Nokea
The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?
- A. Ask a regular staff member to confirm the resident's identity
- B. Hold the medication until a family member can confirm identity
- C. Re-orient the resident to name, place, and situation
- D. Confirm the room and bed numbers with those on the medication record
Correct Answer: A
Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.
You may also like to solve these questions
When teaching a patient about the side effects of a new medication, which teaching method is most effective?
- A. Providing a written pamphlet
- B. Giving verbal instructions only
- C. Demonstrating how to take the medication
- D. Using a combination of verbal, written, and demonstration methods
Correct Answer: D
Rationale: The most effective teaching method when educating a patient about the side effects of a new medication is to use a combination of verbal, written, and demonstration methods. This comprehensive approach ensures that the patient receives information through multiple channels, catering to different learning styles. Verbal instructions allow for direct communication, written materials provide a reference for the patient to review later, and demonstrations offer a visual aid that can enhance understanding. Providing a combination of these methods increases the likelihood of the patient retaining and comprehending the information effectively. Choices A, B, and C are less effective as they do not encompass the benefits of utilizing multiple teaching modalities.
What is the primary role of the sinoatrial (SA) node in the heart?
- A. Pacemaker of the heart
- B. Blood pressure regulation
- C. Electrical conduction delay
- D. Stimulating muscle contraction
Correct Answer: A
Rationale: The correct answer is A: Pacemaker of the heart. The SA node, known as the natural pacemaker, initiates the electrical impulses that set the rhythm for the heartbeat. It is responsible for coordinating the heart's contractions by generating electrical signals at regular intervals. Choice B is incorrect as the SA node's primary function is not related to blood pressure regulation. Choice C is incorrect as the SA node does not cause electrical conduction delay but rather initiates and conducts the electrical impulses. Choice D is incorrect as the SA node does not directly stimulate muscle contraction but rather initiates the electrical events that lead to muscle contraction.
A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement?
- A. Teach the client to use a straw when taking the medication to reduce further tooth staining
- B. Advise the client to withhold further doses until consulting with the healthcare provider
- C. Reassure the client that this change indicates the medication is having the desired effect
- D. Determine if the client is also experiencing mouth or gum pain and difficulty swallowing
Correct Answer: A
Rationale: The correct action for the PN to implement is to teach the client to use a straw when taking the medication to reduce further tooth staining. Using a straw minimizes contact between the iron preparation and the teeth, helping prevent additional staining. Choice B is incorrect because withholding doses without consulting the healthcare provider could be detrimental to the client's health. Choice C is incorrect because darkening of tooth color is not an expected effect of liquid iron preparation and should not be reassured as a desired effect. Choice D is incorrect as it does not directly address the client's concern about tooth staining.
A registered nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line, and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?
- A. Blood glucose meter
- B. Noninvasive blood pressure monitor
- C. Electronic infusion pump
- D. Urine test strips
Correct Answer: C
Rationale: An electronic infusion pump is essential for administering TPN to ensure accurate delivery and avoid complications such as fluid overload or improper nutrient delivery. The pump helps regulate the flow rate precisely, which is crucial when infusing TPN. Monitoring the client's blood glucose is important but not immediately necessary before hanging the TPN bag. A noninvasive blood pressure monitor is not directly related to administering TPN and is not the most essential equipment needed for this procedure. Urine test strips are not required for administering TPN via a central line and are not essential equipment for this specific task.
The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?
- A. Stop the procedure and tell the UAP to place the client in a Fowler's position
- B. Praise the UAP for doing the oral hygiene but encourage family participation
- C. Tell the UAP to continue because the unconscious client is positioned safely
- D. Enroll the UAP in a hospital education class on conducting safe client care
Correct Answer: C
Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.