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A nurse is administering insulin glargine to a client. Which of the following actions should the nurse take to prevent medication errors?
- 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: Verification and documentation ensure safety.
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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.
The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
- A. Gives the client a hug and says, 'It’s okay to cry when you are sad.'
- B. While touching the client’s forearm, asks, 'Would you like to talk about it?'
- C. I’m sorry to disturb you at a difficult time. This can wait until later.'
- D. This is a bad time. I can see you are upset. I can come back later.'
Correct Answer: B
Rationale: Empathy encourages communication.
To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.
Nurse’s Notes
The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath
Medical History
• Hypertension
• Heart failure
• Seasonal allergies
• Pneumonia (admitted 3 days ago)
Diagnostic Results
• White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
• C-reactive protein (CRP): 12 mg/L (<3 mg/L)
• Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
• Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
• Chest X-ray: Bilateral infiltrates
Vital Signs
• Temperature: 38.5°C (101.3°F)
• Heart rate: 110 beats per minute
• Respiratory rate: 28 breaths per minute
• Blood pressure: 140/90 mmHg
• Oxygen saturation: 88% on room air
Provider’s Prescriptions
• Administer IV antibiotics as prescribed
• Administer oxygen therapy to maintain SpO2 > 92%
• Monitor vital signs every 4 hours
• Encourage fluid intake
• Perform chest physiotherapy
Physical Examination Results
The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.
A nurse is caring for a client in the intensive care unit. Exhibits:Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Administer diuretics as prescribed, Increase oxygen flow rate, Perform chest physiotherapy, Administer bronchodilators as prescribed, Elevate the head of the bed
- B. Acute respiratory distress syndrome (ARDS),Congestive heart failure exacerbation,Hospital-acquired pneumonia,Chronic obstructive pulmonary disease (COPD) exacerbation
- C. Oxygen saturation, Blood pressure, Respiratory rate, White blood cell count, Serum creatinine
Correct Answer:
Rationale: Hospital-acquired pneumonia fits symptoms; chest physiotherapy clears secretions; oxygen saturation and WBC monitor progress.
Which assessment should the nurse document when charting by exception?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.