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A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
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A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
- A. Bradycardia
- B. Hypotension
- C. Fever
- D. Poor skin turgor
- E. Peripheral edema
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (B) due to decreased blood volume, fever (C) as a result of dehydration and infection, and poor skin turgor (D) due to decreased tissue hydration. Bradycardia (A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
- A. Cover the area with saline-soaked sterile dressings
- B. Apply an abdominal binder snugly around the abdomen
- C. Use sterile gloves to apply gentle pressure to the exposed tissues
- D. Position the client supine with hips & knees bent
- E. Offer the client a warm beverage, such as herbal tea
Correct Answer: A, D
Rationale: Correct Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (Choice A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (Choice D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (Choice B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (Choice C) can introduce contamination and should be avoided.
- Offering a warm beverage (Choice E) is irrelevant and does not address the urgent need to manage the wound.
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.