A: The nurse is ultimately responsible for the error. Nurses are responsible for ensuring the correct administration of medications, which includes verifying the correct dosage. When a nurse administers medication, they must double-check the order, especially if it is unclear or illegible. In this case, the nurse misinterpreted the scribbled order and administered an incorrect dose, making them accountable for the error. Nurses are trained to seek clarification if there is any doubt about a medication order to prevent such mistakes.

B: The health care provider, while responsible for prescribing the medication, is not ultimately responsible for the administration error in this scenario. The provider’s role is to ensure that the prescription is clear and accurate. However, if the order is unclear, it is the nurse’s responsibility to seek clarification before administering the medication. The health care provider would be responsible if the error was due to a prescribing mistake, but in this case, the error occurred during the administration phase.

C: The hospital, as an institution, provides the environment and resources for patient care but is not directly responsible for individual medication administration errors. The hospital’s role includes ensuring that systems are in place for safe medication practices, such as proper training and protocols. However, the responsibility for the error lies with the individual who administered the medication incorrectly.

D: The pharmacist’s role is to dispense medications accurately and provide information about the medication. While pharmacists can catch potential errors in prescriptions, they are not responsible for the administration of the medication. In this case, the pharmacist would not be held accountable for the nurse’s misinterpretation and incorrect administration of the medication.

A: Using a microwave for cooking is generally safe for older adults with decreased vision. Microwaves are user-friendly and reduce the risk of burns or fires compared to stovetops. However, it is important to ensure that the microwave is at an accessible height and that the user can read the controls or has them memorized.

B: Handrails in the bathroom are a safety feature, not a risk. They provide support and stability, reducing the likelihood of falls, which is crucial for individuals with decreased vision. Properly installed handrails can significantly enhance bathroom safety.

C: Electrical cords placed along the walls are typically not a safety risk if they are secured properly and do not create tripping hazards. It is important to ensure that cords are not loose or crossing walkways where they could cause falls.

D: Scatter rugs in the kitchen are a significant safety risk for older adults with decreased vision. These rugs can easily cause tripping and falling, especially if they are not secured with non-slip backing. Removing scatter rugs or securing them properly is essential to prevent accidents.

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.

B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.

C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.

D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.

A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.

B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.

C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.

D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.

A: A BUN level of 165 mg/dL is extremely high and suggests severe dehydration or possible renal failure. This level is far above the normal range and indicates a critical condition.

B: A BUN level of 35 mg/dL is elevated and consistent with dehydration. Dehydration causes the kidneys to reabsorb more water, leading to higher concentrations of urea in the blood.

C: A BUN level of 10 mg/dL is within the normal range and does not indicate dehydration. This level suggests normal kidney function and hydration status.

D: A BUN level of 31 mg/dL is elevated and suggests dehydration. While not as high as 165 mg/dL, it still indicates that the patient is dehydrated and requires intervention.

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

A: Having the client move in with a family member or close friend can provide emotional support and assistance with daily activities. However, it does not specifically address the safety needs related to hearing loss. While this option can be beneficial, it is not the most direct solution for ensuring the client’s safety in their home environment.

B: Encouraging the client to get a roommate can also provide companionship and assistance. However, like option A, it does not directly address the specific safety concerns associated with hearing loss. The presence of a roommate might help in emergencies, but it is not a guaranteed solution for all safety issues.

C: Increasing the sound on all alarms might seem like a logical step, but it is not effective for someone with full hearing loss. This approach does not ensure that the client will be alerted to emergencies, as they may not hear the alarms regardless of the volume.

D: Installing flashing lights for alarms is the most effective recommendation for a client with full hearing loss. Visual alarms can alert the client to emergencies such as fires or intruders, ensuring their safety. This solution directly addresses the client’s inability to hear auditory alarms and provides a reliable method for emergency alerts.

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

A: Dyspnea, or difficulty breathing, can occur in various conditions but is not a primary manifestation of hypovolemia. Hypovolemia primarily affects the cardiovascular system due to reduced blood volume.

B: Increased blood pressure is not a typical manifestation of hypovolemia. In fact, hypovolemia usually leads to decreased blood pressure due to the reduced volume of circulating blood.

C: A weak pulse is a common manifestation of hypovolemia. The reduced blood volume leads to decreased cardiac output, resulting in a weak and thready pulse.

D: Decreased heart rate is not typical in hypovolemia. The body usually compensates for low blood volume by increasing the heart rate (tachycardia) to maintain adequate circulation.