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A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Verification and documentation ensure safety.
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An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Send the UAP to be fitted for a particulate filter mask immediately.
- B. Instruct the UAP that a standard face mask is sufficient.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Advise the UAP to wear a standard face mask to obtain vital signs.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
Which assessment should the nurse document when charting by exception?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
- A. Ensure bevel of the needle is pointing up.
- B. Massage the site gently after injection.
- C. Hold the syringe perpendicular to the skin.
- D. Select upper arm as the injection site.
Correct Answer: A
Rationale: Bevel up ensures proper delivery.
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
- A. Determine the client’s activity tolerance.
- B. Teach the client to shorten the stride to prevent falls.
- C. Initiate a fall risk protocol for the client.
- D. Record the client’s ability to perform ADLs safely.
Correct Answer: D
Rationale: Documentation reflects functional status.