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A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
- A. Administer a PRN sedative prescription.
- B. Leave the door to the client’s room open slightly.
- C. Apply wrist restraints to prevent wandering.
- D. Provide a back rub at bedtime.
Correct Answer: B
Rationale: Back rub addresses agitation non-pharmacologically.
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The primary nurse went on break at 1845. The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?
- 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: Documentation and verification prevent errors.
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
- A. Self-care deficit.
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Risk for impaired skin integrity.
Correct Answer: D
Rationale: Neuropathy increases skin breakdown risk.
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/25 mL'. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 5
Rationale: 200 mg ÷ (1000 mg/25 mL) = 5 mL.
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.