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A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?
- A. Ask the client about any allergies to medications
- B. Review the purposes of each medication
- C. Check for potential drug interactions
- D. All of the above
Correct Answer: D
Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.
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The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?
- A. Ask the client why the bath was refused
- B. Ask family members to encourage the client to bathe
- C. Explain the importance of good hygiene to the client
- D. Reschedule the bath for the following day
Correct Answer: A
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.
The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?
- A. Apply an ice pack
- B. Document the findings and monitor
- C. Notify the surgeon
- D. Clean the wound with sterile saline
Correct Answer: C
Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.
A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?
- A. Blood pressure
- B. Heart rate
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.
Before a client undergoes a Magnetic Resonance Imaging (MRI) scan with contrast, what should the nurse assess?
- A. If the client has any metal implants
- B. If the client has allergies to iodine or shellfish
- C. If the client has a history of claustrophobia
- D. If the client has ever had a similar procedure before
Correct Answer: A
Rationale: Before an MRI scan with contrast, the nurse should assess if the client has any metal implants. Metal implants can interfere with the magnetic field of the MRI, which can pose a risk to the client's safety and compromise the quality of the scan. Assessing for allergies to iodine or shellfish (Choice B) is important for contrast agents but not specific to metal implants. Claustrophobia assessment (Choice C) is relevant for MRI scans due to the confined space but not specific to metal implants. Past procedures (Choice D) are important for comparison but not directly related to the risks associated with metal implants during an MRI scan with contrast.
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?
- A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
- B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
- C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
- D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection
Correct Answer: D
Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.