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A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
- A. Verify the client's name on their identification bracelet with the medication administration record.
- B. Call the pharmacy to determine whether the client's medications are available.
- C. Compare the client's home medications with the provider's prescriptions.
- D. Place the client's home medication bottles in a secure location.
Correct Answer: C
Rationale: The correct answer is C: Compare the client's home medications with the provider's prescriptions. This is essential for medication reconciliation to ensure accuracy and prevent medication errors. By comparing the client's home medications with the provider's prescriptions, the nurse can identify discrepancies, address any missing medications or duplications, and ensure the client receives the correct treatment. Verifying the client's name (A) is important for patient safety but not directly related to medication reconciliation. Calling the pharmacy (B) may provide some information but does not involve comparing home medications with provider prescriptions. Placing home medication bottles in a secure location (D) is not part of the medication reconciliation process.
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
- A. During the admission process.
- B. As soon as the client's condition is stable.
- C. During the initial team conference.
- D. After consulting with the client's family.
Correct Answer: A
Rationale: Correct Answer: A. During the admission process.
Rationale: Discharge planning should start early to ensure a smooth transition. During admission, the nurse can assess the client's needs, resources, and support system. This allows time to address any potential barriers to discharge and create a comprehensive plan. Starting discharge planning later may lead to delays and inadequate preparation for the client's transition. Initiating discharge planning during the admission process promotes continuity of care and helps prevent readmissions.
Summary of Other Choices:
B: Waiting until the client's condition is stable may delay discharge planning and increase the risk of complications during the transition.
C: Waiting for the initial team conference may result in missed opportunities to address discharge needs promptly.
D: Involving the client's family is important, but discharge planning should start early to ensure all aspects of the plan are considered and implemented effectively.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the client in a semi-lying position.
- B. Instill 15 mL of irrigation fluid into the catheter with each flush.
- C. Subtract the amount of irrigant used from the client's urine output.
- D. Perform the irrigation using a 20-mL syringe.
Correct Answer: C
Rationale: The correct answer is C: Subtract the amount of irrigant used from the client's urine output. This is the correct action because when using open irrigation technique, the nurse needs to account for the amount of irrigant introduced into the catheter to accurately assess the client's urine output. By subtracting the amount of irrigant used from the total output, the nurse ensures an accurate measurement of the client's urine output. This is crucial for monitoring the client's renal function and fluid balance.
Choice A is incorrect as the client should ideally be in a supine position during catheter irrigation to prevent spillage. Choice B is incorrect as the amount of irrigation fluid instilled should typically be equal to the amount of urine output, not a fixed amount. Choice D is incorrect as a 60-mL syringe is usually recommended for catheter irrigation to avoid excessive force and pressure on the catheter.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
- A. Advocacy ensures clients' safety health and rights
- B. Advocacy ensures that nurses are able to explain their own actions.
- C. Advocacy ensures that nurses follow through on their promises to clients.
- D. Advocacy ensures fairness in client care delivery and use of resources.
Correct Answer: A
Rationale: The correct answer is A because advocacy in nursing involves actively supporting and promoting clients' safety, health, and rights. Advocacy ensures that nurses prioritize the well-being and best interests of their clients, advocating for their needs and empowering them to make informed decisions about their care. The other choices are incorrect because B focuses on self-explanation rather than client-centered advocacy, C is more about accountability than advocacy, and D touches on fairness but does not directly address the core concept of advocacy for clients' safety, health, and rights.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.