Nokea
A client presents to the doctor's office with a report of fatigue and difficulty sleeping.Which information should the nurse recognize as a potential contributing factor?
- A. Reads a book entitled 'How to Sleep Better'.
- B. Exercises in the morning and afternoon.
- C. Consumes antibiotics twice a day.
- D. Sleeps between 10 PM and 9 AM each night.
Correct Answer: C
Rationale: Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.
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The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?
- A. 3 mL syringe and a sterile needle.
- B. One ounce medicine cup.
- C. 3 mL syringe.
- D. Tuberculin syringe.
Correct Answer: C
Rationale: A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.
The healthcare provider prescribes penicillin 800,000 units intramuscularly (IM) for a patient with a streptococcal infection. The vial available is labeled Penicillin 50,000 units/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.).
- A. 10
- B. 12
- C. 14
- D. 16
Correct Answer: D
Rationale: The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL. To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000). This gives you a result of 16 mL.