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A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.
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Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?
- A. Measure the vital signs
- B. Palpate the abdomen
- C. Assess for breath sounds
- D. Verify tube patency
Correct Answer: D
Rationale: Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent.
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will apply an ice pack to the treatment site if my skin begins to burn.
- B. I will rub baby oil on the site after each treatment to prevent dry skin.
- C. I will use extra measures to protect my skin from sun exposure.
- D. I will wash the treatment site with lukewarm water and mild soap.
- E. I will wear soft, loose-fitting clothing.
Correct Answer: C,D,E
Rationale: Sun protection (C), gentle washing (D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (A) can damage skin, and baby oil (B) may irritate or trap radiation.
The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?
- A. I will always check my blood glucose prior to using the sliding scale.
- B. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin.
- C. I will use a new insulin syringe each time I give myself an injection.
- D. I will use the sliding scale to determine my NPH dose 4 times a day.
Correct Answer: B
Rationale: Eating 30 minutes after NPH and regular insulin (B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (A), using new syringes (C), and sliding scale for regular insulin (D) are correct.
The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?
- A. I will apply the prescribed bacitracin ointment after collecting the wound culture.
- B. I will cleanse the wound by gently flushing it with normal saline.
- C. I will obtain a sample of the drainage accumulated since the last dressing change.
- D. I will perform hand hygiene and apply new gloves before obtaining the wound culture.
- E. I will swab the wound from the outermost margin toward the center.
Correct Answer: B,D
Rationale: Cleansing the wound with normal saline (B) removes contaminants, and hand hygiene with gloves (D) ensures sterility. Applying ointment before the culture (A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (C) may not target active infection.