A mercury-in-glass thermometer is being used in the extended care ...

[viki]

A mercury-in-glass thermometer is being used in the extended care facility. While the nurse is taking the client's temperature, the thermometer falls and breaks on the floor without coming in contact with the nurse or client.
 
  Which of the following should be the nurse's first action? a. Remove the client from the area.
  b. Remove the client's clothing.
  c. Wash his or her hands and bathe the client.
  d. Notify the environmental services department.

Question 2

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800 . At 1400, the nurse notices that the dressing is saturated. What is the nurse's next action?
 
  a. Wait and change the dressing at 1800 as ordered.
  b. Revise the plan of care and change the dressing now.
  c. Reassess the dressing and the wound in 1 hour.
  d. Discontinue the plan of care.

[CourtneyCNorton]

Answer to Question 1

A
The nurse's first action should be to remove the client from an immediate contaminated envi-ronment if no skin contact has occurred.
After removing the client from the area, the nurse should remove any clothing or linen that has been contaminated with mercury, using rubber gloves and placing the material in a plastic gar-bage bag.
The nurse should perform hand hygiene thoroughly after changing any clothing or linen that has been contaminated with mercury. It is not required that the client be bathed unless skin contact with the mercury has occurred. The first action of the nurse in this case is to remove the client from the area.
After first caring for the client, the nurse should then notify the environmental services depart-ment or notify occupational health services to obtain a mercury spill kit.

Answer to Question 2

B
Based on evaluative data, the nurse revises, discontinues, or continues a patient's plan of care. Because the dressing is saturated, the nurse needs to revise the plan of care and change the dressing now. Waiting until 1800 or for another hour is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.

[viki]

Excellent

[AmberC1996]

TYSM