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Which of these actions by the nurse best prevents medication errors when administering medications to a client?
- A. Checking the client's wristband before giving medications
- B. Using two forms of client identification before administering medication
- C. Administering medications at the exact time they are ordered
- D. Verifying the medication order with another nurse
Correct Answer: B
Rationale: Using two forms of client identification (e.g., name and medical record number) is the best practice to prevent medication errors by ensuring the right client receives the medication.
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The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
What does client and family communication and education concerning restraints do?
- A. confuses both groups more
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct Answer: C
Rationale: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints. Well-meaning family members might release restraints if their purpose is not clear.
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
- A. Formula or breast milk
- B. Dilute nonfat dry milk
- C. Warmed fruit juice
- D. Fluoridated tap water
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
Which of these actions should the nurse perform first when a client is admitted with a diagnosis of C-difficile?
- A. Initiate contact precautions
- B. Administer prescribed antibiotics
- C. Obtain a stool culture
- D. Educate the client about hand hygiene
Correct Answer: A
Rationale: Initiating contact precautions is the first step to prevent the spread of C-difficile, which is highly contagious through contact with contaminated surfaces or feces.