• A unit of blood on the floor to administer immediately upon the client's admission.

• Frequent vaginal exams to determine if the position of the placenta has moved.

• Continuous fetal heart monitor

• Insertion of a large IV access

Answer explanation

• ✅ Continuous fetal heart monitor: Essential to evaluate fetal well-being and detect early signs of distress since bleeding or placental compromise can threaten oxygen supply to the fetus.

• ✅ Insertion of a large IV access : Ensures rapid access for IV fluids or blood products if significant hemorrhage occurs, which is a high-risk complication with placenta previa.

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  ❌ Preparation for cesarean section: While C-section is the likely delivery method, it is not the immediate nursing action upon admission; monitoring and stabilization come first.

• ❌ Blood on the floor immediately: Blood should be typed and crossmatched, but not every patient requires immediate transfusion on admission.

• ❌ Frequent vaginal exams: Contraindicated because digital exams can cause life-threatening hemorrhage in placenta previa.

Nurses on the unit are completing an annual satisfaction survey. On the survey, they all indicate that their nurse manager is a transformational leader. What behavior by the nurse manager led the nurses to this conclusion?

• Dictates the rules in the department, relying on their personal insight and experience

• Rewards nurses who come to work on time with bonuses and penalizes those who do not

• Takes a “hands-off” approach and does not enforce the facilities policy on lunch hours

• Incorporates the perspectives of nurses on the unit and empowers them to be innovative

Answer explanation

• Transformational leaders inspire and motivate staff, empower innovation, and encourage shared decision-making.

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  Dictates rules → reflects an authoritarian / autocratic style.

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  Rewards/punishments → aligns with transactional leadership.

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  Hands-off approach → describes laissez-faire leadership.

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  Empowering and valuing staff input → hallmark of transformational leadership, leading to higher job satisfaction and team collaboration.

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FYI

1. Transformational

• Inspires and motivates the team with a shared vision.

• Encourages innovation and creativity.

• Focuses on growth and development of staff.

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2. Authentic

• Leads with honesty, transparency, and integrity.

• Builds trust by being genuine and consistent.

• Values relationships and open communication.

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3. Authoritarian (Autocratic)

• Makes decisions without input from others.

• Strict, rule-focused, and expects obedience.

• Efficient in emergencies but can lower morale.

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4. Democratic

• Involves the team in decision-making.

• Encourages participation, feedback, and collaboration.

• Builds teamwork and morale, but decisions may take longer.

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5. Laissez-Faire

• “Hands-off” style, gives staff full freedom.

• Little guidance or direction from leader.

• Works best with highly skilled, self-motivated teams.

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6. Interactional

• Focuses on relationships and interactions between people.

• Balances task completion with staff satisfaction.

• Builds cooperation through personal connections.

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7. Situational

• Adapts leadership style to the needs of the situation.

• May be directive during crises and supportive during routine tasks.

• Flexible and responsive to staff skill levels and circumstances.

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8. Transactional

• Based on rewards and punishments.

• Staff are motivated by incentives (bonuses, recognition) or fear of penalties.

• Effective short-term but doesn’t inspire long-term engagement.

A nurse in the obstetrician's office receives a call from a client who gave birth 8 days ago. The client says, "I thought they said that my bleeding would become pinkish brown, then yellow, and eventually fade away. I still have bright red bleeding." The nurse tells the client to come in immediately. In planning for the client's care upon arrival, what is most important for the nurse to include in the plan?

• Prepare to take samples of blood to determine the client's clotting factors

• Prepare to assist with a possible procedure to remove retained placental fragments

• Prepare to teach the client how lochia should progress during the postpartum period

• Prepare to administer an intravenous antibiotic to the client.

Answer explanation

Prepare to assist with a possible procedure to remove retained placental fragments

• Lochia progression:

  • _{Days 1–3: Lochia rubra (bright red)}

  • _{Days 4–10: Lochia serosa (pink or brown)}

  • _{After day 10: Lochia alba (yellow/white)}

• Bright red bleeding on postpartum day 8 is abnormal and suggests secondary postpartum hemorrhage, commonly caused by retained placental fragments.

✅ Key Point: Persistent or recurrent bright red bleeding after the first few postpartum days is a danger sign of retained placenta or hemorrhage, requiring urgent evaluation and possible intervention (like dilation and curettage).

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  Blood samples for clotting factors: Important if a bleeding disorder is suspected, but not the most common or immediate cause.

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  Teaching: Education is not appropriate until the cause of abnormal bleeding is addressed.

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  IV antibiotics: Used for infection, but the client’s symptoms point to hemorrhage, not infection (no fever, foul odor, or uterine tenderness reported).

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There has been an outbreak of influenza and the community health nurse plans a presentation at the community center for older adults on ways to prevent the spread of influenza. What should the nurse include in the presentation? Select all that apply.

• Wash hands carefully for 10 seconds

• Talk with the healthcare provider about getting the flu vaccine

• Wear a high efficiency particulate air filter mask when going into crowded areas

• If others have flu in the home, clean surfaces with disinfectant wipes

• People with the flu should stay at home.

Answer explanation

• Wash hands for 10 seconds → ❌ Hand hygiene should be done for at least 20 seconds with soap and water, or use alcohol-based sanitizer if unavailable.

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  Flu vaccine → ✅ Annual influenza vaccination is the most effective prevention measure, especially for older adults.

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  HEPA mask in public → ❌ Not recommended for general community use; regular surgical masks and avoiding crowded places are more realistic preventive measures.

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  Clean surfaces with disinfectant wipes → ✅ Influenza virus can survive on surfaces; cleaning helps reduce transmission.

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  Stay home when sick → ✅ Prevents spread to others and supports recovery.

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✅ Key Point: The best influenza prevention for older adults = vaccination, good hand hygiene (20 seconds), environmental cleaning, and avoiding exposing others when symptomatic.

The nurse working in a telehealth center speaks with an older adult client reporting “heartburn”. The nurse suspects the client is experiencing gastroesophageal reflux disease (GERD). To determine if the client is experiencing GERD, what important question should the nurse ask the client?

• Do you have a ride to get to the clinic? We’ll need you to come in today.

• Please describe your heartburn and tell me how often it occurs.

• Please tell me what you had for breakfast this morning.

• Do you smoke cigarettes and drink alcohol?

Answer explanation

• (Please describe your heartburn and tell me how often it occurs.) ✅ GERD is characterized by chronic, frequent heartburn that worsens after meals or when lying down. Asking about the nature, timing, and frequency of symptoms helps confirm the suspicion of GERD.

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  (Do you have a ride to get to the clinic? We’ll need you to come in today.) ❌ Arranging transportation is not the immediate priority in telehealth triage unless the client reports severe or emergent symptoms (e.g., chest pain, difficulty swallowing).

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  (Please tell me what you had for breakfast this morning.) ❌ One single meal detail (breakfast) does not give enough information; a broader dietary history may be helpful later.

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  (Do you smoke cigarettes and drink alcohol?) ❌ Smoking and alcohol are risk factors, but asking about symptom pattern comes first for diagnosis.

A client with a history of bipolar disorder called the provider office to report a new onset of symptoms. “I’ve had nausea and vomiting since yesterday, and I’m so sleepy, it seems like I just can’t get enough sleep. My hands are shaky too.” For the following nursing responses, which one is appropriate to say?

• The provider will discuss alternatives to lithium with you.

• These are expected side effects of your medication & increase your fluid intake & rest at home.

• The hemodialysis nurse will prepare for your arrival.

• “Do not take your next dose of lithium”

• “It is best if you can come to see the provider today”

Answer explanation

Analysis of Nursing Responses

• “The provider will discuss alternatives to lithium with you” → Appropriate
  ✔ Safe and supportive, acknowledges the provider’s role in adjusting medication.

• “Do not take your next dose of lithium” → Appropriate
  ✔ Holding the next dose is correct until toxicity is ruled out.

• “It is best if you can come to see the provider today” → Appropriate
  ✔ Urgent assessment is needed; these symptoms should not wait.

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  “These are expected side effects of your medication” → NO
  ❌ Wrong. Nausea, tremors, and excessive sleepiness are toxicity signs, not expected side effects.

• “The hemodialysis nurse will prepare for your arrival” → NO
  ❌ Hemodialysis is for severe toxicity; this decision is not made by a nurse over the phone.

• “Your lithium dose will likely need to be increased” → NO
  ❌ Incorrect; the dose would likely be reduced or discontinued, not increased.

The nurse cares for a client who lost 7 year old twins in a house fire 8 months ago. The client was admitted today for major depression. The client says to the nurse, “they took my 2 babies away from me, so what is the point of living. They were all I had”. What is the most important thing for the nurse to include in the client’s care plan?

• Place client on continuous observation

• Prevent client from going back to bed in the daytime

• Remove all items from the meal tray that can cause harm

• Arrange for the client to visit the grave of the children

• Arrange for young family members to visit and cheer for the client.